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

This citation pertains to intake #3094708Based on observation, interview, and record review the facility failed to ensure ADLs (Activities of Daily Living) specifically, nail care, for dependent residents, were completed for 2 (Resident #101 and Resident #104) of 4 residents reviewed for ADLs resulting in an unkept appearance and the potential for the spread of infection.Findings include:Resident #101Review of an admission Record revealed Resident #101 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: debility, hemiparesis of left non-dominant side (paralysis of one side of the body), and late onset alzheimer's disease.Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 5/31/2026 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #101 was severely cognitively impaired. Review of Section GG Self-Care revealed Resident #101 was dependent for personal hygiene.Review of Work List Task Completion for Resident #101 revealed give thorough bed bath-family preference for this resident- Q (every) Tu (Tuesday) & F (Friday).On 7/28/26 at 12:26 pm, Resident #101 was in bed, and her fingernails were observed to be long, jagged, and soiled with black debris. In an interview on 7/28/26 at 2:10 pm, Certified Nurse Assistant (CNA) AA reported Resident #101 was given a bed bath twice a week on Tuesday and Friday and that nail care was done during the bed bath or shower if the resident allowed. CNA AA confirmed Resident #101 was given a bed bath today.On 7/28/26 at 2:15 pm, Resident #101 was in bed, and her fingernails were observed to be long, jagged, and soiled with black debris.On 7/29/26 at 11:35 am, Licensed Practical Nurse (LPN) LL was observed cleaning and clipping Resident #101's fingernails while she was in bed. LPN LL reported CNA P had asked her to try to clean Resident #101's fingernails since she, (CNA P) had been unsuccessful. In an interview on 7/29/26 at 11:40 am, CNA P reported she checked and completed nail care for everyone when she provided care. CNA P Resident #101 often had her hand inside her brief, and her nails needed to be checked frequently. Resident #104Review of an admission Record revealed Resident #104 was a male who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: pressure ulcer of the sacral region Stage IV (full thickness tissue loss with bone exposure; lower back, upper buttock area of the body) numbness of the right lower extremity, and right hand pain.Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 5/28/26 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #104 was cognitively intact. Review of Section GG Self-Care revealed Resident #104 required partial moderate assistance with personal hygiene. Review of Work List Task Completion for Resident #104 revealed assist with bathing/showering - Q Tuesday / Friday.On 7/28/26 at 2:40 pm, Resident #104's fingernails were noted to be long, jagged, and soiled with dirt and debris. Resident #104 reported he preferred to keep his nails short and clean and had asked for assistance but had not gotten any help yet. Resident #104 reported the staff had not offered to cut his nails for him.On 7/29/26 at 8:50 am, Resident #104's fingernails were noted to be long and jagged, and soiled with dirt and debris. Observed on the counter near the sink was an unopened packaged nail clipper and two wooden sticks with angled tips used to clean fingernails. In an interview on 7/29/26 at 10:24 am, CNA N reported nail care was to be done with every shower or when resident's need it.In an interview on 7/29/26 at 11:45 am, CNA X reported nail care should be done with showers and if a resident refuses nail care, the nurse was to be notified.In an interview on 7/30/26 at 8:05 am, Registered Nurse (RN) H reported nail care was to be done with showers and bed baths on the resident's assigned shower day.In an interview on 7/30/26 at 9:10 am, Nurse Manager (NM) M reported the expectations was that nail care was done with showers and bed baths or when needed. NM M reported typically nail care was completed by the CNAs.In an interview on 7/30/26 at 9:25 am, Director of Nursing (DON) B reported nail care was not documented specifically in a residents' medical record. Nail care was considered a standard of care and was expected to be completed with assigned shower days or as needed.

Based on observation, interview, and record review the facility failed to ensure the kitchen/kitchenettes' food contact and/or non-food contact surfaces were consistently maintained in a clean and sanitary manner and failed to consistently date, label, and discard food items appropriately with the potential to effect any resident out of the census of 98 who consumed food/beverages from the kitchen resulting in the potential for foodborne illness, physical food contamination, and/or pest issues.Findings include:Food Contact and/or Non-Food Contact Surfaces Not Maintained in a Clean and Sanitary Manner by Area:Ice Machines-During an observation and interview on 04/14/2026 at 9:29 AM, the ice machine in the kitchen had unknown black, orange, and pink material accumulated on the exterior of the white ice chute. Maintenance Staff F reported the ice machines of the kitchen were cleaned by a third-party vendor, he thought cleaning was done approximately bi-annually (twice a year), and ice machines were last cleaned approximately around the time of late January/early February (2026).During an observation on 04/15/2026 at 8:14 AM, the ice machine in the kitchen remained visibly soiled as was observed on 04/14/2026 at 9:29 AM.During an observation on 04/14/2026 at 10:57 AM, the ice machine across from the dining room and just outside of the kitchen had unknown orange and black material on the white ice chute that dispensed ice. The external clear plastic ice chute cover that protected, contained, and directed ice downward had an unknown red material on the inner and outer surface.During an observation on 04/15/2026 at 8:46 AM, the ice machine located just outside the kitchen remained visibly soiled as it was observed on 04/14/2026 at 10:57 AM.Review of the ice machines' Service Order Form, dated 2/6/26, stated, 02/06/2026 .Cleaned Ice Machine. Review of the 2022 Food and Drug Administration's Food Code, stated, Frequency . 4-602.11 Equipment Food-Contact Surfaces and Utensils .Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Kitchenettes' Refrigerator/Freezers-During an observation on 04/14/2026 at 10:23 AM, the freezer/refrigerator located in the kitchenette of the back 200 unit was soiled with some dead bugs and brown debris in the freezer door and a large red colored spill on the bottom of the freezer's interior. During an observation and interview on 04/14/2026 at 10:30 AM, the freezer/refrigerator located in the kitchenette of the front 200 unit had a brown spill on the bottom of the freezers and refrigerators' interior. Kitchen Supervisor UU reported refrigerators should be cleaned daily.During an observation on 04/14/2026 at 10:36 AM, the freezer/refrigerator located in the kitchenette of the front 100 unit had a brown spill on the bottom interior of the refrigerator and freezer. There was also unknown debris on the bottom interior of the freezer and a spill in the middle drawer of the refrigerator.During an observation on 04/14/2026 at 10:41 AM, the freezer/refrigerator located in the kitchenette of the back 100 unit had a spill with some debris in the bottom drawer of the freezer. There was red frozen material that had spilled and froze to the three wire racks in the freezer. There was a brown spill on the bottom of the refrigerator's interior.Review of the 2022 Food and Drug Administration's Food Code, stated, 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.Storage Drawer and Food Storage Pans-During an observation and interview on 04/14/2026 at 10:02 AM, a clear plastic food pan on the bottom shelf of the drying rack in the kitchen had various brown and white debris accumulated on the inside bottom surface. Kitchen Supervisor UU confirmed the plastic food pan was not clean.During an observation on 04/14/2026 at 12:08 PM, a large clear plastic food pan on the bottom shelf of the kitchen's food preparation table across from the griddle contained packages of open and unopened disposable cups/lids. This container had no lid and had collected various white and yellow debris across the bottom of the container which was directly touching clean disposable single use cups/lids.During an observation on 04/15/2026 at 8:56 AM, in the drawer of the kitchen's food preparation table that the coffee maker sat on had debris accumulated on the bottom of the drawer that was in direct contact with clean disposable single use cups/lids. One lid was resting directly on the bottom of the drawer which had brown staining on the bottom of the lid and an approximately 2.5-inch diameter circular stain present on the bottom of the drawer from where it had been resting. Review of the 2022 Food and Drug Administration's Food Code, stated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.Food Processors-During an observation on 04/14/2026 at 10:04 AM, the kitchen's silver colored food processor located next to the toaster had standing water in the bottom of the food processor's bowl with the blade resting directly in the water.During an observation on 04/15/2026 at 8:49 AM, the kitchen's silver colored food processor had what appeared to be dried orange and white food debris on the bottom of the food processor's bowl.During an observation on 04/15/2026 at 8:51 AM, the kitchen's black colored food processor located next to the silver food processor had standing water at the bottom of the food processor's bowl.Review of the 2022 Food and Drug Administration's Food Code, stated, 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored .Can Opener-During an observation and interview on 04/14/2026 at 12:03 PM, the can opener attached to the kitchen's central food preparation table had sticky black and brown debris accumulated on the can opener's piercing part. Kitchen Supervisor LL reported the can opener would have been used about an hour or hour and a half prior to open food cans to make ambrosia salad. Kitchen Supervisor LL reported the can opener should be cleaned after it was used and confirmed the colored debris on the can opener was not a color of any ingredients in ambrosia salad. Dating, Labeling, and Discarding of Food Items:During an observation and interview on 04/14/2026 at 9:37 AM, the small refrigerator located next to the tray line had a plastic cup with disposable lid filled with a brown thickened liquid. There was no label to indicate what the beverage was, when it was prepared, or the date it should be discarded. Kitchen Supervisor UU reported it was a nectar thick beverage supplement for a resident, confirmed there was no label (no item name or dates of preparation/use-by), and discarded the product.Review of the 2022 Food and Drug Administration's Food Code, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES. or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.During an observation and interview on 04/14/2026 at 9:45 AM, in the kitchen's refrigerator on the right side was a plastic food storage container the facility labeled cheese with a use by date of 4-13 (4/13/2026). Kitchen Supervisor UU confirmed the cheese was past its use by date and reported the expiration of the cheese noted on the label was the expiration date from the cheese's original packaging.Review of the 2022 Food and Drug Administration's Food Code, stated, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, . or discarded.During an observation and interview on 04/14/2026 at 10:00 AM, in the kitchen's walk-in refrigerator there was a clear food storage container of sliced beets with a label that indicated 4-13-26. Kitchen Supervisor UU confirmed 4/13/26 was the expiration date. During an observation and interview on 04/14/2026 at 12:10 PM, on the kitchen's central food preparation table under the hanging pot rack was an unlabeled and undated clear squeeze bottle (not the product's original container) that contained an unidentified yellow liquid. Kitchen Supervisor LL reported it should have been labeled and was vegetable oil (cooking oil).Review of the 2022 Food and Drug Administration's Food Code, stated, 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils . shall be identified with the common name of the FOOD.

Based on observation, interview, and record review the facility failed to honor food preferences for 1 (Resident #121) of 20 sampled residents reviewed for food preferences resulting in feelings of frustration and anger.Findings include:Resident #121Review of a Face Sheet revealed Resident #121 was a female who was admitted to the facility on [DATE] and had pertinent diagnoses which included: amyotrophic lateral sclerosis (ALS; a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord leading to a loss of muscle control, including muscle weakness, difficulty speaking, swallowing and eventually breathing), unspecified protein-calorie malnutrition, dysphagia (difficulty swallowing), and vegetarian (a person who does not eat meat).In an interview on 4/14/26 at 10:32 AM, Resident #121 reported she requested yogurt to be served at every meal, and she was not getting it. Resident #121 reported she and Family Member (FM) TT had both spoken to Registered Dietitian (RD) I regarding her preference for yogurt at every meal. Resident #121 stated she and FM TT were frustrated and angry with the lack of follow through to provide yogurt with each meal. Resident #121 stated I have no idea why this request is so hard. Review of Adult Diet Order for Resident #121 reviewed on 4/14/26 revealed .General, dysphagia; dysphagia solids: pureed (mash, crush, smash to a paste consistency); dysphagia liquids: moderately thick (liquid with a thick consistency to be consumed with a spoon). with an order date of 4/11/26 and nutrition supplements fortified frozen supplement; orange: lunch and dinner with a start date of 4/13/26 and nutrition supplements regular; chocolate; AM snack PM snack; with a start date of 4/15/26.In an observation and interview on 4/14/26 at 12:50 PM, a bowl of pink colored yogurt was present on Resident #121's meal tray in her room, no orange frozen supplement was observed on the tray. Resident #121 reported the yogurt was not on the tray when she was served her lunch. Certified Nurse Assistant (CNA) Q who was present in the room assisting Resident #121 to eat her lunch reported she had called down to the kitchen to request the yogurt, and it was delivered. CNA Q reported Resident #121 requested that each bite of her pureed food be dipped in yogurt as that made it easier for her to swallow.In an observation and interview on 4/15/26 at 9:05 AM, Resident #121 was in her room with her breakfast meal in front of her. Resident #121 reported she was not served yogurt at dinner the night before. Resident #121 also reported she had not been served ice cream of any kind or flavor since she had arrived at the facility. Noted on the tray was a bowl of pink yogurt, mostly consumed. Review of the tray ticket present did not list yogurt as a preference.Review of meal tray tickets on 4/15/26 for Resident #121 dated Thursday (4/16/26) for breakfast, lunch, and dinner, revealed no listed preference for yogurt at each meal nor orange frozen supplement at lunch and dinner.Review of Care Plan for Resident #121 revealed .Problem: has a potential for altered nutrition and hydration; potential for inadequate oral intake related to decreased ability to consume sufficient calories/protein as evidenced by. ALS, (food options are restricted secondary to dysphagia and may be contributing to inadequate protein/energy intake) malnutrition and overall decline. Goal: food and fluids as desired per goal of comfort care.Interventions: honor food preferences as able.provide additional calories/ protein; provide nutritional supplements as ordered continue to offer snacks between meals. all with a start date of 4/13/26.Review of clinical nutrition assessment for Resident #121 with a plan of care addendum dated 4/15/26 authored by RD I revealed .RD (RD I) met with pt (patient) at bedside to follow-up on intake and supplemental acceptance. Resident is currently on a pureed diet with mildly thick liquids and no straws.spoke with (redacted FM TT) over the phone several times r/t (related to) getting food preferences and putting (redacted Resident #121) on a vegetarian diet. However, resident [(sic) FM TT] had many complaints as to why (redacted Resident #121) was not getting yogurt. RD explained to (redacted FM TT) that our yogurt here has gelatin in it and causes yogurt to not be allowed on a vegetarian diet. (Redacted FM TT) reports that (redacted Resident #121) needs increased calories with ALS, and reported using protein supplements at home. In a telephone interview on 4/15/26 at 4:07 PM, FM TT reported she was aware Resident #121 was being served yogurt irregularly, and when it was served, it was not nearly enough. FM TT reported the facilities process to honor food preferences was really bad and it was ridiculous that Resident #121 was not being served enough calories. FM TT reported Resident #121 had always been vegetarian and had always consumed yogurt, milk and eggs. FM TT reported Resident #121 would consume over 32 ounces of yogurt a day when she was at home. FM TT reported Resident #121 dipped everything she ate in the yogurt to make it easier for her to swallow and increase her caloric intake. FM TT reported Resident #121 would eat a very large bowl of ice cream every night to ensure she had consumed enough calories for the day.In an interview on 4/15/26 at 4:23 PM, Manager of Support Services (MSS) JJ reported Resident #121's recorded preferences as she could see them included vegetarian diet, strawberry yogurt was ok, yogurt, pudding packs, and ice cream. When quarried, MMS JJ reported yogurt was not listed at all on any of Resident #121's meal tickets, and if it was not listed on the meal ticket the dietary staff would not know to serve it with a meal. In an interview on 4/15/26 at 4:33 PM, RD I reported Resident #121 could not have yogurt on a pureed diet nor on a vegetarian diet and the dietary department computer program restricted it. RD I reported she was waiting for FM TT to respond to her text message regarding the facilities yogurt not being allowed on a vegetarian diet. When quarried if she spoke to Resident #121, RD I reported she had but Resident #121 had difficulties communicating and FM TT was very involved in Resident #121's care. RD I reported Resident #121 had not been receiving yogurt or should not have been due to her pureed and vegetarian diet orders. When quarried, RD I reported for Resident #121 to be given yogurt, staff had to override the computer system with her initials, which had been done for lunch today, when Resident #121 was served yogurt. Review of Adult Diet Order for Resident #121 reviewed on 4/16/26 revealed .General, dysphagia; Restrictions vegetarian, No straws; dysphagia solids: pureed; dysphagia liquids: moderately thick. Please allow resident to have yogurt with all meals regardless of the vegetarian diet.with an order date of 4/16/26. Review of Resident #121's medical record revealed no noted documentation to address and/or override the restriction of yogurt on a pureed diet. In an interview on 4/16/26 at 9:30 AM, Resident #121 reported she still was not getting her preferences with her meals. Resident #121 reported she told RD I she ate eggs, milk and yogurt. Resident #121 stated I am a vegetarian, I do not eat meat, I eat milk, yogurt, and eggs, that is what a vegetarian is; I am not vegan (a person who does not eat any food derived from animals). Resident #121 reported she knew the difference between vegan and vegetarian, and she was frustrated and angry because it felt like the staff of the facility was not listening to her about what she wanted and needed. Resident #121 began crying while stating I was diagnosed with ALS in November (2025), and I cannot eat a lot of different foods. I have spent months figuring out how to keep my calorie intake up and that included consuming large amounts of yogurt, milk, and ice cream every day. I feel like I am declining while being here, because no one will listen to me about the foods I prefer to eat.

This citation pertains to intake: 2568667.Based on interview and record review, the facility failed to prevent the use of unnecessary psychotropic medications without adequate indication for use and without resident monitoring in 1 of 1 resident (Resident #101) reviewed for psychotropic medications, resulting in an Immediate Jeopardy when on [DATE] Resident #101 was prescribed a psychotropic medication, who then sustained a fall with a impacted acetabulum (hip socket) and pelvic fracture on [DATE] and subsequent death. Findings include: Resident #101 was prescribed lorazepam daily beginning [DATE]. Resident #101 had falls on 5/12, 5/20, and 5/28 with no major injury after no falls since February admission. No monitoring for or recognition of adverse consequences from psychotropic medications occurred after these falls. On [DATE], Resident #101 fell while ambulating and sustained impacted acetabulum and pelvic fractures, was hospitalized , and died as a result of the fall per the medical examiner.The Immediate Jeopardy began on [DATE] when Resident #101, who was prescribed lorazepam daily beginning [DATE] and had falls on 5/12, 5/20, and 5/28 with no major injury after no falls since February admission. No monitoring for or recognition of adverse consequences from psychotropic medications occurred after these falls. On [DATE], Resident #101 fell while ambulating and sustained impacted acetabulum and pelvic fractures, was hospitalized , and died as a result of the fall per the medical examiner. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on [DATE] at 2:24 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at actual harm due to not all staff had received education and sustained compliance had not been verified by the State Agency. Review of an admission Record revealed Resident #101 was a female with pertinent diagnoses which included severe late onset Alzheimer's dementia with agitation, recurrent falls, insomnia, and depression. Review of Minimum Data Set (MDS) dated [DATE] revealed, a Brief Mental Status Score (BIMS): 11 which indicated moderate cognitive impairment.Review of Care Plan for Resident #101, started on [DATE], revealed Resident #101 was at risk for falls due to impaired balance, did not ask for assistance, but prefers to remain independent. Resident #101 was on psychoactive medications which increase her risk. Interventions included Monitor medication side effects for potential gait disturbances or other safety issues and Visual checks per facility policy. Note: Requested policy for visual checks and was informed the facility does not have a policy for visual checks. Review of Resident Care Summary dated [DATE], revealed, .Independent: Bed Mobility, Chair to Bed/Chair transfers, and Walk 10 feet. Review of electronic correspondence received from Director of Nursing (DON) B on [DATE] revealed, fall dated [DATE] occurred at 5:10 AM. Review of Event Summary Report dated [DATE], revealed, CENA alerted by roommate that resident had fallen. Resident was lying on her back parallel to the bed. She had just come out of the bathroom at the time of fall per roommate. C/O (complaint of) increased pain to the L (left) hip.Unable to properly assess the L hip d/t (due to) pain. Placed pillows under her to make her more comfortable and called (Initial) the On-call Provider to have her transported to the ER for an eval. No indication that Resident #101's medications were reviewed at the time of fall to determine if they contributed to the fall despite an increase in behaviors after starting Lorazepam. In an interview on [DATE] at 11:00 AM, Registered Nurse (RN) M reported when she went into the room, Resident #101 was on the floor on her R (Right) side. Resident #101 was in a lot of pain. RN M reported she wanted to do her own thing and was angry at staff when staff checked on her because she felt she could do it herself. In an interview on [DATE] at 3:25 PM, CNA II reported Resident #101 had gotten up, went to the bathroom and the roommate had turned on the call light to alert us. CNA II reported she went into the room and found Resident #101 on the floor between her and her roommate's bed, and she was in a lot of pain. CNA II reported Resident #101 was independent, she liked to do a lot of things herself, and she didn't like staff to assist her, but was not aggressive or combative.Review of ED Triage Notes dated [DATE] revealed, .Closed displaced combined transverse-posterior fracture of left acetabulum; ground level fall. (complex fracture of the left hip socket's bony structure, characterized by a break that runs across the socket and extends to its posterior (back) wall, is not open to the outside (closed) and has bone fragments that have moved out of alignment).Review of CT of the Pelvis without Intravenous Contrast dated [DATE] at 7:45 AM, revealed, .Impression: 1. Complex and displaced left acetabular fracture with extension into the left iliac wing resulting in a posttraumatic protrusion appearance of the femoral head.2. Mild to moderately angulated and minimally displaced fracture of the left inferior pubic ramus.Review of Geriatric Trauma Consult dated [DATE] at 8:29 AM, revealed, . She is planned for fixation of her displaced acetabular fracture.Falls: -unwitnessed, patient with 3 other falls in May, may be mechanical/med (medication) associated - has had increasing falls since starting lorazepam on 5/9.-Symptoms associated with the fall not clear as patient had unwitnessed fall.-Falls in the past 6 months Yes - 3 other falls in May. one fall in February. taking lorazepam, which can increase fall risk, poor strength. Geriatric Assessment: Patient's daughter/DPOAH (FM OO) is at the bedside. Reviewed how (Resident #101) had been living in LTC since February as she was having more falls. Prior to that she had lived with (FM OO). Discussed how she has had 3 falls in May and now this fall in June. Explained that she has had an increase of falls since starting lorazepam for restlessness and agitation. In an interview on DON B reported Resident #101 returned back to the facility following the fall on [DATE] on hospice services. Review of (Medical Examiner) autopsy report received on [DATE] revealed, . CONCLUSION: Based upon the examination findings and the history as available to me, it is my opinion that (Resident #101) died as a result of the sequelae (consequences of) of left-sided pelvic fractures. Alzheimer's dementia is contributory to the death.CAUSE OF DEATH: Sequelae of left-sided pelvic fractures.In an interview on [DATE] at 3:27 PM, Family Member (FM) OO reported Resident #101 had a fall at home and was admitted to the facility following evaluation at the hospital. FM OO reported when Resident #101 was admitted to the hospital following the last fall on [DATE], she was informed Resident #101 was being given Ativan at night she reported she was not aware nor was she contacted to discuss the addition of the medication or provide her consent. FM OO reported Resident #101's hip bone broke and went through her pelvis. FM OO reported Resident #101 never had aggressive, never had angry behaviors, she was a very, very active and continued to be able to walk prior to this last fall on [DATE] and due to that mobility, she felt Resident #101 shouldn't have received Ativan. FM OO reported Resident #101 was more active at night, got up frequently and believed she had sundowners. FM OO reported Resident #101 had surgery to correct the fractures and returned to the facility on hospice services, and Resident #101 passed a few weeks later. FM OO reported the medical examiner report indicated Resident #101 died due to the fall she had while at the facility. According to Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies Markota ([NAME] et al. Mayo Clinic Proceedings, Volume 91, Issue 11, 1632 - 1639) .This widespread prescription of benzodiazepines in a population for which they are generally contraindicated because benzodiazepine use is associated with risk of dependence, cognitive deficits, falls resulting in fractures, and overall mortality .Elderly patients in residential care facilities are at a higher risk of being exposed to benzodiazepines. Use of benzodiazepines in elderly patients with a history of falls recommendation is to avoid benzodiazepines .These drugs possess minimal efficacy in treating insomnia beyond acute periods measured in days and considerably increase the risk of adverse effects, including delirium, falls, and fractures .In the elderly, however, even short-term use of benzodiazepines can have dangerous adverse effects .With regard to older adults with particularly high risk of falls and fractures, patients who frequently use the restroom at night, and those with a history of falls are particularly vulnerable . Review of Psychotropic Medication Risk/Benefit Consent [DATE] revealed, Resident #101 nor FM OO had provided consent for the Ativan orders. In an interview on [DATE] at 09:07 AM, Social Worker (SW) H reported consents for medications would be signed electronically by the decision maker or resident when admitted or when there was a change in medications where consents were needed. SW H was unable to locate notes for Resident #101 as well as notes which had indicated a conversation had been had with the decision maker for the medication. During an observation and interview on [DATE] at 2:32 PM, Nurse Liaison C reported during review of Resident #101's chart she only had the consent for an antidepressant, and a note from provider dated [DATE] to start the Ativan, and no documentation in the note of having a conversation with the FM OO. Review of Progress Note dated [DATE] at 1:41 PM, revealed, . (Resident #101) is a 87 y.o. female seen today for reports of increased wandering into other patients' rooms at night and agitation. She is alert but confused, as is her baseline.Assessment & Plan: Severe late onset Alzheimer's dementia with agitation: Will add Ativan 0.5 mg po at HS (before bedtime) prn (as needed) x 14 days and reevaluate need for use in 14 days for wandering with intermittent anxiety and agitation. Benefits are felt to outweigh risks of patient distress and risk of safety to self and others with wandering into spaces not intended for her to be able to access. Other insomnia.Melatonin prn, Ativan prn x 14 nights.Review of Resident #101's orders did not show an order for monitoring for adverse effects of psychotropic medications. Review of Resident #101's care plans did not show a focus for monitoring psychotropic medications. Review of Behavior Logs for Resident #101 starting [DATE] through [DATE], revealed Resident #101 was confused, ambulated without assist in room and hallways where redirection was effective in most instances. Resident #101 was noted in bed at appropriate times such as 2100 (09:00 PM), 0000 (12:00 AM), and 0800 (8:00 AM) throughout the multiple months of Resident #101's behavior documentation. The Behavior Logs revealed no increase in wandering or agitation documented until [DATE] at 2000 (8:00 PM) which revealed, Resident #101 was .restless, confusion, refusal, repeating thoughts, agitated.Up in chair. From date [DATE] - [DATE] there were no other documented behaviors. Review of Behavior Logs for Resident #101 revealed, on [DATE] at 0230 (2:30 AM) Resident #101 was found standing in hall, looking for her daughter, knocking on another resident's door and was able to be redirected. At 0430 (4:30 AM) Resident #101 was found standing in hall asking for a phone number. There was no indication of agitation or anxiety. From [DATE] - [DATE] there were no other documented behaviors. Review of Behavior Logs for Resident #101 revealed, on [DATE] and [DATE] resident #101 exhibited behaviors of refusal of assistance/care but was redirectable. From [DATE] - [DATE], there were no other documented behaviors. Review of Care Management Note entered by Nurse Practitioner (NP) H dated [DATE] at 1:10 PM, revealed, .Ativan prn order placed - benefit felt to outweigh risk as patient is quite anxious and argumentative with staff, which seems to make her more likely to attempt to roam the facility talk to staff about things that upset her, increasing her risk for falling. Will reassess in 7 to 14 days and discontinue prn Ativan use if appropriate. Review of Order for Resident #101 dated [DATE], revealed an addition of, .Lorazepam (Ativan) tablet 0.25 mg Oral, 3 times daily, PRN (As needed) .Associated Diagnosis: Anxiety Disorder.Review of MAH for Resident #101 revealed, .Lorazepam (Ativan) tablet 0.25 mg Oral, 3 times daily, PRN (As needed) .Associated Diagnosis: Anxiety Disorder.Given at [DATE] at 1420 (2:20 PM) and Given at [DATE] at 2228 (10:28 PM) . Review of Behavior Log dated [DATE] - [DATE], revealed, Resident #101's behaviors escalated with the use of Lorazepam.Review of the Medical Administration History dated [DATE] to [DATE] revealed, .Lorazepam (Ativan) tablet 0.5 mg Oral, nightly, Associated Diagnosis: Other insomnia.Times: 2100 (9:00 PM) revealed, Noted as R (Refused) on [DATE], [DATE], .G (Given) on [DATE], [DATE] - [DATE], [DATE] - [DATE] and then [DATE] - [DATE] - noted as H (Hospital). Review of Event Summary Reports dated [DATE] (no time) revealed Resident #101 had a fall without injury. On [DATE], Resident #101 had a fall that resulted in a small hematoma to the top of her head. Resident #101 was sent to the hospital for review. On [DATE], Per (Registered Nurse (RN) U) .Resident observed on the bathroom floor in her room. Resident sitting on the floor on her bottom. Resident has hematoma (swelling, bruise, or lump) noted to left side of head bleeding with some swelling noted. Resident #101 was sent to the hospital for review and found to have a urinary tract infection at that time. No indication that Resident #101's medications were reviewed after each fall to determine if they contributed to the falls after starting Lorazepam. In an interview on [DATE] at 1:34 PM, Certified Nursing Assistant (CNA) Z reported Resident #101 would get up and go to the bathroom on her own. CNA Z reported when she found Resident #101 on [DATE], she was holding on to the baseboard of her roommate's foot of her bed. CNA Z reported she believed Resident #101 was attempting to ambulate to the bathroom. CNA Z reported Resident #101 was able to walk on her own. CNA Z reported she didn't have any observations of Resident #101 being very aggressive, physical with staff, or swear/call names to staff. In an interview on [DATE] at 1:01 PM, CNA X reported she had placed Resident #101 in her bed on [DATE] and Resident #101 had slipped in the bathroom as she would get up during the night and was not able to make it to the bathroom and she urinated on the floor. CNA X reported Resident #101 would go to bed but then she would get up in the night. In an interview on [DATE] at 12:26 PM, Registered Nurse (RN) U reported on [DATE], the CNA informed her Resident #101 was on the bathroom floor, bleeding. Resident #101 laying on the floor, on her left side, blood was pooling on the floor by her head, there was water or urine on the floor in the bathroom, and she had slipped and fell. RN U reported she assessed the resident, took her vitals, completed range of motion (ROM), cleaned up Resident #101's head as she had a laceration. RN U reported she got an order to send her out to the emergency room (ER). RN U reported Resident #101 was impulsive and would get up whenever, and she wanted to do her own thing. RN U reported the interventions to keep her safe were redirection, bed low, everything in reach for her, nonskid socks. RN U reported when she would get up in the middle of the night, if she was told it was the middle of the night, she would go back to sleep. RN U reported she felt she got up to use the bathroom and with her confusion she slipped and fell. In an interview on [DATE] at 3:53 PM, Licensed Practical Nurse (LPN) QQ and RN L reported she would come and talk to them, could be feisty, wagged her finger at them, had some confusion but she was a fun little lady. LPN QQ reported if she didn't want to do something, she didn't do it. RN L reported she would refuse medications, but he would talk to her, and she would end up taking the medications. In an interview on [DATE] at 12:23 PM, Clinical Nurse Supervisor (CNS) F reported Resident #101 was confused a lot of time, was a cute little lady, she had spent time at the nurse's station, tried to keep extra eyes on her as possible, had multiple conversations in regard to her, felt a memory care unit would be a better option for her. CNS F reported Resident #101 was ambulatory, had a BIMS of 0, and at times she would say some pretty funny stuff, and she had no issues with being combative. CNS F reported there was a behavior log and during morning meeting those were reviewed.In an interview on [DATE] at 11:26 AM, NP D reported she chose to place Resident #101 on Ativan due to her dementia, wandering, and agitation. NP D reported the staff had made multiple attempts to redirect her, she had memory concerns, resident was going into other resident's rooms, and any attempt to intervene she would become agitated and prescribed Ativan to calm Resident #101 down a little bit, so she would wander less. NP H reported medical decision making was a collaboration with the staff and for everyone's benefit. NP H reported she had consulted initially with the pharmacist when she started the Ativan. NP H reported part of her decision-making process, she would speak with the decision maker and in this case the daughter. NP H reported she had spoken in person once with her daughter. NP H reported she may or may not have attempted to call her. NP H reported there was a meeting monthly for residents who were prescribed psychiatric medications, and the resident would be assessed at that meeting for any changes or concerns with the medications and/or behaviors and she would attend that meeting. NP H did not indicate if Resident #101's falls were discussed at these monthly meetings. In an interview on [DATE] at 5:14 PM. Pharmacist RR reported she would review the resident's blood pressure, labs, and check to see if the resident was having behaviors and side effects with those medications, reports of patients of agitation, behavioral log and if the facility had done the GDRs (gradual dose reduction), and within the guidelines. Pharmacist RR reported there was a monthly meeting every third Wednesday where those in attendance discussed if the patient had out of the ordinary type of behaviors and discuss those behavior changes. Pharmacist RR reported a limited view of the electronic medical record as a contractor and had no ability to pull reports such as falls or missed medications and she was very reliant on the facility to provide her with the information when she did her medication reviews. Pharmacist RR reported she was not aware that Resident #101 had an increase in falls after the addition of Lorazepam to her medication regimen. Review of policy, Medication Management - Continuing Care (Rehab and Nursing Centers) dated [DATE], revealed, .The purpose is to ensure each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, free from unnecessary drugs and outline the process for safe administration and storage of medications. administration of the medication based on resident response.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: Chart Review: [DATE] All residents' charts were reviewed to identify all residents on psychotropic medication to ensure adequate monitoring. A total of 61 residents were identified as taking anti-anxiety medication/ antipsychotics/antidepressants or any mood stabilizers. Worklist task/Order Implementation: [DATE] Worklist tasks have been created for all 61 residents to monitor for adverse reactions to psychotropics. Each task specifies the medication class and symptoms to monitor. Consent forms: [DATE] All residents on psychotropic medications were audited for consent forms. Any resident missing a consent form now has one completed and awaiting signature. The goal is to obtain all signed consents by [DATE]. Completed consent forms will be uploaded to Epic. Provider Education: On [DATE], the Medical Director was educated via telephone by the DON on F605 regulations, with emphasis on the appropriate use of psychotropic medications. A list of all residents on psychotropics was provided. The two Nurse Practitioners will be educated on [DATE]. Behavior Monitoring: Behavior logs are reviewed daily during the Interdisciplinary Team (IDT) meeting, including review of care plans for affected residents. Nurses were previously educated on [DATE] regarding the requirement to implement non-pharmacological interventions prior to initiating psychotropics. The social worker is aware of this expectation, and the second social worker will be educated on [DATE]. Nursing Education: Re-education for nurses began on [DATE], led by the DON, for all nursing leaders and on-duty staff. Education will continue throughout [DATE], and no nurse will be permitted to work until this education is completed after [DATE]. Ongoing Monitoring: The DON or designee will pull an Epic report weekly to identify newly prescribed psychotropics and verify that consent forms and monitoring tasks are in place. New symptoms will be reviewed daily during the IDT meeting and communicated to providers using the SBAR format. Social Work Education: Social workers were previously educated on obtaining consent for psychotropic medications. On [DATE], one social worker was re-educated by the DON, and the second will be re-educated on [DATE]. Consultant Pharmacist Education: On [DATE], the consultant pharmacist was educated by the DON on the medication review process and verbalized understanding.

This citation pertains to intake: 2614764Based on interview and record review, the facility failed to ensure residents maintained their right to self-determination in 1 of 1 resident (Resident #100) reviewed for choices, resulting in frustration with not being able to go to sleep at a preferred bedtime, an altercation with staff and a left fractured humerus. Findings include: Resident #100: Review of an admission Record revealed Resident #100 was a female with pertinent diagnoses which included chronic pain, contracture of the left upper arm, debility, stroke, paralysis affecting left side, and dementia. Review of current Care Plan for Resident #100, revised on 3/24/25, revealed the focus, .(Resident #100) may refuse to return to her room for incontinence care or go to bed at a reasonable time. with the intervention .Assess decision making ability.Provide a consistent daily routine.Environmental precautions (confusion).Assess for mood changes.Reality orientation as needed. Review of Event Summary Report dated 9/2/25, revealed, .Resident complained of pain with staff nurse during first shift. Nurse assessed resident's pain area, including skin. Nurse found that left arm and shoulder area was swollen compared to the right arm and shoulder area, Resident given pain medication as ordered.Resident reported that her arm was pulled during care, and she has a diagnosis of closed fracture of surgical neck of left humerus.Review of ED Course dated 9/2/25 at 12:28 PM, revealed, .presents to emergency department via EMS for acute onset left shoulder pain.at her care facility when a nurse pull on her arm, she had significant pain noted to the left shoulder.had a previous stroke and has no motor function to the left upper extremity.Patient is sitting in bed uncomfortable appearing. Significant exam findings include significant tenderness palpation of the left shoulder with overlying swelling. No significant bruising or redness to the area. Review of ED (Emergency Department) Provider Notes dated 9/2/25 at 2:37 PM, revealed, (Resident #100) is a [AGE] year old female who presents to the ED (emergency department) for evaluation of L (left) shoulder pain. Patient reports she felt like her arm got yanked and she now has LUE (left upper extremity) pain. She denies other falls or trauma. Patient reports pain is terrible; she received 100 mcg fentanyl en route. Patient is main historian.On exam, patient is awake, alert, conversant .Patient is sitting in bed, LUE abducted, no pain over the L elbow, forearm, wrist, or hand, limited ROM (range of motion) of LUE which patient reports is at baseline. Swelling and tenderness noted to the L lateral (side) shoulder. Distal radial pulse 2+, distal sensation intact.XR (x-ray) obtained of L shoulder, L elbow, L hand.Imaging shows L humeral neck fracture.Sling placed advised to follow up within 5 days with ortho. During an observation on 09/24/25 at 10:33 AM, observed Resident #100 in the dining room she had on a sling for her left arm, she had a tray table on that side of the wheelchair, she had a bag with tissues, binder, papers, clipboards in it, and she had anti-tippers on the back of her chair which were shiny and looked new. In an interview on 09/24/25 at 2:22 PM, Resident #100 reported she wasn't doing so good, she reported someone had lifted her arm up and broke her arm, and when queried further she was unable to tell this writer what had happened to her. In an interview on 09/25/25 at 10:24 AM, CNA Y reported Resident #100 was upset and agitated when she had arrived at work earlier in the day. CNA Y reported she decided to leave her alone. CNA Y reported Resident #100 never wanted to lay down or go to bed. CNA Y reported between 9:00 PM and 10:00 PM, she started to get residents in bed, and she took Resident #100 to her room to lay her down, indicated it was common for her not to want to go to bed, and Resident #100 didn't want to lie down even for brief changes. CNA Y reported so she took her to her room to take her clothes off and put her in bed, and she started to swing her right arm at me as she was taking her shirt off when she reached her left arm to raise it up to take the shirt off, Resident #100 started fighting and screaming at her. CNA Y reported when she started fighting, she had left the room to go seek assistance from other staff. CNA Y reported she was swinging her right arm at her and had a pencil in her hand. CNA Y reported she had never seen Resident #100 act like that as she usually complied when took her to her room to change her and get her into bed. CNA Y reported Resident #100 did have behaviors but nothing like she had that night. In a second interview on 9/29/25 at 2:43 PM, CNA Y reported she had Resident #100's shirt off and had one of her arms in her gown, her right arm and that was when she started to fight. CNA Y reported she just left her alone and went to go get help from another staff member. CNA Y reported she had someone else to help to try to finish her getting ready for bed, CNA Y reported Resident #100's gown was on but not on her completely, but her shirt was off. CNA Y reported CNA FF came to Resident #100's room to assist and when she came in the room and she was still wanting to fight, we didn't' do anything else to help, left the room and went to inform the nurse. CNA Y reported Resident #100 still would cry when it was time to get in bed, but she will calm down once she got into bed. In an interview on 9/29/25 at 7:45 AM, CNA FF reported that she went into the room and Resident #100 was swinging her arm, yelling do not touch me, so she didn't say anything or do anything with Resident #100. CNA FF reported she just turned around, walked back out and went to tell the nurse. CNA FF reported as she left Resident #100's room, CNA KK was entering her room. In an interview on 9/29/25 at 1:44 PM, CNA KK reported (CNA Y) and (CNA FF) approached the nurse's station reported Resident #100 refused to go to bed. CNA KK reported she walked to Resident #100's room to assist them. CNA KK reported she was informed Resident #100 was very irritable and tried to hit them. CNA KK reported when she entered Resident #100's room she was not attempting to hit her; she had no issues with Resident #100. CNA KK reported Resident #100 had already had her gown on and the Hoyer was in the room to get her into her bed. CNA KK reported if she had explained to Resident #100 it was getting late, and she was trying to get in to bed before the next shift, she would comply with her. CNA KK reported Resident #100 did not want either CNA Y and CNA FF in the room to assist with placing her in her bed. CNA KK reported she had hooked up the Hoyer sling and transferred Resident #100 to her bed. CNA KK reported Resident #100 was crying and upset with them, called them all sorts of names. CNA KK reported Resident #100 typically gets upset and can cuss you out when she had to go to bed. CNA KK reported she had never seen Resident #100 hit at other staff just agitated with them. CNA KK reported after she had got her in bed and changed, she went later to check on her and Resident #100 was sleeping. CNA KK reported Resident #100 had woken up approximately 3:00 AM and she was painful on her left shoulder. CNA KK reported she wanted the nurse to give her some Tylenol because her arm was hurting. Licensed Practical Nurse (LPN) T gave her some Tylenol, and she went back to sleep. CNA KK reported if a resident was resistive to going to bed and were attempting to get the resident undressed, staff should just leave them and go back a little later or set up a time with the resident to start to get ready for bed. In an interview on 09/25/25 at 09:51 AM, CNA HH reported she worked with Resident #100 on restorative care. CNA HH reported exercises were not done on the left arm as she had contracture of her shoulder. CNA HH reported Resident #100 would pull up her arm to move it, she kept it on the lap tray on her wheelchair. CNA HH reported Resident #100 was able to lift the elbow up so she can move it to place on the lap tray but can't' move it up and definitely not attempt to extend her arm. CNA HH on shower days she was able to get under her left arm to clean the area and to put her tops on. CNA HH reported the arm does not have forward or backward movement. CNA HH reported when she went to perform care on Resident #100 on 9/2/25, she rolled her over on to her left side, she started to cry out, cry and she was in agony from the pain. CNA HH reported she did not exhibit pain like that prior when care was performed, it was not normal for her to act that way. CNA HH went and informed the nurse of her pain on the left side. CNA HH reported Resident #100 had not told her what had happened. CNA HH reported Resident #100 was crying hysterically and she went to touch her arm to look at it and she screamed out in pain. CNA HH reported when queried Resident #100 reported it was a staff member who had red hair or what looked like red hair to her. CNA HH reported the nurse supervisor sent her out for an x-ray of her arm. CNA HH reported when EMS arrived the shoulder was red and swollen and it looked like it had been broken. In an interview on 09/24/25 at 12:50 PM, CNA EE reported she reported Resident #100 was a restorative get up, and the restorative aide went in there and Resident #100 was crying and in pain, indicated they broke her arm went and got the nurse. Resident #100 reported to nurse, CNA EE and the restorative aide, they broke her arm, when she was asked who she said the lady with the red hair. The staff asked her how it happened, and she motioned her left arm was lifted up. CNA EE reported Resident #100 kept repeating to EMS they broke my arm. CNA EE reported Resident #100 liked to stay up at night and was up first thing in the morning. CNA EE reported Resident #100 did not like to lay down for check and change as she thought staff were going to have her stay in bed. In an interview on 09/24/25 at 2:23 PM, Registered Nurse (RN) S reported Resident #100 was usually up and goes around the building. RN S reported she was told Resident #100 was in the dining room cursing at the CNAs as she was told it was time to go to bed and when they took her to her room she had started to fight the staff. RN S reported another CNA assisted and placed Resident #100 in bed. RN S reported she was in the room with another resident when she heard Resident #100 yelling, she didn't want her (CNA) to use the lift, she was refusing the use of the lift. RN S reported Resident #100 wanted to stay up and she would usually refuse to go to bed. RN S reported this event happened around 10:00 PM and indicated Resident #100 could have stayed up and night shift could have put her in bed. During an observation on 09/25/25 at 09:34 AM, Resident #100 was self-ambulating down the hallway. She had grimacing on her face, and she said she was in pain, but the nurse had given her pain medication, and she was waiting for it to kick in. Review of Behavior Log dated 9/1/25 at 4:00 PM, revealed, .Behavior: Patient was swearing, and swinging hitting & kicking because she didn't want to go to bed. I left the room to get assistance to calm her down. Another aide took over and put her to bed for me.(CNA Y). Review of Care Management Note Addendum dated 9/3/35 at 1:11 PM, .SW (Social worker) asked what happened with her left arm and she said it was pulled by one of the aides. When asked she said she thinks she feels safe in the facility.Review of Progress Note dated 9/3/25 at 12:04 PM, revealed, .SUBJECTIVE: (Resident #100) is a 78 y.o. (year old) female seen today for acute visit, post ED visit yesterday. Information based on staff report, chart review and conversation with patient .Resident with a history left sided hemapheresis (paralysis on one side of the body) due to a history of CVA (cerebrovascular accident), She is noted to have left hand contracture (structural changes in the body's soft tissues, like muscles, tendons, ligaments, and skin that cause them to stiffen and shorten, can limit range of motion, and cause pain) at baseline. She is usually seen wheeling herself around the building independently using her right hand to control her wheelchair, with left hand elevated on wheelchair support. At baseline, patient has chronic pain managed with fentanyl. At the beginning of the shift yesterday, patient complained of pain that was worse than her usual baseline. At the time, staff noted that patient was complaining of left shoulder pain with touch. She reported her pain as being 10/10. Patient was transferred to ED for further evaluation. At the ED, she reported that her arm was pulled during care .Care giver indicated that she did not pull the arm up any higher than usual. It was noted that patient was agitated in the evening prior to care. She was upset because of a missing bag, of which the bag was found. But that set off her mood to where she was unusually combative with care.Assessment & Plan: Acute pain of left shoulder.Resident sent to ER to evaluate acute shoulder pain.Closed fracture of surgical neck of left humerus.Scheduled for orthopedic consult on 9/8.Sling to support shoulder- continue monitoring Pain medication to keep patient comfortable Transfer to ED if symptoms worsen. In an observation on 9/29/25 at 8:50 AM, Resident #100 was observed in the seating area at entry, she was dressed, had on her sling, she was grimacing as in pain. In an interview on 09/25/25 at 10:56 AM, Clinical Nurse Supervisor (CNS) G reported the floor nurse went to assess Resident #100 that morning and they were not able to touch that extremity without causing pain. CNS G reported it was recommended she have an x-ray right away to see what was happening to her left arm/shoulder. CNS G reported she had received report from the ER; Resident #100 had a fracture. CNS G reported it was believed the break happened the night before when Resident #100 was agitated. CNS G reported Resident #100 typically didn't want to do to bed or get in bed. CNS G reported staff could've let her know they would be back in a little bit to get her ready for bed, take care to know her likes and dislikes, maybe distracted her with activities she liked. CNS G reported Resident #100 had behaviors, but it wouldn't linger too long. CNS G reported Resident #100 liked to get up to go to activities, she self-ambulated around the facility, and would joke with staff as well. CNS G reported it was Resident #100's right to not go to bed, staff would leave her, reapproach her again later, and explain what they could do to help her. CNS G reported staff could have provided a diversional activity and developed a compromise with the resident to go to bed after the activity was completed. Review of Your Rights and Protections as a Nursing Home Resident, revealed, .As a nursing home resident, you have certain rights and protections under Federal and state law that help ensure you get the care and services you need. Be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in the activities you choose. You have the right to decide when you go to bed, rise in the morning, and eat your meals. Be Free from Abuse and Neglect: You have the right to be free from verbal, sexual, physical, and mental abuse.If you feel you have been mistreated (abused) or the nursing home isn't meeting your needs (neglect), report this to the nursing home, your family, your local Long-Term Care Ombudsman, or State Survey Agency. The nursing home must investigate and report all suspected violations and any injuries of unknown origin within 5 working days of the incident to the proper authorities.

Based on record review and interview, the facility failed to implement care plan interventions and the facility policy to prevent falls in 1 of 7 residents (Resident #102) reviewed for fall prevention, resulting in the potential for falls and injury. Findings includeResident #102:Review of an admission Record revealed Resident #102 was a male with pertinent diagnoses which included dementia, confusion, incontinence, reduced mobility, fall risk, and end stage Alzheimer's disease. Review of current Care Plan for Resident #102, revised on 9/5/2025, revealed the focus, .(Resident #102) does not want to experience a fall resulting in major injury. with the intervention .Bed in low position.Accompany resident (ex. 1:1, stand by assist, dayroom monitoring, 15 min checks, line of sight).Visual checks per facility policy. Review of Resident Care Summary dated 9/8/25, revealed, .Safety: Bed by all for increased floor space.Fall mattress next to open side of bed for increased protection from injury.Review of Event Summary Report dated 9/5/25, revealed, .Safety: Bed by wall for increased floor space (fall mattress) 9/4/25 at 10:00 PM.Bed Mobility: Supervision/Touching (9/4/25 4:00 PM). Summary of Events: CNA (Certified Nursing Assistant) walked by room to see resident getting out of bed and sliding to the floor in a sitting position. Resident said he was trying to leave.Resident was gotten up in wheelchair and placed by nurses' station. Full thickness mattress placed by resident bed for additional protection from injury should another fall of a similar nature occur.Referred to Quality Assurance for further review .Investigation: This resident was extremely confused at the time of admission. The fall occurred several hours after admission. The new environment was likely a contributory factor. The resident seemed unaware that he could not walk and thought he could leave. When he attempted to stand, he slid to the floor. The low bed prevented injury. Staff appropriately got the resident out of bed and kept him under observation near the nurse's station.IDT (Interdisciplinary Team) Recommendations: Resident reviewed with Interdisciplinary team r/t (related to) his recent fall. Risks, current status and interventions reviewed. Resident is at risk for falls R/T confusion, weakness and lack of safety awareness. Risks, current status and interventions reviewed and remain appropriate at this time. Recommend to continue with current plan of care and implement the following changes to plan of care: One side of bed was placed next to the wall, and a full thickness mattress was placed on the other side of the bed-to be used whenever the resident is in bed. Resident's care plan and care summary have been updated appropriately. During an observation on 09/24/25 at 2:10 PM, Resident #102 was observed in bed, fall mattress was placed on its side at the side of his bed, not next to the bed lying flat on the floor. During an observation and interview on 09/24/25 at 2:11 PM, Licensed Practical Nurse (LPN) O was observed placing the fall mattress on the floor next to Resident #102's bed. She placed a wedge on his right side and tucked it under him; enabler bar was up on the right side. LPN O reported she was in the room diagonal, across the hallway giving medication to another resident, and she was coming to see Resident #102 in a second. LPN O reported the CNA should have laid down the mattress when she left the room. In an interview on 09/24/25 at 2:17 PM, CNA EE reported she had to take his roommate out in his wheelchair, and she had forgot to lay the fall mattress back down on the floor next to Resident #102's bed. CNA EE reported she thought LPN O was going to go right in Resident #102's room but she should have laid it down. In an interview on 09/25/25 at 1:27 PM, Clinical Nurse Supervisor (CNS) G reported Resident #102 had been a resident at the facility a couple of weeks. CNS G reported the staff were keeping a closer eye on him as he was a fall risk, have him in the open area so more eyes can be on him. CNS G reported the fall mattress was in place for Resident #102 in case he would roll out of bed. Resident #102 can be redirectable approximately 80% of the time but he does attempt to get up out of his chair as well. In an interview on 09/24/25 at 10:25 AM, Director of Nursing (DON) B reported the facility was using fall mattresses and fall mats for residents who had falls or were fall risks. Review of policy, Falls: Risk Screening, Prevention, and Post Fall Follow Up dated 7/21/24, revealed, .To outline the process to identify fall risk, interventions to prevent falls and patient or resident injuries, and to outline the required process for post fall follow-up for rehab and nursing centers .A patient fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can). When a patient rolls off a low bed onto a mat or is found on a surface where you would not expect to find a patient, this is considered a fall. If a patient who is attempting to stand or sit and falls back onto a bed, chair, or commode, it is only considered a fall if the patient is injured .Care planning and evaluation will be completed by a licensed nurse who will initiate and update the plan of care and interventions to address risk for falls in the electronic health record (EHR) .Rehab and Nursing Centers: 1. Assess the resident/patient for injury and circumstances surrounding the injury and determine if the resident/patient can be moved safely. In cases where the resident/patient may not be moved safely, contact appropriate medical providers, staff, or emergency medical response team for assistance. 2. Evaluate and monitor resident by placing the post-fall assessment order. 3. Check blood glucose for diabetic patients. 4. Notify the appropriate individuals including the physician/designee and family members.5. Review the resident's care plan and update as indicated incorporating interdisciplinary team feedback .

Based on observation, interview and record review, the facility failed to prevent the risk of urinary tract infection and ensure urinary catheter tubing and drainage bag were not resting on the floor in 2 of 2 residents (Resident #102, #105) reviewed for urinary catheter use, resulting in the potential of a urinary tract infection.Findings include: .A CAUTI (Catheter associated urinary tract infection), or a UTI associated with a catheter, is common if you have an indwelling catheter inside your urethra.Symptoms are similar to a general UTI and include bloody or cloudy urine, gritty particles or mucus in your urine, urine with a strong odor, pain in your lower back, chills and fever. (https://www.healthline.com/health/sediment-in-urine)Resident #103: Review of an admission Record revealed Resident #103 was a male with pertinent diagnoses which included stroke and gross hematuria (blood in urine). During an observation on 09/24/25 at 2:32 PM, Resident #103 was observed lying in his bed, bed was low to the ground, and his catheter bag was on the floor without a barrier under it. Licensed Practical Nurse (LPN) V entered the room and confirmed the catheter bag was on the floor. LPN V obtained a towel and placed it under the catheter bag she had placed on the fall mattress next to Resident #103's bed. In an interview on 09/25/25 at 12:48 PM, Clinical Nurse Supervisor (CNS) F reported Resident #103 had a foley and was diagnosed gross hematuria. CNS F reported the foley catheter was last changed in August 25. Resident #105: Review of an admission Record revealed Resident #105 was a female with pertinent diagnoses which included dementia, insomnia, diabetes,Review of current Care Plan for Resident #105, revised on 10/23/24, revealed the focus, .(Resident #105) has an indwelling catheter and is at risk for health care complications. with the intervention .Secure foley.Keep catheter tubing free of kinks. Keep drainage bag below level of bladder. During an observation on 09/24/25 at 11:31 AM, Resident #105 was observed self-ambulating in her wheelchair, she had the catheter bag in a privacy bag, but the tubing was dragging on the floor from when it came down the front of the chair into the privacy bag under her chair. There was approximately 12 inches of catheter tubing running along the floor as she ambulated around the building. During an observation on 09/24/25 at 11:36 AM, staff had stopped to assist Resident #105 with her blankets, and after Resident #105 headed in the other direction the catheter tubing was still dragging along on the ground under the wheelchair. The urine in the tubing appeared to be dark yellow in color with an orange tinge to it as well as cloudy in appearance. During an observation on 09/25/25 at 09:14 AM, Resident #105 was observed in the back 200 hallways, self-propelling down the hallway. The catheter bag was in the privacy bag, which was dragging on the ground, the tubing was draped down the front of her wheelchair and tucked in the bag and the tubing was dragging on the floor underneath the chair into the catheter bag. In an interview on 09/25/25 at 09:19 AM, LPN R reported Resident #105 had had recurrent urinary tract infections. Review of Comprehensive Visit dated 9/9/25 at 6:23 PM, revealed, .Note based on chart review and conversation with staff. Resident was seen wheeling herself around the building .Staff reported that she has been confused recently, more than her baseline. Orders for UA (Urinalysis) to rule out UTI (urinary tract infection) .Review of Urinalysis (UA) Do Culture if Indicated results note dated 9/9/25 at 7:40 PM, revealed, Resident #105 had yellow .turbid, cloudy .trace of blood .protein .Large leukocyte esterase .white blood cells .bacteria- many .In an interview on 09/25/25 at 1:02 PM, CNS F reported Resident #105 had a UTI earlier this month, the catheter was changed on 9/9/25 and she was prescribed an antibiotic. CNS F reported the catheter tubing should not be dragging on the floor as it contaminated the tubing, and then the bag. In an interview on 9/29/25 at 3:27 PM, Infection Preventionist (IFP) E reported the catheter tubing should not be dragging on the ground, because the floor was dirty and the catheter tubing was connected to the catheter bag and can lead to contamination.Review of policy, .Urinary Catheter Care and Management Policy - Rehab and Nursing Centers dated 4/21/24, .Indwelling Collection Devices: A closed sterile urinary drainage system .Indwelling Urinary Catheter - A catheter placed in the bladder via the urethra, with the intent to remain in place after insertion, to provide continuous urinary drainage to an external collection device .Maintain catheter tubing and drainage bag off the floor .

This citation pertains to intake: 2568667Based on interview, and record review, the facility failed to obtain informed consent for psychotropic medications for 1 of 7 (Resident #101) residents reviewed for psychotropic medications, resulting in the resident/resident representative's inability to make decisions on risk vs benefit of medication use and alternative treatment options. Findings include: Resident #101:Review of an admission Record revealed Resident #101 was a female who was admitted on [DATE] with pertinent diagnoses which included severe late onset Alzheimer's dementia with agitation, ground level fall, insomnia, and depression.Review of all Care Plans for Resident #101, revealed no focus or interventions for the use of psychotropic medications with monitoring for adverse consequences. Review of Order dated 5/9/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.5 mg Oral, nightly, Associated Diagnosis: Other insomnia. Review of Order dated 5/29/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.5 mg Oral, Once, 1200.Associated Diagnosis: Other insomnia.Anxiety Disorder.Review of Order dated 6/4/25 for Resident #101, revealed, .Lorazepam (Ativan) tablet 0.25 mg Oral, 3 times daily, PRN (As needed).Associated Diagnosis: Anxiety Disorder.In an interview on 9/24/25 at 3:27 PM, Family Member/Durable Power of Attorney (DPOA) (FM) OO reported when Resident #101 was admitted to the hospital following a fall on 6/8/25, she was informed Resident #101 was being given Lorazepam at night which she was not aware Resident #101 had been receiving that medication. FM OO reported she did not give her permission for Resident #101 to take Lorazepam and because Resident #101 was so mobile she felt that Resident #101 should not have been put on that medication.Review of Psychotropic Medication Risk/Benefit Consent dated 4/17/25 revealed, no consent for the Lorazepam orders were completed and there was no signature. The document only indicated FM OO was a participant as of 9/25/25. No documentation submitted to indicate consent was provided verbally. In an interview on 9/25/25 at 09:07 AM, Social Worker (SW) H reported consents for medications would be signed electronically by the decision maker or resident when admitted or when there was a change in medications where consents were needed. SW H reported she would be able to call the decision maker to obtain verbal permission from them with two person's present as witnesses. SW H reported also if the decision maker was not able to come to the building and electronically sign the document, the consent could be sent out to them for signature and social work would have to follow up for return. SW H reported there was not a standard of work process in place from corporate on consents. SW H was unable to locate notes for Resident #101 as well as notes which had indicated a conversation had been had with the decision maker for the prescribed lorazepam medications.During an observation and interview on 09/25/25 at 2:32 PM, Nurse Liaison C reported that there was no documentation in Resident #101's record that there was a verbal consent received for Lorazepam.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: During an initial tour of the kitchen, at 10:32 AM on 3/3/25, an interview with Certified Dietary Manager (CDM) Z found that the maintenance staff takes care of the ice machine cleanings and has a vendor that comes and deep cleans the machines. Observation of the dispensing spout of the ice machine found an increase accumulation of black and brown debris on the surface of the inside spout. During a tour of the main kitchen, at 10:35 AM on 3/3/25, observation of the microwave found increase accumulation of debris on the inside top portion of the unit. Further review of the unit found chipping and degrading surfaces on the inside. During a tour of the main kitchen, at 10:39 AM on 3/3/25, an interview with CDM Z found that staff clean the utensil drawer weekly. Observation of the three utensil drawers found that two of the drawers, containing tongs and mechanical scoops, were found with increased accumulation of crumb debris on the back portion of the drawers. During a tour of the hallway ice machine, at 11:23 AM on 3/3/25, it was observed that on the floor behind the ice machine found an increased accumulation of items and debris. Items on the floor included a box of single use straws, a package of plastic lids, and a stack of Styrofoam cups. Portions of old wet pieces of broken ceiling tile were also found behind the ice machine. CDM Z stated that there was a leak in that area and some tiles were replaced. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During a tour of the kitchen, at 10:37 AM 3/3/25, it was observed that an open gallon container of soy sauce was stored under the preparation table. A review of the container found that it stated to Refrigerate After Opening. According to the 2022 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less. During a tour of the dish machine area, at 10:48 AM on 3/3/25, an interview with CDM Z found that staff have been working with a new log, but have not been great about routinely filling it out to help ensure the dish machine is working properly. At this time, a staff member was de-liming the dish machine and only one day worth of dish machine log was available to review. When asked if the dish machine was tested regularly, CDM Z stated they were using the an irreversible registering dish plate thermometer, but staff stated the device was not working properly. During a revisit to the kitchen, at 11:46 AM on 3/3/25, it was observed that the dish machine's data plate, which shows its minimum operational requirements, states the machine has a Wash tank minimum temperature: 160F. Through running five cycles of the dish machine, it was not able to achieve the minimum wash temperature as well as the FDA food codes minimum internal contact temperature of 160F. The wash temperature gauge was observed between 150F-160F and two irreversible registering thermometers read between 150F-158F through the five cycles. CDM Z stated that she would reach out to their vendor and have it checked out. During a revisit to the kitchen, at 11:45 AM on 3/4/25, observation of the dish machine found the same results as the day before. CDM Z stated the vendor was coming in today to look over the machine. A revisit to the kitchen, at 3:02 PM on 3/4/25, found the vendor working on the dish machine. After that the vendor turned up and adjusted the booster heater, the machine was observed achieving temperatures above the minimum requirements. According to the 2017 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature. According to the 2017 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions . During an interview with CDM Z at 9:40 AM on 3/3/25, it was found that staff do not cool food from service or preparation and do not keep cooling logs. During a review of the walk-in cooler, at 9:41 AM on 3/3/25, it was observed that the following items were found saved from meal service the previous day, a gallon container of chili, creamy vegetable soup, and a cooked pork loin. All three items were 42F when a temperature of the items were taken with a rapid read thermometer. When asked how these items were cooled, CDM Z stated they probably used the walk-in freezer, but we don't usually save food, so I am going to discard. During a revisit to the kitchen, at 3:25 AM on 3/4/25, it was observed that a six-inch deep 1/4 pan of pork gravy was found in the walk-in cooler, tightly covered in tin foil and dated 3/4. At this time, a temperature of the food product was found to be 69F. When asked if she knew about the pork gravy or what it was saved for, CDM Z was unsure and discarded the product. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD.

This citation has two Deficient Practice Statements DPS A Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: During a tour of the facility with, Maintenance K and Regional Maintenance HHH, starting at 9:50 AM on 3/4/25, it was found that Maintenance K is newer to the facility and has not been involved much in the water management plan. When asked if he was aware of regular flushing the facility is doing on minimum use or unused domestic water fixtures, Maintenance K was unaware. Regional Maintenance HHH stated some facilities do a wasting water Wednesday, but he is not sure what's done here. During a tour of the front 200 soiled utility room, at 9:52 AM on 3/4/25, observation of the hopper spray found brown and discolored water momentarily came out of the hose when flushed. During a tour of the front 200 spa room, at 9:55 AM on 3/4/25, it was observed that a wheelchair washer was in the process of being installed and the rooms is not currently used for showers, as residents have personal showers in their rooms. When asked if this area is flushed, Maintenance K was unsure. During a tour of the back 200 spa room, at 10:15 AM on 3/4/25, it was observed that brown water was found in the spa commode. Further observation found that there were multiple dried brown lines in the basin of the commode indicating that the water evaporated slowly over time with no routine flushing. A spa tub was observed in this room, when asked if this tub is regularly used, Maintenance K stated he didn't think it was used much. When asked if it was flushed regularly, he was unsure. During a tour of the back 200 soiled utility room, at 10:29 AM on 3/4/25, it was observed that brown water was flushed out of the hopper spray. [NAME] and discolored water remained for roughly three seconds before starting to run clear into the hopper. During an interview with Regional Environmental Health and Safety (EHS) GGG, Regional Maintenance HHH, and Maintenance K, at 10:44 AM on 3/4/25, regarding the water management plan, it was found that the facility did not have an active team onsite that oversaw the plan and provided an annual review of the program. When asked if the facility uses supplemental disinfection or secondary treatment of the domestic water supply, Regional EHS GGG stated that they do. When asked if the treatment system is permitted through the state department of Environment Great Lakes and Energy, Regional EHS GGG was unsure and said she would have to reach out and see. When asked about routine flushing, it was stated that the housekeeping department flushes fixtures in the facility. During a tour of the back 100 soiled utility room, at 11:25 AM on 3/4/25, it was found that the spray wand was turned off at the foot pedal. The surveyor used the plumbing key on the foot pedal to turn the water on to flush the spray wand. At this time, the spray wand ran brown and discolored water for roughly 5 seconds before running clear. When the hopper was attempted to be flushed, it was found with a stuck flush valve and didn't allow the hopper to remove the discolored water from its basin. A follow up interview with Regional EHS GGG, at 2:47 PM on 3/4/25, found that she had reached out about the permit and found they were in the process of obtaining the permit, but there was not currently a permit for the secondary treatment in use. During a tour of the back 100 spa room, at 2:43 PM on 3/4/25, found that the commode was empty with no water in the basin. When flushed, the commode refilled with water, indicating that the fixture had not been used in so long that all of the water had evaporated from the commode between since last flush. During a tour of the front 100 spa room, at 2:50 PM on 3/4/25, found that it had a spa tub available for use. An interview with the Nursing Home Administrator (NHA) at this time found that residents don't use the tubs regularly. A review of the document entitled Water Safety and Management Plan, revised 3/23/24, found that under section 5.8 Potable Water Systems Preventative Maintenance and Operation Procedures it states that, If distal outlets (sinks, showers) are in a room or space that has been unoccupied for seven consecutive days the outlets shall be flushed to move fresh water through the system . The policy goes on to state that Flushing and commissioning of potable water systems is performed to remove physical debris, sediment, and air from the piping system and to provide a level of disinfection to reduce the presence of microorganisms in the water system . 47955 DPS B 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 2 (Resident #52 and Resident #65); 2. Ensure proper PPE (personal protective equipment) for enhanced barrier precautions were used during medication administration via a G-tube (a tube placed directly into the stomach and used for nutrition, hydration, and medication administration) in 2 (Resident #1 and Resident #29); 3. Ensure proper PPE for enhanced barrier precautions were used during a G-tube dressing change in 1 (Resident #1); and 4. Ensure the cleanliness of a feeding pump pole in 1 (Resident #1) of 22 total sampled residents reviewed for infection control practices resulting in the potential for the introduction of infection, cross-contamination, and disease transmission. Findings include: Resident #52 Review of a Face Sheet revealed Resident #52 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: cognitive deficits following a non-traumatic intracerebral hemorrhage (bleeding in the brain), hemiparesis (paralysis) on the left non-dominate side, and debility. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 12/4/2024 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #52 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). On 3/5/25 at 10:29 AM., Certified Nurse Assistant (CNA) QQ was observed providing incontinent care to Resident #52. CNA QQ was wearing gloves, and removed Resident #52's soiled brief, retrieved a washcloth, soaked it in soapy water in a basin, and proceeded to provide peri-care (cleaning of the private area of a body). CNA QQ then assisted Resident #52 to roll onto her left side, and with the same gloved hands reached for a clean washcloth, soaked it in the same soapy water in the basin, and provided peri-care again. CNA QQ removed the soiled brief, placed a clean brief, and assisted Resident #52 to roll to her right side. CNA QQ then, with the same gloved hands, positioned the clean brief and secured it. CNA QQ was observed with the same gloved hands adjusting Resident #52's gown, and blankets on the bed. At no time during incontinence care (dirty to clean) did CNA QQ change her gloves or perform hand hygiene. Resident #1 Review of a Face Sheet revealed Resident #1 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dysphagia (difficulty swallowing), functional quadriplegia (no purposeful or intentional movement of the arms or legs), and G-tube feedings (nutrition supplies to the G-tube). Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 11/26/2024 revealed a Brief Interview for Mental Status (BIMS) score of 0/15 which indicated Resident #52 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). Review of Medication Order for Resident #1 revealed Promote 1.0 with fiber liquid per G tube, 75mg/hour daily with a start date of 12/3/24. Review of Other Orders for Resident #1 revealed initiate Enhanced Barrier Precautions continuous with a start date of 4/23/24. In observations on 3/3/25 at 9:27 AM., 3/4/25 at 7:49 AM., and 3/5/25 at 7:58 AM., the feeding pump pole present in Resident #1's room next to the head of her bed was noted to be soiled with dried formula on the pole and base. In an observation on 3/5/25 at 7:58 AM., Registered Nurse (RN) EEE while wearing gloves, disconnected the feeding tube, and then removed the split gauze dressing from Resident #1's G-tube, RN EEE soaked down gauze with normal saline, cleansed around the G-tube insertion site, retrieved dry gauze, dried around the G-tube site, and applied a new split gauze around Resident #1's G-tube. RN EEE then secured the dressing to Resident #1's skin with tape. RN EEE then repositioned the over the bed table with the same gloved hands, opened drawers on the bed side stand and rummaged through the drawers to locate the piston syringe. RN EEE then used the piston syringe (a type of syringe used for medical purposes with a G-tube) to check residual (formula that had been undigested in the stomach) from Resident #1's G-tube with the same gloved hands. RN EEE then administered medications through Resident #1's G-tube wearing the same gloves. While RN EEE was administering Resident #1's medication through her G-tube, Resident #1's feeding pump began alarming. RN EEE reached with her gloved hand to push the button to silence the alarming pump. When RN EEE was done administering Resident #1's medications, with the same gloved hands, RN EEE repositioned the fall mat on the floor next to Resident #1's bed. At no time during this observation did RN EEE wear a gown or change her gloves or perform hand hygiene. In an interview on 3/5/25 at 8:05 AM., RN EEE confirmed that Resident #1's feeding pump pole was soiled and reported that it would not come clean, and the dried formula wound need to be scrapped off. When queried about who cleaned the feeding pump poles RN EEE stated night shift nurse or EVS (environmental services personnel). I don't have time to read their job descriptions, I have enough to do. In an interview on 3/5/25 at 8:14 AM., upon exiting Resident #1's room with RN EEE this surveyor queried RN EEE about the signage noted on the door frame to Resident #1's room that indicated Resident #1 was in enhanced barrier precautions (EBP), RN EEE reported that the enhanced barrier precautions were for when the CNAs performed care for Resident #1. This surveyor queried RN EEE about wound care as indicated on the sign as a time to use (EBP), and RN EEE reported there was a difference between a wound and a stoma. Resident #1 had a stoma (permanent surgical opening through the skin {for her G-tube placement}) and that was not a wound, and since it was not a wound, she did not have to wear a gown when performing a G-tube dressing change, nor when administering medications through a G-tube. When further queried, regarding glove use, glove changes, and hand hygiene during the observed care for Resident #1, RN EEE stated I don't see the need to change my gloves if I'm working on the same resident. Resident #29 Review of a Face Sheet revealed Resident #29 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: dysphagia, feeding via G-tube and functional quadriplegia. Review of Medication Order for Resident #29 revealed Jevity 1.5 Cal with fiber liquid per G tube daily volume to be delivered 1000ml (milliliters) with a start date of 2/17/25. Review of Other Orders for Resident #29 revealed initiate Enhanced Barrier Precautions continuous with a start date of 4/29/24 and 2/28/25. During an observation and interview on 3/4/24 at 11:21 AM., Licensed Practical Nurse (LPN) XX entered Resident #29's room, applied gloves, stopped Resident #29's feeding, disconnected the feeding tube, retrieved a stethoscope from her scrub shirt pocket, and used a piston syringe to check Resident #29's residual all while wearing the same gloves. LPN XX was then observed administering one medication and a water rinse via a piston syringe into Resident #29's G-tube with the same gloved hands. LPN XX then reconnected the feeding and started the pump. LPN XX did not wear a gown during the administration of medications via Resident #29's G-tube. When queried, LPN XX reported that the EBP sign on the door frame of Resident #29's room was for the CNAs when they performed care, they needed the gown incase of splashing. LPN XX reported she did not need to wear a gown to administer medications via G-tube. In an interview on 3/5/25 at 11:24 AM., Director of Nursing (DON) B reported an EBP sign was posted on a resident's door to inform staff of the need for and what PPE to wear. DON B reported her expectations were that the appropriate PPE was worn during cares. 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 .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 . 41027 Resident #65 Review of Resident #65's Care Plan revealed, .has an indwelling foley (a tube inserted into the bladder through the urethra to drain urine) catheter related to bladder outlet obstruction. Interventions: .Nursing staff will provide catheter care every shift and as needed . Review of Resident #65's Resident Care Summary revealed, .Initiate enhanced barrier precautions 1/30/25 . During an observation and interview on 03/04/25 at 02:09 PM signage was observed outside of Resident #65's room, indicating enhanced barrier precautions were in place. Certified Nursing Assistant (CNA) JJJ entered the room, and donned gloves, but did not put a gown on. CNA JJJ transferred the resident into bed using the hoyer (mechanical lift). CNA JJJ moved the resident's catheter bag from the wheelchair and attached it to the bed frame. CNA JJJ removed Resident #65's incontinence brief, and washed the resident's front side and then the back side. There was a small amount of feces noted on the disposable wipe. CNA JJJ finished incontinence care, and then applied a clean brief on Resident #65 and transferred him back to his wheelchair. While still wearing the same gloves, CNA JJJ emptied the urine from Resident #65's catheter bag into a urinal. In an interview on 03/04/25 at 02:28 PM, CNA JJJ reported that she puts gloves on when she enters a resident room and keeps them the entire time, unless she gets feces on them. CNA JJJ reported that she had folded the disposable wipe that she used during incontinence care, so that the feces would not get on her gloves. CNA JJJ reported that enhanced barrier precautions were new for Resident #65 due to testing that the facility was doing. In an interview on 03/05/25 at 09:05 AM, Staff Educator/Infection Preventionist (SE-IP) O reported that she conducts a lot of on the spot education to staff regarding Enhanced Barrier Precautions, and the expectation is that staff wear a gown and gloves at all times with those residents during high contact care, including transfers, incontinence care, catheter care, etc. SE-IP O reported that staff are frequently audited for hand hygiene related to in and out of resident rooms, but it is not often that glove use during incontinence care is audited.

Based on observation, interview, and record review, the facility failed to ensure foley catheter (a tube inserted into the bladder through the urethra to drain urine) tubing was secured to prevent pulling and perform incontinence care per standards of practice in 2 residents (Resident #98 & #65) of 5 residents, reviewed for bowel and bladder incontinence, resulting in the potential for dislodgement of the catheter tubing with pain and urethral damage, and the potential for skin breakdown, cross-contamination and development/spread of infection. Findings include: Resident #98 Review of Resident $98's Skin Care Plan revealed, Start 9/18/24 .at risk for compromised skin integrity r/t (related to) impaired mobility and incontinence .Toileting Plan . Review of Resident #98's Catheter Care Plan revealed, .Indwelling Catheter Maintenance: .Nursing staff will provide foley catheter care every (sic) twice daily and as needed . During an observation on 03/05/25 at 08:54 AM Resident #98 was seated in her wheelchair in the dining room. In an interview on 03/05/25 at 12:03 PM, CNA NN reported that Resident #98 had been in her chair since about 7:00 AM (5 hours). CNA NN reported that the resident does not get toileted because she has a catheter. In an interview on 03/05/25 at 12:06 PM, Registered Nurse (RN) SS reported that Resident #98 should be toileting every 2 hours, or possibly less often due to her having a catheter. RN SS reported that it was her responsibility to ensure the resident received appropriate care, and that she was not aware the resident had not received incontinence care since 7:00 AM. During an observation on 03/05/25 at 12:48 PM in Resident #98's room, CNA NN was preparing to transfer the resident from chair to bed. There was a catheter bag observed and attached to the bed frame. CNA NN changed Resident #98's incontinence brief, but did not perform foley catheter care. Resident #98 was complaining that her catheter was causing her pain. It was observed that Resident #98's catheter was pulled tight, and not secured to her leg with an anchor device. Resident #65 Review of Resident #65's Care Plan revealed, .has an indwelling foley catheter related to bladder outlet obstruction. Interventions: .Nursing staff to offer toilet every two hours as needed.Nursing staff will ensure foley catheter leg strap (securement device) is in use. Nursing staff will provide catheter care every shift and as needed . In an interview on 03/03/25 at 03:44 PM, CNA KKK reported that Resident #65 spent most of his time in his wheelchair. During an observation and interview on 03/04/25 at 02:09 PM signage was observed outside of Resident #65's room, indicating enhanced barrier precautions were in place. CNA JJJ entered the room, and donned gloves, but did not put a gown on. CNA JJJ transferred the resident into bed using the hoyer (mechanical lift). CNA JJJ moved the resident's catheter bag from the wheelchair and attached it to the bed frame. CNA JJJ removed Resident #65's incontinence brief, and wash the resident's front side and then the back side. Resident #65 was yelling that the wipes were cold. There was a small amount of feces noted on the disposable wipe. CNA JJJ finished incontinence care, and then applied a clean brief on Resident #65 and transferred him back to his wheelchair. A barrier cream was not applied to the resident. While still wearing the same gloves, CNA JJJ emptied the urine from Resident #65's catheter bag into a urinal. In an interview on 03/04/25 at 02:28 PM, CNA JJJ reported that she put gloves on when she entered a resident room and kept them on the entire time, unless there was feces visible on the gloves. CNA JJJ reported that she had folded the disposable wipe that she used during Resident #65's incontinence care, so that the feces would not get on her gloves. In an interview on 03/05/25 at 09:05 AM, Staff Educator/Infection Preventionist (SE-IP) O reported that nurses and CNA's should be ensuring that all foley catheters are secured with an anchor on the resident's leg. SE-IP O reported that there was no known reason for Resident #98 to not have an anchor; all catheters should have a securement devices. SE-IP O reported that staff are frequently audited for hand hygiene related to in and out of resident rooms, but it is not often that glove use during incontinence care is audited. In an interview on 03/05/25 at 10:47 AM, Clinical Nurse Supervisor (CNS) I reported that Resident #65 should have a catheter securement anchor in place on his leg, and that she would see to it that one was applied. Review of [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 68514-68515). Elsevier Health Sciences. Kindle Edition. revealed .Securing indwelling catheters reduces risk of urethral trauma, urethral erosion, CAUTI (Catheter-Associated Urinary Tract Infection), or accidental removal . Review of a Centers for Disease Control and Prevention (CDC) presentation titled Indwelling Urinary Catheter Insertion and Maintenance, no date, revealed .Maintenance: Catheter Care Essentials .Properly secure catheters to prevent movement and urethral traction .Maintain Unobstructed Urine Flow . Use a catheter securement device to anchor the catheter . Retrieved from https://www.cdc.gov/infectioncontrol/pdf/strive/CAUTI104-508.pdf

Based on observation, interview and record review, the facility failed to provide preventative care, consistent with professional standards of practice for 2 residents (Resident #98 & #65) of 5 residents reviewed for at risk for the development of pressure injuries, resulting in the potential for worsening of pressure wounds, the development of an avoidable pressure ulcer, infection, and overall deterioration in health status. Findings include: Resident #98 Review of Resident #98's Braden Assessment (risk of developing pressure ulcers) dated 12/16/24 revealed, 17 indicating that resident was at a mild risk. Review of Resident $98's Skin Integrity Care Plan revealed, Start 9/18/24 .at risk for compromised skin integrity r/t (related to) impaired mobility and incontinence .History of skin problem: PI (pressure injury) to L (left) and R (right) buttock .Interventions: Assist with repositioning .Utilize appropriate lift or transfer devices .Toileting Plan, Observe and relieve pressure to bony prominences. Review of Resident #98's Pressure Ulcer Care Plan revealed, Start 12/16/24 .has a pressure ulcer location right heel. Interventions: Pad appropriate medical devices . Assist with positioning . During an observation on 03/03/25 10:01 AM Resident #98 was seated in her wheelchair in the hall outside of her room, leaning to her left side, with blue boots (to reduce pressure) on both feet that were resting directly on the foot pedals. During an observation on 03/04/25 at 10:40 AM Resident #98 was sleeping in her wheel chair in the common area by the nurse's station. The blue boot from her left foot was laying on the floor next to her wheelchair. Resident #98's left foot/back of ankle is resting directly on the foot pedal. In an interview and observation on 03/04/25 at 01:53 PM Resident #98 was lying in her bed and reported that her feet hurt. Resident #98 was observed with blue boots on both feet, but they were turned to the side and not securely attached. During an observation on 03/05/25 at 08:54 AM Resident #98 was seated in her wheelchair in the dining room. During an observation on 03/05/25 at 10:22 AM Resident #98 was seated in her wheelchair in the common area by the nurse's station; she is slouched down in her chair with her eyes closed. During an observation on 03/05/25 at 11:27 AM Resident #98 was seated in her wheelchair in the common area by the nurse's station. Resident #98's position had not changed from the previous observation. During an observation on 03/05/25 at 12:01 PM Resident #98 was seated in her wheelchair in the dining room, still slouched down, and her left blue boot is turned to the side and not fully attached. In an interview on 03/05/25 at 12:03 PM, CNA NN reported that Resident #98 had been in her chair since about 7:00 AM (5 hours). CNA NN reported that the resident did not get toileted because she had a catheter. CNA NN reported that Resident #98 had a wound on her right heel from the wheelchair foot pedal. During an observation on 03/05/25 at 12:48 PM in Resident #98's room, CNA NN was preparing to transfer the resident from chair to bed. CNA NN wrapped her arms around Resident #98, lifted her up and sat the resident on the bed. Resident #98 tried to bear weight on her right foot (pressure wound on heel), but did not stand upright during the transfer. CNA NN changed Resident #98's incontinence brief, but did not perform catheter care. Resident #98's right foot was observed with a gauze wrap covering the heel. In an interview on 03/05/25 at 12:06 PM, Registered Nurse (RN) SS reported that Resident #98 had a pressure ulcer on her heel, and that she could not reposition herself while in her chair. Resident #65 Review of Resident #65's Braden Assessment (risk of developing pressure ulcers) dated 3/2/25 revealed, 15 indicating that the resident was at a mild risk. Review of Resident #65's Care Plan revealed, .at risk for compromised skin integrity related to vascular dementia, hx (history) of CVA (stroke). Interventions: Assist with repositioning: See Resident Care Summary (RCS) .Observe and relieve pressure to bony prominences . Review of Resident #65's RCS revealed, .Skin care and precautions: cream-barrier; turn schedule-remind and assist to turn every 2 to 3 hours; W/C (wheelchair) cushion-pressure reducing 10/18/24 . In an interview on 03/03/25 at 03:44 PM, CNA KKK reported that Resident #65 spent most of his time in his wheelchair. During an observation on 03/04/25 at 10:49 AM Resident #65 was seated in his wheelchair in the dining room. The resident was sitting on a hoyer (mechanical lift) sling and there was not a pressure reducing cushion on the seat of the wheelchair. During an observation and interview on 03/04/25 at 02:09 PM CNA JJJ transferred the resident into bed using the hoyer (mechanical lift). CNA JJJ finished incontinence care, and then applied a clean brief on Resident #65 and transferred him back to his wheelchair. In an interview on 03/04/25 at 02:28 PM, CNA JJJ reported that Resident #65 did not have a cushion for his wheelchair and she had not ever seen one. During an observation on 03/05/25 at 08:53 AM Resident #65 was seated in his wheelchair in the dining room. He was sitting on the hoyer sling, and there was not a pressure reducing cushion in his wheelchair. During repeated observation on 03/05/25 at 10:33 AM, 11:24 AM, and 12:13 PM the resident was in the same location, seated in his wheelchair without a pressure reducing cushion in place. Review of Fundamentals of Nursing ([NAME] and [NAME]) 9th edition revealed, The presence and duration of moisture on the skin increases the risk of ulcer formation. Moisture reduces the resistance of the skin to other physical factors such as pressure and/ or shear force. Prolonged moisture softens skin, making it more susceptible to damage. Immobilized patients who are unable to perform their own hygiene needs depend on nurses to keep the skin dry and intact. Skin moisture originates from wound drainage, excessive perspiration, and fecal or urinary incontinence. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 71334-71338). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 9th edition revealed, Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Reposition patients frequently because uninterrupted pressure causes skin breakdown. Teach patients to shift their weight in a chair every 15 minutes. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 28081-28083). Elsevier Health Sciences. Kindle Edition.

This citation has 2 DPS statements. DPS A: Based on observation and interview the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. This resulted in an increased risk of injury among residents in the facility. Findings Include: During a tour of the facility, at 10:23 AM on 3/4/25, observation of the back 100 spa room found that the hot water reached 128F when tested with a rapid read thermometer. Further observation found that the sink had a point of use mixing valve that should temper the water under the maximum 120F in resident care areas. During an interview with Maintenance K and Regional Maintenance HHH, at 10:45 AM on 3/4/25, it was found that the facility does not take regular hot water temperatures to ensure excessive hot water does not exist in resident care areas. 41027 DPS B Based on observation, interview, and record review, the facility failed to ensure resident safety with chair to bed transfers for 2 residents (Resident #98 & #65) of 5 residents reviewed for accident hazards, resulting in the potential for avoidable accidents and serious injury. Findings include: Resident #98 Review of a Minimum Data Set (MDS) assessment for Resident #98, with a reference date of 1/23/25 revealed, under Functional Abilities that Resident #98 required substantial/maximum assistance (helper does more than half of the effort) for transfers from chair to bed. Review of Resident #98's Care Plan revealed, .potential for falls and fall related injuries: .Interventions: .Use gait belt for all transfers . Review of Resident #98's Resident Care Summary (RCS) revealed, .Transfer: substantial/maximal . Review of Resident #98's most recent Physical Therapy Discharge Summary dated 12/23/24 revealed, .Assessment/Plan: .Patient has made no progress .continues to require .dependent with max A of 2 (staff) for bed to/from w/c (wheelchair) t/fs (transfers) and unable to ambulate. Barriers during skilled physical therapy have included . R (right) hip pain, R heel wound . and overall weakness . The documentation indicates that the resident requires assistance from 2 staff for transfers. In an interview on 03/05/25 at 12:03 PM, Certified Nursing Assistance (CNA) NN reported that Resident #98 had been in her chair since about 7:00 AM (5 hours). CNA NN reported that the resident does not get toileted because she has a catheter. CNA NN reported that Resident #98 had a wound on her right heel from the wheelchair foot pedal. During an observation on 03/05/25 at 12:48 PM in Resident #98's room, CNA NN was preparing to transfer the resident from chair to bed. CNA NN did not use a gait belt or have assistance from a second staff member. CNA NN wrapped her arms around Resident #98, and lifted her up holding onto her pants and sat the resident on her bed. Resident #98 tried to bear weight on her right foot (pressure wound on heel), but did not stand upright during the transfer. Resident #98's right foot was observed with a gauze wrap covering the heel. In an interview on 03/05/25 at 01:01 PM, CNA NN reported that they should have been using a gait belt during the resident's transfer to bed. In an interview on 03/05/25 at 02:00 PM, Restorative CNA (RCNA) MMM reported that Resident #98 does not help to stand or bear weight. RCNA MMM reported that the resident was not safe to transfer with one staff member, and at times required the mechanical lift. In an interview on 03/05/25 at 03:12 PM, Director of Nursing (DON) B reported that Resident #98 required substantial/maximum assistance, based on the documentation in flowsheet. DON B reported that it meant that the resident required almost total assistance, but that the documentation did not specify if the resident required 1 or 2 staff for transfers. Resident #65 Review of Resident #65's Care Plan revealed, .Requires assistance with ADLs (activities of daily living) related to dementia: .has declined in his abilities .requires hoyer (mechanical) lift for transfers. Review of Resident #65's RCS revealed, .Weight Bearing/Activity: None. Transfer: Lift-Mechanical . In an interview on 03/03/25 at 03:44 PM, CNA KKK reported that Resident #65 spent most of his time in his wheelchair. During an observation and interview on 03/04/25 at 02:09 PM in Resident #65's room, CNA JJJ wheeled the hoyer into the resident's room. CNA JJJ attached the hoyer lift sling that was under the resident, to the hoyer handle bar, then used the remote to lift the resident out of his chair. During the transfer, Resident #65's right hip/leg were hanging down lower than the left side, and the right leg section of the hoyer sling was observed not looped under the resident's right thigh. The left side of the hoyer sling was looped under his left thigh, and in place between the legs. The hoyer lift was a Maxi-Move lift. In an interview on 03/04/25 at 02:10 PM, CNA JJJ reported that the hoyer sling leg sections were supposed to be looped under both thighs and then attached to the hoyer bar to ensure that the resident does not slide out. Review of Maxi-Move (hoyer lift) instruction manual dated 1/2014 revealed, .Bring attachment loops B (picture reference) and the leg sections of the sling underneath the patient's thighs. Ensure that the leg sections of the sling are not twisted underneath the patient. Hook the attachment loops onto the hooks on the opposing side of the spreader bar . In an interview on 03/04/25 at 11:01 AM, Licensed Practical Nurse (LPN) LLL reported that Resident #65 is a serious fall risk, and required the hoyer lift for a safe transfer from bed to chair. In an interview on 03/05/25 at 03:28 PM, DON B reported that Resident #65's transfer status was currently via hoyer.

Based on observation, interview and record review the facility failed to ensure residents received care in accordance with physician orders for medications and professional standards in 1 resident (Resident #49) of 22 residents reviewed for quality of care, resulting in a delay in treatment and worsening of a medical condition, and the potential for residents not attaining or maintaining their highest practicable level of wellbeing. Findings include: Resident #49 Review of an Admission Record revealed Resident #49 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: CHF (congestive heart failure) (when your heart can't pump blood well enough to give your body a normal supply; over time blood and fluids collect in the lungs and legs causing swelling) and pacemaker (a device placed under the skin that stimulates the heart to beat regularly.) Review of a Minimum Data Set (MDS) assessment for Resident #49, with a reference date of 2/5/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #49 was cognitively intact. In an interview on 03/03/25 at 03:51 PM, Resident #49 reported that when he admitted into the facility in December, they failed to order his lasix (diuretic medication used to reduce excessive fluid build up due to CHF) and that's why he gained so much weight and ended up in the hospital. Resident #49 reported that it was his cardiology doctor that figured it out on 12/11/24 when he was there for a pacemaker check. Resident #49 reported that he tried to relay the information back to the nursing staff that he needed to take lasix, but they would not listen. Resident #49 reported that he had went to the hospital to have his pacemaker replaced on 1/14/25, and his cardiologist made him stay until 1/19/25 because he had gained so much weight due to not having his lasix regularly. Resident #49 was observed seated in his wheelchair, with an enlarged abdomen and significant swelling in his legs. In an interview on 03/05/25 at 12:26 PM, Clinical Nurse Supervisor (CNS) I reported that Resident #49 had a diuretic listed on his hospital paperwork when he admitted , but it was not administered as ordered upon admission to the facility; the medication was administered only 1 time on 12/6/24. CNS I reported that there was no indication as to why the medication was discontinued and/or not administered as needed for the increased edema, and it was not anything that she was aware of at that time. CNS I reported that all newly admitted residents had their weight monitored every day for 3 days, then once weekly for 4 weeks, and then monthly. CNS I reported that Resident #49 had a CHF, therefore his weight was obtained daily, and significant changes should have been reported to the physician; there should be documentation in the provider notes if the nursing staff had talked to the provider. CNS I reported that Resident #49 had a couple 3 or more pounds increase in his weight during December and a significant increase in his weight in January that was not addressed by the facility. Review of Resident #49's Weight Record indicated a multiple increases in the resident's weight, from admission on 12/5/24 to re-hospitalization on [DATE]: 12/5/24 94.2 kg (207 pounds) 12/9/24 95.5 kg (210 pounds) 12/17/24 97.4 kg (214 pounds) 1/1/25 102.9 kg (226 pounds) 1/4/25 103.5 kg (228 pounds) 1/9/25 104.3 kg (229 pounds) 1/10/25 possible error 1/11/25 error 1/12/25 error 1/13/25 possible error with hoyer (mechanical lift) 1/14/25 at 7:00 AM (at facility) 106 kg (233 pounds) possible error with hoyer 1/14/25 at 5:50 PM (at hospital) 104 kg (229 pounds) In an interview on 03/05/25 at 01:24 PM CNS I reported that she had spoken to the provider and there was no documentation of the provider being notified of Resident #49's significant weight changes, and there were no adjustments to his diuretic medications. CNS I reported that Resident #49 saw his cardiologist on 12/11/24; there was no record that the provider reviewed the cardiology recommendations at that time. CNS I reported that Resident #49 went to the hospital on 1/14/25 for a scheduled pacemaker replacement and was admitted due to worsening of CHF and the need for diuresis (removal of excessive fluids by medical interventions). In an interview on 03/05/25 at 01:36 PM, Nurse Practitioner (NP) NNN reported that according to the notes in the computer, Resident #49 saw the facility Medical Doctor (MD) OOO on 12/10/24 and his medication list included Lasix 40 mg as needed, but he was not getting it. Resident #49 then saw his cardiologist on 12/11/24 for a pacemaker check and it was noted that the resident had not been receiving his usual Lasix dose and would require hospitalization for further diuresis. NP NNN reported that normally with CHF, residents are on a diuretic regularly and weights are monitored closely, but that it did not appear that this was addressed for the resident. NP NNN reported that she had seen Resident #49 on 1/13/25, but that she was made aware of his weight gain at that time; Resident #49 was admitted to the hospital the following day. Review of Resident #49's After Visit Summary (discharge from hospital to facility) dated 12/5/24 revealed, .Medication list: .furosemide (generic name for lasix) 40 mg take 1 tablet by mouth daily as needed for (weight gain more that 3 pounds with LE (legs) edema (swelling cause by excessive fluid collection) . Review of Resident #49's Physician Note dated 12/6/24, by MD OOO revealed, .Admission History and Physical .Assessment & Plan: Chronic combined systolic an diastolic congestive heart failure: .Continue furosemide .Medications: .furosemide (lasix) tablet 40 mg daily PRN (as needed) .Physical exam: .lower extremity scaling consistent with episodes of edema .Wt (weight): 94.2 kg (207 pounds) Review of Resident #49's Physician Note dated 12/10/24, by MD OOO revealed, .staff reported coughing more .Assessment & Plan: (listed by diagnoses) . #1. Chronic combined systolic and diastolic congestive heart failure (HCC): .Continue furosemide .#23. Cough: given his heart failure history, discussed with him my concerns he may have pulmonary edema contributing to his cough. Recommended furosemide (lasix) for three days .Medications: .Start on 12/11/24 furosemide (lasix) tablet 10mg .Wt: 95.5 kg (210 pounds) . The note does not list that the resident was receiving furosemide at the time of visit, but indicates that the resident should continue the furosemide that he had been taking for his heart failure, and receive furosemide 10mg for three days for cough. The resident's weight increased by 3 pounds and was not addressed. Review of Resident #49's Medication Administration Record (MAR) for the month of December 2024 indicated that Lasix 40 mg was given 1 time on 12/6/24, Lasix 10mg was given 3 times (12/11/24, 12/12/24, 12/13/24). There were no other diuretic medications administered for December. Review of Resident #49's Cardiology Provider Progress Note dated 12/11/24 revealed, .he (Resident #49) has not received his usual lasix while at (facility name) and has gained wt and developed severe edema (swelling caused by collection of excessive fluids). Will admit to hospital service after generator change for diuresis and management of his skin breakdowns. This note was entered by the provider following the resident's visit for his pacemaker check. Review of Resident #49's Physician Note dated 12/20/24, by MD OOO revealed, .He stated he didn't think increased lasix helped with cough. He coughs up light yellow .Assessment & Plan: (listed by diagnoses) . #1. Chronic combined systolic and diastolic congestive heart failure (HCC) .continue furosemide .Medications: .Wt: 97.5 kg (214 pounds) . The medication list did not include furosemide. There was no order in place for furosemide at that as indicated in the visit note. The resident's weight increased by an additional 4 pounds and was not addressed, nor was lasix administered. Review of Resident #49's Physician Note dated 1/2/25, by MD OOO revealed, .report of left arm swelling .Lymphedema left arm (fluid accumulation) .Assessment & Plan: (listed by diagnoses) . #1. Chronic combined systolic and diastolic congestive heart failure (HCC) .continue furosemide .Medications: .Wt: 102.7 kg (226 pounds) . The medication list did not include furosemide. There was no order in place for furosemide at that as indicated in the visit note. The resident's weight increased by an additional 12 pounds and was not addressed, nor was lasix administered. Review of Resident #49's Physician Note dated 1/6/25, by MD OOO revealed, .left arm swelling .possible DVT (blood clot) .Assessment & Plan: (listed by diagnoses) . #1. Chronic combined systolic and diastolic congestive heart failure (HCC) .continue furosemide .Medications: .Wt: 103.5 kg (228 pounds) . The medication list did not include furosemide. There was no order in place for furosemide at that as indicated in the visit note. The resident's weight increased by an additional 2 pounds and was not addressed, nor was lasix administered. Review of Resident #49's MAR for the month of January 2025 indicated that Lasix 40 mg was given 1 time on 1/9/25 and twice daily on 1/12/25 and 1/13/25. Review of Resident #49's Physician Note dated 1/13/25, by NP NNN revealed, .no new complaints .Assessment & Plan: (listed by diagnoses) . #1. Chronic combined systolic and diastolic congestive heart failure (HCC) .continue furosemide .Medications: .Furosemide (lasix) tablet 40mg 2 times per day .Wt: 106 kg (233 pounds) . The resident's weight increased by an additional 5 pounds but was not addressed in the visit note.

Based on interview, and record review the facility failed to complete advance directives completely and accurately for 3 residents (Resident #37, Resident #312, Resident #60) of 22 residents reviewed for advance directives resulting in the potential for resident preferences for medical care to not be followed by the facility staff. Findings include: Resident #37 (R37) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R37 admitted to the facility on [DATE] with diagnoses including chronic pain, paraplegia (loss or impairment of voluntary movement and sensation in the lower half of the body including both legs due to damage to the spinal cord), left lower extremity amputation and a pressure injury (wound) to right buttocks. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R15 was cognitively intact (13 to 15 cognitively intact). Review of R37's physician orders revealed Do not resuscitate (DNR) with a start date of 1/1/2025. Review of R37's chart revealed that there was no paperwork on code status that was signed by R37. During an interview on 3/04/2025 at 1:46 PM, Social Worker (SW) M stated that she wasn't sure if she talked to R37 about his code status when he was admitted and hopefully the doctor spoke to him. SW M was unable to locate code status paperwork in R37's chart. During an interview on 3/04/2025 at 3:21 PM, R37 stated that he probably wants to be a DNR but he wasn't completely sure. R37 also wasn't sure if anyone spoke to him about his code status when he admitted to the facility and he stated that he didn't sign any paperwork related to it. An email from Nursing Home Administrator (NHA) A on 3/05/2025 at 10:51 AM revealed that there was No specific code status paperwork for (R37). Resident #312 (R312) Review of the Admission Record revealed R312 admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia and failure to thrive. Brief Interview for Mental Status (BIMS) reflected a score of 9 out of 15 which indicated R312's cognition was moderately impaired (8-12 moderately impaired). Review of R312's physician orders revealed Do not resuscitate (DNR) with a start date of 2/20/2025. Review of R312's DNR-Michigan Out of Hospital Form revealed that the resident didn't sign the form, the first advocate didn't sign the form and the second advocate signed the form on 2/20/2025. Review of R312's chart revealed that there wasn't a capacity form (form completed by the physician or psychologist to tell the court about cognitive abilities such as problem solving and critical thinking) indicating that R312 was unable to make his own decisions or the required 2 physician signatures (ensures a higher level of accuracy and objectivity when determining a patient's mental capacity). During an interview on 3/04/2025 at 11:16 AM, SW M looked in R312's chart and could not find any paperwork/forms in R312's chart regarding his capacity along with 2 physician signatures. SW M also agreed that R312's 2nd advocate signed the DNR instead of the 1st advocate. During an interview on 3/5/2025 at 11:20 AM, NHA A stated that the facility was working on a better process to streamline code status when they come from the hospital and making sure appropriate paperwork was filled out. The Resuscitation Status-Adult Policy with an effective date of 7/21/2024 revealed 3. Policy: I .The admitting provider is accountable to discuss and document the patient's resuscitation status within 24 hours of admission . II. Documentation of Resuscitation Status C. The initial and all subsequent discussions with a patient and/or their medical designee about their Resuscitation Status order will be summarized in the medical record. The summary should include who made the decision (patient or designee) and why the decision is appropriate 41027 Review of Resident #60's Physician Orders dated 12/30/24 revealed, Do Not Resuscitate (DNR) .Discharge summary 12/08/24 DNR. Review of Resident #60's DNR paperwork revealed no paperwork on record. In an interview on 03/04/25 at 01:36 PM, Social Worker (SW) M reported that Resident #60 had an order in place for DNR, but the facility did not have signed documentation from the resident and physician indicating that the resident elected the no code status. SW M reported that the facility must discuss the resident's wishes upon admission and ensure that the documentation is in the record, prior to entering the order. SW M reported that reviewing hospital discharge paperwork indicating that the resident was DNR in the hospital, cannot be used for a DNR order in the facility. SW M reported that at that time she was not aware of the issue for this resident, and would have to discuss advance directives to seek clarification and obtain a signed document of his wishes.

Based on observation, interview, and record review the facility failed to maintain a clean comfortable environment with clean, sanitized medical equipment for 1 resident (Resident #75) of 2 residents, resulting in the potential for cross contamination and bacterial harborage. Findings include: Review of Facesheet revealed Resident #75 was a male with pertinent diagnoses which included macular degeneration (loss of in the center of the field of vision), legal blindness, dementia, diabetes, anxiety, kidney disease stage 3, neuropathy (weakness, numbness, and pain from nerve damage), anemia, and stroke. Review of Resident Care Summary dated 3/5/25, revealed, .Safety: Dated 1/24/25 .Low bed, bed by wall for increased floor space, bedside mat .Lay down between meals so he doesn't slid (sic) out of w/c (wheelchair) .Dependent for transfers, bed mobility . During an observation on 03/03/25 at 09:52 AM, Resident #75 was observed lying in bed with a mattress on the floor placed next to the right side of his bed. The mattress was covered with spotted dried liquid stains, dried food, and had dusty shoe prints on it. During an observation on 03/03/25 at 01:01 PM, the mattress which would go beside Resident #75's bed was leaned up against the far wall and it was covered from end to end with spots of dried liquid, dried spilled food, dusty shoe prints, and white dried material as well. During an observation on 03/04/25 at 11:10 AM, Resident #75 was not in his room, his bed was stripped down, there were gouges on the wall by his enabler bar on the wall side of the bed. The paint was missing and there were gouges in the drywall as well as gouges to the wall where the corner of the head of the bed was placed along the wall. The corner of the wall had approximately 18 inches of plaster/drywall mud broken off and the metal corner guard was exposed. In an interview on 03/05/25 at 12:42 PM, Certified Nursing Assistant (CNA) III reported the CNAs would inform the nurse, or if they were able to, they would put in a work order. In an interview on 03/05/25 at 12:44 PM, Registered Nurse (RN) EEE reported depended on EVS(environmental) or Maintenance work order. RN EEE reported she would verbally tell environmental services as they see then all the time. RN EEE reported the staff were able to contact maintenance by calling the service number or if they had access to the computer they were able to submit a ticket there. RN EEE reported when they contacted the service number they spoke to someone to report the concern. In an interview on 03/05/25 at 12:20 PM, Housekeeping Manager AA reported the housekeepers were responsible for keeping the mattress on the floor clean as well as cleaning under the mattress so it was clean underneath. Housekeeping Manager AA reported she would review the housekeeper's responsibilities with them. In an interview on 03/05/25 at 12:24 PM, Maintenance L and this writer went to Resident #75's room to observe his walls. Maintenance L reported his boss was in the process of trying to get funding for some room refreshers but it had not come to fruition yet. Maintenance L reported when the beds were placed along the wall for resident safety it allowed for the dings and dents in the walls. Maintenance L examined the wall next to Resident #75's bed and reported since the bed was moved along the wall when the bed was moved it created the dings and dents in the walls. This writer expressed those were gouges in the wall with exposed drywall or plaster and not a dent or ding in the wall. Maintenance L observed the broken off drywall/plaster on the corner and this writer expressed concern with the exposed metal to the corner for resident safety. Maintenance L reported he believed this occurred when staff would run equipment into the corner. Maintenance L was unable to report if he had received a work order for the gouges, missing paint and missing drywall/plaster concern. He reported he was unable to review the history of the completed work orders. Maintenance L reported the staff would file an electronic work order, he would get the notice on his computer screen, he would complete the maintenance request and it would then go into the history. He reported the staff were not completing very many work orders in the system. Maintenance L reported he was the only maintenance staff present in the building. The facility had an HVAC person but they were split between multiple buildings. Maintenance L reported funds to have the rooms refreshed was the goal and has been on the radar but no movement yet on the capital funds. Using the reasonable person concept, though Resident #75 had decreased ability to verbally express his own thoughts due to his cognitive deficits, he would not prefer to reside in a room with a heavily soiled fall mattress and gouges/scraps with missing paint on the walls, and drywall missing from the corner of the wall.

Based on interview and record review, the facility failed to transmit Minimum Data Set (MDS) discharge assessments timely for 2 residents (Resident #82, Resident #93) of 2 reviewed for MDS transmission resulting in the potential for inaccurate tracking of discharges. Findings include: Resident #82(R82) Review of R82's chart revealed that she discharged from the facility on 9/19/2024. Review of R82's chart revealed a MDS discharge assessment -return not anticipated with an ARD of 9/20/2024 was in progress and incomplete: GG, J, M, N, O, P (sections GG, J, M, N, O, P). The MDS was not transmitted. Resident #93(R93) Review of R93's chart revealed that she discharged from the facility on 9/17/2024. Review of R93's chart revealed a MDS discharge assessment -return not anticipated with an ARD (assessment reference date) of 9/17/2024 was in progress and incomplete: K (section K). The MDS was not transmitted. During an interview on 3/05/2025 at 1:23 PM, MDS nurse D stated that a discharge assessment should be completed whenever a resident discharges from the facility. Then, it should be transmitted. MDS D verified that a MDS discharge assessment for R82 should have been completed on 10/4 and then transmitted. MDS D verified that a MDS discharge assessment for R93 should have been completed on 10/1 and then transmitted.

Based on interview and record review the facility failed to ensure that PASARR (Preadmission Screening and Resident Review) Level II (a comprehensive evaluation completed by the local (state mental health aruthority) was completed for 1 (Resident #16) of 4 residents reviewed for PASARR Level II screening resulting in the potential for unmet mental health care needs. Findings include: Resident #16 Review of a Face Sheet revealed Resident #16 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: recurrent major depressive disorder, dementia with behavioral disturbances, and bipolar affective disorder. Review of a Minimum Data Set (MDS) assessment for Resident #16, with a reference date of 1/3/2025 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #16 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). Review of Resident #16's electronic medical record revealed no noted PASARR Level II assessment. In an interview on 3/4/2025 at 3:16 PM., Social Worker (SW) M reported Resident #16's PASARR Level I (an initial pre-screen assessment used to determine if a resident would benefit from state mental health authority involvement) was completed on 7/3/2024 and indicated that Resident #16 needed a Level II assessment completed. SW M reported she kept paper copies of the Level I assessments to ensure she would follow up for completion of the needed Level II assessments. SW M did not produce a paper copy of Resident #16's Level I assessment. SW M accessed the OBRA (Omnibus Budget Reconciliation Act- Nursing home reform act) website and revealed there was no completed Level II assessment nor a recommendation letter available on the OBRA website for Resident #16. No PASARR Level II assessment nor a recommendation letter from OBRA was provided by survey exit.

Based on interview and record review, the facility failed to develop a person-centered care plan related to Hospice care for 1 resident (Resident #58) of 22 reviewed for person centered care plans resulting in the potential for unmet care needs of the resident. Findings include: Resident #58 (R58) Review of the Admission Record and Minimum Data Set (MDS) dated [DATE] revealed R58 admitted to the facility on [DATE] with diagnoses including dementia and Alzheimer's disease. Brief Interview for Mental Status (BIMS) reflected a score of 3 out of 15 which indicated R58 cognition was severely impaired (0-7 severe impairment). Review of R58's chart revealed he had a significant change MDS (minimum data set) dated 1/21/2025 due to him declining and starting Hospice care. Review of R58's care plans revealed that there wasn't a Hospice care plan. During an interview on 3/05/2025 at 1:13 PM, MDS nurse D revealed that R58 signed onto Hospice on 1/15/2025. MDS D stated that she thought that Social Worker (SW) M was responsible for completing the Hospice care plan when a resident goes under Hospice care. After placing a call to the other MDS nurse in the facility, MDS D stated that she was wrong and she was supposed to do the Hospice care plans. Review of the Care Planning and Coordination Policy with an effective date of 3/21/2022 revealed The plan of care is developed, documented, and implemented using an individualized approach. The plan of care is reviewed, and revisions are made as needed according to patient health status 3. Policy Each patient must receive an individualized written plan of care, including services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the agency in collaboration with the patient, anticipates will occur as a result of implementing and coordinating the plan of care as well as patient specific goals .

Based on observations, interview, and record review the facility failed to provide activities of daily living (ADLs) specifically nail care to a dependent resident for 1 (Resident #52) of 5 residents reviewed for activities of daily living, resulting in an unkept appearance and the potential for the spread of infection. Resident #52 Review of a Face Sheet revealed Resident #52 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: cognitive deficits following a non-traumatic intracerebral hemorrhage (bleeding in the brain), hemiparesis (paralysis) on the left non-dominate side, and debility. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 12/4/2024 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #52 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment). During an observation and interview on 3/3/25 at 10:24 AM., Resident #52 was lying in her bed, and it was noted that her fingernails were long and caked with dirt and debris that appeared black in color underneath her fingernails. Resident #52 reported that she liked her nails clean and trimmed. Review of Care Plan for Resident #52 revealed Problem: ADL maintenance .this has affected her (Resident #52) ability to completed ADLs independently; requires extensive to total assistance .interventions assist with ADLs as needed .with a start date of 4/11/2024. During an observation on 3/4/25 at 8:14 AM., Resident #52 was lying in her bed, and it was noted that her fingernails were long and caked with dirt and debris that appeared black in color underneath her fingernails. In an interview on 3/4/25 at 4:23 PM., Certified Nurse Assistant (CNA) JJ reported nail care should be completed during showers but can be done any time it is needed. During an observation on 3/5/25 at 8:29 AM., Resident #52 was lying in her bed, and it was noted that her fingernails were long and caked with dirt and debris that appeared black in color underneath her fingernails. In an interview on 3/5/25 at 8:30 AM., CNA HH reported that nail care should be done on the resident's shower days. During an observation and interview on 3/5/25 at 10:26 AM., CNA QQ was in Resident #52's room, providing a bed bath and ADL care. When queried, CNA QQ confirmed that Resident #52 was dependent for care, and needed staff to provide nail care. CNA QQ confirmed that Resident #52's nails were long and soiled with dirt and debris black in color under her nails. During an observation and interview on 3/5/25 at 10:36 AM., Licensed Practical Nurse (LPN) XX entered Resident #52's room while CNA QQ was providing ADL care and stated I'm here to cut her (Resident #52's) nails. When queried, LPN XX reported that nail care should be done with showers, skin assessments, and any time a resident needs nail care. On 3/5/25 at 10:38 AM., LPN XX was observed exiting Resident #52's room without completing nail care. In an interview on 3/5/25 at 10:39 AM., LPN XX was queried about completing Resident #52's nail care and LPN XX reported she no longer had time to provide nail care to Resident #52. LPN XX stated if I have time, I don't have time now, I'm going to finish my work before I do her (Resident #52) nails. In an interview on 3/5/25 at 10:49 PN., Clinical Nurse Supervisor (CNS) I reported nail condition was a specific question during a weekly skin assessment completed by nurses. Review of Resident #52's record revealed no documentation related to nail care. In an interview on 3/5/25 at 11:27 AM., Director of Nursing (DON) B reported her expectations were that the nails of residents were cut and clean and that nail care was done as needed, and/or during showers, and/or as requested by the resident. DON B reported CNAs were responsible for resident nail care unless otherwise recommended that nail care be done by a nurse.

This citation pertains to intake #: MI00147147 Based on interview and record review the facility failed to ensure the safety and provide monitoring and/or supervision while eating in of 4 residents (Resident #1), reviewed for safety and supervision, resulting in Resident #1 choking on food and subsequent death. Findings: Resident #1 (R1) Review of an Admission Record revealed R1 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Dementia with behavioral disturbances, oropharyngeal dysphagia (difficulty swallowing), and a history of larynx cancer. R1 was his own responsible party (able to make his own decisions). Review of a Minimum Data Set (MDS) assessment for R1, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated R1 was cognitively impaired. The medical record revealed R1 was a full code (resuscitation and all life saving measure in the event of a medical emergency). The medical record revealed R1 was hospitalized for sepsis due to bilateral lower lobe aspiration pneumonia (inhalation of foreign substance into airway/lungs such as food or stomach contents) from [DATE]-[DATE]. Review of R1's SLP Evaluation and Plan of Treatment signed by SLP A on [DATE] revealed, .Resident will complete effortful swallow ex correctly in in 80% of trials, given verbal and visual/tactile cues .Current ([DATE]) 75% (Indicating R1 did not meet expected goals at the time of the assessment) . Resident currently receiving NDD3/IDDSI 6 diet (soft, bite sized, extra moisture) per his demand/insistence .Precautions: Likely chronically aspirating very slight amounts. NDD3/IDDSI 6 diet per pt request .Demonstrating improved carryover with trained swallow strategies, though remains a significant aspiration risk/likely ongoing in very small amounts. Resident aware .Reviewed resident status with RD (registered dietician), dietary manager, and select care team personnel . Review of R1's SLP Discharge Summary signed by SLP A on [DATE] revealed, .D/C (discharge) Reason: Highest Practical Level Achieved .Resident will complete effortful swallow ex correctly in in 80% of trials, given verbal and visual/tactile cues .Current ([DATE]) 75% . Progress & Response to Treatment: Cooperative and benefited from cuing and instruction. Tolerating preferred diet for the most part . aspiration risk will be chronic/ongoing. Resident is aware of same .Team Communication/Collaboration: reviewed resident status with resident and select care team personnel . Compensatory Strategies/Positions: Upright position, small bites and sips. Alternate bites with sips and execute double swallow as needed; take time to eat/don't rush . Prognosis to Maintain CLOF (current level of function) = Good with consistent staff follow-through . Review of R1's Quarterly Nutrition assessment dated [DATE] revealed, (R1) continues on a NDD3+ NAS diet. Per FAR (food acceptance record), his meal intake is between ,d+[DATE]% and he enjoys snacks between meals .No GI (gastrointestinal) concerns .Will continue to monitor. According to the International Dysphagia Diet Standarization Intitiative (July, 2021), A level 3 National Dysphagia Diet includes bite-sized, soft, moist, not sticky, foods in bite-sized pieces. These foods are easier for you to chew and swallow. Avoid foods that are hard, sticky, crunchy, or very dry. Breads: Plain white or wholemeal bread can only be eaten if finely chopped into pieces no larger than 15mm and must be softened/pre-soaked in soups or sauces. Seeded breads are not suitable. Review of R1's Flowsheet nursing note dated [DATE] at 1:00 PM revealed, choking episode with Heimlich performed with resident expelling piece of bread which was lodged in throat . There was no documentation as to why the resident had a piece of bread or what the size was that was expelled. During an interview on [DATE] at 2:32 PM, Nursing Home Administrator (NHA) confirmed that there were no incident reports, new orders/consults, follow-up documentation related to the choking event that occurred on [DATE] (event information, description, comprehensive assessment, notifications, vital signs, witness statements, precipitating events, follow-up assessments, etc). NHA reported that R1's provider requested the completion of a Diet Education Form with R1 following the choking incident. During an interview on [DATE] at 12:13 PM, Registered Dietician (RD) B reported that following the incident of choking on [DATE], R1 was provided a Diet Education Form regarding his refusal to follow the recommended dysphagia diet and that eating in a communal dining area was the intervention implemented for safety. RD B reported that R1 preferred to eat in the Main Dining Room so he could visit with his friend but would also choose to eat in his room. RD B did not report any interventions implemented to ensure R1's safety while eating in his room. Review of R1's Diet Education Form dated [DATE] revealed R1 was educated on the failure to adhere to the recommended diet could lead to aspiration with the greatest risk being death. The document was signed by R1 on [DATE]. The document did not provide education on any other interventions listed on the care plan that included the need to eat in a public location. The diet listed was Diet level 2 (mechanical altered) IDDS level 5 (minced and moist). The resident indicated he wanted a NDD3 diet (soft, moist, non-sticky foods). Review of R1's Care Plans revealed, Problem: Altered Nutrition and Hydration-Problem Details as of [DATE] .INTERVENTIONS: -Diet as ordered. -Honor food preferences as able. -Meal location: -see Resident Care Summary . -Assist with meals as needed/Provide assistance per Resident Care Summary (RCS). He has been educated to eat in DDR (Day Dining Room) where there is clinical staff in case of another episode while eating. Speech has also spoke (sic) with him on the aspiration risks . -Observe food acceptance. He has had a few choking/aspiration events while eating. He has been educated a few times to follow SLPs Compensatory Strategies: -upright for all intake -remain upright for 30 minutes after meals -small bites and sips -alternate solids and liquids -double swallow/or swallow two times per bite . Review of the Assignment Book located at the nurses' station revealed R1 was Independent (in contrast from above document) for feeding and Eats In the MDR (Main Dining Room) for breakfast, lunch, and dinner. On the whiteboard located at the Unit nurses' station that listed the staff working and the location of their assignments, there was a sign/paper taped to the outer aspect that reflected that R1 was to eat in the Main Dining Room for breakfast, lunch and dinner. Review of R1's Resident Care Summary (RCS- used by facility staff to direct necessary care) revealed Eating-Set-up/Clean up. Diet: NDDS, NAS .Eating Safety-Up in Chair for Meals. The RCS did not indicate where R1 was to consume his meals, compensatory strategies, or the specific level of his dysphagia diet. During an interview on [DATE] at 1:11 PM, with NHA and DON, NHA confirmed the RCS did not include resident specific interventions related to his dysphagia diet and preferences/refusals. NHA reported that R1 was provided education, and the IDT met on [DATE] following his choking event that occurred on [DATE]. There was no SLP consult ordered at that time or new/additional changes to his swallowing strategies. The care plan was updated at that time to reflect that R1 was educated to eat meals in the communal dining areas for increased supervision in the event R1 had another choking incident, however, that was not reflected on the RCS. DON reported that R1 was self-directed where he ate, and he made his own choices. NHA and DON confirmed that there were no additional safety interventions implemented for R1 when he ate in his room despite being a high risk for aspiration/choking. DON and NHA were not aware of any additional incidents of choking outside of [DATE]. Review of R1's Behavioral Health Progress Note (psychiatric consultant group) dated [DATE] revealed, Resident is referred to (consult company name omitted) for psychological evaluation and treatment of mood and cognitive status .Memory: Moderate Cognitive Impairment .Insight: Impaired .Judgment: Moderate Impairment . Review of R1's Behavior Tacking Logs from [DATE]-[DATE] did not reflect refusals to eat in the Main Dining Room or the Day Dining Room. During an interview on [DATE] at 12:07 PM, Assistant Director of Nursing (ADON) H reported that R1 was encouraged to eat in the communal dining rooms, either the Day Dining Room or the Main Dining Room for meals. ADON H reported R1 was at risk for choking and required supervision but confirmed that when R1 chose to eat in his room and there were no interventions implemented to ensure his safety while eating alone/unsupervised. Review of the Covid Outbreak Investigation revealed that on [DATE]- All (specific unit omitted) residents tested - 4 positives. Placed in enhanced respiratory precautions. Surveillance ongoing. Community events and dinning stopped for unit residents. During an interview on [DATE] at 2:06 PM, DON confirmed that during the covid outbreak the Main Dining Room was closed for meals and activities. Review of R1's Event Reporting System incident dated [DATE] revealed, At 1758 (5:58 PM), Nurse (Registered Nurse RN C) and (RN D) observed patient sitting on wheelchair in slumped over position, Nurses went in the room and found patient unresponsive. No pulse, no respirations noted. CPR was initiated immediately, 911 called at 1800 (6:00 PM) .After about 30 minutes of CPR patient was declared dead at 1832 (6:32) PM .Autopsy report stated that patient died from accidental death of choking on food bolus . During an interview on [DATE] at 10:40 AM, Registered Nurse (RN) C reported that she had just arrived to work but had not yet punched in for her shift when she found R1 slumped over in his wheelchair in his room. RN C reported she did not know how long he had been unresponsive, and she and RN D called for help and immediately initiated CPR. During an interview on [DATE] at 11:34 AM, RN D reported she was not normally R1's nurse but was walking down the hall with RN C when they found R1 slumped over in his wheelchair. RN D reported that R1 was supposed to eat in the dining room so staff could keep an eye on him. RN D reported that if R1 was not eating in a dining room staff were to check on him more frequently due to his recent choking episodes. During an interview on [DATE] at 3:00 PM, RN J reported she was R1's nurse on [DATE]. RN J reported she was unaware of his choking incident (on [DATE]) and had last seen R1 at 3:00 PM when she gave him a pain medication. RN J reported that R1 normally ate in the Main Dining Room but due to the covid outbreak the Main Dining Room was closed. RN J reported she was not aware of increased supervision needs for R1 if he ate his meal in his room. Review of the Prehospital Care Report Summary (paramedic summary) dated [DATE] revealed the 911 was received by the dispatcher at 6:02 PM. Airway-Oral Intubation .was never attempted to be placed, airway was just assessed for tube placement First attempt: steak in the oropharynx .During airway assessment, piece of steak was found in back of oropharynx. Steak was removed . Review of R1's Death Certificate revealed R1's cause of death was Choking. During an interview on [DATE] at 1:03 PM, Family Member (FM) I reported she was involved in R1's care. FM I reported that the facility was aware of his history of throat cancer and his issues with choking as he had choked a couple of times at the facility. FM I reported that she was aware that the Main Dining Room was closed due to a Covid outbreak but reported that on each unit there were small dining rooms (Day Dining Room) and technically he should have been in there for his safety because of history of choking and she expected staff to be available to ensure he was safe if he was to eat alone in his room. FM I reported she arrived to the facility shortly after she was notified of her father's death while the Medical Examiner (ME) was still present. FM I reported the ME notified her that pulled food out of his throat. During an interview on [DATE] at 10:45 AM, SLP A reported that since returning from the hospital in January he had been a chronic aspirator due to his glottal cancer. SLP A reported that that R1 did not need 1:1 supervision but did require regional supervision (oversight and monitoring) and it was recommended that he eat in the dining room. SLP A stated that due to his history of choking, refusal to follow the recommended dysphagia diet, and need for supervision and occasional cuing he shouldn't have been eating in his room. SLP A reported that he had a right to choose a diet that wasn't recommended, and he was provided education, but it was not a waiver (for the facility to relinquish responsibility), it's education and supervision to prevent and/or intervene during choking should have been implemented. SLP A reported that when she completes an evaluation and has recommendations, she notifies nursing management to have it added to the care plan and care guide (RCS). SLP A reported that R1 enjoyed eating in the main dining room because of a friend that he would dine with which served him well due to his need for supervision. However, there was a covid outbreak in the facility and because of that R1's unit and the Main Dining Room were closed. SLP A reported that the Certified Nursing Assistants (CNAs) were unable to feed dependent residents and supervise other residents simultaneously because the residents were to eat in their room. When the CNAs were feeding the dependent residents in their rooms there was less supervision on the units and no staff available to supervise/cue the residents that required those interventions. SLP A reported she was not aware of his exacerbated symptoms of dysphagia (incident occurring on [DATE]) and had not been notified/ordered to reevaluate R1 for new compensatory strategies. During an interview on [DATE] at 12:25 PM, CNA G reported she was not aware that R1 required supervision while eating and would have looked for that information in R1's care plan or RCS. During an interview on [DATE] at 2:52 PM, CNA F reported that on [DATE] the Unit was on lockdown due to a Covid outbreak resulting in the Main Dining Room being temporarily closed. CNA F reported she passed R1 his dinner around 5:,d+[DATE]:20 PM, set up his tray, and got him a coffee. CNA F reported she did not see him again until after CPR had been initiated. CNA F was not aware of any interventions to increase supervision while R1 ate in his room.

Based on observation, interview, and record review, the facility failed to comprehensively assess pressure related injuries and implement care plan interventions to prevent the development of a pressure ulcers in 1 of 3 residents (R201) reviewed for pressure ulcer prevention, resulting in the development of a pressure ulcer and the potential for infection, and overall deterioration of health status. Findings include: According to R201's Minimum Data Set (MDS) dated [DATE], R201 had diagnoses that included severe hypoxic ischemic encephalopathy and was dependent on staff for all activities of daily living. Section M revealed the resident was at risk of developing pressure ulcers and had received a clinical assessment with no unhealed pressure ulcer(s) at Stage 1 or higher. During an observation and interview on 1/31/23 at 9:54 AM R201 was lying in bed on his back. Both of his legs were contracted bent at the knees rubbing up against each other and the side rail to resident's right side. A pillow was on top of both knees, and not between the knees or the bedrail and knees. An open area was observed on the right knee that had slough and a scant amount of blood smearing outside of the wound. Registered Nurse (RN) ZZ stated, (R201) has pressure wounds with dressings changed on M-W-F (Monday-Wednesday-Friday). I would be notified if he had any new wounds. During an observation and interview on 1/31/23 at 4:08 PM Certified Nursing Assistant (CNA) GG and RN S entered R201's room to perform incontinence care and reposition resident. Both resident's knees were contracted and pulled up to his right side with right knee rubbing on bed rail. No dressing was on the knee. Wound to right knee approximately 1.5 inches by 0.5 inches with slough and opened bloody area. RN ZZ stated, There should be a dressing to that. After the CNA and RN finished incontinence care they positioned R201 to his left side. RN stated, When I looked at the wound earlier it had a dressing on it. I will check the orders and see if he is to have a dressing on it. No dressing was applied to resident's knee. During an observation and interview on 2/01/23 at 7:52 AM Wound RN V was with R 201 in his room completing wound treatments. RN stated, (R201) has nine wounds at this time. I just saw the wound on his right knee today. It had a dressing on it. It looks like it must have been rubbing on the bed rail. I will put an order in for the dressing to be applied and looked after. A pillow should be placed between his knees and the bedrail. I see him every Wednesday. The nurses should be placing their findings in the progress notes as well. During an interview and record review on 2/1/2023 12:08 PM, Director of Nursing (DON) B stated, If a new wound is found, the wound nurse should be notified. She will evaluate the wound and begin treatments. A wound nurse does the wound treatments. She does extensive notes, educates staff, informs the MDS nurses, then the MDS nurses updates the care plans. I was told (R201) looks like his knee has a new wound from not being positioned very well. It is a new wound. The CNAs have daily contact with the residents. When the CNA sees something wrong with a resident's skin, they are to tell the nurse, and the nurse tells the wound nurse who will assess the wound. This is the process. During an interview and record review on 2/1/23 at 11:26 AM with Registered Nurse (RN) W, stated, (R201) skin should be checked at least every shift, and aides change position every 2 hours. If there is a new wound area, I would catch it or a CNA would catch it and report to me. Last time I worked, was Monday (1/30/2023) day shift. It was reported to me this morning (Wednesday 2/1/2023) by the wound nurse of the new wound on (R201's) knee. I was not notified of new wound on knee on Monday (1/30/2023) or else I would have written a note. I did not do wound care on him Monday (1/30/2023. I did do check and change (bowel incontinence) every 2 hours on him Monday (1/30/2023). RN W reviewed R201's electronic medical chart with this Surveyor and stated, I do not see where the wound nurse wrote a note on the new wound today, but she told me about it. It should be written as an event by the nurse that found it. I do not see an event was written by the nurse (RN S) yesterday (Tuesday 1/31/2023). Any skin event would be marked here. I would find out about new wounds on the 24-hour report. The treatment for the new wound would be placed on the treatment side of the MAR /TAR (Medication Administration Record/Treatment Administration Record). In the TAR, an order is put in when treatments are to start, the dates when the order is entered, and when the last treatment is done. I do not do resident Care Plans. They are usually done by the Social Worker. Usually, when an event is documented, like a fall, that is followed up by the nurse that was working during the time it happened and they will address it in the Care Plans. Review of R201's Orders dated 12/22/2022 revealed, Turn pt (patient/resident) Q (every) 2 hr (hours) using body wedges and/or pillow .General (POC-Task) Every 2 hours: 16:00, 18:00, 20:00, 22:00, 00:00, 02:00, 04:00, 06:00, 08:00, 10:00, 12:00, 14:00 . Please make sure resident is turned every 2 hours Every Shift Day 07:00-15:00, PM 15:00-23:00, Nights 23:00 - 07:00 . Review of R201's POC ((Plan of Care) tasks performed by CNAs) revealed, Task: Turning/Positioning were documented as being completed: -2/1/2023 13:28 (1:28 PM) -1/31/2023 14:20 (2:20 PM) -1/31/2023 11:34 (AM) -1/30/2023 22:26 (10:26 PM) -1/30/2023 16:30 (4:30 PM) -1/30/2023 14:28 (2:28 PM) -1/29/2023 20:36 (8:36 PM) It was noted after review of the POC tasks 1/30/23 00:00 to 2/1/23 2:41 PM, R201 was not turned/repositioned every 2 hours per Orders. Review of R201's Care Plan problem Pressure Ulcer 12/6/2022 reported the resident's admission Braden Scale score was 8, indicating very high risk for pressure ulcers. Resident has a strict repositioning schedule with continued use of body wedges and pillows. The Goal was for R201's skin to be free of nonblanchable erythemia (reddened area) and to remain intact. The facility's Approach was to encourage/assist the resident with repositioning, monitor for s/s (signs/symptoms) of early breakdown: persistent redness on knees (back and front), and systematically assess skin condition daily during personal care, Review of R201's Progress Note 12/6/2022 15:13 (3:13 PM) reported the resident was admitted to the facility following hospitalization in a comatose state and came with a trach and peg tube. It is noted there was no documentation of pressure injuries. Review of R201's Progress Note - Wound Nurse Initial Assessment 12/6/2022 15:26 (3:26 PM) reported a skin assessment was complete. Resident's coccyx had mild erythema and no open areas. Pt (patient/resident) without open areas/wounds. Review of R201's Progress Note 1/31/2023 07:19 (AM) revealed, (Recorded as Late Entry on 2/1/2023 07:26 (AM) The resident was noted to have some redness on the right knee area .wound nurse will evaluate further.

This citaion pertains to intake number MI 277. Based on interview and record review, the facility failed to provide cardiopulmonary resuscitation (CPR) per the advanced directives in 1 of 6 residents (Resident #100) reviewed for advanced directives , resulting in an immediate jeopardy when, on [DATE] at approximately 6:25 AM, Resident #100 who was a full code, was found without a detectable pulse or respirations, CPR was not initiated, a call to 911 alerting Emergency Medical Services was not placed, and Resident #100 was pronounced deceased by facility nursing staff. This deficient practice placed 32 additional residents, identified as a full code, at risk for serious harm and/or death. Findings include: On [DATE] at 03:50 P.M. the Nursing Home Administrator was verbally notified and received written notification of the Immediate Jeopardy that began on [DATE] and was identified on [DATE] due to the facility's failure to adequately monitor, assess, and perform cardiopulmonary resuscitation (CPR) on Resident #100. A written plan for removal for the immediate jeopardy was received on [DATE] and the following was verified on [DATE]. 1. On [DATE], Cardiopulmonary Resuscitation (CPR) Policy revised, and changes made to reflect that CPR is to be initiated until the arrival of emergency medical services. 2. The two RNs that did not provide CPR were re-educated on the new CPR policy for Full Code residents. One in person by the Director of Nursing (DON) and the other one via phone again by the DON to start performing CPR if the resident is a full code until the arrival of emergency medical services. 3. Re-education of all licensed nurses (30) except for those on vacation or a leave of absence (3) has been initiated by Staff Educator, RN on CPR regulations as well as the new policy and procedure (as of [DATE]). Nurses present in the building (10) signed physical copies of the attestation. Re-education for all nurses on the new policy will be completed by the end of the day Monday [DATE]. Education includes location of code status for each resident. Licensed nurses on vacation or leave of absences will not be allowed to work until educated and an attestation is signed. 4. Certified Nursing Assistant (CNA) education to call a nurse immediately if a resident is not responding will be completed by noon on [DATE]. 5. Beginning [DATE] new hires (licensed nurses) will be educated on CPR regulations as well as the updated facility policy and procedure, accordingly. 6. On [DATE], an initial CPR certification audit revealed that ,[DATE] licensed nurses hold current certification. There is a CPR certified nurse available for each shift. 7. A Quality Assurance Performance Improvement (QAPI) Performance Improvement audit will be implemented to monitor for compliance. This audit will begin on [DATE]. DON/designee to monitor for code status compliance by interviewing licensed nurses weekly about facility CPR policy and procedure for a month. 8. Beginning [DATE] the DON/designee will audit new admissions to compare the resident's advance directives to the electronic record weekly on an ongoing basis and until a date determined by the QAA Committee meeting. 9. [DATE]- A DON designee completed a chart audit on all residents and compared advance directives to the electronic record that is used for nurses to check code status. Two inaccuracies were identified and rectified. 10. Person responsible for compliance will be the Director of Nursing or designee. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency. Findings include: Review of policy and procedure CPR-Cardiopulmonary Resuscitation Policy revised on ,[DATE], revealed, .It is the policy of this facility will provide basic life support, including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order [REDACTED]. o A valid Do Not Resuscitate order is in place and/or a legally valid document expressing the resident's wishes to not be resuscitated. o Resident presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) are present o Initiating CPR could cause injury or peril to the rescue . Review of the Face Sheet revealed Resident #100 was a [AGE] year-old male, who was originally admitted to the facility on , [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Advanced Care Planning document dated [DATE], revealed Resident #100 indicated he wanted cardiopulmonary resuscitation (CPR) performed to maintain life support. Review of Advance Care Plan/Power of Attorney for Healthcare dated [DATE], revealed, Resident #100 initialed, .If my heart of breathing stops .I want CPR in all cases .Advanced Interventions: Use intubations, advanced invasive airway interventions, mechanical ventilation, cardioversion, and other advance interventions as medically indicated. Transfer to hospital if indicated; includes intensive care . During an interview with Social Worker JJ and Social Worker II on [DATE] at 12:03 PM, reported Resident #100 was indeed a Full Code. Social Worker II reported this designation can be determined by the notation on the Face Sheet in the electronic medical record and on the hard chart there is a sticker if they are designated as a Do Not Resuscitate (DNR). During an interview on [DATE] at 10:53 AM, Certified Nursing Assistant (CNA) BB reported she was going around and checking the vitals of the residents and went into room [ROOM NUMBER] to check those of Resident #100. Resident #100 was observed on the floor and he looked as if he was sleeping and upon further observation noticed he was not breathing. CNA BB reported she went to find someone to assist and had Registered Nurse (RN) J come to assist. During an interview on [DATE] at 11:58 AM, Registered Nurse (RN) J reported when she found Resident #100 and he looked as though he attempted to stand up and his feet had went out under him as she believed Resident #100 slipped on the bowel movement which was on the floor under Resident #100. RN J reported she checked the carotid artery and asked Certified Nursing Assistant BB to find Licensed Practical Nurse (LPN) L. RN J reported she did not perform cardiopulmonary resuscitation on Resident #100. Registered Nurse (RN) J reported RN F and Licensed Practical Nurse (LPN) L came to Resident #100's room and assisted with the response. During an interview on [DATE] at 12:55 PM, RN F reported he was providing report to the oncoming nurse Licensed Practical Nurse L when he was alerted to respond to Resident #100's room. Registered Nurse (RN) F reported they did not perform cardiopulmonary resuscitation (CPR) on Resident #100 and he was pronounced deceased . During an interview on [DATE] at 01:54 PM, Director of Nursing (DON) B reported, .If you (Nursing staff) walk in and they might still be breathing, start cardiopulmonary resuscitation (CPR), and call 911. If they (Resident) appear to have been dead for a while and they are no longer breathing, you pronounce them and start the notification of the family, provider, and funeral home. In this case with (Resident #100), the two nurses pronounced him dead at that time . DON B reported, .With them being professionals and using their judgement they felt he (Resident #100) had been dead for a while and CPR was not going to be effective . During an interview on [DATE] at 12:27 PM, Licensed Practical Nurse (LPN) L reported, .(Resident #100) was observed sitting on the floor, leaning against the bed, he didn't appear to be breathing . Licensed Practical Nurse (LPN) L reported, Registered Nurse (RN) F and RN J performed the assessment on him. LPN L reported she left and made the phone calls to the Nurse Practitioner EE and the Medical Examiner. LPN L reported they did not perform cardiopulmonary resuscitation (CPR) on Resident #100. Review of Investigative Report completed by(NAME)Knapp, Berrien County reported, Facility reported (Resident #100) was last seen approximately 0445 this am then was found deceased by CNA around 0625am .RN pronounced death at 0625 am (Resident #100) was pronounced deceased by facility staff .room was cleaned and decedent was lying on his back on the bed prior to my arrival .(Resident #100) was cool to the touch .Rigor Mortis was not present .Livor Mortis was slight and consistent with the position (Resident #100) was in on my arrival . Review of CPR Certified Staff document provided on [DATE] of those nursing staff trained to perform cardiopulmonary resuscitation (CPR) revealed Registered Nurse J and Licensed Practical Nurse L were not CPR certified on [DATE]. Review of Recent expired CPR license of PR (Pine Ridge) nursing staff provided on [DATE] revealed, Registered Nurse J and Licensed Practical Nurse L were not included in those allowed an exemption during the COVID-19 outbreak.

This citation pertains to MI 903 & MI 416. Based on observation, interview and record review the facility failed to provide adequate supervision and ensure resident safety in 2 of 4 sampled residents (#102 and #100) reviewed for safety, from a total sample of 4 residents, resulting in Resident #102, who was known to disable her alarm, disabled her alarm and fell causing a hip fracture and Resident #100, who was a known elopement risk, eloped from the facility unbeknownst to facility staff and was found over 600 feet from the facility, near a 2 lane, 45 miles per hour (MPH), divided road. Findings include: Resident #102 According to the facility's Resident Admission Record, Resident #102 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. After a fall at the facility on 4/27/15, Resident #102 was readmitted with the [DIAGNOSES REDACTED]. According to the quarterly MDS, dated [DATE], Resident #102 was assessed to have significant memory impairment, moderate depression, usually understood others and was understood by others, exhibited inattention and disorganized thinking and rejected care. Resident #102 required minimal assist of 1 staff for bed mobility, transfers, walking in her room with a walker, propelling her wheelchair, dressing, hygiene, bathing and toileting, was continent of bowel and bladder and required set up only for eating. When asked if she had pain, Resident #102 answered no, and had no observable indications of pain. According to the 5-day re-admission MDS, dated [DATE], Resident #102 required higher levels of assistance in the following areas: transfers, walking in her room with her walker, bathing and toileting. Resident #102 was now having pain as exhibited by vocal sounds of distress and protecting the painful area, and her answer of yes when asked if she had pain. According to the Falls care plan, dated 5/12/15, Resident #102 had the following interventions: check alarm devices (no designation on what kind and where placed) and anti-rollbacks on wheels of wheelchair for placement and function every shift, assist with transfers, give verbal reminders to call for assist and ensure call light was within place, keep bed in lowest position with brakes locked when Resident #102 is in bed, keep environment free of clutter and monitor for debris or spills, orient Resident #102 of new furniture placement or other changes in environment occur, keep personal and often used items within reach and encourage rest periods during care and strenuous activity. Although requested on 6/23/15, no policy and procedure on falls was provided by Director of Nursing (DON) B, and this surveyor was informed by DON B that there was no policy and procedure about maintaining alarms to prevent falls. On 6/24/15 at approximately 3:00 p.m., Resident #102 was observed supine (face up) in her bed with eyes closed and mouth slightly open. She was covered with a light-colored blanket and a pressure alarm box was observed on her night stand, which was approximately 18 inches away from Resident #102's left side. Fall mats were on the floor and a tab alarm was observed clipped to the back of Resident #102's wheelchair. According to the facility incident report, dated 4/27/15 at 4:25 a.m., Resident #102 was discovered on the floor by her wheelchair, next to her bathroom door. The report did not clarify if the alarm on her bed was sounding. Resident #102 complained of pain in the groin area, blood was observed on 4 fingers of her hand, she was sent to the hospital and required surgery to repair her hip fracture. The report indicated that Resident #102's black shoes were not on her feet properly. A written statement by Certified Nurse Aide (CNA) C said that Resident #102's alarms were checked and OK around 12:00 p.m. Nothing more was asked/written about the last time Resident #102 was checked on by CNA C, nor whether the alarms were rechecked to be sure they were working. Another written statement, by Nurse D said that the alarm on the bed was not sounding. There was no mention of whether the alarm was a tab or pressure-sensitive alarm. Nurse D documented that they had witnessed Resident #102 tampering with the alarm boxes. Once, Nurse D found an alarm box under Resident #102's pillow, and that Resident #102 was very quick and would get herself to the toilet. In a telephone interview on 6/24/15 at 9:20 a.m., CNA NN said that she was first to enter Resident #102's room around midnight on 4/27/15 to deliver fresh water. CNA NN said she had checked Resident #102's alarm, and it was working. At around 2:00 a.m., CNA NN observed Resident #102 in her bed. When asked, CNA NN thought Resident #102 was asleep. CNA NN did not hear the alarm sound when Resident #102 fell , and said that she (Resident #102) would often go to the bathroom, sometimes using her wheelchair, without calling for help and would be discovered in her chair. If asked, Resident #102 would say she had been to the bathroom. CNA NN stated, She (Resident #102) was very quick. In an interview on 6/24/15 at 4:10 p.m., CNA HH reported that Resident #102 could disable her fall alarms. CNA HH reported that Resident #102 often fidgeted with things, including her alarm boxes. In an interview on 6/24/15 at 4:12 p.m., Nurse MM reported that Resident #102 had turned off the alarms after they rang previously. Nurse MM stated, It's like she tries to fix the noise. On 6/24/15 at 5:00 p.m., Assistant Director of Nursing (ADON) E was interviewed. When asked if she was aware that, prior to her fall and fracture, Resident #102 disabled her alarms, ADON E said, Yes, we were aware of that. ( ) Resident #100 Resident #100 was no longer a resident of the facility at the time of survey. Resident #100 had been transferred to another facility that had a closed unit, with family consent. According to the undated facility policy titled, (facility name) Elopement Prevention Policy and Procedure, under Community Resource, Local police and other emergency agencies are aware of the potential danger of resident wandering from local long term care facilities. Share pertinent information with them to guide their search efforts. According to the undated facility policy titled, (facility name) Code Green Procedure, Missing Person. Procedure for when a resident is believed missing. The policy directed what to do if a resident was discovered missing, but does not discuss how the search, by employees should be done such as how far outside of the facility doors should an employee look after an alarm has sounded. Under, The Search. Search efforts must be organized and thorough. Be prepared to provide searchers with. (sic) the name of resident, description of clothing worn when last seen, a photograph of the person, known likes, dislikes, nicknames, traditional home or other clues, cognitive status and other pertinent medical information may be released to the police. According to the Resident Admission Record and the Physician's History and Physical dated 5/8/15, Resident #100 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], Resident #100 had moderate cognitive impairment, wandered in the facility, required no assistance with bed mobility, was a 1 person assist with transfers and could self-propel. According to the Behavior care plan dated 6/1/15, Resident #100 was, at risk for eloping (leaving facility without supervision) from the facility. She leaves her unit for other parts of the building and tells staff that she is looking for the parking lot so she can go home. (Resident #102) cannot remember why she is here because of her dementia. Interventions included: a WanderGuard (resembles a wrist watch) placed on her wheelchair, re-direct when feeling the need to leave, provide diversional activities, remind (Resident #102) that she was here for therapy, reassure (Resident #102) that she is safe in the building. No interventions were planned to check on Resident #102 frequently to be sure of her location. In an interview on 6/23/15 at 11:10 a.m., Administrator (ADM) A reported that Resident #100's family told them that Resident #100 had left her unsecured, senior living building prior to admission to the facility. When asked for the facility's elopement risk assessment, Director of Nursing (DON) B provided a copy of page 10 of the MDS dated [DATE], Section B, Behavior, titled, Wandering - Presence & Frequency. The checked area indicated that Resident #100 wandered 1 to 3 days in the past week. No documentation was provided that the family was asked if Resident #100 had a history of [REDACTED]. According to a progress note by Nurse Practitioner (NP) Q, dated 6/15/15, Resident #100 said that she was, Trying to make arrangements to leave the building, go to a hotel and meet her daughter. According to the Incident report, dated 6/16/15 at approximately 6:30 p.m., Physical Therapy Assistant (PTA) N was off duty and driving by the facility when she recognized a resident near the public road, in front of the facility. PTA N stopped her car, and, with the help of Certified Nurse Assistant (CNA) GG, returned Resident #100 to the facility. There were no injuries to Resident #100, but the facility was unsure how, when, and where Resident #100 got outside the facility. The facility staff were unsure if the WanderGuard alarm failed to sound, or if it had been inappropriately silenced. On 6/23/15 at 9:10 a.m., PTA N was interviewed. When asked to walk outside with this surveyor and recall what happened on the evening of 6/16/15, PTA N said that she was driving in her car, heading north on Cleveland Avenue at approximately 6:30 p.m. and saw Resident #100 wheeling herself, in her wheelchair, on the sidewalk, just passing the maple tree across from the mailbox, towards the avenue. PTA N stated she made a U-turn in her car at the first driveway north of the facility main entrance, and pulled about 25 feet into the entrance. As she exited her car, she called Resident #100's name. PTA N said that Resident #100 had reached the driveway of the home on the same road the facility was on and was about to cross the street. The street was observed to be a 2 lane highway with a center turn lane, and the posted speed was 45 miles per hour. CNA GG was walking on the same path, and reached Resident #100 before PTA N did. When asked how staff might find out which residents were potential elopement risks, PTA N said that she believed a list was kept at the front desk located at the main entrance. In an interview on 6/24/15 at 8:20 a.m., CNA GG said that she was taking her usual walk on the sidewalk that circled the facility grounds. Shortly after 6:20 p.m. on 6/16/15, she was about 3/4 through her walk when she saw a blue car pull into the entrance to the facility. CNA GG stated she saw PTA N get out of the car and call to Resident #100 who was on the sidewalk and heading towards the road. CNA GG stated she began to run because, She (Resident #100) was as very quick when she moved. CNA GG reported she then wheeled Resident #100 back into the facility. On 6/23/15 at 11:45 a.m., Maintenance Director H, accompanied by this surveyor to measure the distance from the main entrance, up the sidewalk to the road where Resident #100 was stopped from crossing. The distance was measured at 642 feet. Maintenance Director H also estimated the incline of the sidewalk at 10-15 degrees uphill. The distance from the mailbox, where PTA N first spotted Resident #100, to the driveway at the home where Resident #102 was noted to be was 363 feet. In an interview on 6/23/15 at 2:00 p.m., CNA M said that Resident #100 had been looking for her daughter earlier that afternoon (on 6/16/15) . CNA M said that Resident #100 ate in the Front-200 dining room that night, and wheeled herself out after she was done. CNA M stated that, She (Resident #100) usually sat at her table until we wheeled her out of the dining room. CNA M said that she had observed Resident #100 near the Front-200 nurse's station after 6:00 p.m. and sometime after that the WanderGuard alarm sounded. Then shortly after that, a visitor was yelling about a resident getting away, and CNA M ran out the front door and saw CNA GG wheeling Resident #100 back to the facility. When asked, CNA M said that there was no book or list of residents with WanderGuards. In an interview on 6/23/15 at 10:45 a.m., Registered Nurse (RN) K stated that she heard the WanderGuard alarm sound on 6/16/15 and that CNA L went to check. After approximately 5 minutes, CNA L returned to the Front-100 unit and reported that she noticed Resident #104 (assumed she wore a WanderGuard) seated in her usual place between the furniture and the front door, and returned her to the 200 unit. RN K stated that shortly after that, Resident #106 came and said that staff needed to be outside because a resident was getting away. RN K and CNA L ran outside the front door to the end of the center sidewalk until they could see a blue car parked in the entrance and Resident #100 was being returned to the facility by someone in a green scrub uniform. When asked how they knew to go to the front door, RN K said that each alarm had a different sound. In an interview on 6/23/15 at 3:15 p.m., CNA L said that she was working the Front-100 unit, and the front door alarm sounded between 5:00 and 5:30 p.m. When she ran to the front lobby, she saw Resident # 104 in her usual position, in her wheelchair between the front doors and the water dispenser and was Resident #105 outside with Family OO. CNA L believed that Resident #104 had activated the alarm, but went as far as the area between the 2 sets of doors at the front and looked around. CNA L said she saw no other residents, so she came back inside, reset the alarm, wheeled Resident #104 back to her own area on the 200-hall and reported to RN K back on her unit. CNA L stated she was unsure if Resident #105 wore a WanderGuard, but believed that Resident #104 did. When asked how far outside the building she should have looked, CNA L said that she felt she did what she was supposed to do. In an interview on 6/22/15 at approximately 2:15 p.m., Administrator (ADM) A stated that the facility was aware that Family Member OO took Resident #105 outside through the front door and that Resident #104 was seated by the front door in their wheelchair in their usual spot. ADM A reported that CNA L responded to the WanderGuard alarm and entered the area between the 2 sets of doors at the front entrance, and as she looked around, noticed Resident #104 inside the first set of doors to the front entrance and Resident #105 outside with Family Member OO, then walked inside and reset the alarm. ADM A reported that Family Member OO came back in approximately 15 minutes later and yelled that a resident was getting away. ADM A stated that RN K, Licensed Practical Nurse (LPN) J, and CNA L ran out the front door and saw that PTA N and CNA GG were with Resident #100. ADM A reported that several days later, Family Member OO told him that Resident #100 asked to go outside with her and Resident #104. In an interview on 6/23/15 at approximately 3:00 p.m., Staff PP said the desk by the front door was usually staffed until 7:00 p.m., but Tuesday, June 16, was a regular night off for that staff member. On 6/22/15 at 2:30 p.m., all doors in the facility were checked for WanderGuard alarm functionality, accompanied by Maintenance Director H. The front entrance made a loud noise when the WanderGuard was near, but the door could be opened. Each of 4 doors in the corners of the facility were labeled with a code, and the doors would open when the code was entered into a key pad. Maintenance Director H was also observed as he checked for WanderGuard placement and function with a hand held device for residents with a WanderGuard. DON B provided a list of residents (Resident #103 and Resident #'s 107 - 113) who were to have Wanderguards attached to their wheelchairs, and Maintenance Director H tested them as functioning. Resident #103 was on the list, but her WanderGuard could not be located. Maintenance Director H said that Resident #103 used to have one, but he was unable to locate it. There was no signage posted by the front entrance, advising visitors to avoid allowing residents or anyone unknown to them, to accompany them outside the facility. In an interview on 6/22/15 at 3:40 p.m., RN K said there was no book of who was an elopement risk. When asked how staff knows which residents are an elopement risk, RN K said, We know them and recognize them. There is no list. In an interview on 6/22/15 at 3:50 a.m., Unit Clerk S indicated she overheard this surveyor asking about a list of residents who wandered and said that there was a list in the computer. Unit Clerk S said there was a list on the computer on the G drive. Upon review, the list included the names and a few tiny pictures of Resident #108, Resident #110 & Resident #'s 113-123. The list did not have Resident #103 (who's WanderGuard hadn't been located), Resident #107, Resident #109, Resident #111, and Resident #112, all of whom had WanderGuard's. One icon on the computer, dated 6/22/15, was labeled, Residents at Risk for Elopement, but would not open. In an interview on 6/22/15 at 4:10 p.m., CNA KK reported that those residents who have WanderGuard's are usually listed in the care plan or the Kardex (CNA care guide). CNA KK stated, When I'm outside my regular assignment, the nurse knows. ( )

This citation pertains to MI 903. Based on observation, interview, and record review, the facility failed to update a care plan to ensure the safety of a resident who had a history of [REDACTED]. 4 sampled residents (#102) reviewed for care plan updates, from a total sample of 4 residents, resulting in Resident #102 disabling her safety alarm, falling, and sustaining a [MEDICAL CONDITION]. Findings include: According to the facility's Resident Admission Record, Resident #102 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. After a fall at the facility on 4/27/15, Resident #102 was readmitted with the [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set ((MDS) dated [DATE], Resident #102 was assessed to have significant memory impairment, moderate depression, usually understood others and was understood by others, exhibited inattention and disorganized thinking and rejected care. Resident #102 required minimal assist of 1 staff for bed mobility, transfers, walking in her room with a walker, propelling her wheelchair, dressing, hygiene, bathing and toileting, was continent of bowel and bladder and required set up only for eating. When asked if she had pain, Resident #102 answered no, and had no observable indications of pain. According to the 5-day re-admission MDS, dated [DATE], Resident #102 required higher levels of assistance in the following areas: transfers, walking in her room with her walker, bathing and toileting. Resident #102 was now having pain as exhibited by vocal sounds of distress and protecting the painful area, and her answer of yes when asked if she had pain. According to the falls care plan, dated 5/12/15, Resident #102 had the following interventions: check alarm devices (no designation on what kind and where placed) and anti-rollbacks on wheels of wheelchair for placement and function every shift, assist with transfers, give verbal reminders to call for assist and ensure call light was within place, keep bed in lowest position with brakes locked when Resident #102 was in it, keep environment free of clutter and monitor for debris or spills, orient Resident #102 if new furniture placement or other changes in environment occur, keep personal and often used items within reach and encourage rest periods during care and strenuous activity. Although requested on 6/23/15, no policy and procedure on falls was provided by Director of Nursing (DON) B. This surveyor was notified by DON B that there was no policy and procedure about maintaining/checking alarms to prevent falls. On 6/24/15 at approximately 3:00 p.m., Resident #102 was observed supine (face up) in her bed with eyes closed and mouth slightly open. She was covered with a light-colored blanket and a pressure alarm box was observed on her night stand, which was approximately 18 inches away and to Resident #102's left. Fall mats were on the floor and a tab alarm was observed clipped to the back of Resident #102's wheelchair. According to the facility incident report, on 4/27/15 at 4:25 a.m., Resident #102 was discovered on the floor by her wheelchair, next to her bathroom door. The report did not clarify if the alarm on her bed was sounding. Resident #102 complained of pain in the groin area, blood was observed on 4 fingers of her hand, she was sent to the hospital and required surgery to repair her [MEDICAL CONDITION]. The report further stated that Resident #102's black shoes were not on her feet properly. A written statement by CNA C said that they checked that Resident #102's alarms were OK around 12:00 p.m. Nothing more was asked/written about the last time Resident #102 was checked on by CNA C, nor whether the alarms were rechecked to be sure they were working. Another written statement, by Nurse D said that the alarm on the bed was not sounding (at the time of the fall). There was no mention of whether the alarm was a tab or pressure-sensitive alarm. Nurse D said that Resident #102 had a history and they had witnessed Resident #102 tampering with the alarm boxes. Once, Nurse D found an alarm box under Resident #102's pillow, and that Resident #102 was very quick and would get herself to the toilet. On 6/24/15 at 9:20 a.m., Certified Nurse Aide (CNA) NN was interviewed via phone. When asked to recall what happened that night in April that Resident #102 fell and broke her hip, CNA NN said that she was first in her room around midnight to deliver fresh water. She checked Resident #102's alarm, and it was working. Around 2:00 a.m., or just after, CNA NN observed Resident #102 in her bed. When asked, CNA NN believed Resident #102 was asleep. CNA NN did not hear the alarm when Resident #102 fell , and said that she (Resident #102) would often go to the bathroom, sometimes using her wheelchair, without calling for help and would be discovered in her chair. If asked, Resident #102 would say she had been to the bathroom. CNA NN stated, She (Resident #102) was very quick. On 6/24/15 at 4:10 p.m., CNA HH was interviewed. When asked if, prior to her fall and fracture, staff was aware that Resident #102 would disable her fall alarms, CNA HH said that, yes, she (Resident #102) often fidgeted with things, including her alarm boxes. On 6/24/15 at 4:12 p.m., Nurse MM was interviewed. When asked if, prior to her fall and fracture, were staff was aware that Resident #102 would disable her fall alarms, Nurse MM said that, yes, she (Resident #102) had turned off the alarms after they rang. Nurse MM stated, It's like she tries to 'fix' the noise. On 6/24/15 at 5:00 p.m., Assistant Director of Nursing (ADON) E was interviewed. When asked if she was aware that, prior to her fall and fracture, Resident #102 disabled her alarms, ADON E said, Yes, we were aware of that. ( )

Based on observation, interview, and record review, the facility failed to implement preventive measures to prevent the development of a pressure ulcer in 1 of 1 residents (Resident #7) reviewed for pressure ulcers, from a total sample of 17 residents, resulting in the development of a facility acquired pressure ulcer. Findings include; Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #7 was a [AGE] year old female admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS revealed Resident #7's ability to make daily decision was severely impaired and she was totally dependent on one facility staff member for bed mobility, dressing, hygiene, bathing, and toilet use. Review of the Nursing Assessment & History dated 11/25/13 at 1530 (3:30 p.m.) revealed under mobility that Resident #7 did not ambulate, transferred with a Hoyer lift, and needed to be turned every 2 hours. Review of the Admission Skin assessment dated [DATE], revealed Resident #7 had a diagram that indicated Resident #7 had "redness on coccyx mostly left side [MEDICATION NAME] applied..." The Admission Pressure sore Risk Assessment total score was "9" which indicated Resident #7 required immediate interventions that included pressure relief pad in wheelchair (w/c), turn schedule to be placed on Kardex (Aide guide to care) if unable to turn unassisted, and heels up. Review of the Nurse's Progress Notes dated 11/25/13 at 1940 (7:40 p.m.), revealed Resident #7 arrived on the floor at 3:30 p.m., was total care, buttocks red mostly on left side, [MEDICATION NAME] applied, and that Resident #7 is non-verbal but shakes head when ask questions. Review of the Initial Care Plan dated 11/25/13 (no time), revealed Resident #7 was at Risk for alteration of skin integrity, as evidenced by decreased mobility, and incontinence of bowel. The Initial Care Plan goal revealed Resident #7 "Will not experience any alteration to skin as evidence by absence of redness, irritation or break to integrity." In interviews on 2/12/13 at 8:52 a.m. and 2/13/14 at 3:30 p.m., Registered Nurse (RN) #22 Wound Care Specialist, reported that she could not locate her initial assessment or the Braden scale assessment she completed on 11/25/13 for Resident #7. RN #22 reported that she did not recall Resident #7 having any skin break down on her buttocks when she was admitted and the Braden score was rated a "12" (indicating a moderate risk for skin breakdown). RN #22 reported that Resident #7 was kept on a geo mattress which was a dense foam, already had splint boots for heel protections to prevent foot drop, skin barrier cream, and a Roho cushion were initiated. RN #22 reported assisting with Resident #7's 4:00 a.m. turn and education of staff members about re-positioning due to Resident #7's legs having the tendency to want to bend upward. RN #22 reported that she was called to assessed a purple and red area that she suspected was a deep tissue injury. RN #22 reported that eventually the wound opened and bad tissue came out which created depth to the wound bed, the treatment plan had changed, and Resident #7 appeared to be responding well. RN #22 reported that Resident #7 has had to change to a geri chair and spend less time up due to the wound. Review of the Skin/Wound Assessment Record dated 12/3/13 (no time), revealed Resident #7 had an unstagable pressure wound located on her left buttock/gluteal fold measuring 8.2 cm x 3.0 cm by unknown depth with irregular wound edges. The Skin/Wound Assessment Record revealed Resident #7 was "a recent transfer from an acute setting hemorrhagic stroke, Resident found to have a localized area on her lt. (left) buttocks/gluteal that is maroon in color-intact-nonblanchable-warm to touch. Will continue to monitor-maintain pressure relief-changed to a Dolphin mattress-already has Roho cushion-bilat foot splints." Review of the Skin/Wound Assessment Record dated 1/27/13 (no time), revealed Resident #7 had a Stage III pressure wound located on her left buttocks/gluteal that measured 3.9 cm x 2.0 cm x 2.0 cm with undermining/tunneling and irregular wound edges. In an interview on 2/13/14 at 8:50 a.m., RN #15 reported that on admisstion, the left side of Resident #7's buttock was real red, there was no skin break down, apply cream to buttocks, and reposition with turn every 2 hours. RN #15 reported that she supplied the Certified Nursing Assistants (CNA's) with [MEDICATION NAME] cream to use when they did peri care. RN #15 reported that the nursing staff did weekly skin checks, unless the CNA's asked them to check a resident sooner. An observation on 2/12/14 at 8:52 a.m., revealed Resident #7 laying in bed, the Surveyor was given permission to observe wound care. RN #21 put on clean gloves and removed the old dressing and packing with noted serous fluid from the wound just above and to the left of Resident #7's tailbone. RN #21 cleaned her hands, put on clean gloves then irrigating the wound area with normal saline, the wound area was approximately 2 cm long, no odor or drainage was notable. RN #21 cleaned her hands, changed to clean gloves and began to pack the wound with a q-tip and [MEDICATION NAME] (absorbent dressing) into the hole just above and to the left of Resident #7's tailbone that appeared to measure approximately 1.5 to 2.0 cm deep and wide. RN #21 put a dressing over the packing and dated the dressing. In an interview on 2/13/14 at 10:00 a.m., Family Member #23 reported that he was informed the pressure wound to Resident #7"s left buttocks occured due to her sitting on the "hard clip" on the sling that attaches to the Hoyer lift. Family Member #23 reported that Resident #7 used to sit up in her wheelchair before the pressure wound from approximately 10:00 a.m. to 1:00 p.m.on the days he would visit. Family Member #23 stated that he tries to visit almost every day. #

Based on interview and record review, the Facility failed to report immediately to administration, failed to protect Residents from an alleged Perpetrator and failed to investigate thoroughly an allegation of Nursing Staff to Resident physical abuse for 1 of 4 Residents (#101), resulting in Resident #101 and all other Residents at the Facility to be potentially abused by NA"B" by allowing him to continue to work at the Facility after an incident of alleged physical Staff to Resident abuse on 11/13/10 between 10:30PM and 11:00PM. Findings: Review of the Facility's investigation report signed by the Director of Nursing on 11/19/10 for the incident of alleged abuse dated 11/13/10 regarding Resident #101 and NA"B" titled "Facility investigation after Resident Complaint of Mistreatment by a CNA", revealed NA"B", a part time employee, had only been employed by the Facility for 2 months and was not normally assigned to Resident #101. The Facility had no statements of what occurred the evening of 11/13/10 at approximately 10:55PM from the Staff other than the alleged perpetrator, NA"B"s statement dated as written 11/19/10. In an interview on 3/15/11 at 10:16 AM, when asked to explain an incident that was reported to have occurred on 11/13/10, in the evening, regarding a Nurse Aide changing her because she had spilled something on her clothing, Resident #101 said, "The report is wrong. A man nurse aide came in and said he'd put my gown on and I said wait till I'm done. I wasn't ready, I was watching TV and he said, No you're going to put it on now and he wrestled with me and I was resisting him and I guess he got mad and I hollered for help because he scared me. Three Nurses came but they didn't come right away and that scared me. He manhandled me and it scared me because he said, ain't nobody can hear you and it really scared me. It was the second shift I think. It happened at the beginning of the shift. Happened in November. I ain't seen him since." Resident #101 continued to inform the Surveyor that it was the first time that Nurse Aide took care of her and the last time he took care of her. Resident #101 did not know the Nurse Aide's name but said, "he twisted my arm trying to get my clothes changed. " Resident #101 named Licensed Practical Nurse (LPN"C") as one of the Nursing Staff that came to her rescue. LPN "C" said something to NA"B", Resident #101 said, "and I was crying. I was so shocked!" In a phone interview on 3/15/11 at 11:00AM, LPN"C" said he was the Charge Nurse on 11/13/10 from 6:00PM until 6:00AM on 11/14/10 for 100 Hall (the Hall Resident #101 lived on). LPN"C" said, in the late evening of 11/13/10, he heard a female voice yelling and went to Resident #101's room where the door was shut. LPN"C" said he knocked and opened the door and saw Resident #101, sitting in her wheelchair "sobbing". LPN"C" said, NA"B" was standing near the closet with gloves on and a gown in his hand. LPN"C" said it took a few minutes for Resident #101 to calm down enough to tell him what had happened. Resident #101 told LPN"C" that NA"B" just came in and started taking her shirt off and grabbed her arm and hurt it and she told him no not right now. LPN"C" said NA"B" told him he was gentle with her. LPN"C" told NA"B" to take care of other Residents but not Resident #101 because she didn't want him to take care of her. LPN"C" assigned a female CNA (Certified Nurse Assistant) to take care of Resident #101 for the rest of the night. LPN"C" said he did not document the incident, he did not complete an incident report, and he did not notify his supervisor or any administration about the incident of abuse that had occurred towards Resident #101. LPN"C" said he told the next shift Nurse who worked the day shift on 11/14/10 about the incident. LPN"C"said he was not asked by management to write a statement as to what had occurred that night (11/13/10). LPN"D" said, in an interview on 3/15/11 at 2:25PM, that he was the Charge Nurse on 11/14/10 in the morning and he received a verbal report from LPN"C" that there was an allegation of physical abuse by Resident #101 regarding NA"B". LPN"D" said LPN"C", "did nothing about it". LPN"D" said he reported it to his Supervisor at about 8:00AM on 11/14/10 but was not sure which Supervisor. LPN"D" said he spoke to Resident #101 who said she did not want NA"B" to take care of her. Review of the clinical record face sheet revealed Resident #101 was a [AGE] year old woman, admitted to the facility on [DATE]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed her [DIAGNOSES REDACTED]. According to the MDS section "J" under Pain Assessment, Resident #101 said she rarely had pain. Review of the Geriatric Psychiatry Initial Consultation dated 1/24/11 revealed Resident #101 was tearful and crying and the report said she did report to the Psychiatrist a complaint during the review of symptoms that she was still "afraid someone will hurt her". The Facility's Social Service Technician (SST) said, in an interview on 3/15/11 at 10:47AM that she was asked to speak with Resident #101 regarding the incident of 11/13/10. SST said she spoke with Resident #101 on 11/15/10 and that Resident #101 reported to her that she was treated roughly by a CNA. SST said she spoke to two other female Residents who voiced no complaints to her regarding NA"B". Review of the personnel file of NA"B" revealed that his date of hire by the Facility was 9/13/10. There was a Certified Nurse Aide Certificate from a different State and not from the State the Facility was located in. According to the Administrative Assistant (AA), NA"B" was no longer employed at the Facility because he did not have a Certificate for the Facility's State and did not pass the test to acquire a current Certificate. "AA" said NA"B" had moved out of State and filed for unemployment in a different State and there were "no disciplinary actions in his file". During a phone interview on 3/16/11 at 2:26PM, NA"B" said that on 11/13/10 at about 10:30PM or 11:00PM, he walked into Resident #101's room and she was eating something and spilling all over her self. NA"B" said he offered to change her gown and when he was all done she started screaming, "help, help, help". NA"B"said, "I assumed she thought I was going to put her to bed, but I wasn't". NA"B" said he asked her what was wrong but she didn't answer and then LPN"C" came in and NA"B" said he left Resident #101's room to help someone else. When asked if he wrote a statement, NA"B" said "yes but I didn't write it the same night." NA"B" said, "I only worked 2 days a week". Review of the statement written by NA"B" on 11/19/10 revealed a handwritten note dated for the incident that occurred on 11/13/10 at about 11:00PM with Resident #101. The note stated that NA"B" had offered to change Resident #101's gown and she agreed. NA"B" said he removed her gown and then asked if she wanted her blouse off which was under her gown and NA"B" said Resident #101 agreed also. NA"B' said when he was all finished changing her she started screaming and he tried to talk to her but she would not listen and would not stop screaming and that is when LPN"C" came in so he left the room. In a phone interview on 3/15/11 at 2:15PM, CNA"A" said she worked on 11/13/10 and was asked to take care of Resident #101 because NA"B" didn't finish. When I went in to finish, Resident #101 said NA"B" hurt her. CNA"A" said she did not write a statement of what had occurred that night because no one at the Facility had asked her to write one. In a phone interview on 3/16/11 at 3:25 PM, Registered Nurse (RN"E") said he worked on 11/13/10 and said at about 10:30PM or 11:00PM he heard Resident #101 crying and he went to see what was going on. RN "E" said, "She was crying loudly!" RN"E" said LPN"C" told him, according to Resident #101 NA"B" was rough with her and he was forcing her to go to bed. RN"E" said he assessed Resident #101 but did not document. RN"E" said he did not write a statement of what had occurred that night because no one at the Facility had asked her to write one. Review of the Facility's undated, 41 page, Policy and Procedure titled, "Abuse Prevention and Intervention Program" presented to the Surveyor by the Administrator on 3/15/11 who stated in an interview that he checked in his computer but was not able to locate a date as to when the Policy and Procedures were last updated. The Program revealed on page 2 the Preface which had written, "....It is designed to be a guide to understanding the Abuse regulations effective July 1, 1999 and subsequent updates." Further review on page 27 was titled, "Resident Protection During Abuse Investigation Policy and Procedure" under the section Policy was written, "Any employee who is accused of patient abuse, whether physical or verbal will be suspended without pay pending further investigation." Under Procedure: was written, "#1. An alleged or suspected neglect or abuse, whether physical, verbal, sexual, involuntary, or mental will cause a thorough investigation conducted immediately by management." Under #4 was written, "The Administrator, Director of Nursing, ADON or Charge Nurse will complete the investigation with a written, dated and signed statement from all persons involved." Under #5. was written, "The investigation form and written statements from all persons involved will be forwarded to the Administrator within 24 hours of occurrence. An immediate investigation will be conducted by both the Director of Nursing and Administrator. Review of page 29 under Procedure was written, "1. Any person(s) witnessing or having knowledge of potential or actual abuse must report the incident to the Administrator and/or his/her designee immediately. 2. The person reporting the abuse must complete a patient safety report which includes: Name of person making report. Date of the report. Date and time of the report. Who was involved in the incident: alleged victim and alleged perpetrator. A Description of the incident (specifically describing words and actions). Any other person(s) present (witnesses) To whom the incident was reported Time of report Any other pertinent information. The report is to be given to the Administrator or Designee for further investigation." The Director of Nursing was not at the Facility during the investigation. The Administrator said she was on a vacation. Review of the nurse's notes dated 11/10/10, 11/11/10, 11/12/10 and 11/13/10 under "mood" revealed Resident #101 was "Pleasant, Nice, Cooperative, Alert and orientated and no behavior problems noted by all shifts of Nursing Staff" until 11/15/10 (2 days after the alleged abuse), when LPN"C" had written a late entry for 11/13/10 regarding Resident #101 being heard "yelling and screaming" and crying when reported that the Nurse Aide had twisted her arm. Resident #101 said NA"B" "came in like a mad man, he was a crazy man." ( )