Every finding on record at Corewell Health Rehabilitation & Nursing Center -

Based on observation, interview, and record review, the facility failed to follow the standards of infection control for Kangaroo pumps (a portable, electronic medical device used for enteral feeding), and IV poles cleaning for five residents (R1, R2, R25, R47, and R105) of 5 residents reviewed for tube feeding, and oxygen concentrator cleaning for one resident (R118) of 1 resident reviewed for receiving oxygen, resulting in the potential for cross-contamination and the spread of disease to a vulnerable population.Findings include:R1According to R1's Face Sheet, the resident's diagnoses included skin breakdown at gastrostomy tube site, and presence of gastrostomy for nutrition. Review of R1's Order Summary, printed and provided on 9/8/25 by facility, indicated the resident had a J-tube (a tube inserted into a small part of the stomach) to provide nutrients and medications. Observed on 9/08/2025 at 10:26 AM, R1 had at bedside a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.R2According to R2's Face Sheet, the resident had diagnoses that included multifocal vascular strokes, dysphagia, and PEG status.Review of R2's Order Summary printed 9/8/25 by facility, indicated the resident had a PEG J-tube (a tube inserted into a small part of the stomach) to provide nutrients and medications. Review of R2's Care Plan Altered Nutrition/Hydration dated 7/9/2024, indicated the resident was dependent on a feeding tube for nutrition/hydration with goals that included tolerating the tube feedings. Interventions to meet this goal included feeding tube care per standing orders. Observed on 9/8/25 at 11:55 AM, R2 had at bedside a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/9/25 at 2:25 PM, R2 had at bedside a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/10/25 at 9:10 AM, R2 had at bedside a Kangaroo pump attached to an IV pole. The top of the pump was completely covered with a dried substance. The pole and base of pole had splatters of a dried substance resembling tube feeding.R25According to R25's MDS dated [DATE], the resident had a PEG tube with diagnoses that included traumatic brain dysfunction and cardiorespiratory conditions. Review of R25's Order Summary printed 8/26/25 by facility, indicated the resident had a PEG J-tube to provide nutrients and medications. Review of R25's Care Plan Altered nutrition and Hydration, dated 11/18/2021, indicated the resident was dependent on a feeding tube for all nutrition and hydration needs. Goals included resident tolerating the tube feedings with an intervention of feeding tube care per standing order. Observed on 9/9/25 at 11:13 AM, R25 had a Kangaroo pump attached to an IV pole at bedside. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/9/25 at 2:05 PM, R25 had a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/10/25 at 8:55AM, R25 had a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/10/25 at 10:05AM, R25 had a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.During an interview on 9/10/25 at 10:05AM, Licensed Practical Nurse (LPN) MM stated, Feeding pumps and poles should be cleaned when feedings spill on them to prevent pathogens and infection control, but also to keep bugs from feeding on it.During an interview on 9/10/25 at 11:05 AM, Director of Nursing (DON) B stated, Tube feeding pumps and poles should be cleaned when visibly dirty and between uses for infection control purposes. The pumps and poles are cleaned all the time.R47According to R47's MDS dated [DATE], revealed the resident had a percutaneous endoscopic gastrostomy (PEG) tube with diagnoses that included traumatic brain dysfunction and cardiorespiratory conditions. Review of R47's Order Summary, printed and provided on 9/10/25 by facility, indicated the resident had a PEG J-tube (a tube inserted into a small part of the stomach) to provide nutrients and medications. Review of R47's Care Plan, Altered Nutrition/Hydration, dated 11/10/2021, indicated the resident was dependent on feeding tube for hydration and nutrition needs with a goal to tolerate tube feeding. Interventions used to obtain/maintain goals included feeding tube care per standing orders.Observed on 9/8/25 at 10:05AM, R47 had a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/9/25 at 10:25 AM, R47 had a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/9/25 at 2:05 PM, R47 had a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding. Observed on 9/10/25 at 9:15 AM, R47 had a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.R105According to R105's Face Sheet, the resident had diagnoses that included chronic necrotizing pancreatitis with multiple chronic intra-abdominal abscesses and duodenal and colonic fistula and Total parenteral nutrition (TPN). Review of R105's Order Summary printed 9/8/25 by facility, indicated the resident had a PEG J-tube (a tube inserted into a small part of the stomach) to provide nutrients and medications. Review of R105's Care Plan Altered Nutritional/Hydration dated 2/23/2024, indicated the resident was TPN dependent with goals that included tolerating the TPN. Interventions included receiving TPN as ordered. Observed on 9/8/25 at 12:00 PM, R105 had at bedside a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/9/25 at 10:17 AM, R105 had at bedside a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/9/25 at 1:55 PM, R105 had at bedside a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Observed on 9/10/25 at 9:05AM, R105 had at bedside a Kangaroo pump attached to an IV pole. The pump, pole, and base of pole had splatters of a dried substance resembling tube feeding.Oxygen FiltersAccording to R118's Face Sheet, the resident had diagnoses that included chronic respiratory failure, centrilobular emphysema, restrictive lung disease, obstructive sleep apnea, lung nodule, and shortness of breath (SOB). Review of R118's Order Summary dated 1/19/2024, revealed, Oxygen therapy 2 lpm (liters per minute), nasal cannula continuous.Review of R118's Care Plan, Cardiology, dated 6/1/25, revealed the resident would not experience SOB as a goal. Interventions included administer oxygen as ordered. Observed on 9/08/2025 at 2:34 PM, R118 was in bed wearing oxygen running at 2.5 lpm (liters per minute) via nasal cannula (NC). The oxygen tubing was dated 9/3. The filter on the back of the oxygen concentrator was covered with dust, lint, and a dried substance resembling applesauce. There were streaks of dried substances on the concentrator. Observed on 9/9/25 at 2:00 PM, R118 was in bed wearing oxygen running at 2.5 lpm (liters per minute) via nasal cannula (NC). The filter on the back of the oxygen concentrator was covered with dust, lint, and a dried substance resembling applesauce. There were streaks of dried substances on the concentrator. It was noted on 9/8/25, the oxygen tubing was dated 9/3 and the concentrator filter was in the same condition as observed the day prior. Observed on 9/10/25 at 9:00 AM, R118 was in bed wearing oxygen running at 2.5 lpm (liters per minute) via nasal cannula (NC). The filter on the back of the oxygen concentrator was covered with dust, lint, and a dried substance resembling applesauce. There were streaks of dried substances on the concentrator. The concentrator filter was in the same condition as observed the two days prior. During an interview and record review on 9/9/25 at 2:10 PM, Respiratory Therapist, Z stated, (R118) has emphysema, right sided paralysis, and restrictive lung disease. (R118) also receives nebulizer treatments. Oxygen tubing is changed once a month unless a humidifier is used then the tubing is changed once a week. The concentrator filters should be checked and cleaned at the same time as the filters or if something is spilled on the concentrator. The filters could become clogged.During an interview on 9/10/25 at 11:07 AM, Director of Nursing (DON) B stated, The respiratory team audits all oxygen concentrators and tubing. They check the machines and should check the filters at the same time for respiratory hygiene and infection control.

This citation pertains to intake # 2603853Based on observation, interview and record review, the facility failed to ensure all residents maintained their right to self-determination for 1 (Resident #74) of 1 resident reviewed for choices, resulting in Resident #74 not receiving feeding assistance while others ate around him, missed opportunities to experience joy while eating, and a loss of autonomy.Findings include:Review of Alternative Nutrition and Hydration in Dysphagia Care, American Speech-Language-Hearing Association, https://www.[NAME].org/practice-portal/clinical-topics/adult-dysphagia/alternative-nutrition-and-hydration-in-dysphagia-care/, revealed .Recommendations for supplemental feeding may include pleasure feeding. This option is often limited to the patient consuming tastes or small amounts of food types while following clear precautions; pleasure feeding is administered (or taken) to improve quality of life.Patient autonomy, or the right to self-determination, is a key factor in health care decision making.Resident #74Review of an admission Record revealed Resident #74 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: traumatic brain injury (TBI), oropharyngeal dysphagia (a disorder or impairment in initiating a swallow) and functional quadriplegia (complete inability to move due to severe disability).Review of a Minimum Data Set (MDS) assessment for Resident #74 with a reference date of 8/18/25, revealed a Brief Interview for Mental Status (BIMS) score of 00/15 which indicated Resident #74 could not complete the evaluation. Further review of the MDS revealed Resident #74 had short- and long-term memory deficits and never/rarely made decisions for himself. Section GG of the MDS revealed Resident #74 was dependent (helper provides more than 50% of the effort) for eating.Review of a Care Plan for Resident # 74 with a reference date of 8/7/25, revealed a problem/goal/interventions of: Problem: (Resident #74) is at risk for Altered Nutrition and Hydration.Goal: (Resident #74) desires no significant changes in weight, will consume po(oral) diet for pleasure. Interventions.requires enteral feeding.diet as ordered, honor food preferences, meal location-see Resident Care Summary, assist with meals as needed/Provide assistance per Resident Care Summary, provide additional calories.chocolate pudding, Greek yogurt.Review of a Resident Care Summary for Resident #74 with a reference date of 8/13/25 revealed Eating Safety: 1:1 (one patient per one staff member); Swallow strategy- 1 Bite, 1 Swallow; Up in Chair for Meals.Review of Physician Orders for Resident #74 with a reference date of 2/18/25 revealed Adult Diet Type.pureed.no liquids.In an interview on 9/9/25 at 9:06am, Durable Power of Attorney (DPOA)/Family Member (FM) EEE reported Resident #74 was dependent on staff for eating and was supposed to be helped with a pleasure feeding at every meal. DPOA/FM EEE reported she arrived on 8/24/25 at approximately 10am and assisted Resident #74 with eating a snack. DPOA/FM EEE reported Resident #74 ate the entire snack and appeared hungry. DPOA/FM EEE reported when she told Certified Nursing Assistant (CNA) C that Resident #74 ate an entire snack, CNA C admitted Resident #74 had not been assisted with eating his pleasure feeding at breakfast.In an interview on 9/9/25 at 2:31pm, CNA C reported she cared for Resident #74 on 8/24/25 and realized sometime mid-morning that Resident #74 had not been assisted with breakfast. CNA C reported she was busy assisting other residents with their breakfast, assumed another CNA would assist Resident #74, and did not feel comfortable assisting Resident #74 due to his swallowing issues. CNA C reported she had witnessed other staff skipping assisting Resident #74 with eating before, because it was just a pleasure feeding. CNA C confirmed she was aware Resident #74 should be assisted with eating at each meal.In an interview on 9/10/25 at 10:41am, Licensed Practical Nurse (LPN) MM confirmed Resident #74 was not assisted with eating his pleasure feeding at breakfast on 8/24/25. When further queried, LPN MM reported the resident was supposed to receive pleasure feedings at every meal but the CNA caring from Resident #74 did not ensure the resident was assisted. LPN MM reported at breakfast time that day, Resident #74 was seated near the dining room, where the resident likely heard the sounds of mealtime and smelled the food. LPN MM reported he felt Resident #74 enjoyed being offered food and had seen the resident nod his head and point when he liked the taste of something that was being offered. LPN MM stated even if most of the food falls out of his mouth, he enjoys tasting it.In an interview on 9/10/25 at 10:59am, CNA DD reported she had assisted Resident #74 with eating his pleasure feeding meals many times in the past. CNA DD reported it was obvious the resident enjoyed eating because he would smile when he ate certain foods and would consistently communicate his food preferences by making small movements either with his finger or by lifting his right leg. CNA DD reported when Resident #74 was very excited about a food he was tasting, he would lift his right leg up and down repeatedly. When further queried, CNA DD reported she had witnessed other staff members not assisting Resident #74 with eating when they were assigned to be his care partner. CNA DD reported when that happened, Resident #74 would be left in the dining area while others ate. CNA DD reported it was the expectation that Resident #74 be assisted with eating at every meal, even though his primary source of nutrition was an enteral feeding.During an observation on 9/10/25 at 12:05pm, Resident #74 sat in the dining room and was assisted by an unknown CNA who placed small amounts of pureed food in his mouth via spoon. Resident #74 lifted his right leg in response when the CNA inquired if the resident liked the food. The CNA asked Resident #74 if he wanted more of the food and the resident again raised his right leg. The CNA placed another small amount of food in Resident #74's mouth and the resident responded with a slight chewing motion.In an interview on 9/10/25 at 9:04am, DPOA/FM EEE reported the facility had agreed to assist Resident #74 with pleasure feedings three times per day. DPOA/FM EEE having normal mealtime experiences was important to Resident #74 because he had always enjoyed eating, had a big appetite, and mealtime was an enjoyable part of his daily life prior to his injury.Review of an Oral Intake Flowsheet for Resident #74 with a reference date range of 8/11/25-9/9/25 revealed 11 of 90 meal opportunities in which there was no record of a pleasure feeding being offered.In an interview on 9/10/25 at 2:12pm, Director of Nursing (DON) B indicated she was not aware Resident #74 was supposed to be assisted with pleasure feedings at every meal, or that it was not always being offered.Using the reasonable person concept, though Resident #74 could not verbalize his desire to eat, the resident clearly displayed a feeling of joy when he was assisted with pleasure meals and his DPOA, who was appointed to make decisions on his behalf, had expressed the desire for the resident to have support with oral intake at each mealtime.

This citation pertains to Intake MI00152599. Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect in 2 (Resident #100, Resident #101) of 4 residents reviewed for abuse, resulting in feelings of diminished self-worth and frustration. Findings include: Resident #100 Review of an Admission Record revealed Resident #100 was a male, with pertinent diagnoses which included: diarrhea, anxiety, and cerebral palsy (a disorder that affects movement, muscle tone, or posture). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 3/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #100 was cognitively intact. In an interview on 4/28/25 at 10:05 AM, Resident #100 reported Certified Nurse Aide (CNA) P had yelled at him because he had an accident. Resident #100 reported he had had a bowel movement accident and CNA P came in his room and started yelling because he had had the accident. Resident #100 reported Licensed Practical Nurse (LPN) Q witnessed the interaction. In an interview on 4/29/25 at 9:04 AM, LPN Q reported he had been in the hall when CNA P had been in Resident #100's room. LPN Q reported hearing escalating tension in the voices of both Resident #100 and CNA P and had gone into the room to deescalate the situation. LPN Q reported CNA P had a condescending tone in the way she was approaching the situation with Resident #100. LPN Q reported CNA P was projecting the frustration that she felt due to having to clean up Resident #100. LPN Q reported it wasn't the words CNA P used; it was the tone. LPN Q reported CNA P would consistently cut Resident #100 off when he was trying to express himself and how he felt. LPN Q reported CNA P had not been treating Resident #100 with dignity and respect during the interaction. In an interview on 4/28/25 at 11:04 AM, Social Worker (SW) E reported Resident #100 had complained that CNA P had yelled and had a harsh tone with him when she went into his room to change him. In an interview on 4/28/25 at 1:34 PM, SW D reported Resident #100 had come to her and said that CNA P had raised her voice with him and was yelling at him. SW D reported Resident #100 presented as quite upset at how CNA P had talked to him and had said he could almost cry. SW D reported she reported the incident to Nursing Home Administrator (NHA) A immediately. In an interview on 4/28/25 at 2:34 PM, NHA A reported that she, along with SW E and Nursing Supervisor (NS) I had talked to Resident #100 following the interaction between himself and CNA P and Resident #100 had basically said that he didn't like how loud CNA P talked and that he didn't like her tone but that his needs had been met. In an interview on 4/28/25 at 1:11 PM, CNA P reported management had spoken to her because a resident had said they did not like the tone of her voice. CNA P reported when she went into Resident #100's room, he was in his wheelchair in the bathroom, and he was upset because he couldn't wait to get on the toilet and had messed himself. CNA P reported she kept telling Resident #100 in a regular tone that it was okay and that we were going to get him cleaned up. CNA P reported later in the day a manager had told her that Resident #100 had not liked her tone. In a follow-up interview on 4/29/25 at 12:30 PM, Resident #100 reported he felt CNA P had not treated him with respect and that he had already been humiliated that he had had an accident in his wheelchair and when CNA P started yelling at him, it made him feel even worse. Resident #101 Review of an Admission Record revealed Resident #101 was a male, with pertinent diagnoses which included: current mild episode of major depressive disorder and hemiplegia (weakness or paralysis on one side) of left nondominant side as late effect of nontraumatic intraparenchymal hemorrhage (a type of stroke) of brain. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 3/7/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #101 was cognitively intact. In an interview on 4/28/25 at 10:27 AM, Resident #101 reported CNA P did not treat him with dignity and respect at times. Resident #101 reported CNA P had been rude and made him feel little and insignificant 3 or 4 weeks ago when he placed his call light on, and she had come in the room and made him feel like he was a bother to her. Resident #101 reported he had told CNA P that he needed to use the restroom, and she had told him he didn't need to go because he had just gone. Resident #101 reported he has had accidents waiting to be toileted.

Based on interview and record review, the facility failed to implement policies and procedures for immediate reporting to the State Agency for 1 (Residents #100) of 4 residents reviewed for abuse reporting, resulting in the potential for further instances of abuse going undetected, unreported, or without thorough investigation. Findings include: Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 3/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated Resident #100 was cognitively intact. In an interview on 4/28/25 at 10:05 AM, Resident #100 stated, I had one of the aides that verbally abused me. Resident #100 reported he had had a bowel movement accident. Resident #100 reported the aide (CNA Certified Nurse Aide P) had come in his room and started yelling at him because he had had an accident. Resident #100 reported that he had complained to the facility. Resident #100 reported that a nurse (Licensed Practical Nurse, LPN Q) had witnessed the incident and encouraged him to report it. Resident #100 reported he had told Social Worker (SW) D. Resident #100 reported he had a meeting with Nursing Home Administrator NHA A, SW E, and Nursing Supervisor (NS) I shortly after reporting the incident and told them that CNA P had yelled at him to which they said they would speak to the CNA. Resident #100 reported he had also reported CNA P approximately 3 months earlier for how she had spoken to him. Resident #100 reported at that time, management had also said they would talk to her. In an interview on 4/28/25 at 11:04 AM, SW E reported Resident #100 had complained that CNA P had gone into his room and had been yelling at him with a harsh tone when he had needed to be changed. SW E reported there have been other residents who have complained about CNA P in the past. In an interview on 4/28/25 at 11:17 AM, NS I reported Resident #100 had concerns with the way CNA P had spoken to him. NS I reported they had investigated Resident #100's concern and followed up with CNA P. NS I reported he, along with NHA A, and SW E had a conversation with Resident #100 who had reported he didn't feel safe with CNA P providing cares to him, so they developed a plan to make Resident #100 feel safe. In an interview on 4/28/25 at 1:34 PM, SW D reported Resident #100 had reported to her that CNA P had raised her voice with him and was yelling at him. SW D reported Resident #100 had soiled himself with bowel movement and was quite upset with how CNA P had talked to him. SW D reported Resident #100 had said that a nurse had heard CNA P's tone of voice and come into the room. SW D reported Resident #100 had said he felt like the incident was abusive and that he felt he could almost cry. SW E reported when she heard the word abuse, she reported the incident to NHA A immediately. In an interview on 4/28/25 at 2:34 PM, NHA A reported after the incident between Resident #100 and CNA P had been reported to her, staff, including herself, had spoken to the resident for over an hour. NHA A reported Resident #100 had basically said he didn't like how loud CNA P talked and that he didn't like her tone. NHA A reported Resident #100 had said he had gotten the cares he needed from CNA P. NHA A reported Resident #100 did not use the word abuse when speaking with her. NHA A reported normally an incident of this nature would have been put on a grievance form but since it was handled right at the time, a clinical note was entered in the resident's medical record instead. In an interview on 4/29/25 at 9:04 AM, Licensed Practical Nurse (LPN) Q reported he had witnessed the incident between Resident #100 and CNA P. LPN Q reported he had heard the situation escalating and tension in the voice of Resident #100 and CNA P, so he went into the room to deescalate the situation. LPN Q reported CNA P's tone was condescending. In a follow-up interview on 4/29/25 at 11:24 AM, NHA A reported when they had met with Resident #100, he talked about his concerns, but his concern was just how he didn't like how CNA P spoke with him and that all his needs were met. NHA A reported when they were discussing the incident with Resident #100, she (NHA A) was under the impression that CNA P always talked loudly, and Resident #100 didn't like her tone. NHA A reported she felt like meeting with Resident #100 and talking about it with him that he was okay with it. NHA A reported immediately after Resident #100 had reported he did not like how CNA P talked to him; Resident #100 was taken off CNA P's assignment. In a follow-up interview on 4/29/25 at 1:12 PM, NS I reported he had talked to LPN Q following the reported incident between Resident #100 and CNA P but did not document the conversation. Review of a Nursing Note dated 4/8/25 at 4:00 PM revealed, Spoke with (Resident #100) regarding his raising concerns about a specific staff member. Building administrator and social worker were present for this conversation. He stated that he had needed to use the restroom and staff had not made it into his room in time to assist him and he had an accident. (Resident #100) expressed frustration with the communication between him and this staff member. (Resident #100) also verbalized that there were no concerns with the cares provided by the staff member during this interaction. Leadership validated (Resident #100)'s feeling and discussed multiple solutions to help prevent this from happening in the future. The first solution included taking (Resident #100) off the float run and assigning him to one of the aides that stays on the unit so that he can receive more timely care. The second was to have two staff members provide cares to (Resident #100) to ensure that communication is always done in a manner that is acceptable to him. (Resident #100) was assured that follow up would be occurring with the specific staff member regarding the situation. (Resident #100) verbalized satisfaction with and appreciation for the follow up occurring. (Resident #100) was encouraged to continue to bring any concerns he has to building leadership to be addressed. There was no evidence of interviews with other residents or other staff conducted to immediately verify that abuse did not occur. Review of the policy Resident Abuse Program Procedure effective date 10/30/23 revealed, .11. Reporting/response 11.3.1. (State Survey Agency name omitted) reporting: In compliance with Federal law, an immediate report is provided to the Administrator/designee and the State Survey Agency (name omitted) of alleged violations involving physical, mental, involuntary seclusion and sexual abuse, as well as neglect, mistreatment, misappropriation, and injuries of unknown origin. The Administrator/designee must report to (State Survey Agency name omitted) within two hours. The initial report must provide sufficient information to describe the alleged violation and indicate how the residents are being protected .

Based on observation, interview, and record review the facility failed to maintain proper infection control practices as evidenced by failure to 1. Ensure proper hand hygiene was completed during incontinence care for 1 (Resident #14); and 2. Ensure proper PPE (personal protective equipment) for enhanced barrier precautions was used during personal cares for 1 (Resident #14) of 15 total sampled residents reviewed for infection control practices resulting in the potential for the introduction of infection, cross-contamination, and/or disease transmission. Findings include: Resident #14 Review of a Face sheet revealed Resident #14 was male and was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: Traumatic brain injury (TBI; a brain injury that occurs when a sudden external physical assault happens to the brain), dysphagia (difficulty or the inability to swallow), and neurogenic bladder (a lack of coordination between the brain and the bladder resulting in the inability to feel the bladder is full, urine leakage, and urinary incontinence.) On 3/10/25 at 11:45 a.m. a sign was observed posted on the wall outside of Resident #14's room indicated that Resident #14 was in enhanced barrier precautions (EBP). On 3/10/25 at 11:50 a.m. this surveyor entered Resident #14's room and observed Rehab Tech/Certified Nurse Assistant (RT/CNA) O kneeling beside Resident #14's bed emptying Resident #14's urinary catheter bag (a closed drainage bag that collects urine from a catheter inserted into the bladder) of urine. RT/CNA O was wearing gloves but was not wearing a gown. RT/CNA O reported she was assisting Resident #14 with a bed bath and to get dressed for the day. RT/CNA O was then observed opening cupboards and drawers around the room locating supplies, wetting down washcloths in the sink in the bathroom, and washing Resident #14's face and hands. RT/CNA O wore the same pair of gloves she was wearing when she emptied the catheter bag. At 12:02 RT/CNA applied clean gloves and continued to provide bathing assistance to Resident #14. RT/CNA O was then observed retrieving the dirty linen cart from the bathroom and placing it closer to the bedside while wearing the same pair of gloves. RT/CNA O then retrieved a washcloth from the bed, wet it down in the wash basin at the bed side and continued Resident #14's bed bath. RT/CNA O then retrieved more washcloths from the cupboard with gloved hands and returned to the bedside and continued Resident #14's bed bath. RT/CNA reported Resident #14 had a daily schedule for being out of bed and resting, and RT/CNA walked to the cupboard in Resident #14's room, opened it to reveal Resident #14's schedule on the inside of the door. RT/CNA O then returned to the bedside and removed Resident #14's gown and continued his bed bath. RT/CNA O was still wearing the same gloves. RT/CNA O completed Resident #14's bed bath, assisted Resident #14 to be dressed, and placed a sling under Resident #14 for transfer; RT/CNA O then removed her gloves, sanitized her hands and exited the room. At 12:09 p.m. RT/CNA O re-entered Resident #14's room, cleaned up the dirty linen, wash basin and bed bath supplies and completed a mechanical lift transfer of Resident #14 from his bed to his wheelchair, adjusted Resident #14's clothing and body position for comfort in his wheelchair. At no time after re-entering the room did RT/CNA O sanitize her hands or wear any kind of PPE (gown or gloves). At 12:13 p.m. RT/CNA O donned (put on) a pair of gloves and applied Resident #14's hand splints to both hands, made Resident #14's bed, opened the window cover, straightened up the room, and applied lip balm to Resident #14's lips. RT/CNA O did not change gloves or perform hand hygiene between these observed tasks. Review of Enhanced Barrier Precautions signage posted outside of Resident #14's room revealed wear gown and gloves for all high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs/assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. In an interview on 3/10/25 at 12:20 p.m. RT/CNA O reported that the signage outside of Resident #14's room indicated he was in enhanced barrier precautions and that she should have worn gloves and a gown during the cares she performed. Review of Other Order for Resident #14 initiated on 4/3/2024 revealed initiate enhanced barrier precautions continuous. On 3/10/25 at 2:38 p.m. RT/CNA N was observed wearing gloves as she applied Resident #14's splint to his bilateral arms. RT/CNA was noted to be leaning over the bed and within close proximity to resident during the application of hand splints. RT/CNA N was observed positioning Resident #14 in bed, with his splints in place and pillows for comfort. RT/CNA N did not wear a gown during cares. RT/CNA N reported that enhanced barrier precautions meant that staff needed to wear a gown and gloves when providing care. In an interview on 3/10/25 at 2:53 p.m. CNA R reported that enhanced barrier precautions were put into place for residents who had tubes, lines, or drains such as G-tube. (a tube placed directly into the stomach and used for nutrition, hydration, and medication administration) and a foley catheter. CNA R reported the staff needed to wear a gown and gloves when providing high contact care, such as a bed bath or incontinence care. In an interview on 3/10/25 at 2:56 p.m. CNA DD reported that enhanced barrier precautions were put in place for residents with tube feedings. (G-tubes) and staff needed to wear a gown and gloves when in the room. On 3/11/25 at 2:54 p.m. this surveyor entered Resident #14's room and observed CNA FF and CNA DD preparing to transfer Resident #14 via a mechanical lift (the sling under Resident #14 was already connected to the lift) from his wheelchair into his bed. Neither CNA FF nor CNA DD were wearing a gown. CNA FF transferred Resident #14 to bed, removed the sling from under him, and removed his pants. CNA FF then removed Resident #14's brief and found it to be soiled with bowel movement (BM). CNA FF took washcloths to the bathroom sink to wet them down and performed peri-care for Resident #14. During peri-care, CNA FF asked CNA DD to retrieve a towel from the cupboard, which she did with gloved hands. CNA FF then wet down the corner of the towel in the sink and finished cleaning Resident #14's buttock of BM. CNA FF then used the other end (the dry part) of the towel to dry Resident #14's buttock. CNA DD wore the same pair of gloves through the observation. In an interview on 3/11/25 at 3:06 p.m. CNA FF reported every person on the unit was on enhanced barrier precautions for their G-tubes. CNA FF reported that enhanced barrier precautions were only for the nurses when they were working with the G-tubes, it did not apply to the CNAs. When queried CNA FF stated No, I don't wear a gown for residents in EBP when I provide care. In an interview on 3/12/25 at 10:14 a.m. LTC Nurse Supervisor (LTC/NS) F reported enhanced barrier precautions were used for open wounds, foley catheters, and G-tubes, to prevent the spread of bacteria. LTC/NS F reported that a gown and gloves needed to be worn when the staff was in the room to care for the wound, catheter, or the G-tube and the staff should wear it during a transfer. In an interview on 3/12/25 at 10:20 a.m. Infection Preventionist (IP) E reported staff was to wear a gown and gloves when performing high contact care activities with residents who were in enhanced barrier precautions. IP E reported CNAs should wear a gown when performing peri-care, transfers, and emptying foley catheters and nurses should wear a gown and gloves when working with a G-tube. In an interview on 3/12/25 at 10:30 a.m. Director of Nursing (DON) B reported her expectations were that the staff followed the signage posted outside of the resident's room prior to entering and providing care. Review of facility policy Isolation Precautions for Continuing Care- Rehab and Nursing Centers with a last revision date of 7/10/2024 revealed .Enhanced Barrier Precautions require gown and glove use for certain residents during specific high-contact resident care activities that have been found to increase MDRO (multi-drug resistant organism) transmission such as .dressing, bathing/showering, transferring, providing hygiene, changing briefs .device care or use: . feeding tube .enhanced barrier precautions will also be implemented when Resident has wounds and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube .) regardless of MDRO colonization status.

This citation pertains to Intake # MI00146599. Based on observation, interview, and record review, the facility failed to ensure showers were provided per resident preference and plan of care for 1 (Resident #101) of 3 resident reviewed for Activities of Daily Living (ADL) care, resulting in inadequate personal hygiene, missed showers, and dissatisfaction with care and hygiene concerns. Findings include: Resident #101 Review of an Admission Record revealed Resident #101 was a female, originally admitted to the facility on [DATE], with pertinent diagnoses which included age related physical debility. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 10/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated Resident #101 had moderate cognitive impairment. Review of Resident #101's current Care Plan revealed, (Resident #101) requires assistance with ADL's .Interventions .Showers as scheduled .Start date: 2/7/24 . Review of Resident #101's Daily Cares revealed that Resident #101 did not have documentation of any showers or baths provided on the following scheduled shower dates: 10/19/24, 10/26/24, 11/13/24, 11/16/24, and 11/20/24. During an observation and interview on 12/4/24 at 12:47 PM, Resident #101 was sitting in her wheelchair in her room. Resident #101 reported that she had concerns with the facility staff not assisting her with showers on her scheduled shower days. Resident #101 reported that she was scheduled to have showers on Wednesdays and Saturdays, but she was not consistently getting two showers a week. During an interview on 12/5/24 at 9:51 AM, Nursing Supervisor (NS) R reviewed Resident #101's Electronic Health Record (EHR) with this writer and confirmed that Resident #101 did have any documentation to verify that Resident #101 had received or refused showers or a bath on 10/19/24, 10/26/24, 11/13/24, 11/16/24, and 11/20/24. NS R reported that she was not aware that Resident #101 had missed multiple showers. NS R confirmed that Certified Nursing Assistants (CNA's) were responsible for documenting that they had provided showers for residents. NS R reported that nurses were responsible for completing skin assessments on resident's shower days, but that documentation of nursing skin assessments did not indicate that a shower had been completed. On 12/5/24 at 2:02 PM, Director of Nursing (DON) B provided additional CNA documentation for Resident #101's showers. It was noted that the CNA documentation did not include documentation for showers or refusals for Resident #101 on 10/19/24, 10/26/24, 11/13/24, 11/16/24, and 11/20/24. On 12/5/24 at 3:57 PM, DON B provided Nursing Skin Assessments for Resident #101 for the following dates: 10/19/24, 10/26/24, 11/17/24, & 11/20/24. It was noted that each nursing skin assessment did not note that a shower was provided for Resident #101. During an interview on 12/5/24 at 4:03 PM, Registered Nurse (RN) L reported that nurses were responsible for completing skin assessments for residents on their scheduled shower days. RN L reported that nurses would typically complete the skin assessment right before of after the resident's shower, but that they were required to complete the assessment even if the resident missed the shower. RN L confirmed that documentation of a nursing skin assessment would not indicate that a resident had received a shower unless it was noted that the resident had received a shower. During an interview on 12/5/24 at 4:12 PM, RN GG reported that nurses were responsible for completing skin assessments on resident's scheduled shower days. RN GG reported that if the nurse had completed the skin assessment during the resident's shower, that they would document that the shower was completed in their skin assessment note. RN GG reviewed the skin assessment notes for Resident #101 on 10/19/24, 10/26/24, 11/17/24, & 11/20/24 with this writer and reported that the notes did not indicate that a shower had been completed.

This citation pertains to Intake # MI00146599 & MI00146889. Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for 2 (Resident #101 and #102) of 3 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs. Findings include: Resident #101 Review of an Admission Record revealed Resident #101 was a female, originally admitted to the facility on [DATE] with pertinent diagnoses which included age related physical debility. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 10/23/24, revealed a Brief Interview for Mental Status (BIMS) score of 12/15, which indicated Resident #101 had moderate cognitive impairment. Review of Resident #101's current Care Plan revealed, .(Resident #101) does not want to experience a fall with major injury .Interventions .Call light within reach .Start date: 1/21/23 . Review of Resident #101's Nursing Note dated 11/1/24 and documented by Nursing Supervisor (NS) R revealed, Had a conversation with (Resident #101) regarding concerns about her call light not being left with her on Saturday 10/26. After speaking with (Resident #101), it was determined that she had her call light clipped to her shirt and called out appropriately for cares to provide to her. She stated that she felt safe and I reminded that we are here is she has any further concerns. Review of Resident #101's Care Conference Note dated 11/5/24 revealed, IDT (Interdisciplinary team) met for scheduled care conferences .(Resident #101) expressed concerns related to her call light and nursing response times. Questions/concerns addressed in the moment. (Resident #101) expressed satisfaction with response/follow up. Will continue to remain available for additional support as needed throughout her stay . During an observation and interview on 12/4/24 at 12:47 PM, Resident #101 was sitting in her in wheelchair watching television. Resident #101 reported that she had concerns that the facility staff did not ensure that her call light was within reach so that she could call for assistance. Resident #101 reported that she could not get to her call light if staff did not clip it to her shirt when she was in her wheelchair. Resident #101 reported that she had voiced her concerns about call lights to several staff members at the facility, but she was still experiencing issues with having access to her call light and she did not feel that the facility had resolved her concerns. During an observation and interview on 12/5/24 at 8:36 AM, Resident #101 was sitting in her room in her wheelchair. Resident #101 reported staff had just brought her back to her room from the dining area. Resident #101 reported that she needed assistance from staff, but they had not left her call light within reach. It was noted that Resident #101's call light was hanging on the wall behind her, and out of reach. During an observation and interview on 12/5/24 at 8:42 AM, Registered Nurse (RN) L entered Resident #101's room with this writer and confirmed that Resident #101's call light was out of her reach. During an interview on 12/5/24 at 11:15 AM, Certified Nursing Assistant (CNA) W reported that she was the staff member that had assisted Resident #101 back to her room earlier in the morning. CNA W reported that she had forgotten to place Resident #101's call light within her reach. CNA W confirmed that she was aware that Resident #101 required a call light to be attached to her shirt so that she could use it to call for staff assistance. During an interview on 12/5/24 at 9:51 AM, NS R reported that she was aware that Resident #101 had ongoing concerns related to her call light. NS R reported that she had been made aware on 11/1/24 that Resident #101 had reported her call light being left out of her reach on 10/26/24. NS R confirmed that she was not able to verify that Resident #101 had her call light in reach on 10/26/24 because she did not make any observations, but that when she met with Resident #101 on 11/1/24 that Resident #101's call light was in reach that day. NS R reported that she had not completed any audits after she spoke with Resident #101 on 10/26/24 to confirm that staff were continuing to place Resident #101's call light within in her reach. NS R confirmed that facility staff were expected to ensure residents had call lights placed within reach. Review of the facility's Call light Accessibility, Use, and Response policy dated 9/23/22 revealed, Purpose: The purpose of this policy is to ensure each resident call light is accessible, functional for use and responded to appropriately .Policy .With each interaction in the resident's room, bathroom, or bathing facility team members will ensure the call light is within reach of resident and secured as needed . 36221 Resident #102 Review of a Face Sheet revealed Resident #102 was a male, with pertinent diagnoses which included PTSD (Post-Traumatic Stress Disorder), TBI (Traumatic Brain Injury), anxiety, chronic pain, depression, and seizures. Review of a current Care Plan for Resident #102 revealed the problem .at risk for communication deficits related to cognitive communication deficits . with a start date of 8/4/22, and interventions which included .Specialized call light . Review of a current Care Plan for Resident #102 revealed the problem .at risk for falls or injury . with a start date of 8/4/22, and interventions which included .Call light within reach . Review of a Resident Care Summary (RCS) for Resident #102 revealed .Encourage Patient to use pillows for positioning and to have call light placed on left side near hip . dated 10/28/24. In an observation on 12/5/24 at 9:03 AM, Resident #102 was noted in a specialty reclining wheelchair in his room. Observed Resident #102's specialized call light was out of reach, clipped to the cord on the wall several feet behind his wheelchair. In an observation on 12/5/24 at 9:13 AM, Resident #102 was noted in a specialty reclining wheelchair in his room. Observed Resident #102's specialized call light was out of reach, clipped to the cord on the wall several feet behind his wheelchair. In an observation on 12/5/24 at 9:33 AM, Certified Nursing Assistant (CNA) U assisted Resident #102 with a transfer from his specialty wheelchair to his bed. Once Resident #102 was in bed, observed CNA U place his specialized call light on the blanket, near Resident #102's right shoulder. In an interview on 12/5/24 at 9:42 AM, CNA U reported nursing staff reference the Resident Care Summary (RCS) to determine how to care for a resident and specific/individualized care needs. In an observation and interview on 12/5/24 at 11:46 AM, Resident #102 was noted in a specialty reclining wheelchair in his room. Observed Resident #102's specialized call light was out of reach, clipped to the cord on the wall several feet behind his wheelchair. Family Member N present at this time, and reported a concern that the nursing staff do not always check the computer (RCS) prior to caring for Resident #102. In an observation on 12/5/24 at 1:49 PM, Resident #102 was noted in a specialty reclining wheelchair in his room. Observed Resident #102's specialized call light was out of reach, clipped to the cord on the wall several feet behind his wheelchair. In an observation on 12/5/24 at 2:08 PM, Resident #102 was noted in bed in his room. Observed Resident #102's specialized call light was clipped to the blanket near his right shoulder. In an interview on 12/5/24 at 2:12 PM, CNA U reported no specific placement was required for Resident #102's specialized call light. CNA U stated .I just try and clip it somewhere close to him .

Based on observation, interview, and record review the facility failed to properly implement enhanced barrier precautions for 2 (Resident #35 and Resident #72) of 2 residents sampled for infection control, resulting in the potential for cross contamination and spread of infection. Findings include: Review of Consideration for the Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, published June 2021, by the Centers for Disease Control and Prevention, revealed: Residents in skilled nursing facilities are disproportionately affected by multidrug-resistant organism (MDRO) infections . Resident-to-resident pathogen transmission in skilled nursing facilities occurs, in part, via healthcare personnel, who may transiently carry and spread MDROs on their hands or clothing during resident care activities . Residents who have complex medical needs involving wounds and indwelling medical devices are at higher risk of both acquisition and colonization by MDROs. Resident #35 Review of an Admission Record revealed Resident #35, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic diastolic heart failure (condition causing decreased blood flow), cellulitis (infection of the skin) of the right lower extremity, peripheral vascular disease (circulatory condition causing narrowing of blood vessels), venous stasis dermatitis (skin inflammation of the lower leg potentially resulting in wounds), blister left leg. Review of a Minimum Data Set (MDS) assessment for Resident #35, with a reference date of 5/23/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #35 was cognitively intact. Section GG of the MDS revealed Resident #35 required dependent assistance (helper does all the effort) for toileting hygiene, and maximal assistance (helper does more than half the effort) for dressing and transferring out of bed. Review of a facility policy titled Isolation Precautions for Continuing Care for all RNC's (corporate name omitted, all skilled nursing facilities) section 4.7 revealed: Enhanced Barrier Precautions require gown and glove use for certain residents during specific high-contact resident care activities: dressing .transferring, providing hygiene .changing briefs . Section 4.8 revealed Enhanced Barrier Precautions will also be implemented when: Resident has wounds . Review of a Resident Care Summary for revealed Resident #35 occupied bed 2 of her room. A section labeled Precautions revealed 7/2/24 at 9:03am, Initiate Enhanced Barrier Precautions (RNC use Only) continuous, Comments: Venous Ulcer. Review of a physician's order dated 7/1/24 at 9:03am, revealed Initiate enhanced barrier precautions, continuous. Comments: venous ulcer. During an observation on 8/15/24 at 8:47am, signage that read Enhanced Barrier Precautions hung outside the door to Resident #35's room, in a holder labeled Bed 2. During an observation on 8/15/24 at 8:48am, Certified Nursing Assistant (CNA) R assisted Resident #35 with grooming while wearing only gloves. In an interview on 8/15/24 at 8:51am, CNA R reported she assisted Resident #35 with a brief change, dressing, transfer and grooming and wore gloves while providing the cares but did not wear a gown. When further queried, CNA R reported she did not know Resident #35 was in enhanced barrier precautions. In an interview on 8/15/24, at 9:22am, Resident #35 confirmed CNA R assisted her with personal hygiene, a brief change, dressing, and donning compression hose on her lower extremities. Resident #35 reported CNA R wore gloves but no gown while assisting her. Resident #35 also confirmed she had a wound on her left lower extremity. 41027 Resident #72 Review of an Admission Record revealed Resident #72 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: bladder obstruction, and multiple skin wounds. Review of Resident #72's Physician Orders revealed, Initiate Enhanced Barrier Precautions .Start 4/3/24 During an observation and interview on 08/13/24 09:50 AM outside of Resident #72's room there was signage indicating Enhanced Barrier Precautions. Resident #72 was in his room, sitting in his wheelchair, and there was a catheter bag with urine in it hanging by his side. Resident #72 reported having wounds on his bottom and his legs, and having had a urinary catheter for a long time. Resident #72 reported that he will occasionally get UTI's (urinary tract infections) and wound infections. During an interview on 08/14/24 at 11:40 AM, CNA (Certified Nursing Assistant) S reported that Resident #72 had a foley (urinary tract) catheter that the CNA's clean around during incontinence care and also empty the urine from the bag every shift. CNA S reported that Resident #72 also had his legs and feet wrapped due to open areas, and a bandage in place on his buttocks. During an observation on 08/14/24 at 01:13 PM, CNA S and CNA HH were preparing to transfer Resident #72 from his wheelchair to bed, using a mechanical hoyer lift. CNA S donned gloves and emptied Resident #72's catheter bag, and discarded the urine in the toilet. CNA S did not wear a gown or goggles. CNA HH and CNA S both donned gloves and proceeded to transfer Resident #72 from his wheelchair and into his bed, requiring extensive physical manipulation of the resident's upper and lower body to get him centered on the bed as requested. The CNA's were not wearing gowns. In an interview on 08/14/24 at 01:43 PM, CNA S reported that she was not aware that Resident #72 had orders for EBP, that he did have a urinary catheter, and that she was thinking that only people that had infections required EBP. CNA S reported that she saw the sign, but was confused because the bin of PPE (personal protective equipment) was located on the other side of the hallway. In an interview on 08/14/24 at 01:40 PM, Nurse Supervisor (NS) C reported that Resident #72 had multiple wounds that were currently being followed by Wound Nurse (WN) PP. In an interview via email on 08/14/24 at 1:21 PM, Director of Nursing (DON) B reported that Resident #72 had EBP ordered due to having a catheter and wounds.

Based on interview and record review, the facility failed to ensure that residents with a history of trauma received trauma informed care for 1 (Resident #99) from a total sample of 28 residents, resulting in the potential for exposure to trauma triggers and re-traumatization. Findings include: .According to the National Institute on Mental Health, 2019, PTSD (Post Traumatic Stress Disorder) is a disorder that some people develop after experiencing a shocking, scary, or dangerous event. It is natural to feel afraid during and after a traumatic situation. This fear triggers many split-second changes in the body to respond to danger and help a person avoid danger in the future. The fight or flight response is typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people will recover from those symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened even when they are no longer in danger . https://www.nimh.nih.gov/health/publications/post -traumatic-stress-disorder-ptsd/ptsd-508-0517201. Resident #99 Review of an Admission Record revealed Resident #99 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: PTSD. Review of Resident #99's Trauma assessment dated [DATE] revealed, Trauma Screening: Have you had any life experience that has interfered with your day-to-day functioning, has caused you distress, and/or has affected you negatively? Yes, Are there situations, events or other things that may trigger these feelings for you? Yes .Trauma Assessment: difficult or stressful event identification: .transportation accident: Happened to me .physical assault: Happened to me .Life threatening illness or injury: Happened to me .Worst event details: .(Resident #99 was in a car accident while leaving a bowling alley. She was in a field off the expressway and took an hour for rescue crews to get her out .(Resident #99's) father was also physically abusive . The document did not indicate what Resident #99's triggers were to these events. Review of Resident #99's Care Plan revealed, Problem: .actual or potential for mood/behavior impairment related to PTSD: Start: 11/11/21 .Interventions: Assess family knowledge of (Resident #99's) mood/behaviors. Assist to identify possible contributing factors. Give (Resident #99) time to express concerns, feelings, fears. Medication: See MAR (medication administration record). Monitor for side effects of psychotropic medications. Mental health services as appropriate. Monitor effectiveness of interventions. Monitor mood/behavior. Document abnormalities. Offer cues, reminders, and clear expectations as needed. Provide education to (Resident #99)/responsible party of potential risks of noncompliant behavior. Provide supportive visits. Prefers to take medication via PEG (feeding tube) hx (history) of catastrophic reactions when offered to take po (by mouth). If (Resident #99) is resistant and aggressive, staff may terminate their task and re-attempt later. Care plan updated so she wakes and gets ready for the day when she wants, has her brief changed as she allows. This was 1 of 2 similar care plan problems. See below. Review of Resident #99's Care Plan revealed, Problem: .actual or potential mood/behavior impairment related to: History of trauma. Start: 5/10/23 .Interventions: Assess family knowledge of (Resident #99's) mood/behaviors. Assist to identify possible support systems, strategies to overcome obstacles. Evaluate behavior for potential contributing factors. Give resident time to express concerns, feelings, fears. Psychotropic Medication: See MAR. Monitor for side effects of psychotropic medications. Mental health services as appropriate. Monitor effectiveness of interventions. Monitor mood/behavior. Document abnormalities. Offer cues, reminders, and clear expectations as needed. Provide education to resident/responsible party of potential risks of noncompliant behavior. Provide supportive visits. See Trauma assessment flow sheet. Guardian endorsed resident having history of past trauma and is triggered by it. There were no triggers indicated. Review of Resident #99's RCS (Resident Care Summary: care guide) revealed, no information related to PTSD and/or past trauma. In an interview on 08/15/24 at 08:33 AM, Nurse Manager (NM) JJ reported that Resident #99 had a diagnosis of PTSD, but did not know what the resident's triggers were, based on the information in the care plan and/or the RCS. NM JJ reported that the Certified Nursing Assistants (CNA) use the RCS to know how to provide care, including knowing if the resident has past trauma. NM JJ reported that Resident #99's RCS did not include history of trauma and/or triggers to past trauma, and the resident's trauma triggers were not listed in the care plan interventions. In an interview on 08/15/24 at 09:23 AM, Social Worker (SW) L reported that Resident #99 should have a care plan specifically related to her individual trauma and a list of identified triggers. SW L reported that Resident #99's care plan did not list her personal traumatic events, but it indicated to refer to the trauma assessment. In an interview on 08/15/24 at 09:23 AM, SW D reported that Resident #99's trauma history was not listed on her RCS, because of general privacy rights, and was not necessary for the CNA to provide care. SW D reported that she did not know if the CNA's were familiar with the resident's trauma history, but that they could review her trauma assessment if they wanted to see that information. In an interview on 08/15/24 at 09:46 AM, Certified Nursing Assistant (CNA) BB reported that when she is not familiar with a resident, she refers to the RCS for care needs. CNA BB reported that she was not aware of Resident #99 having any history of trauma. CNA BB referred to the electronic health record and reviewed the RCS with this surveyor, and confirmed there was no information related to trauma. CNA BB reported that she did not know how to access the resident's list of diagnoses, care plan, and did not know where trauma assessments would be located in the record.

Based on interview and record review, the facility failed to accurately assess, monitor, treat, and implement interventions for a residents with pressure ulcers for 1 (Resident #27) of 3 residents reviewed for pressure ulcers resulting in the worsening condition of a pressure ulcer. Findings include: Resident #27 Review of an Admission Record revealed Resident #27 was originally admitted to the facility on [DATE] with pertinent diagnoses which included pressure injury of left buttock, stage 3. Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 6/4/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #27 was cognitively intact. Review of Resident #27's Care Plan revealed, (Resident #27) has a stage 3 pressure injury . Goal: (Resident #27) will demonstrate improvement in skin integrity AEB (as exhibited by) no signs and symptoms of infection. Interventions: . monitor for s/sx (signs and symptoms) of infection: warmth, redness, tenderness, swelling, decline in healing, fever, increased drainage treatments- see orders and/or work lists tasks . start date: 11/21/22 Review of Resident #27's Orders on 8/15/24 revealed, .Wound Care: Wound Dressing- daily.Comments: Perianal wound: Irrigate wound with NS (normal saline), cut 1/8 inch wide, 1/2 inch long plain packing strip. Line the packing strip with Woun' Dres gel. Fill wound with packing strip. Cover with foam dressing Review of Resident #27's Wound care treatment orders for July 2024 revealed a treatment was not documented as completed on 7/4/24. Review of Resident #27's Wound care treatment orders for August 2024 revealed a treatment was not documented as completed on 8/8/24. Review of Resident #27's Wound assessment dated [DATE] revealed, wound length: 0.3 cm, wound width 0.2 cm, wound depth 0.2 cm . Review of Resident #27's Wound assessment dated [DATE] revealed, wound length: 1 cm, wound width 0.3 cm, wound depth 0.8 cm During an interview on 8/14/24 at 12:31 PM, Resident #27 reported that staff were frequently skipping his daily wound care treatment for his stage 3 pressure wound. Resident #27 reported that the facility had recently missed completing the wound care treatment for 4 days in a row. Resident #27 reported that he had voiced his concerns about treatments being skipped to Wound Care Nurse PP. During an interview on 8/15/24 at 9:22 AM,Wound Care Nurse, PP reported that Resident #27's wound dressing was ordered to be changed daily. Wound Care Nurse PP reported that Resident #27 had informed him that facility staff were missing his wound care treatments and had recently missed treatments for four days in a row. Wound Care Nurse PP reported that Resident #27's pressure ulcer was noted to have increased in size at the last assessment. Wound Care Nurse PP reported that he had recently changed Resident #27's wound treatment to be completed during the day shift because the night shift staff were inconsistent with completing treatments. Wound Care Nurse PP reported that nurses were suppose to document the wound care treatment as completed under the work list section of the electronic health record (EHR) and they were also suppose to document an assessment under the flowsheet section of the EHR. Wound Care Nurse PP reviewed Resident #27's EHR with this surveyor and reported that nurses had been signing off the wound care treatment as completed, but there was not documentation of a wound assessment from 7/26/24 to 8/8/24. Wound Care Nurse PP reported that he had reported that staff were missing wound care treatments for Resident #27 to Nurse Supervisor (NS) C. During an interview on 8/15/24 at 10:16 AM, Registered Nurse AA reported that she had recently missed completing the wound care treatment for Resident #27. RN AA reported that it was easy to miss treatments in the evening if the unit was busy. RN AA reported that she did not know how to document the wound care treatment as missed in the work list, so she had to sign off on it as completed. RN AA reported that she had asked management how to correctly document a missed treatment, but she had never gotten an answer on what to do, so she continued to document the treatment as completed even when it was missed. During an interview on 8/15/24 at 12:51 PM, Licensed Practical Nurse (LPN) P reported that she had missed Resident #27's wound care treatments. LPN P reported that when she missed the treatments it was because she did not have time to complete the treatment. During an interview on 8/15/24 at 10:38 AM, Nurse Supervisor (NS) C reported that nurses were supposed to document Resident #27's wound treatment as completed under the work list task and then document a wound assessment under the flowsheet task in the EHR every day. NS C reviewed Resident #27's EHR with surveyor and confirmed that Resident #27 was missing wound care assessments on 7/26/24 through 8/8/24, 7/18/24 through 7/26/24 and 6/29/24 through 7/11/24. NS C reported that the facility had started completing wound treatment audits in June, but that Resident #27's missed wound treatments had not been found in the facility audits. NS C reported that she had recently been made aware by Wound Care Nurse PP that staff were not completing Resident #27's wound care treatments. NS C reported that she was unable to report why the facility staff had missed multiple wound care treatments for Resident #27.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed for self-administration of medications for 3 (Resident #84, 44 and 74) of 5 residents reviewed for self administration of medication, resulting in unsupervised administration of medications and the potential for mismanagement of medication and potential for adverse side effects. Findings include: Resident #84 Review of an Admission Record revealed Resident #84 was originally admitted to the facility on [DATE] with pertinent diagnoses which included vascular dementia without behavioral disturbance. Review of Resident #84's Orders revealed Hydrocodone-acetaminophen (norco) (opioid pain medication) 5-325 mg per tablet. Dose: 1 tablet. Freq (frequency): 3 times daily. Route PO (by mouth) . During an observation and interview on 8/13/24 at 12:40 PM, Resident #84 approached Licensed Practical Nurse (LPN) H and requested her pain medication. LPN H took Resident #84's medication from the medication cart and placed one pill in a medication cup and then handed the cup to Resident #84. Resident #84 placed the medication cup on her walker and began walking towards her room. LPN H reported that she did not need to observe Resident #84 take her medication and that she always stopped for her pain pill on her way to her room after lunch. LPN H did not know if Resident #84 had been assessed to safely self administer medications without supervision. LPN H reported that the pill she had given Resident #84 was norco. At 8/13/24 at 12:41 PM, LPN H walked down to Resident #84's room door and asked her from the doorway if she had taken her pain pill. LPN H did not enter Resident #84's room. During an interview on 8/14/24 at 9:50 AM, Registered Nurse (RN) U reported that Resident #84 was not able to take medication without supervision. RN U reported that Resident #84's medications were supposed to be crushed and administered in applesauce. RN U reported that Resident #84 could be forgetful and therefore it would not be safe for Resident #84 to self administer her medications without supervision. During an interview on 8/15/24 at 10:38 AM, Nurse Supervisor (NS) C reported that it was her expectation that nurses observe residents when administering medications, especially narcotic medication. NS C reviewed Resident #84's electronic health record (EHR) and confirmed that Resident #84 had not been assessed for self administration of medications and she did not have an order to self administer medications without supervision. NS C reported that Resident #84 was not be eligible to self administer medications as she was at high risk for aspiration. Review of the facility's Medication Management Policy, dated 4/21/2023, revealed, .Resident Self-Administered Medications (SAM). 4.10.1. Evaluate resident ' s cognition, vision, and fine motor abilities.4.10.2. Prescriber order is required for a resident or designee (e.g., parent) to self-administer medications. 4.10.3. Prior to initiating the licensed personnel must teach resident/ designee how to self administer and resident/ designee must demonstrate competency. 4.10.4. All medications must be stored in designated medications storage areas. 4.10.5. Medications must be in locked storage when kept in the room. 4.10.6. Medications used for self-administration shall be medications that are used to manage conditions of which the resident/ designee understands the medication, dose, frequency, associated adverse drug reactions. 4.10.7. Nurse must monitor and validate SAM administration and document as required in eMAR . 46999 Resident #44 Review of an Admission Record revealed Resident #44, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: chronic back pain, functional tremor, chronic heart failure (condition causing poor blood circulation), type 2 diabetes mellitus (condition causing elevated blood sugars), dysphagia (difficulty swallowing), and choking. Review of a Minimum Data Set (MDS) assessment for Resident #44, with a reference date of 6/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #44 was cognitively intact. Section E of the MDS revealed Resident #44 did not experience hallucinations or delusions (false beliefs about reality) and did not reject care. Review of physician's orders for Resident #44 revealed she was prescribed more than 30 medications including an anticoagulant (blood thinner), a narcotic (prescription strength pain medication), an anti-spasmatic (muscle relaxer), and a diuretic (drug that causes the body to remove extra fluid). During an observation on 8/13/24 at 10:04, Resident #44 sat at the edge of her bed, leaned forward and picked medications up off the floor. The resident then placed the medications in her mouth. No staff were present in the room. In an interview on 8/13/24, at 10:06am, Resident #44 reported the nurse left her medications on the table in a small clear cup and Resident #44 spilled the medications on the floor when she tried to take them. Resident #44 stated I think I got most of the medications, referring to her attempt at self-administering her medications. Resident #44 reported she had a difficult time seeing the medications and was not sure what she took. Resident #74 Review of an Admission Record revealed Resident #74, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: hypertension (high blood pressure), type 2 diabetes mellitus (condition resulting in elevated blood sugar levels), intracranial hemorrhage (rupture of arteries or blood vessels in the brain), and end stage renal disease. Review of a Minimum Data Set (MDS) assessment for Resident #74, with a reference date of 5/29/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #74 was cognitively intact. During an observation on 8/13/24 at 2:47pm, 2 clear medication cups, 1 with approximately 5 white pills, 1 with 2 white, large disk-shaped medications, sat on Resident #74's bedside table. No staff were present in the room. The door to the room was open.

Based on interview and record review, the facility failed to provide adequate assistance based on therapy recommendations to prevent an accident for 1 of 4 residents (Resident #106) reviewed at risk for falls, resulting in a fall with fracture of left olecranon (elbow) and the potential for a decline in overall health and wellness. Findings include: Review of an Admission Record revealed Resident #106 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: falls and hip fracture. Review of Resident #106's Fall Risk assessment dated [DATE] indicated 14, at moderate risk for fall. Review of Resident #106's Fall Report from 11/2/23 at 3:50 PM revealed, .Resident was walking with 4WW (4 wheeled-walker) assisted by CNA (certified nursing assistant) from bathroom to the bed. While aide was moving the bedside table and resident was standing at her 4WW, resident stepped her left foot back and lost balance and fell . Resident sustained a full thickness skin tear to left elbow measuring 6 cm x 3.5 cm with moderate blood loss and resident c/o (complained of) pain with treatment of wound. Resident also had localized swelling to back rt (right) of head and expressed pain with palpation of area .c/o pain to bilateral hips, left arm and right knee .transport resident to hospital .Patient's attempted action prior to fall: Ambulation. At time of fall, person was observed but unassisted. Patient's level of mobility prior to fall: ambulation with supervision .Prior to fall, was patient cooperative with fall risk interventions? Yes .Environmental risk factors contributed to fall? None .In the ED (emergency department) .Xray of left elbow .fracture involving the olecranon process . In an interview on 3/8/24 at 1:08 PM, Therapy Supervisor (TS) I reported that Resident #106 was seen for therapy services in September 2023, and at the time of discharge (9/16/23) required minimal assistance of 1 person and a walker for transferring. TS I reported that minimal assistance meant that a gait belt should be used and held on to the entire time, and the staff member would perform up to 25% of the activity. TS I reported that Resident #106 required constant steadying, and walked only with therapy or restorative services. TS I reported that the therapy department enters the resident's level of assistance in the RCS (resident care summary), and at times the IDT (interdisciplinary team) may make adjustments as recommended by the therapy department. TS I reported that Resident #106's status was entered in her RCS as minimal assist of 1 person for transfers, when the resident discharged from therapy services in September 2023, but that a nurse had changed it to SBA (stand by assist) on 10/3/23. TS I reported that SBA or supervision during transfers and/or walking would not have been safe; Resident #106 required constant physical assistance to keep her balance. Review of Resident #106's Physical Therapy Discharge Note dated 9/18/23 revealed, .now able to perform bed mobility, transfers and short distance ambulation with steadying assist to min A x1 (minimal physical assistance of 1 person) with support of 4 wheeled walker .Functional amb (ambulation) in room [ROOM NUMBER] ft (feet) with 4WW, steadying assist; patient had 1 instance of small knee buckle on left side requiring min-mod A x1 (minimal to moderate physical assistance from 1 person) to prevent fall .Patient denied symptoms of room spinning this date but did report this can occur occasionally . The report indicated that Resident #106's ambulation (walking) status at discharge was up to 15-20 feet with 4 WW, requiring steadying and up to a 25 % physical assistance of 1 person, and Resident #106's transfer status was SBA to minimal physical assistance of 1 person. Review of Resident #106's RCS dated 9/16/23 updated by physical therapy department revealed, .Ambulation/Mobility: Ambulate with therapist only; wheelchair assist off unit; wheelchair assist on unit .Transfer: Assist x 1; walker-front wheeled; pivot; limited; family may transfer . Review of Resident #106's RCS dated 10/3/23 updated by nursing department revealed, .Ambulation/Mobility: Other (see comment) .Transfer: Walker-front wheeled; pivot; family may transfer; Supervision .Comments: Encourage and assist patient with sunscreen . There was no information related to the resident's status for ambulation. In an interview on 3/12/24 at 8:57 AM, Nurse Manager (NM) A reported that Resident #106's transfer status change on 10/3/23 from 1 person assist to supervision, should have been based on a therapy recommendation, but the record indicated Registered Nurse (RN) L made the changes. NM A reported would have to check why the changes were made. NM A reported that CNA O witnessed Resident #106's fall on 11/2/23, and that the report did not specify if a gait belt was being utilized and/or if CNA O was physically touching the resident at the time of the fall. NM A reported that with a status of supervision, a gait belt would still need to be used, but CNA O would not have to be touching the resident during transfer or ambulation, and a status of 1 assist would require that CNA O have hands on the resident. In a subsequent interview on 3/12/24 at 11:30 AM, NM A reported that RN L made that change to Resident #106's RCS based on the facility's reference for functional status; limited assist x1 was equivalent to supervision, because supervision included intermittent touching or cues. This surveyor attempted to interview RN L and CNA O via phone on 3/12/23, but was not able to reach the staff members. NHA attempted to contact CNA O on 3/12/24, but was not able to reach the staff member. In an interview on 3/12/24 at 10:00 AM, CNA K reported that if a resident had a status of supervision, that the CNA would not physically assist or touch the resident during transfers and ambulation. CNA K reported that a status of assist x1 would require a gait belt to be used, and the CNA to physically assist the resident during transfers and ambulation. In an interview on 3/12/24 at 1:43 PM, Occupational Therapist (OT) R reported that a transfer or ambulation functional status of supervision, would not require any physical touching by staff, and assist x1 would require physical touching for the entire activity. Review of Resident #106's Restorative Therapy Note dated 10/31/23 revealed, .Ambulation, 44 ft, hallway, 4WW, What level of assist did you provide? Touching assist, contact guard, steadying . Noted that this was 2 days prior to the resident's fall.

This citation pertains to intake MI00138935. Based on interview and record review, the facility failed to promote resident dignity in 1 (Resident #101) of 3 residents reviewed for dignity, resulting in feelings of diminished self worth and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well being. Findings include: Review of an Admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included depression and heart disease. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 7/28/2023 revealed a Brief Interview for Mental Status (BIMS) which indicated Resident #101 was cognitively intact. Further review of same MDS assessment revealed Resident #101 required assistance with toileting. In an interview on 11/6/2023 at 1:00 PM, Resident #101 described a verbal altercation that took place between herself and Certified Nursing Assistant (CNA) N on 8/4/2023 at approximately 9:20 PM. Resident #101 reported while CNA N was assisting her to the bathroom commode with the sit to stand lift, CNA N pulled her pants and brief down but did not remove her soiled brief. Resident #101 reported CNA N then dropped a disposable wipe on the floor and picked it up. Resident #101 reported she told CNA N not to use the wipe on her as CNA N acted as if she were still planning to use the wipe to clean her. Resident #101 reported CNA N stated, you don't pay my salary. Resident #101 reported CNA N tried to pull up the dirty brief without wiping her, and Resident #101 held on to her pants with one while CNA N attempted to pull them up. Resident #101 reported she asked CNA N to get the nurse multiple times before CNA N complied with her request. Resident #101 stated this event made her feel like I was less than a person, told me that I had no rights. In an interview on 11/7/2023 at 8:10 PM, CNA Team Lead C reported she was team lead the evening of 8/4/2023 when the event took place between Resident #101 and CNA N. CNA Team Lead C reported the nurse caring for Resident #101 contacted her to inform her that Resident #101 was upset about an interaction with CNA N. CNA Team Lead C reported Resident #101 was upset that her old brief was left on by CNA N while she was on the commode when she wanted it to be removed. CNA Team Lead C reported CNA N dropped some disposable wipes on the floor and Resident #101 did not want them to be used on her. CNA Team Lead C reported there was a discussion between Resident #101 and CNA N regarding who paid CNA N. CNA Team Lead C reported CNA N told Resident #101 that the facility paid her, and Resident #101 told CNA N that she paid CNA N. CNA Team Lead C reported she notified Nursing Home Administrator A of the situation. On 11/7/2023 at 10:35 AM, CNA N was unable to be reached for an interview. Review of the facility Event Summary and Investigation Worksheet regarding incident dated 8/4/2023 at 9:20 PM, revealed . (Resident #101) and (CNA N) became involved in a verbal disagreement regarding how the cares were being provided and who pays the aide's salary resulting in the resident feeling disrespected in the moment . As a result of this incident, the CNA did receive performance coaching from her upline which included review of: provision of bathroom cares, residents' rights (including to direct their own individual care), and recommendation to always bring in additional staff support when conversations/situations with residents become challenging . The investigation did not show all staff had received any education on resident rights and professional conduct after the indicent with Resident #101 occurred. On 11/7/23 at 12:13 PM, this was confirmed by NHA A. Review of CNA N's Performance Correction Documented Coaching regarding the verbal altercation between Resident #101 and CNA N, dated 8/7/2023, revealed .Team member caring for resident during toileting. Resident directing care, team member did not honor residents request while providing care. Including timing of soiled brief removal and seeking alternative care provider . Team member engaged in unprofessional conversation, related to salary . Policy and/or Procedure Violated . Professional Expectations . Resident Rights . Expectations for Improvement . Team member will allow resident to direct care, seek alternative care provider as resident requests . Team member to adhere to Professional expectation policy when communicating with team members, residents and patients as a representative of (facility) . Review of facility policy/procedure Resident Rights, effective 10/30/2023, revealed .Every resident shall be entitled to humane care and treatment provided with dignity and respect . Resident self-determination through support of resident choice should be promoted by the facility .

Based on observation, interview, and record review, the facility failed to: 1. Ensure frozen food items were stored under sanitary conditions, and 3. Discard out-of-date and expired resident food items. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all residents who consume food from the kitchen/pantries. Findings include: During an observation/interview with Nutrition Services Manager (NSM) TT during the initial kitchen tour on [DATE] at 10:05 in the Main Kitchen Freezer, noted a moderate amount of ice build-up on the pipes next to the blower fan located above opened, and loosely sealed frozen food product. It was noted that pieces of ice from the ice build-up on the pipes had fallen into the opened boxes of frozen garlic toast, biscuits, and yeast roll dough that were located below the pipes. NSM TT acknowledged visualization of the same, reported product would need to be discarded, and a work order would be created to get the issue fixed. During an observation/interview with NSM TT during the initial kitchen tour on [DATE] at 10:40 AM in the Woods and Gardens resident refrigerator/freezer, noted an opened bottle of cranberry juice in the refrigerator that was 75% empty and was not labeled with an opened or discard date, and a box of frozen waffles in the freezer with a best by date of [DATE]. NSM TT reported the juice should have been labeled with an opened date and discard date and since it had not been, it should be discarded. NSM TT reported that the waffles should have already been discarded. During an observation/interview with NSM TT during the initial kitchen tour on [DATE] at 10:50 AM in the Dunes resident refrigerator/freezer, noted 2 boxes of French toast sticks in the freezer with a use by date of [DATE]. NSM TT reported the French toast sticks should have already been discarded. During an observation/interview with NSM TT during the initial kitchen tour on [DATE] at 11:00 AM in the Lakeshore resident refrigerator/freezer, noted a chicken vegetable stir fry packaged frozen meal with a best by date of [DATE], 2 boxes of prepared packaged creamed chipped beef with a best by date of March, 2023 and a container of prepared packaged broccoli cheddar soup with a use by date of [DATE]. NSM TT reported all products should have already been discarded.

This citation pertains to intake: MI00130314, MI00137046 Based on observation, interview, and record review, the facility failed to promote dignity in 4 (Resident #117, Resident #74, Resident #281, Resident #16) of 25 sampled residents, and 12 of 13 residents who attended a confidential resident meeting), resulting in: 1.) requests for assistance (call lights) not responded to within a timeframe to meet residents' individualized preferences and needs (Resident #117, Resident #74, Resident #281, and 12 of 13 residents who attended a confidential resident meeting), 2.) Resident #16 referred to by staff in an undignified and disrespectful manner, and 3.) feelings of diminished self-worth and frustration by all residents involved. Findings include: Resident #117 Review of a Face Sheet revealed Resident #117 was a female, with pertinent diagnoses which included: spasticity (stiff or rigid muscles) as late effect of cerebrovascular accident (stroke), and dysuria (painful or difficult urination). Review of a Minimum Data Set (MDS) assessment for Resident #117, with a reference date of 4/21/23 revealed the Staff Assessment for Mental Status indicated Resident #117's Short-term Memory was OK and Resident #117's Long-term Memory was OK. Further review of said MDS revealed Resident #117 required extensive, one-person physical assist for Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair .) and Toilet use (how resident uses the toilet room, commode, bedpan, or urinal, transfer on/off toilet, cleanses self after elimination) and that Resident #117 was Frequently incontinent of urine. Review of a current Care Plan for Resident #117 revealed, (Resident #117) has a communication concern related to global aphasia (inability to understand or express speech resulting from brain damage, stroke). In an observation/interview on 7/10/23 at 11:40 AM, Resident #117 was seated in her wheelchair in her room visiting with Family Member (FM) YY. Resident #117 was non-verbal during the interview but did respond by nodding head for yes/no questions. FM YY reported call light wait time had been so long that they (FM YY) have had to go and look for somebody to assist Resident #117 but was unable to provide specific date(s) that this had occurred. Resident #117 nodded head backwards and forwards in agreement. FM YY reported Resident #117 needed a hoyer lift (a machine used to transfer a person between surfaces) for transfers and has had to wait too long to go to the bathroom or get cleaned up after being incontinent. 41027 Resident #74 Review of a Minimum Data Set (MDS) assessment for Resident #74, with a reference date of 5/12/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #74 was cognitively intact. In an interview on 07/10/23 at 03:23 PM, Resident #74 reported waiting 1-2 hours at times for cares to be provided, after turning on the call light and stated, .I had to pee myself .good thing they give us briefs . Resident #74 reported that at times the nursing staff refuse to assist the aides to answer call lights. In a confidential resident group meeting on 7/11/23 at 3:00 PM, 12 of 13 residents reported that they wait an extended period of time for care needs to be met when turning on their call light. The residents reported that staff turn the call lights off, say they are busy and promise to come back, but they do not. The residents reported that licensed nursing staff often times will not answer call lights when the aides are busy. 45410 Resident #16 Review of a Face Sheet revealed Resident #16 admitted to the facility on [DATE] with pertinent diagnoses which included multiple sclerosis, depression, and physical deconditioning. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 4/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #16 was moderately cognitively impaired. Further review of the same MDS assessment revealed Resident #16 required assistance with eating. In an interview on 7/11/2023 at 3:13 PM, Resident #16 reported CNA RR told her she was mean to her and told her she was a feed. Resident #16 stated, she talks to me in that way and I cry. In an interview on 7/11/2023 at 3:35 PM, CNA RR stated, (Resident #16) is a feed, so she has to be in the dining room, all supervision and all feeds need to be in the dining room. In an interview on 7/12/2023 at 8:06 AM, Resident #16 reported she told Nurse Manager U the previous evening that CNA RR had been mean to her and Nurse Manager U was planning to talk to CNA RR. In an interview on 7/12/2023 at 10:59 AM, Nurse Manager U reported Resident #16 told her CNA U forced her to get out of bed for breakfast and was mean to her. Nurse Manager U reported she instructed CNA U that using the term feed describing a resident is not appropriate and that this should be described as needing assistance with meals. Resident #281 Review of a Face Sheet revealed Resident #281 admitted to the facility on [DATE] with pertinent diagnoses which included atrial fibrillation, obesity, and urinary incontinence. Review of a Minimum Data Set (MDS) assessment for Resident #281, with a reference date of 5/23/2023 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #281 was cognitively intact. Further review of same MDS assessment revealed Resident #281 required assistance with toileting. In a telephone interview on 7/10/2023 at 4:35 PM, Resident #281 reported she was given a bell to ring in place of her call light while on suicide precautions, but staff was unable to hear the bell. Resident #281 reported she wet herself in bed once because she was unable to hold her urine until staff came to assist her. Resident #281 reported this made her feel very isolated. Review of facility policy/procedure Resident Rights - Continuing Care, effective 10/17/2022, revealed .Every resident shall be entitled to humane care and treatment provided with dignity and respect .

Based on observation, interview, and record review, the facility failed to implement care planned interventions for 1 (Resident #105) of 25 sampled residents resulting in the potential for increased pain, swelling, and contractures (A condition of shortening and hardening of muscles, tendons, or other tissues that often leads to deformity of joints). Findings include: Review of an Admission Record revealed Resident #105, was originally admitted to the facility on [DATE] with pertinent diagnoses which included cognitive impairment secondary to a TBI (traumatic brain injury), quadriplegia (paralysis of all four limbs) and osteoporosis (condition which bones become brittle and fragile). Review of a Minimum Data Set (MDS) assessment for Resident #105, with a reference date of 3/31/23 revealed the Staff Assessment for Mental Status indicated Resident #105's cognitive skills for daily decision making was severely impaired. Review of Resident #105's Care Assessment Summary indicated, Nursing Activities and Treatment: Brace Splint- Continuous. Comments: Apply per therapy schedule/recommendation. Duration: until specified. Extremity: Right and left arm. Upper extremity brace: Wrist/hand palm protector. Start date 1/26/22 . Review of Resident #105's Care Assessment Summary indicated, Nursing Activities and Treatment: Brace Splint- Continuous. Comments: Apply WHO (Wrist-hand orthosis) to R UE (right upper extremity) per schedule. Duration: until specified. Extremity: Right arm. Upper extremity brace: Wrist/hand finger splint. Start date: 1/4/22 . In an observation on 7/10/23 at 10:47 AM, Resident #105 was sitting in his wheelchair watching television. It was noted that both of Resident #105's hands were contracted. The fingers on Resident #105's right hand were bent towards the right palm and did not move. Resident #105 was not wearing any splints/braces or palm protectors on either of his hands or arms. In an observation on 7/10/23 at 2:20 PM, Resident #105 was sitting in his wheelchair watching television. It was noted that Resident #105 was not wearing any splints/braces or palm protectors on either of his hands or arms. In an observation on 7/11/23 at 8:32 AM, Resident #105 was sitting in his wheelchair watching television. It was noted that Resident #105 was not wearing any splints/braces or palm protectors on either of his hands or arms. During an interview on 7/11/23 at 12:40 PM, Licensed Practical Nurse (LPN) DD reported that they (LPN DD) were unsure if Resident #105 had any devices used for his hands or arms. During an interview on 7/11/23 at 02:21 PM, Certified Nursing Assistant (CNA) KK reported that they thought Resident #105 used to wear a splint but had not seen the splint or palm protectors for awhile, so assumed that the order was discontinued. During an interview on 7/12/23 10:17 AM, Therapy Director UU reported that Resident #105 had active orders which were placed by therapy in 01/2022 to wear a brace on his right arm daily and bilateral (right and left) palm protectors daily. During an observation on 7/12/23 at 11:04 AM, Resident #105 was sitting in the main dining area of unit without any splints/braces or palm protectors on either of his hands or arms. During an observation and interview on 7/12/23 at 11:18 AM, LPN BB reported not being sure if Resident #105 had orders for and braces/splints, but could find out by looking at the Resident #105's up down schedule which was posted in Resident #105's closet. LPN BB entered Resident #105's room with surveyor and reviewed Resident #105's up down schedule and determined that Resident #105 did have orders in place to wear a splint on his right arm and bilateral palm protectors when he was not wearing the splint on his right arm. LPN BB searched Resident #105's room and found a splint in his closet and palm protectors in a drawer in his night stand. LPN BB reported that the CNA is responsible for ensuring the devices are placed on residents when they get residents up for the day and following the up down schedule. LPN BB reported that the nurse is responsible for ensuring the CNA's are completing their tasks and that it was missed that day. Review of Resident #105's Up Down Schedule revealed, Right WHO (Wrist-Hand Orthosis) 2 clicks. Put on at 10:00 am. Take off at 12:00 pm. Put on at 6:30 PM. Take off at 9:00 PM. Bilateral palm protectors. Take off at 10:00 am. Put on at 12:00 PM. Take off at 6:30 PM. Put on at 9:00 PM. During an interview on 7/12/23 at 12:53 PM, CNA KK reported that they were responsible for ensuring that Resident #105's splint/brace and palm protectors were on and off per schedule. CNA KK reported that it was missed the past two days because the therapy aides would sometimes complete this task for CNA's and they (CNA KK) forgot to ensure it was completed. CNA KK reported that this task was not something that had to be checked off in the daily charting so it was easy to forget. During an interview on 7/12/23 at 1:00 PM, Nursing Supervisor (NS) P reported that there was not anywhere in the EHR (electronic health record) that CNA's or Nurses were charting when they would place and remove splints/braces. NS P reported that CNA's were to follow the Up Down Schedule for each resident that is posted in the resident's closet, and that the nurse is responsible for ensuring that the tasks are completed. A request for additional documentation related to therapy recommendations and orders for nursing staff regarding the splint/palm protectors, and 6/9/23 care conference note was sent to the Administrator and Director of Nursing via email on 7/12/23 at 1:25 PM. No additional records were received.

Based on observation, interview, and record review, the facility failed to honor resident choice for dining location for 1 resident (Resident #16), of 1 resident reviewed for choices, resulting in the potential for this resident to not meet her highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #16 Review of a Face Sheet revealed Resident #16 admitted to the facility on [DATE] with pertinent diagnoses which included multiple sclerosis, depression, and physical deconditioning. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 4/28/2023 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated Resident #16 was moderately cognitively impaired. Further review of the same MDS assessment revealed Resident #16 required assistance with eating. Review of a Resident Care Summary for Resident #16, dated 7/12/2023, revealed . (Resident #16) prefers to eat breakfast in bed and get out of bed after breakfast . In an observation on 7/11/2023 at 8:21 AM in the dining hall, resident was up in her wheelchair eating breakfast with staff assistance. In an interview on 7/11/2023 at 3:13 PM, Resident #16 reported that she prefers to stay in bed for breakfast, but the Certified Nursing Assistants (CNAs) had been telling her that she had to get up to the dining hall for breakfast. Resident #16 reported the CNAs have been forcing her to get up for breakfast for about a week. Resident #16 reported CNA RR recently stated, I am not going to argue with you, you are going to get up for breakfast, this is the way we are going to do it. Resident #16 reported CNA RR told her she is a feed and must get up to the dining hall for meals. Resident #16 stated, she talks to me in that way and I cry. Resident #16 reported the previous day CNA RR moved her to another table while eating because the state was here and stated, you have to sit over here. In in interview on 7/12/2023 at 8:06 AM, Resident #16 reported she discussed her desire to eat breakfast in bed with Nurse Manager U the previous night. Resident #16 reported Nurse Manager U told her she needed to be up in the dining room for all three meals and would be updating her care plan to reflect this. Resident #16 reported Nurse Manager U stated, I am in charge of this hallway. In an interview on 7/12/2023 at 10:59 AM, Nurse Manager U reported she spoke to Resident #16's Durable Power of Attorney that morning, who confirmed that Resident #16 preferred to stay in bed for breakfast. In an interview on 7/12/2023 at 11:31 AM, Nursing Home Administrator (NHA) A reported the facility will honor Resident #16's choice to remain in bed for breakfast. Review of facility policy/procedure Resident Rights - Continuing Care, effective 10/17/2022, revealed .Every resident shall be entitled to humane care and treatment provided with dignity and respect. Residents are entitled to all the freedom and privileges of any other citizen . Participation in planning care, medical treatment, and determining appropriate changes is encouraged .

Based on observation, interview, and record review, the facility failed to provide appropriate Activities of Daily Living (ADL) care, specifically assistance with getting out of bed and incontinence care for 1 resident (Resident #94) of 5 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for residents who are dependent on staff for assistance. Findings include: Resident #94 Review of an Admission Record revealed Resident #94 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Vascular Accident (stroke) and Hemiplegia and hemiparesis (paralysis) following cerebral infarction affecting left non-dominant side. Review of a Minimum Data Set (MDS) assessment for Resident #94, with a reference date of 6/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #94 was cognitively intact. Review of the Functional Status revealed that Resident # 94 was completely dependent on 1 person for transfers, and required supervision for eating. Review of Resident #94's Resident Care Summary (guide for direct care) revealed, .Eating Safety: Supervision/Aspiration Risk; Up in Chair for Meals; Upright After Meals - 30 minutes .Bed Mobility: Dependent; Assist x 2 .Transfer: Dependent; Lift - Mechanical; Sling - X-Large; Assist x 1 .Toileting: Bladder Incontinent; Bowel Incontinent; Brief .Assist x 1 .Comments: Prefers to lay down after meals, please offer following meals . In an interview on 07/10/23 at 09:23 AM, Resident #94 reported that he was frustrated with staff not maintaining his up-down schedule and stated, .likes to get up for breakfast, lay down around 10:00 AM and then back up for lunch . Resident #94 reported that staff get him up into his chair around 6:00 AM and sometimes don't lay him down until after 12:00 PM. During an observation and interview on 07/11/23 at 12:49 PM Resident #94 was sitting in his chair and reported that he had been in his chair since 6:00 AM (7 hours), was wet, tired and needed to lay down. Certified Nursing Assistant (CNA) W transferred Resident #94 into bed using the Maxi Move hoyer (mechanical) lift. CNA W reported that third shift staff had gotten Resident #94 dressed and into his chair to help out first shift. CNA W performed incontinence care for Resident #94; Resident #94's incontinence brief was observed heavily saturated with urine, and noted to be lined with 2 additional incontinence pads that were also saturated. The saturated brief and incontinence pads were replaced with new dry ones. CNA W reported that it would make sense for Resident #94 to be on an up-down schedule, but that there was no information in the residents record to indicate that and stated, .it just says up with meals and offer to lay down . During an observation and interview on 07/12/23 at 08:51 AM Resident #94 was lying in his bed, with the head of bed (HOB) at approximately 20 degrees (not sitting up). Resident #94 was eating from his breakfast tray in front of him. Resident #94 reported that he had asked staff to lay him down after breakfast yesterday, but they did not, therefore he wasn't getting up until after lunch this time. During an observation on 07/12/23 at 10:36 AM Resident #94 was lying in bed with his clothing protector from breakfast still in place. During an observation and interview on 07/12/23 at 11:53 AM Resident #94 was lying in bed with his clothing protector from breakfast pushed to the side of his head, and holding his call light in his hand. Resident #94 reported that he had pressed his call light earlier that morning to get a brief change and up for lunch, and had spoken to staff and they told him that they would be back later. Resident #94 reported that the last time he had a brief change was on third shift. In an interview on 07/12/23 at 12:25 PM, Nurse Supervisor (NS) HH reported that Resident #94 does have an up-down schedule and stated, .up for all meals and laid down after meals .and in the dining room for meals because of the risk for aspiration . NS HH reported that the facility does not use additional incontinence pads in the incontinence briefs due to increased risk of skin breakdown and infections, and that Resident #94 should not have multiple incontinence products used at the same time. During an observation and interview on 07/12/23 at 12:29 PM in Resident #94's room, CNA GG was preparing to get Resident #94 up into his chair. Resident #94's incontinence brief was observed heavily saturated with urine and noted to have 2 additional incontinence pads inside that were also saturated. CNA GG reported that Resident #94 gets double briefs just in case he urinates a lot and that she does it because that's the way it's always done.

Based on observation, interview, and record review, the facility failed to ensure resident safety with bed mobilty, mechanical-lift transfers and eating for 1 resident (Resident #94) of 2 residents reviewed for accident hazards, resulting in the potential for accidents and serious injury. Findings include: Resident #94 Review of an Admission Record revealed Resident #94 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Cerebral Vascular Accident (stroke) and Hemiplegia and hemiparesis (paralysis) following cerebral infarction affecting left non-dominant side. Review of a Minimum Data Set (MDS) assessment for Resident #94, with a reference date of 6/16/23 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #94 was cognitively intact. Review of the Functional Status revealed that Resident # 94 required extensive assistance of 1 person for bed mobility (moves side to side, to and from lying position), total dependence of 1 person for transfers, and supervision for eating. The information related to bed mobility differs from the care summary. Review of Resident #94's Resident Care Summary (guide for direct care) revealed, .Eating Safety: Supervision/Aspiration Risk; Up in Chair for Meals; Upright After Meals - 30 minutes .Bed Mobility: Dependent; Assist x 2 .Transfer: Dependent; Lift - Mechanical; Sling - X-Large; Assist x 1 . The care needs for bed mobility defer from the MDS assessment record. In an interview on 07/10/23 at 09:23 AM, Resident #94 reported that he preferred to get out of bed for meals. Resident #94 reported that he had wounds on his feet from the hoyer (mechanical) lift and stated, .they (staff) bang my feet every day . During an observation and interview on 07/11/23 at 12:49 PM Resident #94 was sitting in his chair, Certified Nursing Assistant (CNA) W transferred Resident #94 to bed using the Maxi Move hoyer lift; Resident #94 was raised into the air from his chair and CNA W maneuvered the hoyer lift over to the bed, then came around the side and positioned Resident #94 over the bed and used the remote to lower the resident into bed. CNA W reported that it was difficult to maneuver the lift with one person, and that most people asked for a second person because of the residents size, but that the facility did not require 2 people for this particular lift. CNA W performed incontinence care for Resident #94, repositioning the resident onto his side and then back multiple times. CNA W did not have a second staff member to assist with bed mobility, the bed was in high position, and Resident #94 was not able to hold onto the hand rail when turned to his right side due to his left arm paralysis. During an observation and interview on 07/12/23 at 08:51 AM Resident #94 was lying in his bed, with the head of bed (HOB) at approximately 20 degrees (not sitting up). Resident #94 was eating from his breakfast tray in front of him. Resident #94 reported that he had asked staff to lay him down after breakfast yesterday, but they did not, therefore he wasn't getting up until after lunch this time. In an interview on 07/12/23 at 12:25 PM, Nurse Supervisor (NS) HH reported that Resident #94 does have an up-down schedule and stated, .up for all meals and laid down after meals .and in the dining room for meals because of the risk for aspiration . During an observation on 07/12/23 at 12:29 PM in Resident #94's room, CNA GG was preparing to get Resident #94 up into his chair. Resident #94's feet were observed with gauze bandages on right big toe, right pinky toe, and left big toe. With the bed in high position, CNA GG rolled Resident #94 onto his right side, the resident was on the very edge of the bed, with his chest up against the hand rail. Resident #94 was not able to hold the hand rail due to his left arm paralysis. CNA GG reported that Resident #94 gets double briefs just in case he urinates a lot. CNA GG rolled Resident #94 back and forth in bed several times during incontinence care, getting dressed and to place the hoyer sling underneath him; there was not a second staff member to assist with bed mobility. Using the hoyer lift, CNA GG maneuvered Resident #94 approximately 10 feet in distance across the room (high in the air) and into his chair. During the transfer, Resident #94's feet banged up against the wall, and then Resident #94's legs began to spasm (shake). CNA GG did not acknowledge that Resident #94's feet had hit the wall. In a subsequent interview on 07/12/23 at 12:48 PM, CNA GG reported that it was not easy to roll Resident #94 in bed and transfer into his chair and stated, .he should be a 2 person for safety, but with that new lift we can do it with 1 person .

Based on observation, interview, and record review the facility failed ensure post dialysis assessment and monitoring for 1 resident (Resident #75) of 1 resident reviewed for dialysis care, resulting in the potential for the resident to not meet her highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #75 Review of a Face Sheet revealed Resident #75 admitted to the facility on [DATE] with pertinent diagnoses which included end stage kidney disease and dialysis. Review of a Minimum Data Set (MDS) assessment for Resident #75, with a reference date of 6/2/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #75 was cognitively intact. Review of current dialysis Care Plan interventions for Resident #75, initiated 9/30/2021, directed nursing staff to obtain vitals and weight upon return from dialysis, observe for and document signs and symptoms of infection to area around access site, observe site for bleeding, and assess site for thrills and bruits. In an observation on 7/11/2023 at 12:40 PM in Resident #75's room, Resident #75 was sitting in her wheelchair waiting for her lunch. Resident #75 reported staff had not evaluated her since she returned to the facility after having offsite dialysis treatment that morning. In an interview on 7/11/2023 at 12:46 PM, Licensed Practical Nurse (LPN) SS reported Resident #75 returned from dialysis at 11:00 AM. LPN SS reported he had not yet evaluated Resident #75 since she returned from dialysis. In an interview on 7/11/2023 at 4:25 PM, LPN SS reported that he had not yet evaluated Resident #75 since she returned from dialysis that morning. LPN SS reported he normally gets a set of vitals, listens for a thrill, checks the site, and reviews the hemodialysis communication sheet when residents return from hemodialysis. In an interview on 7/12/2023 at 8:23 AM, Resident #75 reported staff never check her vitals when she returns from dialysis, and they never look at her access site. Resident #75 reported there are times when dialysis staff do not place the bandage on her arm tight enough after dialysis and she bleeds through to her clothing and her clothing needs to be changed. In an interview on 7/12/2023 at 10:45 AM, Nurse Manager U reported staff should assess residents upon return from dialysis, including the access site for bleeding. In an interview on 7/12/2023 at 11:31 AM, Director of Nursing (DON) B reported nursing staff are expected to get vital signs and perform an assessment upon return from dialysis including assessing the access site. In an email correspondence dated 7/12/2023 at 3:41 PM, DON B reported nursing practice post dialysis treatment is to .Enter nurses note indicating (resident) has returned and an assessment was completed- including cognition, (hemodialysis) site, comfort level, (vitals), and that completed paperwork was received . Review of facility policy/procedure Care for Hemodialysis Patients and Residents, effective 2/3/2021, revealed .(hemodialysis) interventions may be found throughout the person-centered care plan including the physician orders and will include . Monitoring of vitals and weights as ordered . Monitoring of access site and any associated care . Post-(hemodialysis) monitoring as ordered .

This citation pertains to intake number MI 255 Based on observation, interview, and record review, the facility failed to fully implement infection control practices per facility policy and national CDC (Centers for Disease Control) recommendations for COVID-19 for 31 of 35 sampled residents, resulting in an immediate jeopardy when the facility failed to: 1.) use the appropriate personal protection equipment (PPE) in 2 of 35 sampled residents (Residents #109 and #110) when Resident #109 admitted on [DATE] and Resident #110 admitted [DATE] to the same room as #109, both were diagnosed as Covid positive on [DATE], and Resident #109 died on [DATE] from Covid 19; 2.) ensure or promote social distancing and face coverings during activities in 4 of 35 sampled residents (Residents #107, #108, #116, and #119), 3.) prevent communal dining that includes social distancing and source control in 13 of 35 sampled residents (Residents #113, #114, #115, #120, #121, #111, #117, #118, #119, #112, #116, #123, and #124), 4.) prevent communal dining in the 14-day observation unit in 6 of 35 sampled residents (Residents #125, #128, #131, #127, #132, #133), 5.) ensure appropriate source control, PPE use and hand hygiene by facility staff in 4 of 35 sampled residents (Residents #116, #134, #135, and #102), 6.) maintain communication with the local health department regarding the facility's Covid 19 status. This deficient practice placed all residents in the facility at risk for serious harm and or death. On [DATE] at 4:20 pm, the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy that began on [DATE] due to the failure to follow facility adopted national CDC standards of infection control. A written plan for removal for the immediate jeopardy was received on [DATE] and the following was verified on [DATE]: 1. As of 9 ,[DATE], all new admissions, readmissions, [MEDICAL TREATMENT], and returning from outside appointments' patients/residents are placed in single occupancy room on 14Day Surveillance/Observation Unit and immediately placed on Severe Respiratory Precautions. Residents with known or suspected COVID-19 should be cared for using all recommended PPE which includes use of a N95 or higher-level respirator (or face mask if respirator not available), eye protection (face shield), gloves, and gown. As of ,[DATE] 2020, all 14-Day Surveillance Observation residents should not be out of their room per the CDC unless absolutely necessary. If deemed necessary to be outside their room, resident must wear mask and be encouraged by staff to wear mask. As of ,[DATE] 2020, all non- 14-Day Surveillance/Observation residents outside their rooms wear masks or will be encouraged to by staff to wear masks when outside rooms and maintain social distancing. 2. As of ,[DATE] 2020, no Communal Dining of all 14-Day Surveillance/Observation residents will continue per the Executive Orders. All those requiring meal assistance/supervision will be provided I individual assistance/supervision in their room. 3. As of 9 ,[DATE], no Communal Dining of all non- 14-Day Surveillance/Observation residents will continue per the Executive Orders. All those requiring meal assistance/supervision will be provided individual assistance/supervision by designated staff in the dining area while maintaining 6 feet social distancing. 4. As of 9 ,[DATE], 14-Day Surveillance/Observation Dietary Staff must wear appropriate PPE (N95 mask, face shield, hair nets, and gloves), adhere to contamination prevention of PPE, and perform appropriate hand hygiene while serving food. 5. As of 9 ,[DATE], all staff must wear appropriate 14-Day Surveillance/Observation Unit PPE (N95 mask and face shield) while walking in the hall. If accompanying a resident, PPE must also include gown and gloves. 6. As of [DATE], hand hygiene is performed upon entry and exiting of resident rooms. 7. As of [DATE], all face shields must be cleaned when soiled, contaminated and between resident rooms. 8. As of [DATE], all group activities remain cancelled. 9. On [DATE], all of the following applicable facility policies and procedures were reviewed/revised according to CDC recommendations: -Infection Prevention Hand Hygiene Policy -COVID-19 Assessment, Management and Response Policy -Infection Prevention Standard Precaution O Spectrum Health -Disinfection for Eye Protection - Staff Test Tracking - Strategies for Optimizing the Supply of Eye Protection (CDC) -Preparing for COVID-19 in Nursing Homes Infection Control for Nursing Homes (CDC) - Using Personal Protective Equipment (PPE) (CDC) 10. Beginning [DATE], education was provided to all team members regarding appropriate P PE usage, hand hygiene and communal dining room process. As of this date, completion of this education is required of all team members prior to the start of their scheduled shift. 11. On [DATE], the Administrator hired an outside consultant, (name of counsultant), to improve the facility's infection control program within the facility. 12. Infection Preventionist or IC certified designee will continue to oversee infection prevention and control education for all new hires since date of hire [DATE]. 13. Beginning [DATE], the local health department will be immediately notified of all positive COVID resident and staff test results by the Infection Preventionist or Administrator and documentation of this communication will be maintained. Although the immediate jeopardy was removed as of [DATE], the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the fact that not all facility staff have received education and sustained compliance had not yet been verified by the State Agency. Findings include: Review of the CDC guidance, Responding to COVID-19 Considerations for the Public Health Response to COVID-19 in Nursing Homes, Updated Apr. 30, 2020, revealed . All facilities should adhere to current CDC infection prevention and control recommendations, including universal source control measures . promptly notifying the health department about any of the following: Resident or HCP with suspected or confirmed COVID-19, Resident with severe respiratory infection resulting in hospitalization or death, or (greater or equal to) 3 residents or HCP (health care professionals) with new-onset respiratory symptoms within 72 hours of each other. These situations should prompt further investigation and testing for [DIAGNOSES REDACTED]-CoV-2, [MEDICAL CONDITION] that causes COVID-19.Resident Cohorting .Considerations for new admissions or readmissions to the facility . Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19 . All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown . Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE . New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html Review of facility policy, COVID-19 Assessment, Management and Response - Continuing Care (Rehab and Nursing Centers, Neuro Rehabilitative Services -Residential), effective date: [DATE], revealed, Purpose The purpose of this policy is to articulate assessment, management, and response to patients, residents and staff with suspected or diagnosed coronavirus (COVID-19) across (name of facility) Rehab and Nursing Center . a. The Infection Preventionist/designee will assess facility risk associated with COVID-19 through surveillance activities of emerging diseases in the community and illnesses present in the facility . Threat detected: the facility will respond promptly and implement emergency and/or outbreak procedures . When COVID-19 is identified in the facility, staff may be required to wear all recommended Personal Protective Equipment for the care of residents in the facility regardless of symptoms, per recommendation by the Center for Disease Control and/or the Michigan Department of Health and Human Services . If COVID-19 is suspected, the following steps should be followed by a facility appointed designee . Implement Severe Respiratory Isolation precautions. Wear gloves, gowns, goggles/face shields, and masks upon entering room and when caring for the resident, per available supply. Place residents in appropriate room per directions by Centers for Medicare and Medicaid Services, Centers for Disease Control, and/or state and local health department . Notify local health department of confirmed COVID-19 unless the (facility name) has a designated reporting system in place (e.g. Laboratory Services contacting the local health department) . Utilize transmission-based precautions as determined for the individual when caring for the resident (in collaboration with local health department) .e. Admitting a resident with suspected or known COVID-19 . Residents may be placed in well-ventilated triage areas or private rooms with closed doors .f. Interventions to prevent the spread of COVID-19 within the facility . Restrict residents with fever or acute respiratory symptoms to their room. Have them wear a facemask (if tolerated, possible, and per supply) if they must leave the room for medically necessary procedures. Use the appropriate precautions with eye protection, if possible and per supply, unless suspected [DIAGNOSES REDACTED]. Implement heightened surveillance activities or consult public health authorities for additional guidance if there is transmission of COVID-19 in the community . Educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, including eye protection (as necessary and appropriate) . According to CDC (Centers for Disease Control), .Identify Space in the Facility that Could be Dedicated to Monitor and Care for Residents with COVID-19 .Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents . During an interview on [DATE] at 9:45 AM Nursing Home Administrator (NHA) A stated, Currently, there is 1 (one) resident that was recently COVID-19 positive who has gone through her 10-day observation with no symptoms. There is no one back in the COVID-19 unit right now and the wall has been taken down. There was another positive COVID-19 resident, who became worse and was sent to the hospital where she died . There are 2 (two) observation units; both downstairs. One is on the rehab side, the other is on the other side of the building. The non-rehab observation unit is where the residents that go to [MEDICAL TREATMENT] or appointments stay. During an interview on [DATE] at 10:30 AM with NHA A and ICP P, NHA A stated, As far as N-95 masks and face shields are concerned, it sounds like the recommendation is for staff exposure to positive and presumed COVID-19 residents 15-minutes or longer staff should be wearing an N-95 mask and face shield all the time while working with observation residents or passing them in the observation hall?. ICP P stated, I called the LHD a couple of times. The LHD referred me to CDC documents. The facility's upper management is the liaison with the LHD. NHA A stated, The corporate compliance officer sends the county positivity rate (Positivity rates indicate the likelihood of possible prevalence) twice a month to me. There are conference call meetings every week on Monday, Wednesday, and Friday with the compliance officer about COVID-19 to touch base and discuss new CDC/CMS guidelines. During an interview on [DATE] at 11:08 AM, Infection Control Preventionist (ICP) P stated, Staff testing for COVID-19 is weekly. Self-testing is observed by the screener who could be a unit aide or CNA. They all have had the same video training for nares testing to perform the self-testing. Residents are tested weekly from their last positive COVID-19 test. The facility follows CDC guidelines for PPE use. On the isolation unit and observation units, PPE that should be used on the units are N-95 masks and face shields. Once in a room, staff will don gown and gloves. When residents are out of their room, they are encouraged to wear a mask and practice social distancing. In the observation unit and all other units, residents are encouraged to wear masks. On the observation unit and all units, eating in the dining room is not considered communal dining because residents should practice social distancing 6 feet apart during dining. Mask use for all staff should be over their mouth and nose. Gloves should be used on the observation units, COVID-19 unit, and any isolation room. Staff should wash their hands before donning gloves. Staff should plan on being exposed to bodily fluids while in a resident room. After leaving a room staff should doff their gloves and clean their hands. The same for a face shield. A face shield should be cleaned after it has something splattered on it. Hand hygiene should be done before putting gloves on and taking them off. Received on [DATE] at 12:55PM, an email correspondence from NHA A, indicating beginning on [DATE] the facility's designated 14-day surveillance/observation areas were on North unit, rooms ,[DATE], and South Left unit, rooms 101, ,[DATE]. On [DATE], rooms [ROOM NUMBER] were extended into the 14-day observation rooms on the South Left unit after surveyor's entrance on [DATE]. Received on [DATE] at 2:55 PM, an email correspondence from NHA A, indicating all residents admitted and readmitted are placed on the 14-day observation unit with these rooms automatically placed on isolation. During an interview on [DATE] at 8:15 AM CNA O stated, I am a CNA and do COVID-19 screening and testing mainly at the employee entrance. All staff, no matter what they do here at the facility, are required to wear a mask and face shield when in resident areas even if you are walking down a hall where there are resident rooms. During an interview on [DATE] at 1:06 PM, Licensed Practical Nurse (LPN) K stated, Upper management and the Infection Control Preventionist gives nursing staff information about PPE almost daily. I am assuming it is from CDC, but I do not know where they got it. The information changes so much at times it is hard to follow the suggested infection control for COVID-19. COHORTING AND PERSONAL PROTECTION EQUIPMENT Resident #109 Review of a Face Sheet revealed Resident #109 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of Resident #109's Hospital Course encounter date [DATE], revealed, .admitted from SAR COVID pneumonia early morning of [DATE] .she was standing up to transfer from chair to eat when she stopped breathing and lost a pulse. She received 30 minutes of ACLS plus systemic TPA but was not successful . Review of Resident #109's hospital discharged as deceased Summary dated [DATE] at 1:03 PM, revealed, date of death [DATE]. Time of Death at 12:07 PM. Preliminary Cause of Death COVID-19. Discharge Disposition: expired . Resident #110 Review of a Face Sheet revealed Resident #110 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. In an interview on [DATE] at 1:00 PM, Director of Nursing B (DON), Nursing Home Administrator A (NHA), Infection Control Preventionist P (ICP) were present for a discussion regarding their COVID 19 positive residents Resident #110 and #109. NHA A, DON B, ICP P collectively indicated Resident #110 and #109 were both admitted to the 14-day observation unit (all new admits, readmits, and residents out on appointments entered this unit for 14 days or more of COVID 19 isolations) after hospital stays. Both residents received a negative COVID 19 test prior to admitting to the facility. Resident #109 on [DATE] and Resident #110 on [DATE] were admitted as roommates to the same room. Both residents had COVID 19 tests on [DATE] due to a previous COVID 19 positive finding in the building. Their COVID 19 test results were found to be positive on [DATE]. Both residents were hospitalized due to severe respiratory symptoms. Resident #109 was admitted to the hospital on [DATE] and died within 24 hours of her hospital admission. Resident #110 admitted to the hospital on [DATE], returned to the facility on [DATE], and discharged home [DATE]. Some staff members had tested positive around the time Resident #109 and Resident #110 were positive. DON B indicated they did contract tracing and it led them to believe no other patient or staff member contracted COVID 19 from Resident #109 and Resident #110 or gave COVID 19 to them. NHA A, DON B, ICP P collectively indicated the facility does not cohort residents anymore; they were following CDC (Center for Disease Control) guidance at that time regarding cohorting. NHA A indicated they have been referring to CDC guidance when handling COVID 19 and infection control. ICP P and DON B indicated neither have directly conferred with their Local Health Department (LHD) regarding COVID 19 recommendations or reported COVID 19 positive case to their Local Health Department (LHD). DON B indicated their Compliance Officer S (CO) directly communicated with the LHD and then reported back to their management team. Review of an emailed received on [DATE] at 1:19 PM from Nursing Home Administrator A (NHA), revealed .Why did we cohort (Resident #110) and (Resident #109)? Both pts (patients) did not test positive prior to admission. They were both admitted within 1 day of each other. We technically had two 14 Day Surveillance/Observation Rooms available on ,[DATE] on the unit. One of those two rooms however, had a patient on HLOA (home leave of absence) returning to it and the other room was reserved for a planned pending admission. In addition, we also have to take into consideration acuity level on each unit to support our nursing staff . Review of the facilities document Contact Tracing completed for both Resident #109 and #110, received [DATE], revealed . There were 4 staff tests that came back positive on [DATE] . 3 of them worked on the North Unit ( Resident #109 and #110's unit) .The 3 staff that worked on North were: (Certified Nursing Assistant Y (CNA) on ,[DATE] and 9/ 3), (Registered Nurse X (RN) on ,[DATE]), (CNA II on ,[DATE] and ,[DATE]). 1 worked in Nutrition services (on another unit) . 1 out of the remaining 3 staff likely had exposure at a wedding. Who (CNA Y) Wedding ,[DATE] . Pt was initially asymptomatic . Pt (Both residents) ate in . room . Did resident require assistance with eating? - (Both residents) NO . (sic) In an interview on [DATE] at 1:30 PM, CNA Y indicated originally presumed contracted COVID 19 from a wedding attended over Labor Day weekend. CNA Y indicted all the attendees at the wedding tested COVID 19 negative. CNA Y indicated had to have gotten COVID 19 from the facility. CNA Y indicated worked 3rd shift and was Resident #109 and #110's aide on ,[DATE] and ,[DATE]. CNA Y indicated became ill on ,[DATE] and called in, was COVID 19 tested on ,[DATE], and was positive for COVID 19 on ,[DATE]. CNA Y indicated often started shift as dinner was finishing up and Resident #109 was frequently in the dining room finishing diner or just sitting in the dining room. Resident #109 needed cueing, tray setup, and supervision. CNA Y indicated there was usually 2 to 3 other residents eating in the dining room with Resident #109. CNA Y indicated on the 14-day observation unit the staff were only required to wear a procedural mask and eye shields in the halls and for resident care. CNA Y indicated were not required to wear N95 mask or gowns for resident care until approximately [DATE]. CNA Y indicated until yesterday residents could linger in the dining room and TV room as much as they wanted. CNA Y indicated was only aware of one other staff member that was COVID 19 positive at that time, CNA II. CNA Y indicated CNA II worked 1st shift and CNA Y gave report to CNA II routinely. In an interview on ,[DATE] at 11:40 AM, RN X worked directly with Resident #109 and #110 on ,[DATE]. RN X indicated got off work on ,[DATE] and went on vacation for the weekend with family. RN X indicated only had contact with family for Labor Day weekend. RN X indicated began to feel ill by ,[DATE], was COVID 19 tested ,[DATE], and was COVID 19 positive on ,[DATE]. RN X indicated all family members from vacation and associates tested COVID 19 negative. RN X indicated when working on the 14-day observation unit staff were required to wear a procedural mask and eye shields for resident care. RN X indicated believe contracted COVID 19 when forgot to wear eye wear into Residents #109 and #110's room on ,[DATE] and gave care to Resident #110 while she was strongly coughing a lot. SOCIAL DISTANCING and FACE COVERINGS Review of the Center for Disease Control (CDC) Coronavirus Disease Healthcare Workers Infection Control Guidance, revised last [DATE], revealed . Encouraging Physically Distancing . when possible, physical distancing (maintaining 6 feet between people) is an important strategy to prevent [DIAGNOSES REDACTED]-CoV-2 transmission . Designating areas . eat, and drink that allow them to remain at least 6 feet apart from each other, especially when they must be unmasked . Implement Universal Source Control Measures .Source control refers to use of cloth face coverings or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Patients and visitors should, ideally, wear their own cloth face covering . upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth face covering .Patients may remove their cloth face covering when in their rooms but should put it back on when around or leaving their room . https://cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Resident #107 Review of a Face Sheet revealed Resident #107 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Resident #108 Review of a Face Sheet revealed Resident #108 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Resident #116 Review of a Face Sheet revealed Resident #116 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Resident #119 Review of a Face Sheet revealed Resident #119 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. In an interview on [DATE] at 8:10 AM, NHA A indicated early this morning a new COVID 19 positive case was discovered on routine resident testing. NHA A indicated Resident #107 was moved to the COVID 19 positive area immediately and his roommate Resident #108 was moved to the 14-day observation unit. In an interview on [DATE] at 9:00 AM, Resident #116 indicated played cards with COVID 19 positive Resident #107's roommate, Resident #108, and Resident #119, yesterday afternoon. Resident #116 indicated these residents start a card game in the afternoon several days a week. Resident #116 indicated they sit within 6ft of each other, they do not wear masks, and staff member rarely suggested they move apart or wear masks. In an interview on [DATE] at 9:00 AM, Certified Nursing Assistant LL (CNA) indicated Resident #107 usually stayed in his room except when he eats in the dining room. CNA LL indicated his roommate Resident #108 is out in the common area and in the dining area frequently socializing. CNA LL indicated Resident #108, #116.and #119 played cards in the dining area often and sit together closely around a dining table. CNA LL indicated has not seen the residents wear masks while playing cards together. COMMUNAL DINING Review of the facility's policy Isolation - Transmission Based Precautions , dated [DATE], revealed, . Ambulation of isolated patients: . Patient to avoid contact with the environment and should remain out of common areas (lounges; nourishment rooms, etc.) based on the type of precautions and infectious agent Patient is to remain on unit and not visit public areas like the cafeteria, lobby or gift shop based on the type of precaution . If close assistance is needed (EX: PT/OT ambulation) the care provider will wear recommended PPE and avoid contact with environment . Resident #113 Review of a Face Sheet revealed Resident #113 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED].Residents Requiring Dining Assistance, created [DATE], revealed Resident #113 required supervision and cueing with dining. Resident #114 Review of a Face Sheet revealed Resident #114 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED].Residents Requiring Dining Assistance, created [DATE], revealed Resident #114 required no dining assistance or supervision. Resident #115 Review of a Face Sheet revealed Resident #115 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED].Residents Requiring Dining Assistance, created [DATE], revealed Resident #115 required no dining assistance or supervision. During an observation on [DATE] at 1:00 PM, in the Woods dining room, Resident #113, #114, and #115 were seated together at a square table less than 6 ft fom each other. No effort by staff to socially distance residents was observed. During an observation [DATE] at 12:50 PM, in the Woods dining room, Resident #113, #114, and #115 were seated together at a square table less than 6 ft from each other. No effort by staff to socially distance residents was observed. Resident #120 Review of a Face Sheet revealed Resident #120 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the facility's list .Residents Requiring Dining Assistance, created [DATE], revealed Resident #120 required no dining assistance or supervision. Resident #121 Review of a Face Sheet revealed Resident #121 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the facility's list .Residents Requiring Dining Assistance, created [DATE], revealed Resident #121 required no dining assistance or supervision During an observation on [DATE] at 1:08 PM, in the Garden dining room, Resident #120 and #121 were seated together at small table within 6 ft of each other. Both residents lingered after the meal was over and talked with no masks. No effort by staff to socially distance residents nor encourage mask usage was observed. During an observation [DATE] at 12:55 PM, in the Garden dining room, Resident #120 and #121 were seated together a small table within 6 ft of each other. No effort by staff to socially distance residents was observed. Resident #111 Review of a Face Sheet revealed Resident #111 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the facility's list .Residents Requiring Dining Assistance, created [DATE], revealed Resident #111 required supervision and cueing with dining. Resident #117 Review of a Face Sheet revealed Resident #117 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the facility's list .Residents Requiring Dining Assistance, created [DATE], revealed Resident #117 required no dining assistance or supervision. Resident #118 Review of a Face Sheet revealed Resident #118 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the facility's list .Residents Requiring Dining Assistance, created [DATE], revealed Resident #118 required supervision with dining. Resident #119 Review of a Face Sheet revealed Resident #119 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the facility's list .Residents Requiring Dining Assistance, created [DATE], revealed Resident #119 required no supervision or assistance with dining. Resident #112 Review of a Face Sheet revealed Resident #112 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the facility's list .Residents Requiring Dining Assistance, created [DATE], revealed Resident #112 required 1:1 supervision and limited assist. Resident #116 Review of a Face Sheet revealed Resident #116 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the facility's list .Residents Requiring Dining Assistance, created [DATE], revealed Resident #116 required no dining assistance or supervision. During an observation on [DATE] at 10:30 AM, Resident #112 has a [MEDICAL CONDITION] with a speaking valve (closed [MEDICAL CONDITION] that resident must place finger over [MEDICAL CONDITION] hole to speak) and was seated near the TV in the dining area on Woods hall. Resident #116 was seated at a table by the window in the Woods dining area. Resident #112 called over to Resident #116 and asked Resident #116 to help he (TRUNCATED)

This citation pertains to MI 659 Based on interview and record review the facility failed to prevent a significant medication error for 1 of 35 residents (Resident #105) reviewed for medication administration, resulting in severe medication withdrawal, hospitalization , and physical decline. Findings include: Review of a Face Sheet revealed Resident #105 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. .[MEDICATION NAME] is a corticosteroid. It prevents the release of substances in the body that cause inflammation. It also suppresses the immune system . Steroid medication can weaken your immune system, making it easier for you to get an infection. You should not stop using [MEDICATION NAME] suddenly. Follow your doctor's instructions about tapering your dose .Steroid withdrawal syndrome consist of sleep disturbance, lethargy, fever, myalgia (joint pain), weakness, nausea, and weight changes . can develop following abrupt discontinuance . Acute [MEDICAL CONDITION] (even death) may occur if the drugs are withdrawn abruptly . https://www.drugs.com/monograph/[MEDICATION NAME].html .emphasize the danger of abrupt cessation of corticosteroid therapy to patients and caregivers. Corticosteroids taken for longer than 1 week will suppress adrenal production, and oral corticosteroids must be tapered. Lewis, Sharon M, Linda Bucher, Margaret M. Heitkemper, and Mariann Harding. Medical-surgical Nursing: Assessment and Management of Clinical Problems., 2017. Print. P. 1214 Review of Resident #105's discharge Medication List, printed [DATE] at 2:35 PM, revealed .Continue taking these medications .[MEDICATION NAME] 5 MG tablet .Dose: 15 mg . Take 3 tablets by mouth Every morning . The [MEDICATION NAME] order had Med Staff Review written next to it and circled. Review of the facility's 24 Hour Report, dated [DATE], revealed .Instructions: This is a 2-way communication tool reviewed daily. Any staff member can place an issue on this form. A leader will collect daily and place the response back into the 24 hour binder with a resolution . Patient Name .(Resident #105) . Issue: . med staff eval of [MEDICATION NAME] per PA MMM . Resolution . (blank space, no resolution written). Event Summary and Investigation Worksheet . Alleged Incident . Medication Error . Describe what allegedly occurred: On [DATE], Resident (#105) and her adult children voiced concerns to Nurse Supervisor QQ (NS) regarding [MEDICATION NAME] medication order at start of admission on [DATE] . Investigation initiated . Date Alleged Incident was Discovered/Reported: [DATE] . Describe any action taken by the facility to protect the resident(s) and to prevent a possible reoccurrence during the investigation: Resident (#105) was closely monitored by nursing and med staff from admission on [DATE] to [DATE] when [MEDICATION NAME] medication was discovered not having been ordered, so was initiated. Investigation initiated on [DATE], led to root cause analysis of an isolated med staff incident of not writing a single medication order for a single patient. This finding then led to a facility wide review by Nursing Leadership to ensure all medications match the admission Transfer of Care orders for all patients/residents admitted since [DATE]. No further concerns noted. Proceeded to review and re-educate med staff in safety behaviors (pay attention to detail) to prevent order entry errors and process of properly completing 24 Hour Report which is a daily communication with nursing tool. Nursing Leadership re-educated in process of confirming daily completed 24 Hour Report by med staff. Auditing of tool initiated under direction of QAPI Committee . Prior to this admission and at baseline, (Resident #105) resides in an independent living apartment, ambulated independently with a 4 wheeled walker, and was assisted with 1 meal/day XXX[DATE]- Pt admitted to (facility). Nurse reviewed admission orders [REDACTED]. (PA) questioned why the [MEDICATION NAME] did not have taper orders and requested Med Staff (group of physicians, physician's assistants, and nurse practitioners facility employees for resident rounds) follow up in the am. Nurse noted [MEDICATION NAME] issue for med staff to eval on [DATE] 24 Hour Report. [DATE]- PA NNN given [DATE] 24 Hour Report. [DATE]- Pt (patient) seen and evaluated by PA NNN. Progress note completed; included a note that pt is on chronic [MEDICATION NAME] 15mg daily. Order was not written . Review of facility submitted Medication Event Timeline: .8 /,[DATE]- .questionable weight loss XXX[DATE] order written for [MEDICATION NAME] (sleep aide) . [DATE]- . PA saw pt (patient) for nausea, [MEDICAL CONDITION] (low sodium) XXX[DATE] increased congestion, [MEDICAL CONDITION] XXX[DATE] PA saw pt for . nausea, [MEDICAL CONDITION], emesis, ordered Chest x-ray . [DATE]- PA saw pt for PNA (pneumonia), [MEDICAL CONDITION] [DATE]- Review of medications by Nurse with daughter noted no [MEDICATION NAME] order . Pulmonology contacted. Orders written to start [MEDICATION NAME] XXX[DATE]- Pt complains of SOB (shortness of breath). Sent to hospital for evaluation. In an interview on [DATE] at 2:30 PM, Director of Nursing B (DON) indicated Resident #105 had been in the facility about 2 weeks before Family Member LLL and Registered Nurse VV (RN) discovered Resident #105 was not administered her long term [MEDICATION NAME]. DON B indicated signs of [MEDICATION NAME] withdrawal had not been obvious at first but became more evident on hindsight. DON B indicated we identified the root cause of the missed medication was PA NNN forget to write an order after addressing the medication discrepancy found on the 24 Hour Report. DON B indicated the Physician and their team (PA's and NP's) were responsible for reviewing their progress notes and written orders for continuity and errors. DON B indicated staff at the facility do not review the provider's progress notes for errors. DON B indicated after we determined the root cause we educated the providers and nursing staff on reviewing or double-checking orders and reviewing 24 Hours Reports for follow up. DON B indicated nurse managers and nurse supervisors were responsible for following up on 24 Hours Reports. In an interview on [DATE] at 12:15 PM, Nurse Supervisor CC (NS) indicated every morning the nurse supervisors gather the 24 Hour Reports from the previous day and give the reports to the providers (MD, PA, or NP) at the morning IDT meeting (interdisciplinary team). NS CC indicated the providers were to review the report, address the issues, sign the 24 Hour Report, and write down how they addressed the issue. NS CC indicated the nurse supervisors were to review the provider's written resolution and double check that the resolutions (orders or progress notes) had been completed. NS CC indicated this was not a new process and the double check of resolutions was in place when Resident #105's was admitted , but the double check would sometimes get missed. NS CC indicated the process had some holes, prior to DON B re-educated the nursing staff and providers. NS CC indicated prior to the education the PA's sometimes would check mark or cross out the written issue on the 24 Hour Report and not write in a resolution. NS CC indicated Resident #105's [MEDICATION NAME] order and PA NNN's progress note should have been reviewed by Resident #105's nursing supervisor to avoid errors. NS CC indicated was the nursing supervisor for Resident #105 during her stay. Review of the Resident #105's hospital records, [DATE] (Emergency Department) to Hospital- Admission . , revealed Chief Complaint .SHORTNESS OF BREATH (Per EMS. coming from rehab. (complaint of) pneumonia, difficulty breathing, slightly wheezing.Diagnosis . Healthcare-associated pneumonia . Acute [MEDICAL CONDITION] with [MEDICAL CONDITION] . Brief history and medical decision making: Patient is a 91 (year old) female with prior history of BOOP . She is presenting to (Hospital) on ,[DATE] with ongoing shortness of breath and hypoxic respiratory insufficiency Apparently while at (facility) recently she may have missed some of her maintenance medication . [MEDICAL CONDITION] consulted. Per recommendations will increase [MEDICATION NAME] coverage for BOOP from 15 to 30 mg daily . Plan . Continue [MEDICATION NAME] at home dosing . Pt does report she felt worse when her steroids were accidentally held at rehab . Review of hospital [MEDICAL CONDITION] Consult, dated [DATE], revealed .Chief complaint .Acute on chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] . HISTORIES: . with a history of steroid-dependent [DIAGNOSES REDACTED] (COP or formerly BOOP), admitted for acute [MEDICAL CONDITION] with hypoxemia with bilateral infiltrates (pneumonia). She is my patient in the [MEDICAL CONDITION] clinic. To review her history, she has been followed for many years for history of [DIAGNOSES REDACTED]. She has consistently required systemic corticosteroids ([MEDICATION NAME]) for control . She is now on 15 mg a day of [MEDICATION NAME] for her COP. She has failed weaning of [MEDICATION NAME] lower than 15 mg with relapsed COP . Unfortunately, she was admitted (to hospital) with a fall and a left acetabular (hip) and foot fracture . She was discharged to (facility) . There, it appears her [MEDICATION NAME] was inadvertently held. Our office was contacted on ,[DATE] requesting input on [MEDICATION NAME], and I requested that she increase [MEDICATION NAME] to 30 mg and begin a taper back to 15 mg . In an interview on [DATE] at 2:40 PM, Family Member LLL (FM) indicated Resident #105 has taken [MEDICATION NAME] for a chronic lung disorder, COP, for more than [AGE] years. FM LLL indicated has been under the care of a pulmonologist for the very rare and serious lung disease. FM LLL indicated Resident #105 almost died when the facility accidentally stopped her [MEDICATION NAME] for 2 weeks. FM LLL indicated Resident #105 was very ill and weak and requested on [DATE] to review Resident #105's medications with RN VV. FM LLL indicated they discovered Resident #105's long term [MEDICATION NAME] was had been omitted for 2 weeks. FM LLL indicated the omitted med had explained why Resident #105 had declined rapidly and was having severe withdrawal symptoms. FM LLL indicated Resident #105 was vomiting, would not eat, loss approximately 20 lbs, did not walk or move, and then contracted pneumonia. FM LLL indicated during Resident #105's hospital stay, her pulmonologist told the family if Resident #105 had not restarted the [MEDICATION NAME] on ,[DATE] then she would have likely gone into [MEDICAL CONDITION] within ,[DATE] hours. FM LLL indicated has been Resident #105's medical advocate and went to all of her doctor appointments for the last [AGE] years. FM LLL indicated Resident #105 takes the [MEDICATION NAME] to suppress the pneumonia associated with the COP, and without the [MEDICATION NAME] Resident #105's pneumonia would reoccurs or worsens. FM LLL indicated Resident #105 admitted to the facility to rehab a [MEDICAL CONDITION] and was walking with a walker. FM LLL indicated Resident #105 was now home with a health care aide that provided extensive assistance. FM LLL indicated Resident #105 was very fragile and this last hospital stay has really knocked her down. During the onsite survey, it was noted that the facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome: 1. As of [DATE], identified all facility patients/residents admitted since [DATE]. 2. Reviewed all patients'/residents' Medication Orders to ensure all medications match the admission Transfer of Care. 3. Med Staff reviewed safety behavior of attention to detail to prevent order entry errors and was re-educated in proper completion of daily communication tool 24 Hour Report process between nursing and med staff 4. Nurse Managers and Supervisors have been re-educated to the process of confirming all 24 Hour Report issues/concerns have been addressed and resolutions confirmed. 5. Under the direction of QAPI, auditing of the 24 Hour Report initiated to confirm resolutions present and active. The facility discovered the noncompliance, performed a root cause analysis of the cause of noncompliance, corrected the situation prior to the beginning of the survey, and no current noncompliance was identified during the survey. The facility was granted past noncompliance for this incident.

This citation pertains to MI 532. Based on interview and record review the facility failed to provide timely services to prevent neglect for 1 of 3 residents (Resident #101) reviewed for abuse/neglect, resulting in the fall and subsequent death of Resident #101. Findings include: Review of the State Operations Manual (SOM) dated 11/2018 revealed, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Policy Call light use of dated 05/2017 and reviewed 10/2018 revealed the purpose was To respond promptly to resident/patient's call for assistance. Review of the Policy Resident/Patient Abuse Program procedure dated 6/1/18 revealed neglect .includes the deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Review of the Face Sheet revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 has moderately impaired cognition and was an extensive assist of 1 staff for transfer. The MDS further revealed Resident #101 was frequently incontinent. Review of the Fall Risk assessment dated [DATE] revealed Resident #101 was a HIGH RISK (sic) for falls. Review of the Call light log dated 5/5/18 revealed Resident #101's call light was activated at 6:31 PM. Review of the Fall Scene Investigation Report dated 5/5/18 at 6:45 PM by Licensed Practical Nurse (LPN) P revealed Resident #101 had an unwitnessed (fall). fell face down on floor trying to go to BR (bathroom). The Fall scene investigation report further revealed under What did the patient/resident say they were trying to do just before they fell was Resident #101 was trying to get out of bed to go to the bathroom and .the root cause of the fall for Resident #101 .was attempting to go to bathroom . Review of the Timeline for Resident #101 revealed on 5/5/18 at 6:30 PM, Shift change for nurses (Registered Nurse (RN) I) off and (Licensed Practical Nurse (LPN) P) on. So at this time they are doing report. Nurse aides (Certified Nurse Aide (CNA) H) serving dinner. The Timeline for Resident #101 revealed on 5/5/18 at 6:31 PM, Resident #101's call light went on and on 5/5/18 at 6:40 PM (9 minutes after call light went on), (Per) Video/statements: patient (Resident #101) found on floor by visitor .saw patients feet sticking out .Patient was observed lying face down, parallel to his bed. He has two small cuts to the bridge of his nose and a hematoma (solid swelling of clotted blood within the tissues) between his eyebrows. He was checked an hour before and patient was dry and comfortable in bed. Review of the Timeline for Resident #101 revealed on 5/5/18 at 6:41 PM, Certified Nurse Aide (CNA) H and LPN P entered Resident #101's room (at 6:41pm - 10 minutes after call light went on. Staff to respond to visitor finding resident on floor, not responding to call light). Review of the Call Light log dated 5/5/18 revealed Resident #101's call light was not turned off (no staff response) until staff were alerted by visitor to Resident #101's fall at 6:40 PM (9 minutes after call light activation). Review of Nurse Leadership email undated, un-timed revealed CNA Q stated, Patient (Resident #101) attempted to self transfer out of bed to the bathroom. Patient was observed lying face down, parallel to his bed. In an interview on 10/24/18 at 3:20 PM, LPN P stated, on 5/5/18, I never took actual care of him (Resident #101); Registered Nurse (RN) I took care of Resident #101. In an interview on 10/24/18 at 3:57 PM, RN I stated, on 5/5/18, I was in the dining room watching a fall risk resident who was trying to get up out of his wheelchair (indicated nurse was not able to respond to call light). Review of the CNA Post fall report/statement dated 5/5/18 at 6:40 PM revealed CNA H had left patient at 6:00 PM after changing his brief .(Resident #101) Didn't (sic) use urinal. In an interview on 10/24/18 at 2:35 PM, CNA H stated, on 5/5/18 at approximately 6:45 PM, Resident #101 was on the floor, looked like he rolled out of bed with a few drops of blood to his face. CNA H stated, he (Resident #101) told me he forgot he wasn't able to walk and was trying to get up and go to the bathroom. CNA H further stated Resident #101 was wet (indicted he was incontinent). In an interview on 10/24/18 at 5:14 PM, Director of Nursing (DON) B stated, on 5/5/18 when Resident #101's call light was on for more than 9 minutes that he (Resident #101) waited for his need to be met. In an interview on 10/24/18 at 11:57 AM, the complainant stated Resident #101 needed a lot of help to get up out of bed. The complainant stated on 5/5/18 at approximately 6:45 PM Resident #101 was in bed and stated he (Resident #101) was trying to get to the bathroom. Review of the Emergency Department .Medical Decision Making report dated 5/5/18 at 10:45 PM revealed Resident #101 had a .level fall with hematoma (solid swelling of clotted blood within the tissues) to glabella (area between eyes) and CAT scan (X-ray image made using computerized axial tomography) of head did show a subdural (bleeding of the brain). Review of the Hospital Course dated 5/6/18 at 5:10 PM revealed Resident #101's, Preliminary cause of death was Traumatic subdural hemorrhage (pool of blood between the brain and its outermost covering) with concussion (bruising of brain), with loss of consciousness and death due to [MEDICAL CONDITION] prior to regaining consciousness . Review of the Certificate of Vital Record dated 5/16/18 revealed the cause of death for Resident #101 was Craniocerebral Trauma (Traumatic injuries involving the cranium and intracranial structures (i.e., BRAIN; CRANIAL NERVES; MENINGES; and other structures). Approximate interval between onseat and death: Hours. Manner of death: Accident. Date of injury 5/5/18. Time of Injury: 18:30 (6:30 pm) on or about. Describe how injury occurred: .Fall.

Based on interview and record review the facility failed to ensure 1 resident (Resident #103) had interventions in place to prevent a fall out of 4 sampled residents, from a total sample of 4 residents reviewed for falls, resulting in a hip fracture sustained from a fall at the facility that subsequently lead to the resident's death because of complications from that fracture. Findings: Review of a Face Sheet dated [DATE] indicated Resident #103 was a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set Assessment ((MDS) dated [DATE] indicated Resident #103 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of ,[DATE] and required extensive assistance from one person for bed mobility, transfers, walking in his room and in the corridor, dressing, toileting and personal hygiene. Review of a Fall Risk Assessment dated [DATE] indicated Resident #103 was a high risk for falls. Review of Clinical Notes dated [DATE] timed 10:03 a.m. documented by Licensed Practical Nurse (LPN) E indicated, Patient was found on floor at 9:10 a.m. this morning, patient was attempting to self transfer from W/C to get up and get Pepsi and side table. Patient had Foley catheter bag still attached to wheelchair but wheelchair breaks were locked. Patient was found on floor laying on right side of hip, didn't hit his head of complain of any other injury. Patient was grasping his right hip and was groaning with pain. VSS (vital signs stable) ,[DATE] (blood pressure), 80 (pulse), 16 (breaths per minute), 99.1 (temperature) with BS (blood sugar) 164. Patient was assessed and transferred back to bed with 5 staff members and repositioning sling. Patient resting in bed. Notified (Resident #103's daughter) of self transfer and fall and that med staff is sending to (emergency department) for eval and treat, patient seems increasingly confused and unsure if related to fall or 2PRBC (2 units of packed red blood cells) transfusion he had yesterday a.m. Daughter understood and notified could go up to hospital to meet him. Notified med staff (name) and FM (facility manager) (Registered Nurse (RN) C). Review of a Care Plan Report dated [DATE] initiated by Licensed Practical Nurse (LPN) F, indicated Resident #103 was at risk for falls related to impaired balance, impaired vision, impaired gait, dizziness, chronic kidney disease and the use of a Foley catheter and incontinence. The goal of the care plan was to keep Resident #103 from falling and injuring himself with interventions that included, Yellow alert system in place, fall risk assessment upon admission, quarterly and as needed, monitor medication side effects for potential gait disturbances or other safety issues, check for orthostatic hypotension if (Resident #103) complains of dizziness, apply supportive shoes/non-skid footwear, instruct to change positions slowly, allow for rest periods, give clear, concise directions/education and provide reassurance, reorient to surroundings as needed, keep call light within reach, maintain a clutter free environment, keep bed in low position, keep frequently used items within reach, safety devices: see RST (resident summary template). No intervention specific to Resident #103's catheter was mentioned on the care plan for safety/falls despite the identified risk for fall due to having a Foley catheter. Review of a Care Plan Report dated [DATE] initiated by LPN F indicated Resident #103 required a Foley catheter due to chronic kidney disease (CKD)/Chronic Renal Failure/urinary retention with the goal for Resident #103 being to maintain a patent catheter without signs or symptoms of a urinary tract infection with one of the interventions being to utilize a leg bag when up. Review of a document emailed to this surveyor by Registered Nurse (RN) Con [DATE] explained the Yellow Alert System was used to indicate that any resident with a fall alarm of any kind will also have a yellow wrist band and a yellow fall blanket to alert staff that a patient/resident is at high risk for falls. Clarification provided to this surveyor by RN C indicated those interventions were never in place and the fall care plan intervention Yellow Alert System had been mistakenly added to the care plan by LPN F. During an interview on [DATE] at 3:52 p.m., LPN F was asked about the care plans he put in place for Resident #103 at the time of his admission to the facility. LPN F said he could not recall if Resident #103 was his patient on the day the care plan was developed but described the care planning process as reviewing pertinent clinical records to identify areas of concern. LPN F admitted he added the Yellow Alert System intervention believing he was taking credit for Plan Yellow which was described as a protocol the facility staff use to respond in the event a fall occurs but is not an actual intervention. LPN F stated he identified one of the fall risk factors as being the fact that Resident #103 had a Foley because .obviously that's (the Foley tubing) something that can get caught on something. LPN F then went on to explain that having a leg bag attached to Resident #103's catheter tubing as described in the care plan for catheter use was implemented because .obviously the bag itself is close to the body lessening the risk for a fall due to a trip hazard . Review of a Resident Summary Template dated [DATE] indicated the only safety intervention in place prior to the fall was an elopement alarm. Interventions in place for Ambulation/Mobility indicated Resident #103 needed extensive assistance from one person for ambulation with the assistance of a 4 wheeled walker. Interventions in place for Toileting indicated Resident #103 utilized a Foley catheter and needed the assistance from one person for clothing management and the use of a leg bag for urine collection. Review of Clinical Notes dated [DATE] timed 8:00 a.m. documented by Physical Therapy Assistant (PTA) D reflected 'Is the bus coming to pick me up at eleven to go home?' Patient presents standing up at bedside reaching for items on countertop. Patient unable to explain what he was reaching for. Patient also wearing only tedhose (therapeutic stockings) on feet. Patient educated regarding the importance of using the call light when needing help. Patient able to voice comprehension. Patient also presents more confused this AM-only alert and oriented x 2. RN (Registered Nurse) made aware of increased confusion and possible need for alarms. Patient transferred at the stand-by assist/contact guard assist level during session with use of 4-wheeled walker. Patient brought to therapy gym. Obtained an updated Tinetti (a balance assessment)-patient scored a ,[DATE]-1 point higher than baseline, however still indicating a high fall risk. Gait: patient ambulated in therapy gym/hallways ~150 ft x 2, contact guard assist. Patient with decreased step length, decreased B (bilateral) foot clearance, and left foot drag. Patient able to increase step length with cues. Patient returned to room and left with all needs nearby. Tolerated treatment session well. Plan to continue progressing gait, transfers and balance. During an interview on [DATE] at 4:13 p.m., PTA D could recall working with Resident #103 at 7:30 a.m. the morning he fell and confirmed she had witnessed Resident #103 self transferring without using a call light and without non-slip footwear on. PTA D said she found Resident #103 more confused than prior encounters and confirmed she told Resident #103's nurse what was going on with the expectation that nurse would put an alarm on the resident. (PTA D identified the 'nurse' she reported her concerns to as LPN E and explained that she always uses the abbreviation RN to mean nurse regardless of whether the nurse is an RN or an LPN.) PTA D said she left Resident #103 in his room as described in her progress note and believed she put the Foley Catheter bag under his wheelchair or had it attached to the bedside table. PTA D said she normally assisted residents who had Foley catheters with the catheters due to the possibility it could be awkward to maneuver with. When asked what might happen if a resident were to attempt to ambulate with a Foley catheter attached to a table or under a wheelchair PTA D said Bad things could happen. When asked to clarify what she meant by that, PTA D said it could increase a person's chances for falling. During an interview on [DATE] at 3:00 p.m., Certified Nursing Assistant (CNA) G admitted she was the aide assigned to Resident #103 on [DATE] and therapy staff getting him up at 7:30 a.m. that morning and telling her Resident #103 was done. CNA G admitted she went in to situate Resident #103 but did not put his leg bag on him. During an interview on [DATE] at 2:10 p.m., LPN E admitted she was the nurse who cared for Resident #103 on the day he fell . LPN E could not recall PTA D telling her she thought Resident #103 needed additional interventions to prevent a fall. LPN E went on to say I would think that if someone was worried about a fall then that person shouldn't leave the resident until she knows he is safe. Review of a Fall Event report printed on [DATE] relating to Resident #103's fall on [DATE] indicated Fall event details: (Resident #103) was observed on the floor, was alert and oriented times ,[DATE] with some confusion, (Resident #103) was to be using an assistive device-a walker but, was ambulating without assistance and there were obstacles in Resident #103's path. The Fall Event Details goes on to describe interventions that were in place at the time of the fall which included appropriate footwear/clothing, bed in low position, bed side rails, brakes on (wheelchair), call bell in reach. Follow-up actions detailed in the Fall Event report and documented on [DATE] indicated (Resident #103) self transferred to get up to get pop. Staff had items in reach. Patient with recent noted confusion. Patient with Foley (catheter) still attached under bedside table. Patient with slight elevated temperature. Tab alarms added and patient to have leg bag (for catheter) when up during daytime hours (the leg bag intervention was already care planned but was not in place at the time of the fall). Patient with complaint of hip pain sent out to emergency room for further hip pain evaluation and noted increased confusion. Patient states he did not hit head, neuro's (neurologic exams to detect a change in mental status) initiated, on hold at this time as patient out to hospital. The Fall Event report concluded with a summary description indicating the fall was reviewed by the interdisciplinary team and Patient did not have a history of self transferring (despite documentation describing resident being witnessed self transferring prior to the fall) noted increased confusion that morning with a low temperature (sic) status [REDACTED]. Hip x-ray showed there was a femoral neck fracture with mild superior displacement and medial angulation. No other fractures are seen, the bones are osteopenic. Plan of care followed at time of fall (despite documentation indicating one Resident #103, who had been up for therapy already the morning of the fall, did NOT have his leg bag in place, an intervention intended to mitigate a trip hazard related to using a Foley catheter). Review of a Certificate of Death signed by a Medical Examiner on [DATE], indicated (Resident #103) died on [DATE]. The cause of death was Medical complication of a hip fracture. Other significant conditions contributing to death but not resulting in the underlying cause-Hypertensive Cardiovascular disease. Date of injury: [DATE] on or about 0930 a.m Description of event: fell to floor while transferring himself from wheelchair to bed. Place of injury: Nursing home, location (facility address).

This citation pertains to MI 724. Based on observation, interview, and record review, the facility failed to prevent the elopement and ensure the safety in 1 of 5 sampled residents reviewed for elopement (Resident #101), from a total of 5 sampled residents, resulting in an Immediate Jeopardy when Resident #101, who was at risk for both elopement and falls, eloped from the facility on 5/19/13 at 7:53 PM, unbeknownst to facility staff and was seen walking one-half mile from the facility at approximately 8:05 PM by an off-duty staff member, who returned her to the facility. This deficient practice places 41 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of Resident #101's Minimum Data Set, dated dated [DATE], revealed Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per Resident #101's Care Plan Report, dated 11/09/12, "Safety: (Resident #101) is at risk for falls or injury related to: Impaired balance; Impaired safety awareness; Impaired vision; Impaired gait; Dizziness; Medical condition: dementia - Hx (history) of falls; Incontinence; Psychotropic medication use." Per Resident #101's Care Plan Report, dated 11/09/12, "Elopement: (Resident #101) has a [DIAGNOSES REDACTED]. Review of Clinical Notes Report entered date 5/20/13 at 12:18 AM and Effective Date: 5/19/13 at 11:45 PM, RN/Registered Nurse #12 documented, "(Resident #101) has been wandering around the building all day. She was last seen sitting at the nurses' station around (8:00 PM). She was found outside. She was assisted back to the facility by staff. No injuries noted on (Resident #101). The WanderGuard (wander alert) was on and blinking (charged)". According to a Staff Statement, dated 5/19/13, LPN/Licensed Practical Nurse #16 documented, "I was standing by the medcart (medication cart) near 414. Then heard alarm sounding near exit D wing. In sight was (Resident #103) near me - close to medcart. I am unsure which direction she may have come from - either D wing or 400 hallway. I started to walk down toward D wing and went to alarming door; nobody in sight. I attempted to turn alarm off. Then called fm (facility manager-RN/Registered Nurse #15) and told her alarm was sounding. I didn't not observe any pt (patient) in sight, but maybe (Resident #103) may have come from that direction". In a telephone interview on 5/28/13 at 8:55 AM, LPN #16 stated, "I was standing by the med (medication) cart by room 414, heard alarm, saw (Resident #103) and wasn't sure where she came from. I went to the door that was alarming and didn't see anybody. I called the facility manager (RN #15) and told her I wasn't sure what to do or what the code was to shut off the alarm. She said she was on her way; I saw her coming. I was rushing to give a pain pill to a resident. I did not go outside to look around. Now I know to run outside and check the panel (monitor at reception desk) to see who exited...After we knew that (Resident #101) was found outside, we checked to make sure all (WanderGuard bracelets) were functioning/their lights were blinking and the maintenance man came through and checked all the doors that same night". Review of the facility "Door Alarm Journal" revealed Resident #101 exited the "D wing" door on 5/19/13 at 7:53 PM. In an interview on 5/22/13 at 3:25 PM, Nurse Aide #9 reported she was off duty on 5/19/13 and driving near the facility when she saw Resident #101 walking at a "steady pace" north (in a direction away from the facility), on the sidewalk between "8:05 - 8:10 PM". Nurse Aide #9 described where she found Resident #101 and reported that she stopped her car, went to Resident #101 and greeted her, and called the facility. Nurse Aide #9 stated, "I think (Resident #101) would have get pretty far. She walks all day. She likes to walk." Nurse aide #9 reported Resident #101 had no visible injuries. In an interview on 5/22/13 at 4:12 PM, Dietary Supervisor #13 reported on 5/19/13, she "punched out at 8:05 PM" and then sat in her car for a few minutes before she left the facility and began driving her car home. Dietary Supervisor #13 reported, "(Nurse Aide #9's) hazard lights were on; she was yelling my name." Dietary Supervisor #13 reported she stayed with Nurse Aide #9 and Resident #101 until "somebody came and got (Resident #101)". Dietary Supervisor #13 reported Resident #101's only complaint was that "her feet hurt". On 5/22/13 this surveyor observed the road, adjacent to the sidewalk, Resident #101 was found on was a 4 lane, posted speed limit of 35 mile/hour road; this surveyor measured the distance to be ? mile away from the facility. In an interview on 5/22/13 at 12:05 PM, Maintenance #8 reported he had worked at the facility for 3 years and the wander alert system had been in place for 2 years. Maintenance #8 stated, "The monitor at the receptionist desk shows who is where; it shows what resident is at the door...D wing has a 15 second delay; it must have been pushed for 15 seconds before it opened. The Sondergaard (Wander Guard) alarm sounded. They're (staff) supposed to check outside the door. Whoever it was, didn't follow protocol". Maintenance #8 reported he educated all new staff on the Sondergaard alarm system but checking the monitor at the front desk was not included in his education. Maintenance #8 stated, "It (checking the monitor) would have alerted them that it was (Resident #101) who exited". According to the facility investigation summary statement, Administrator #1 documented, "...(RN/Registered Nurse #15)/Facility Manager explained that she was informed by LPN/Licensed Practical Nurse #16 that (Resident #103) 'had been by the doors on D wing and the door won't stop alarming'. Then (RN #15) said she went to check that door and an alert patient told her 'I know who made it happen, it was (Resident #103). At approximately 8:10 PM, (RN #15) was informed from nursing staff that (Resident #101) was found walking on the sidewalk...The root cause of this incident was an error in the (RN #15's) judgment." In an interview on 5/22/13 at 3:00 PM, Administrator #1 reported her investigation revealed that on 5/19/13 at 7:53 PM, staff 1). failed to look outside the alarming door; 2). failed to follow the facility Missing Adult (Plan ABC - Adult) protocol for a missing resident when the "D wing" door alarmed, and 3). failed to utilize the monitor that indicated that Resident #101 was the resident that triggered the alarm. According to the facility's Plan ABC - Adult policy and procedure, dated 12/01/12, "Some of our adult patient/resident or visitor population may become confused or disoriented, due to a medical condition or medication and wander away from the unit where they, or a loved one, are receiving care. Quick response by our staff may stop the adult patient/resident or visitor from leaving the campus and possibly coming to harm." On 5/24/13 at 9:15 AM, Administrator #1 was notified of the Immediate Jeopardy that began on 5/19/13 at 7:53 PM for Resident #101, who was identified at risk for elopement, and eloped from the facility on 5/19/13 at 7:53 PM unbeknownst to facility staff. On 5/24/13 the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy on 5/19/13: 1). On 5/19/13 at 8:10 PM, staff returned Resident #101 to the facility and verified her Wander Guard was in place and functioning, and an additional 40 residents Wander Guard Tags/bracelets were checked for placement and functioning. 2). On 5/19/13, maintenance staff checked and tested the D wing exit door that Resident #101 exited from and verified it was functioning properly, and all facility exits were checked to verify alarms were functioning properly. 3). On 5/19/13, re-education was immediately initiated regarding Elopement Prevention/Sondergaard System (also known as AcuTouch Wander Guard System); as of end of day 5/20/13, 143 of 278 staff were educated. No staff will be allowed to work prior to receiving the education. 4). On 5/20/13, the Administrator reviewed the Elopement or Missing Resident/Patient Policy and Procedure and deemed it appropriate. 5). On 5/20/13, elopement prevention drills were initiated and will continue at least weekly. Any concern will be addressed immediately. Although the Immediate Jeopardy was removed on 5/19/13, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to all staff had not received education on the facility Elopement Prevention/Sondergaard System (Wander Guard) policies, and sustained compliance had not been verified by the State agency. ( )