Every finding on record at Covenant Skilled Nursing and Rehabilitation at Wel

Based on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Ensure that all partly used or opened foods had a use-by date, resulting in an increased likelihood for food borne illness with hospitalization, and cross contamination affecting a census of 32 residents who consumed oral nutrition from the facility kitchen. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: Review of the facility Dietary Sanitation of Equipment policy, dated 2/13/25, revealed that staff were to clean kitchen equipment daily and stated Safety always come first. Review of the facility Labeling Food Product policy, dated 1/3/2023, stated All food service workers within the unit will be trained on proper labeling prepared foods and products stored for later use. All labels will contain the complete name of the product, the date the product was prepared or opened, the date the product must be utilized by. During the initial kitchen tour done on 3/23/26 at 8:30 a.m., accompanied by Dietary Manager D, the following observations were made and interviews were done: -At 8:38 a.m.: A large gray trash bin with trash filled to the rim, was observed sitting directly next to a food prep area with the top on the floor where [NAME] C was making the noon meal (pork ragu). -At 8:40 a.m.: Clean and ready for use pots and pans were observed sitting on the bottom shelf of a food prep table with pieces of food and crumbs inside several of them; the shelf they were on also had dried food pieces and dust on it. The pans were stacked face up on the shelf (should be face down to prevent contamination). During an interview done on 3/23/26 at 8:40 a.m., Dietary Manager D stated I have only been manager for 3 days -At 8:42 a.m.: A second large gray trash bin with trash in it was observed with the top on the floor, and it was next to the uncovered clean and ready for use floor food mixer. -At 8:43 a.m.: The clean and ready for use large floor mixer was observed to have flour and dried food particles inside the bowel, on the handle and on the attachment area. There was no cover on it. Dietary Manager D stated they (staff) used it last week, they made meat loaf with it, it should be clean and have a cover over it. -At 8:45 a.m.: The clean and ready for use counter mixer was observed to have dried food on the attachment area (directly over the bowel). -At 8:50 a.m.: The large white plastic food container half full of Panco (breading), was observed to have dried yellow colored drippings inside and on the outside. -At 8:51 a.m.: The back food prep area was observed to have an excessive amount of crumbs, dried food particles and dust on it. During an interview done on 3/23/26 at 8:51 a.m., Dietary Manager D stated I agree (the food prep table was dirty). -At 8:52 a.m., another large gray trash bin was uncovered sitting right next to the flat grill with the top again sitting on the floor. Pieces of food, thick grease and papers were above the rim of the trash bin; [NAME] B was cooking and observed putting the extra grease from the flat top grill directly into the trash bin because the grease trap (under grill) was stuck and she could not get the drawer open. The grease trap was noted to have approximately an inch and a half of old grease and pieces of food in side of it. During an interview done on 3/23/26 at 8:52 a.m., [NAME] B stated The guy's (maintenance staff) usually clean it (the grease trap), we can't get it open, I already hurt myself trying. -At 8:55 a.m., several broken and loose floor tiles (one came right up) was observed in front of the flat grill; the floor was buckling under the tiles due to moisture. When this surveyor inspected them, one large whole floor tile came right up and the wood underneath was warped. During an interview done on 3/23/26 at 8:55 a.m., [NAME] B said the tiles had been broken for awhile and she had reported it to the manager, stating I almost tripped on them several times. -At 9:00 a.m., the flat top grill and stove hood metal vents were noted to be bent, with several of them missing exposing large gaps. -At 9:03 a.m., the microwave outsider sides, insider sides and top was found to have an excessive amount of dried food. During an interview done on 3/23/26 at 9:03 a.m., Dietary Manager D stated They (staff) are supposed to clean it daily. Dietary Manager D said the weekend staff did not do their cleaning duties the prior weekend. -At 9:04 a.m., two large plastic containers of peanut butter were observed with peanut butter on the top and down the sides of both of them. -At 9:05 a.m., the salad bar was observed to have dried lettuce and died shredded cheese covering the inside back area. The kitchen had not even served any salad yet (on 3/23/26 in the morning). -At 9:06 a.m., 2 large containers of ice cream were observed in the ice cream freezer, both had been open and partly consumed with no dates on the tops at all; one had the top partly off with some freezer burn noted on the ice cream During an interview done on 3/23/26 at 9:06 a.m., Dietary Manager D said the ice cream containers should of had dates on them when they were open and a use-by date. -At 9:07 a.m., a clean and ready for use silver metal scupper were observed sitting in the clean utensil container with dried food inside of it. -At 9:10 a.m., the pop machine was noted to have dried pop all over the spicket areas. During an interview done on 3/23/26 at 9:10 a.m., Dietary Aid E stated the jobs are supposed to be done every day, it's on the job sheet. Review of the facility Dietary job/duty sheets dated 3/22/26 (Sunday), revealed 42 blank squares (missing staff initials indicating jobs were not completed). -At 9:19 a.m., under the working steamer was noted a large pool of water on the counter. -At 9:20 a.m., a large area of frozen condensation was noted directly above the cooling motor and fan in the walk-in freezer. During an interview done on 3/23/26 at 9:19 a.m., [NAME] C stated it's broken, it's been like that. During an interview done on 3/23/26 at 1:37 p.m., Infection Control Nurse A said he was new and he had done a walk-through (in the kitchen) with the Director of Nursing approximately a week before the State kitchen tour was done (on 3/23/26). During an interview done on 3/23/26 at 2:00 p.m., Maintenance Director F revealed no one had given him any work orders or informed him of the things that needed to be fixed in the kitchen (hood, grease trap, tiles and ice condensation in freezer). On 03/23/2026 at 12:46pm during the main kitchen tour, observed yellow residue in the interior walls of the ice machine in the main kitchen. During this observation, Dietary Manager D was interviewed on how often the ice machine is cleaned, and she answered it's cleaned by maintenance once a month. On 03/23/2026 at 12:48pm observed Pentair Everpure 7FC5-S filter dated 4/5/22, for the tea machine in the main kitchen. Another filter to the juice machine was dated 10/29/24. On 03/23/2026 at 12:56pm observed residue on the mixer. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 03/23/2026 at 12:58pm, the wiping cloth sanitizer bucket was tested with quat strips and the result was zero. During this observation, Dietary Manager D was asked how often it's changed out and she stated it's changed out every 2 hrs. On 03/23/2026 at 1:02pm observed what appeared to be a bee flying above the food prep area. On 03/23/2026 at 1:04pm observed a utility sink with a hose attached and a chemical feed dispenser downstream of an atmospheric vacuum breaker (AVB) in the boiler room adjacent to the kitchen. According to the State of Michigan's 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve). According to the State of Michigan's 2008 Cross Connection Manual on chemical feeder backflow prevention, Another concern with a hose being run from a faucet to the dispenser is that many times a valve is installed on the hose downstream of an AVB, which is not allowed since AVBs cannot be subject to continuous pressure. On 03/23/2026 at 1:30pm interviewed Director of Maintenance F on whether there were cleaning logs for the ice machine in the main kitchen and he stated there weren't any cleaning logs. On 03/23/2026 at approximately 1:30pm interviewed Director of Maintenance F on how often the filters to the tea and juice machine are changed and he stated he wasn't sure if that was his job to do or not. On 03/23/2026 at approximately 1:30pm interviewed Director of Maintenance F on what the procedure is for when they see pests in the kitchen, and he stated they're supposed to call the pest control company and figure out where the pests could be coming from. According to the FDA 2022 Food Code, 6-501.111 Controlling Pests, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by .Routinely inspecting incoming shipments of food and supplies .Routinely inspecting the premises for evidence of pests .Using methods, if pests are found, such as trapping devices or other means of pest control . Eliminating harborage conditions. According to the facility's policy on pest control, Building management will ensure that pest findings are recorded in the log and that written reports are reviewed after each service. Other responsibilities including correcting sanitation and structural deficiencies, as detailed in the written reports, which may lead to pest problems, and compliance with applicable notification and posting requirements. On 03/23/2026 at approximately 1:45pm interviewed Dietary Manager D on what range the rag sanitizer bucket should result at, and she stated it should be between 200 and 400. According to the facility's policy on sanitizer, Sanitation buckets must be established with appropriate sanitizing solution, i.e., generally for bleach, 50-100ppm or Quaternary solution, 200ppm; however, follow manufacturer's recommended directions. According to the FDA 2022 Food Code, 3-304.14 Wiping Cloths, Use Limitation, Cloths in-use for wiping counters and other equipment surfaces shall be .Held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114 and The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit.

Based on observation, interview and record review, the facility failed to ensure daily snacks were offered and delivered per 6 of 6 resident complaints during a confidential resident group meeting, resulting in resident verbalizations of anger and frustration with complaints, and the failure to offer and deliver snacks to residents documented to receive evening snacks. Findings Include:Review of the facility snack policy dated February 2014, stated the snacks were to be given to resident's Between-meal (and) are offered to resident's (daily), except when contraindicated; document snack consumption.During the confidential resident group meeting held on 3/24/26 at 11:10 a.m., 6 of 6 attendees verbalized anger and frustration regarding not knowing they could even have snacks, not being offered daily snacks, and not receiving any snacks.

Based on observation, interview and record review, the facility failed to ensure a clean and safe environment for 5 of 8 residents' room observations (resident rooms: #22, #26, #32, #34, and #40), and for 4 of 6 residents from the confidential resident group meeting which took place on 03/24/36, resulting in verbalization of frustration and anger regarding condition of resident rooms, and an increased risk for cross contamination, risking resident health and welfare. Findings Include: This citation pertains to Intake Number 2806043. Review of the facility Maintaining a Clean Environment policy, dated March 2021, stated Cleaning a resident's room both daily cleanings and upon discharge includes the following: Cleaning all horizontal surfaces, cleaning of all contact points, decontaminating the telephone, remote control, light switches and other high touch areas with a wet cloth and germicide; wet mop floors daily using a detergent germicide (bathroom floor). During the confidential Resident's Group Meeting held on 3/24/26 at 1:00 p.m., 4 of 6 attendee's verbalized frustration and anger regarding staff not cleaning their rooms daily or since admission. During the initial tour done on 3/23/26 from 9:30 a.m. through 11:30 a.m., and at 2:45 p.m. and 3:00 p.m., for 5 of 18 resident rooms observed with interview's revealed, facility staff had not cleaned resident rooms daily (vacuum, bathroom toilet, sink and floor and touchable surfaces disinfected), or at all since admission. -room [ROOM NUMBER] Resident had a BIMS (cognitive assessment 1-15) of 15: Observation and interview done on 3/23/26 at 2:45 p.m., revealed small pieces of dried food and papers on room floor, and the bathroom floor corners were noted to be dirty and the toilet had dried BM inside the rim. The resident stated, they clean my room only once a week. -room [ROOM NUMBER], resident alert and able to answer questions asked: Observation and interview done on 3/23/26 at 10:25 a.m., revealed the floor was dirty at the bottom of the bed, under the bed, and under her wheelchair with food crumbs and with small pieces of tissue and papers. The resident stated I have never seen them (staff) clean yet, they don't vacuum or do the bathroom. -room [ROOM NUMBER], had a BIMS of 14: Observation and interview done on 3/23/26 at 3:00 p.m., revealed small pieces of paper on the floor, dust under the bed, and on the bathroom floor. The resident stated They (staff) don't clean my room at all. -room [ROOM NUMBER], had a BIMS of 10: Observation and interview was done on 3/23/26 at 10:48 a.m., revealed the floor was dirty and had pieces of paper on it, and the bathroom floor had dirt in corners with dried BM on the inside of the toilet rim and bowel. The resident said they had only vacuumed one time since she was admitted , and stated They have never cleaned the toilet.-room [ROOM NUMBER], had a BIMS of 15: Observation and interview was done on 3/23/26 at 10:08 a.m., revealed the floor was dirty with a lot of small pieces of tissues and papers near the side of the bed. The resident stated, They have only vacuumed once or twice, they mop my floor (in bathroom) once a week.Observation done on 3/23/26 at 9:25 a.m., revealed room [ROOM NUMBER] had cold air coming out of the heater and staff had put 3 large bath blankets on top of the heater vents to block the cold air. The wheatear on 3/24/26, was snow; the resident was complaining of being cold. During an interview done on 3/24/26 at 8:17 a.m., Maintenance Staff Member G said that staff changes (the heater/cooling setting) on second shift; it gets cold in resident rooms when they turn the heater down and air on. During an interview done don 3/24/26 at 8:56 a.m., Director of Maintenance F stated The system, the heat to AC balancer goes from hot to cold. I do not know why they (staff) were changing the heaters (turning the heater down and air on during second shift), I had to lock them out this morning (on 3/24/26, after this surveyor saw the bath blankets in room [ROOM NUMBER] on top of the heater). Director of maintenance F had to lock the heater so staff would not turn it down on second shift. During an interview done on 3/24/26 at 3:15 p.m., Infection Control, RN A said that he was new at the facility and had not done and documented environmental rounds.

This citation pertains to Intake Number 2806043. Based on observations, interview and record, the facility failed to ensure proper handwashing was done during dining and medication pass observations, ensure that1 resident's (Resident #16) of 1 resident reviewed for CPAP, mask was properly stored when not in use, and ensure that 1 resident (Resident #55) of 2 residents reviewed for urinary catheter use, catheter bag was off the floor, resulting in an increased risk for cross contamination and respiratory infection, and an increased risk for contamination during meals and medication administration from lack of handwashing, with risk of resident illnesses and hospitalization. Findings Include: Resident #16: Review of the Face Sheet, Diagnosis sheet, Nursing notes dated 3/26, and care plans dated 2/25/26 and 3/10/26, revealed Resident #16 was 88 years-old, alert and able to make own healthcare decisions, required staff assistance with all Activities of Daily Living (ADL's), and non-weight bearing. The residents diagnosis revealed, sepsis, fall with fracture of right fibula (leg bone), and fracture of right ankle. Review of the facility BIPAP/CPAP Therapy policy dated July, 2024, revealed the CPAP mask was to be cleaned by staff weekly. Review of the facility Respiratory Equipment Care & Handling policy dated December 2008, stated After drying, place in a plastic bag. Observation made on 3/23/26 at 9:00 a.m., revealed a dry CPAP mask sitting on the nightstand next to the bed, directly next to a dirty urinal. There was a dated clear plastic bag hanging on the wall above the head of the bed for the mask to be stored in when not in use. During an interview done on 3/23/26 at 9:00 a.m., resident #16 stated he had use it (CPAP mask) last night, and I took it off early this morning. During a second observation done on 3/24/26 at 8:00 a.m., the same dry CPAP mask was again sitting on the nightstand next to the bed. The same dated clear plastic bag was just above the mask hanging on the wall. During a second interview done on 3/24/26 at 8:00 a.m., Resident #16 stated I took it off at 5:00 a.m. this morning, no one puts it in the bag. The resident informed this surveyor that his (Family member) #1 comes in and cleans his CPAP mask, no staff clean it. During a phone interview done on 3/25/26 at 2:30 p.m., Family Member #1 said she was the only one who cleaned the residents CPAP mask, and she verbalized it needed to be put in the plastic bag when not in use. During an interview done on 3/24/26 at approximately 2:00 p.m., Infection Control Nurse, RN A said all CPAP masks were to be cleaned and stored in a sated plastic bag when not in use. Medication Pass Administration: Observation on 03/23/2026 at 8:59 AM with Registered Nurse (RN) R, pushed the medication cart to room [ROOM NUMBER] for medication administration. RN R stated that she did have medications to pass in room [ROOM NUMBER]. Observation of RN R went into room [ROOM NUMBER], unlocked the in-room med cabinet, brought out the plastic medication packs to the med cart in the hallway, reviewed the medications against the computer and punched out the medication packets into a clear med cup and went back into room [ROOM NUMBER] and administered the medications to the resident. RN R then went back out to the medication cart in the hall. Observation on 03/24/2026 at 6:59 AM with Registered Nurse (RN) M, walked away from the 'Team Room' she is the night shift nurse, waiting for her day shift replacement. Medication cart left unlocked in team room, nurse walked out of sight, Surveyor waited for any staff to present. At 03/24/2026 at 7:00 AM RN/MDS staff P came into the 'Team Room' the state surveyor explained that the nurse left the room, and the medication cart was left unlocked, and the treatment cart was left unlocked. Observation and interview on 03/24/2026 at 7:13 AM on the Superior unit Shift change, Night shift nurse License Practical Nurse (LPN) S gave report to oncoming Registered Nurse Q and counted the controlled medications in the medication cart and the Marinol in fridge. Record review of the Superior Unit 2026 'Controlled Medication Shift Change Log' noted that on 3/23/2026 signature of off-going nurse was blank. On the form it is clearly stated that discrepancies are to be reported to Nursing Administration. LPN S stated that we put a yellow sticky note on the Superior Unit 2026 'Controlled Medication Shift Change Log' so the nurse would know to sign the form next time she works. Observation and interview on 03/24/2026 at 7:26 AM on the Lake [NAME] unit with Licensed Practical Nurse (LPN) N the nurse walked into the team meeting room placed his backpack in the room. Observation of LPN N medication pass began with no hand hygiene done. LPN N pushed medication cart to room [ROOM NUMBER], used keys to unlock in room medication cabinet, pulled plastic baggies of medications back out to the med cart, meds placed in cup. LPN N then entered room [ROOM NUMBER] and administered medications for the residents. LPN N then went back to medication cabinet for eye drop medication and then gloved and administered eye medication. LPN N removed the gloves and went back to the in-room medicine cabinet and locked up the cabinet and went out to the medication cart to start the next resident's medication administration. Observation and interview on 03/24/2026 at 8:06 AM with the Lake [NAME] unit Licensed Practical Nurse (LPN) H was moving the medication cart to room [ROOM NUMBER]. LPN H began to chat and explained that the resident in room [ROOM NUMBER] took the medications whole pills with water, and had two antibiotics that were oral, and two nasal sprays. LPN H performed no hand hygiene prior to medication prep, went into the resident's room to unlock the med cabinet and returned to the medication cart. Medications were removed from the plastic baggies and reviewed, punched out of the med packs and placed in a clear medication cup. LPN H then went into room [ROOM NUMBER] administered the medications and then did wash after administration of oral medications. LPN H then gloved for nasal spray application, used the remote control to change the channel for residents, switched gloves but did not wash hands, LPN H stated that the call lights are at 15 minutes now, she was watching the monitor on the unit. LPN H stated that there was a call in for the aide today and we are splitting an agency aide between 2 units. LPN H stated Call lights are going off stated that her unit was a heavy use call light unit. Record review of the facility 'Medication Pass Guidelines dated 9/2023, revealed to assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing the administration oof drugs in an accurate, safe, timely, and sanitary manner and to systematically distribute medications to residents in accordance with state and federal guidelines. Procedure: (1.) Follow infection control practices- complete hand hygiene prior to medication preparation for each medication pass, between resident medications administrations, after direct resident contact and at the completion of medication pass. (10.) Ensure medication and/or treatment cart is locked when unattended. Dining Observation: Observations on 03/23/2026 at 11:33 AM kitchen staff were Observed loading the meal trays in the main dining room, into the insulated rolling boxes. thermal plate warmers and lids are being used. Staff wear gloves for the plating of the food items. Beverages are added to the trays currently also. No residents eat in the dining room area; all were in room trays and taken to the resident rooms. Dining area is well lite, and there are plenty of tables and chairs. area is well ventilated. Will observe sample residents during meals. Observation of residents' meals in rooms, trays were passed with no hand hygiene offered to residents. 03/24/2026 7:44 AM Observation of breakfast trays prepped and placed in thermal boxes and then taken to the resident units and passed by staff members. meal tickets are checked for proper diet, texture and choices. Meals are made in the kitchen across the road and brought into the facility from outside and then the trays are made up and taken to the resident rooms. Observation on 03/24/2026 at 8:40 AM During medication pass meal trays observed as being passed with no hand hygiene offered to residents by staff. Will observe again at noon meals. Observation and interview on 03/24/2026 at 12:05 PM with dietary side V server stated that the dietary staff take the trays to the rooms. Dietary aide V observed to take lunch tray into room [ROOM NUMBER], the tray was delivered, the resident was lying in bed, and no hand hygiene was offered. Dietary aide V moved items on the overbed table and arranged items to make room for the meal tray and then went back to the thermal tray box and got the next tray to pass. Observation on 03/24/2026 12:13 PM Observation of meal tray delivery meal tray delivered by dietary aide W to room [ROOM NUMBER], the dietary aide set the meal tray on the table and did not remove the lid, left the room. Dietary aide W stated that their staff delivering trays was usually only 2 people from the kitchen to deliver the meals, but today they gave us an extra person so there are 3 of us today to make it go quicker. No hand hygiene was observed during the meal tray passing. Observation and interview on 03/24/2026 at12:19 PM with the resident in room [ROOM NUMBER] who had in room meal. Observation of the meal delivery the resident was asked about hand hygiene and replied that no they have not ever offered me hand washing before the meals. Observation of noon meal tray was a piece of fish and white rice; she did not want it. The resident Was noted eating a small salad from the facility and she stated that it was mostly lettuce and not that good and that 4 out of 5 days the food is not that good. Record review of the facility 'hand Hygiene' policy dated 8/2023, revealed hand hygiene shall be regarded by the organization as the single most important means of preventing the spread of infections. All personnel shall follow our established hand hygiene procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. Resident #55: Record review of Resident #55's admission progress note dated 3/21/2026 at 4:45PM revealed a 16french foley catheter with milky discharge observed at foley insertion site of penis. 03/23/2026 9:47 AM Resident seated up on side of bed working with Speech therapy person, observed a clear hard plastic urometer and urine collection catheter bag hanging at the bedside from the doorway. No privacy bag or covering noted, clear yellow urine noted in urine meter on the bag. Bag and spout touching the floor. Surveyor will continue to monitor the catheter bag placement. In an interview on 03/23/2026 at 11:25 AM with Resident #55's family member revealed that the resident was at another long-term care facility and went to the hospital for dehydration and came to the current facility with urinary foley catheter, Observation of the catheter is a clear bag with a urometer, no privacy bag was in place. The family member stated that the resident came from the hospital on Saturday, and his catheter has been hanging there just like that since he arrived and does switch sides of the bed from time to time. The family member also stated that there has not been a covering bag on it. Everyone comes in looks at it and leaves. Observation and interview on 03/24/2026 at 11:40 AM with Registered Nurse (RN) Q observed Resident #55's foley catheter on the floor again clear plastic urometer and catheter bag with clear yellow urine noted, with the catheter tubing under the bed. The state surveyor asked RN Q why the catheter is on the floor. RN Q stated that she was told because the bed needs to be in lowest position, because he was a fall risk. In an interview on 03/24/2026 at 11:47 AM with the Infection Control Preventionist (ICP) A about Resident #55's Urinary catheter, the ICP A stated that the urinary catheter should not be resting on the floor. and that a privacy bag should be in place. ICP A stated that the facility does have Privacy bags for urinary catheters and that the nurses are aware to change the bags out when the residents admit with a catheter. ICP A acknowledged that Cross contamination from floor organisms to catheter and potential infections that can occur. The ICP A was asked if he did resident room rounds for new admission and he stated that he tries to round every day and that he had not gone into Resident #55's room. Record review of the facility 'Indwelling Cather Care' policy dated 10/2027, revealed staff should inspect the catheter and tubing periodically to detect compression or kinking that could obstruct urine flow. Ensure tubing is secured using a leg strap (securement device). Keep the drainage tube and collection bag lower than bladder at all times. Ensure bag and tubing is not lying on the floor. Drainage bags should be placed in a privacy bag.

Based on interview and record review, the facility failed to ensure that a venue that was convenient to both parties was clearly identified in the arbitration agreements for 2 residents (Resident #14 and Resident #43) of 2 residents reviewed, resulting in the likelihood for unresolved arbitration disputes. Findings include: An interview and record review on 03/24/2026 at 12:59 PM with Registered Nurse (RN) P revealed the facility had 2 residents in a binding arbitration agreement. RN P stated that she did not know if anyone has used the arbitration to resolve disputes she is to only get the signatures and not prevue to corporate legal information. RN P stated that she goes over the form and reads the agreement to them and ask if they know what that means and explains that she was not a lawyer so does not give legal advice and do not let them to sign or not sign. RN P stated that she explains to residents that the facility use a third-party mediator for legal disputes, there is a right to cancel agreement section that they cancel the arbitration or change it. Record Review of arbitration agreement documents with Resident #14 and Resident #43's signatures noted that the agreement did not clearly identify a convenient venue to both parties. There was no venue identified in the agreements. Record review of Resident #14's arbitrational agreement for was signed by the resident on 3/18/2026 and Resident #43 signed the arbitrational agreement on 3/2/2026. Record review of the facility 'Binding Arbitration Agreement Policy', dated 3/2024, revealed section 2.) the agreement must:(b.) Provide for selection of a venue that is convenient to both parties.

Based on observation, interview and records review the facility failed to prevent facility-acquired skin injuries for 1 resident (Resident #56) of 22 residents reviewed, resulting in the development of bilateral heel redness with the verbalization for pain and discomfort and likelihood of prolonged illness. Findings include: Resident #56:Record review of Resident #56's admission assessment dated [DATE] skin integrity section noted two open areas with dressings to the left knee and scattered bruising. Observation and interview on 03/23/2026 at 9:29 AM with Resident #56 were observed with her heels resting on the footboard of the bed and the Resident stated that both her heels hurt and that's what woke her up today and she told a nurse and they put some cream on them. Observed at this time with both heels resting on the footboards and the head of the bed elevated high up and the resident's position as scrunched down to the end of the bed, while eating breakfast. Resident stated that She also has a sore on her tail bone also. There are no extra pillows noted in the room for her heels to be off the mattress. Family member was in the room and stated that they just put the tray down and leave. In an interview on 3/23/2026 at 9:32AM with a Family member of the resident #56 interview was performed. The family member stated that the Resident had leg swelling at home and went to the hospital and then came here for strengthening. One of the family comes every day to take care of her, and this is why. They don't assist with the basics, and the bathroom is dirty all the time. Observation and interview on 03/23/2026 at 11:38 AM of Resident #56 revealed she was observed with her feet away footboards, but flat on the mattress (not an air mattress) there were no pillows noted for positioning the resident off her tail bone or raising the heels off the mattress. Resident #56 stated that both heels still hurt, but that she got out of bed and stood on them and was up in for a while. Observation and interview on 03/24/2026 at 10:16 AM Resident #56 were observed with a family member giving a shower to her mother because she was sweaty and gross. The family member stated that she just wheeled (the resident) into the shower and started the water. There were no staff present because they could not find any aid to assist. Observation and interview on 03/24/2026 at 10: 50AM the surveyor observation of resident #56's bilateral feet with nurse Registered Nurse (RN) Q of the back of the heel on each foot, noted red areas the estimated size of golf ball. The resident #56 stated that both were sore and painful to the touch. Resident #56 had told the surveyor yesterday that her heels were sore and that was new since she came to the facility. Record review of Resident #56's care plans pages 1-10, developed on 3/17/2026 revealed potential/actual impairment to skin integrity related to fragile skin. Actual open areas to lower left extremity with scattered scabbing dated 3/18/2026. Interventions included: During review of my skin status work to help determine potential contributive factors and alert the physician/resident representative to implement approaches to address them and document the information 3/17/2026. Help me avoid scratching; keep hands and body parts from excessive moisture as much as possible. Keep fingernails short and filed or without jagged edges 3/17/2026. Keep skin clean and dry. Use lotion on dry skin 3/17/2026. Use facility protocols for treatment od skin treatment 3/17/2026. There were no interventions for an air mattress, positioning devices or a turning schedule noted. Record review of the facility 'Skin Management Facility Guidelines' policy dated 1/2022, revealed staff are to conduct a baseline head to toe skin assessment on each resident upon admission . Record review of the facility 'Comprehensive Care Plans' policy dated 4/2023, revealed it is the policy of the facility to initiate care plans on all residents in accordance with federal regulations and identified needs of the residents. (1.) Complete a full assessment on admission. (2.) Identify resident's problems, risks, needs, and strengths. Record review of the facility 'Alignment and Pressure Reducing Devices' policy dated 1/2022 revealed it is the policy of the facility to provide residents with positioning and alignment support to minimize pressure, maximize comfort, and reduce the risk for further skin breakdown. Various assistive devises can be used to maintain correct body positioning and to help prevent complications that commonly arise when a resident must be on prolonged bed rest . Record review of the facility 'Pressure Ulcer Preventive Measures Policy' dated 1/2022 revealed residents at risk of development of pressure ulcers receive interventions to reduce the risk of pressure ulcers. (18.) .Use devices that relives pressure on the heels, most commonly by raising the heels of the bed. Use pillows under the length of the lower leg, suspending the heels .

This citation pertains to Intake Number 2806043. Based on observation, interview and record review, the facility failed to ensure that 3 residents' care plans (#16, #55 and #56) of 22 residents' care plans reviewed were up to date with resident specific interventions, resulting in the high risk for improper or non-specific nursing interventions with poor continuity of care. Findings Include: Resident #16: Review of the Face Sheet, Diagnosis Sheet, nursing notes dated 3/26, and care plans dated 2/25/26 and 3/10/26, revealed Resident #16 was 88 years-old, alert and able to make own healthcare decisions, required staff assistance with all Activities of Daily Living (ADL's), and was non-weight bearing. The residents diagnosis revealed, sepsis, fall with fracture of right fibula (leg bone), fracture of right ankle, and facility acquired pressure ulcer (PU) on right foot. Review of the residents facility physician orders dated 3/10/26, stated Air Cast with tube sock when out of bed, Cleanse Right foot inner bunion with NS (normal saline), pat dry cover with foam dressing. Review of the facility Comprehensive Care Plans policy dated April, 2023, stated Review care plans and revise as needs change; Include physician orders. Review of the residents Potential/Actual Impairment to Skin care plan dated 2/25/26, up-dated 3/10/26, stated as the Focus/Problem Actual Stage 1 pressure to the inner right ankle and right bunion, small red areas to right small toe. No documentation of any interventions on the care plan regarding care of the newly quired PU on the right inner ankle was found. The new pressure ulcer/PU was documented on 3/10/26, however no interventions were added to the Skin care plan regarding the newly developed PU. During an interview done on 3/2426 at approximately 2:40 p.m., and per review of all resident #16's facility care plans (done with this surveyor and the Director of Nursing/DON); the DON said new interventions for an actual skin impairment (new PU) should have been added to the protentional Skin care plan. Resident #55: Record review of Resident #55's admission progress note dated 3/21/2026 at 4:45PM revealed a 16 French foley catheter with milky discharge observed at foley insertion site of penis. 03/23/2026 9:47 AM Resident seated up on side of bed working with Speech therapy person, observed a clear hard plastic Urometer and urine collection catheter bag hanging at the bedside from the doorway. No privacy bag or covering noted, clear yellow urine noted in urine meter on the bag. Bag and spout touching the floor. Surveyor will continue to monitor the catheter bag placement. In an interview on 03/23/2026 at 11:25 AM with Resident #55's family member revealed that the resident was at another long-term care facility and went to the hospital for dehydration and came to the current facility with urinary foley catheter, Observation of the catheter is a clear bag with a Urometer, no privacy bag was in place. The family member stated that the resident came from the hospital on Saturday, and his catheter has been hanging there just like that since he arrived and does switch sides of the bed from time to time. The family member also stated that there has not been a covering bag on it. Everyone comes in looks at it and leaves. Observation and interview on 03/24/2026 at 11:40 AM with Registered Nurse (RN) Q observed Resident #55's foley catheter on the floor again clear plastic Urometer and catheter bag with clear yellow urine noted, with the catheter tubing under the bed. The state surveyor asked RN Q why the catheter is on the floor. RN Q stated that she was told because the bed needs to be in lowest position, because he was a fall risk. In an interview on 03/24/2026 at 11:47 AM with the Infection Control Preventionist (ICP) A about Resident #55's Urinary catheter, the ICP A stated that the urinary catheter should not be resting on the floor. and that a privacy bag should be in place. ICP A stated that the facility does have Privacy bags for urinary catheters and that the nurses are aware to change the bags out when the residents admit with a catheter. ICP A acknowledged that Cross contamination from floor organisms to catheter and potential infections that can occur. The ICP A was asked if he did resident room rounds for new admission and he stated that he tries to round every day and that he had not gone into Resident #55's room. Record review of Resident #55's Care plans initiated on 3/21/2026 revealed that on 3/23/2026 indwelling catheter related to urinary retention was added to the care plans. Per nursing progress noted dated 3/21/2026 Resident #55 was admitted to the facility with a 16 French indwelling catheter with a milky discharge at the penis opening. Record review of the facility 'Indwelling Cather Care' policy dated 10/2027, revealed staff should inspect the catheter and tubing periodically to detect compression or kinking that could obstruct urine flow. Ensure tubing is secured using a leg strap (securement device). Keep the drainage tube and collection bag lower than bladder at all times. Ensure bag and tubing is not lying on the floor. Drainage bags should be placed in a privacy bag. Record review of Resident #55's care plans pages 1-9, developed on 3/21/2026 revealed that on 3/23/2026 an indwelling catheter related to urinary retention care plan was initiated. Resident #55 was admitted on [DATE] with milky white drainage noted in progress notes. Resident #56: Record review of Resident #56's medical record revealed medical diagnoses of: acute kidney failure, anemia, diaphragmatic hernia, chronic kidney disease, prosthetic heart valve, congestive heart failure, pressure-induced deep tissue damage of sacral region, Kyphosis thoracic, intervertebral disc degeneration . Record review of Resident #56's admission assessment dated [DATE] skin integrity section noted two open areas with dressings to the left knee and scattered bruising. Observation and interview on 03/23/2026 at 9:29 AM with Resident #56 were observed with her heels resting on the footboard of the bed and the Resident stated that both her heels hurt and that's what woke her up today and she told a nurse and they put some cream on them. Observed at this time with both heels resting on the footboards and the head of the bed elevated high up and the resident's position as scrunched down to the end of the bed, while eating breakfast. Resident stated that She also has a sore on her tail bone also. There are no extra pillows noted in the room for her heels to be off the mattress. Family member was in the room and stated that they just put the tray down and leave. In an interview on 3/23/2026 at 9:32AM with a Family member of the resident #56 interview was performed. The family member stated that the Resident had leg swelling at home and went to the hospital and then came here for strengthening. One of the family comes every day to take care of her, and this is why. They don't assist with the basics, and the bathroom is dirty all the time. Observation and interview on 03/23/2026 at 11:38 AM of Resident #56 revealed she was observed with her feet away footboards, but flat on the mattress (not an air mattress) there were no pillows noted for positioning the resident off her tail bone or raising the heels off the mattress. Resident #56 stated that both heels still hurt, but that she got out of bed and stood on them and was up in for a while. Observation and interview on 03/24/2026 at 10:16 AM Resident #56 were observed with a family member giving a shower to her mother because she was sweaty and gross. The family member stated that she just wheeled (the resident) into the shower and started the water. There were no staff present because they could not find any aid to assist. Observation and interview on 03/24/2026 at 10: 50AM the surveyor observation of resident #56's bilateral feet with nurse Registered Nurse (RN) Q of the back of the heel on each foot, noted red areas the estimated size of golf ball. The resident #56 stated that both were sore and painful to the touch. Resident #56 had told the surveyor yesterday that her heels were sore and that was new since she came to the facility. Record review of Resident #56's care plans pages 1-10, developed on 3/17/2026 revealed potential/actual impairment to skin integrity related to fragile skin. Actual open areas to lower left extremity with scattered scabbing dated 3/18/2026. Interventions included: During review of my skin status work to help determine potential contributive factors and alert the physician/resident representative to implement approaches to address them and document the information 3/17/2026. Help me avoid scratching; keep hands and body parts from excessive moisture as much as possible. Keep fingernails short and filed or without jagged edges 3/17/2026. Keep skin clean and dry. Use lotion on dry skin 3/17/2026. Use facility protocols for treatment od skin treatment 3/17/2026. There were no interventions for an air mattress, positioning devices or a turning schedule noted. Record review of the facility 'Skin Management Facility Guidelines' policy dated 1/2022, revealed staff are to conduct a baseline head to toe skin assessment on each resident upon admission . Record review of the facility 'Comprehensive Care Plans' policy dated 4/2023, revealed it is the policy of the facility to initiate care plans on all residents in accordance with federal regulations and identified needs of the residents. (1.) Complete a full assessment on admission. (2.) Identify resident's problems, risks, needs, and strengths. (3.) Considerations for care and interventions for resident will be included when developing the baseline and comprehensive care plans . (5.) At a minimum a baseline care plan must be developed and implemented within 48 hours of admission. The baseline care plan must include instructions needed to provide effective person-centered care for the resident. (8.) Review care plans and revise as needs change and in coordination with the MDS schedule.

Based on Interview and record review, the facility failed to ensure a safe discharge for 1 resident (Resident #53) of 3 closed records reviewed, resulting in the potential for ineffective or mismanaged continued care, an Adult Protective Services referral or safe placement and a facility discharge summary review. Findings include:Resident #53:Record review of Resident #53's hospital Discharge summary dated [DATE] revealed a medical diagnosis of dementia along with other chronic diseases of: chronic cellulitis of legs, chronic wounds, acute kidney injury, chronic heart failure with reduced ejection fraction of 45-50%, aortic stenosis, atrial fibrillation, heart block with pacemaker, history of deep vein thrombosis and pulmonary embolism and was discharged to long-term care facility. Record review of Resident #53's nursing progress notes revealed an admission on [DATE] at 1:54PM a Brief Interview of Mental Status (BIMs) was performed on the resident with a score of 6 out of 15, severe cognitive impairment. On 1/6/2026 at 2:23PM Resident #53 was seen by physician services with noted periods of confusion the spouse noted at bedside. Resident #53's progress health status note dated 1/8/2026 at 4:30PM noted that the resident was upset and refusing to take medications or let staff perform blood pressure tasks. Resident was noted stating he used the call light 47 times and has counted, resident was noted as having stated that he waited 3 hours for a toothbrush and was upset and that he was leaving the facility. Physician was notified and the Assistant Director of Nursing was notified and at bedside to witness Against Medical Advice AMA signature. On 1/8/2026 at 7:03PM Resident #53's daughter and ex-wife were notified and stated they are not picking the resident up. Resident signed AMA paperwork around 5 and still sitting at front doors. Writer had daughter on phone and went to check on resident at the front door. Resident stated he has a ride and does not want to talk anymore. Record review of Resident 53's medical record revealed that there were no referrals for adult protective services or community welfare check referrals for the resident. There was no discharge summary or home care referral found. In an interview on 3/25/26 at 10:07 am with the facility social worker J revealed that she could not recall who Resident #53 was. Record review of Resident #53's medical record revealed that Registered Nurse R had discharged the resident. Resident #53 was found on the facility discharge list and had discharged Against Medical Advice (AMA) with a dementia diagnosis with no follow-up. The social worker J stated that she was not at the facility at the time the discharge occurred and did not review the discharge when she came back to work. She just doesn't review discharges and there was no APS referral because she was not at the facility and RN R did the discharge. in an Interview done on 3/25/26 at 10:55 AM, Registered Nurse (RN) R stated I think I remember him (she did discharge due to SW being off). He did not want to be here; his family didn't want to pick him up. When I went in there, he said he pushed the call light 47 times and He said the red button fell off he pushed it so many times the [NAME] red button fell off. I assessed the call light, and it was working fine. He stated I waited 3 hours for a toothbrush; he did have one in his room. I notified him I would get him a toothbrush and he declined. He stated he was living and I said he was not discharged ; he still left. There was no documentation of what time the resident left the facility, who the resident left the facility with, how the resident left the facility or where the resident was going to live. There were no home care referrals, no adult protective services or community services referrals done by the facility.

Based on interview and record review, the facility failed to ensure that two residents (#3 and #8) of 22 residents reviewed, were fully informed, per consent, of the dosage and frequency of the psychotropic and/or antidepressant medications they were receiving.Findings include: Resident #3: Record review of Resident #3's Minimum Data Set (MDS) dated [DATE] admission revealed a Brief Interview of Mental status (BIMs) score of 13 out of 15, with medical diagnosis of anemia, hypertension, peripheral vascular disease, gastroesophageal reflux disease, renal insufficiency, wound infection, diabetes, arthritis, malnutrition, depression, chronic obstructive pulmonary disease. Record review of Resident #3's March 2026 Medication Administration Record (MAR) and physician orders revealed an antidepressant Mirtazapine Tablet 7.5 MG orally at bedtime. The antidepressant started on 3/2/2026. Record review on 03/24/2026 at 11:20 AM of Resident #3's antidepressant Mirtazapine consent signed by the resident on 3/2/2026, see copy. There is no dosage noted on the consent, no frequency of administration/times per day, Resident #8:Record review of Resident #8's psychiatry notes dated 2/11/2026 revealed that resident was in the nursing home with bipolar and anxiety and depression.Record review of the March 2026 Medication Administration Record (MAR) noted medications of hydroxyzine Pamoate Oral Capsule 50 MG (Hydroxyzine Pamoate) for anxiety, trazodone HCl Oral Tablet 50 MG (Trazodone HCl) for depression, Lurasidone HCl Oral Tablet 20 MG (Lurasidone HCl) for mental disorder, Duloxetine HCl Oral Capsule Delayed Release Sprinkle 60 MG for depression.Record review of consent dated 5/6/2025 was one consent for 4 medications with no dosage or frequency of administration. The consent did not identify the side effects of antidepressants. Record review of the facility 'Psychotropic Medication Assessment & Monitoring' policy dated 4/2019, revealed psychotropic medications are any medications that affect brain activity associated with mental processes and behavior, including antipsychotics, antidepressants, anti-anxiety, and hypnotics. Record review of the facility 'Consent for Psychotropic Drug Use' form, dated 3/2024, revealed: Following a careful assessment of the resident's conditions and needs the physician for the above-named resident has ordered the following medication(s). Because the mood/behaviors observed in the resident are of detriment to the resident's well-being, or the well-being of others around the resident, it is felt the benefits outweigh the risks at this time. Ongoing monitoring of mood/behaviors will continue to determine if there is a continued need for the medication(s). Residents will be monitored for these side effects, and the medication(s) will be discontinued if serious effects develop.

Based on observation, interview and records review, the facility failed to ensure that 1 resident (R #35) had ADL care done daily, and that 1 resident (R#55) had a privacy bag covering the urinary catheter bag, of 22 Residents reviewed for dignity. Findings include: Resident #55: Record review of Resident #55's admission progress note dated 3/21/2026 at 4:45PM revealed a 16 French Foley catheter with milky discharge observed at foley insertion site of penis. 03/23/2026 9:47 AM Resident seated up on side of bed working with Speech therapy person, observed a clear hard plastic urometer and urine collection catheter bag hanging at the bedside from the doorway. No privacy bag or covering noted, clear yellow urine noted in urine meter on the bag. Bag and spout touching the floor. Surveyor will continue to monitor the catheter bag placement. In an interview on 03/23/2026 at 11:25 AM with Resident #55's family member revealed that the resident was at another long-term care facility and went to the hospital for dehydration and came to the current facility with urinary foley catheter, Observation of the catheter is a clear bag with a urometer, no privacy bag was in place. The family member stated that the resident came from the hospital on Saturday, and his catheter has been hanging there just like that since he arrived and does switch sides of the bed from time to time. The family member also stated that there has not been a covering bag on it. Everyone comes in looks at it and leaves. In an interview on 03/24/2026 at 11:47 AM with the Infection Control Preventionist (ICP) A about Resident #55's Urinary catheter, the ICP A stated that the urinary catheter should not be resting on the floor. and that a privacy bag should be in place. ICP A stated that the facility does have Privacy bags for urinary catheters and that the nurses are aware to change the bags out when the residents admit with a catheter. ICP A acknowledged that Cross contamination from floor organisms to catheter and potential infections that can occur. The ICP A was asked if he did resident room rounds for new admission and he stated that he tries to round every day and that he had not gone into Resident #55's room. Record review of the facility admission booklet 'Resident Rights' (undated) page 14, Dignity, Respect & Quality of Life noted the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. On page 38, Privacy- a resident is entitled to privacy, to the extent feasible, in treatment and in caring for personal needs with consideration, respect, and full recognition of his or her dignity. Resident #35 Review of the Face Sheet, nursing progress notes dated 3/26, diagnosis sheet, and care plans dated 2/25/26 and 3/13/26, revealed Resident #35 was 92 years-old, admitted to the facility on [DATE], for end of life care and Hospice services, alert with confusion, and required staff assistance with all Activities of Daily Living (ADL's). The residents diagnosis included, kidney shutdown, cardiomyopathies, heart failure, obesity, abdominal aortic aneurysm without rupture, and lung disease Resident #35 received Hospice services two times per week (for ADL care), had chronic pain and received as needed narcotic pain medication for end of life pain. The resident was unable to participate in any ADL care, nor express his needs. Review of Resident #35's ADL care plan dated 3/13/26, revealed staff were to assist with bed mobility, bathing, dressing and any personal hygiene. Review of the facility Abuse and Neglect Prohibition policy, dated July 2019, stated Residents have the right to free from neglect, exploitation, and misappropriation of resident property. The resident's were to be free from neglect and dignity was to be protected. Observation was made on 3/23/26 at approximately 10:00 a.m., of Resident #35 sleeping in his bed, family were present in the room. The resident had an odor, and his white tee-shirt had a large area on the top left side of dried food. The resident was unable to be interviewed at the time, due to being in the actively dying stage. During an interview done on 3/23/26 at 10:30 a.m., Family Member T stated that staff do not clean him up and they were told by staff (nurses and nursing assistants) that they wait for Hospice (scheduled x2 weekly) to come to do ADL care. A second observation was made on 3/24/26 at 7:50 a.m., the resident was sleeping in his bed with family members present. The same soiled white tee-shirt was on him and he still had an odor. During an interview with Family Members T and U, at 7:50 a.m., both said he had not been cleaned up yet (from 3/23/26), and they had been at the facility with him 24 hours a day; there was always a family member at the facility with the resident. Family Member T stated I can't leave him, I don't trust the staff; I have talked to the nurses about it. They told us they wait for the Hospice Aid to clean him up; no dignity, they won't clean him up at all. During an interview done on 3/24/26 at 7:58 a.m., Nurse, LPN I stated Yes, they should have cleaned him up; his family is confrontational, I did call the DON last night (Director of Nursing). Nurse I said staff were waiting for Hospice to come to clean the resident up. During an interview done on 3/24/26 at 8:10 a.m., Nursing Assistant/CNA B who was starting first shift stated I do clean everyone up (daily); they should clean everyone up daily. During an interview done on 3/24/26 at 9:20 a.m., the Director of Nursing said she had received a call from Nurse I during the night, and she instructed her to go into the residents room and care for him.

This Citation pertains to Intake Number MI00151167. Based on interview and record review, the facility failed to provide showers as scheduled for two residents (#701 and #703) of four residents reviewed for Activities of Daily Living (ADL), resulting in complaints of showers not being provided consistently. Findings include: Resident #701: On 4/2/2025 at 10:20 AM, Complainant E shared Resident #701 was not being showered at the facility and at one point she was in the same clothing for five days. When the concern was addressed with the nurse, they agreed the resident had been in the same clothing and agreed to change them. The next day the Resident reported all they (the facility) did was wipe her butt and change her clothes. Complainant E this upset the resident as she would have liked to be showered according the facility schedule. On 4/2/2025 at approximately 10:45 AM, a review was conducted of Resident #701's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included, Influenza A Virus with Pneumonia, Pleural Effusion, Dysphagia, Heart Disease and Hypertension. Further review of the records yielded the following: Care Plan: .I require 2PA (person assist) with bathing . On 4/2/2025 at 11:30 AM, review was completed of Resident #701's shower documentation from February and March 2025 with the Administrator. The documentation indicated the resident was last showered on 2/19/2025 and not showered again until 15 days later. Resident #701 was scheduled for showers on Monday and Wednesday yet many of the days were marked as NA (not applicable). The administrator expressed understanding of the concern. Resident #703: On 4/2/2025 at 10:40 AM, Resident #703 was observed in her room preparing for the day. When asked about her bathing schedule at the facility she stated she was uncertain as to the days but receives a sponge bath as she has a PICC (Peripherally Inserted Central Catheter) line. On 4/2/2025 at approximately 10:50 AM, a review was conducted of Resident #703's medical records and it revealed she readmitted to the facility on [DATE] with diagnoses that included, Acute Embolism and Thrombosis, Sepsis, Atrial Fibrillation, Sterum Fracture and Pulmonary Hypertension. Further review yielded the following: Kardex: .I am able to: bathe with substantial assist x 1 person . On 4/2/2025 at 11:40 AM, a review of Resident #703's shower documentation was completed with the Administrator. It was found Resident #703 only had two showers at the facility since her admission on 3/10/2025. She was showered on 3/24/25 (Monday) and 3/27/25 (Thursday) with shower days being scheduled on Mondays and Thursdays. On 4/3/2025 at 11:00 AM, review of the infrequent shower documentation was reviewed with the DON (Director of Nursing). It was unclear why facility staff utilized NA when there were other appropriate answers. The DON expressed understanding of the concern.

Based on observation, interview and record review, the facility failed to 1) Maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Ensure all open and partly used foods were dated, resulting in an increased likelihood for food borne illness with hospitalization , and cross contamination affecting 34 residents who consumed oral nutrition from the facility kitchen of a total census of 34 residents. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment. On 2/12/25 at 10:00 a.m., during the initial tour of the main kitchen accompanied by small kitchen Dietary Manager B. Observation of the small facility kitchen was done on 2/12/25 at 10:00 a.m. with Dietary Manager B. -At 10:05 a.m., the large can opener blade was observed to have dried on food on it. -At 10:10 a.m., the dishwasher was opened by staff and it had a crusting of food on both sides and top on the inside. The staff was said the dishwasher was used daily. Observation of the main facility kitchen was done on 2/12/25 at 10:15 a.m., with Dietary Manager C. -At 10:15 a.m., Refrigerator #1 (Dairy) was observed to have dried on milk and food particles on the inside of the bottom and sides by the door. -At 10:16 a.m., the small ice machine was observed to have a light orange colored build-up near the water line; no top on it and next to the ice reservoir. -At 10:18 a.m., the microwave was observed to have dried food inside on the top, sides and glass plate. Also, when the microwave was moved, there was an excessive amount of food particles, dust and crumbs. -At 10:20 a.m., the juice machine was observed to have a build-up of dried juice between spigots'. -At 10:22 a.m., two open and partly used breads were found without any dates written or date stickers found. -At 10:23 a.m., the stove, fryer and the kitchen floor between them was observed an excessive amount of dried on foods, grease and dried liquid spills. The right grease container was black in color and unable to see through it. During an interview done on 2/12/25 at 10:23 a.m., Dietary Manager C stated We are going to change the oil today. -At 10:25 a.m., an observation of a light gray colored trash bin filled to top with trash, a broken off top was noted to be sitting right next to a stack of clean and ready for use white plates. -At 10:30 a.m., the grill that was turned on with a pan cooking food was observed to be coated with dried foods and dried fluid spills; also, the bottom shelf was partly broken off. -At 10:30 a.m., the large can opener was observed to have dried on food and paint chipping off of the blade. -At 10:33 a.m., the large clean and ready for use floor mixer was observed to have dried on food particles at the attachment area, directly over the bowel. -At 10:35 a.m., the Kitchen Aid counter mixer was clean and ready for use was observed to have dried on food and frosting-like substance on the attachment area, directly over the bowel. Review of the facility kitchen duty list dated 2/11/25, revealed all the kitchen duties/job's had been done. -The kitchen policy stated At the beginning of each week print and hang all cleaning checklists at the centralized command center of the kitchen. -15 minutes prior to the end of each shift review the cleaning checklist with each associate to ensure all tasks are completed in a satisfactory manner. At the end of each week collect all the completed sheets. Staple the weeks completed checklists together and file by week.

Based on interview and record review the facility failed to effectively monitor four (#6, 91, 137 & 138) residents of 7 residents reviewed for unnecessary medications, resulting in improper indications for usage and duplicate therapy without rationale. Findings Include: Resident #6: On 2/14/2025 at 10:05 AM, a review was conducted of Resident #6's clinical record and it indicated she admitted to the facility on [DATE] with diagnosis that included, Pneumonia, Heart Disease, Depression and Anxiety. Further review yielded the following: Physician Orders: Buspirone HCl Oral Tablet 10 MG- given 1 tablet by mouth two times a day related to anxiety disorder. Ordered on 1/22/2025. Duloxetine HCI oral capsule delayed release sprinkle 60 MG- give 1 capsule by mouth one time a day related to anxiety disorder. Ordered on 1/25/2025. According to the U.S. Food and Drug Administration, Cymbalta (Duloxetine) is indicated for use for the treatment of major depressive disorder (MDD). It is unknown why Resident #6 does not have the appropriate indication of usage documented for their administration of Cymbalta. Resident #91: On 2/14/2025 at approximately 10:00 AM, a review was conducted of Resident #91's clinical record and it indicated he admitted to the facility on [DATE] with diagnoses that included, Cellulitis, Diabetes, Atrial Fibrillation, Chronic Kidney Disease and Depression. Further review yielded the following: Physician Orders: Nortriptyline HCl Oral Capsule 50 MG Give 1 capsule by mouth at bedtime related to DEPRESSION, UNSPECIFIED Cymbalta Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day related to DEPRESSION. Resident #91 is being administered dual medication therapy for his diagnosis of depression, there was no documentation located from the physician regarding the rational for duplicate therapy. Resident #137: On 2/12/2025 at approximately 1:00 PM, a review was completed of Resident #137's medical records and it indicated she admitted to the facility on [DATE] with diagnoses that included, Pulmonary Embolism, Chronic Kidney Disease, Syncope and Collapse, Dementia and Hypertension. Further review yielded the following: Physician Orders: Quetiapine Fumarate Oral Tablet 25 MG - give one tablet by mouth at bedtime for Alzheimer's. It can be noted Resident #137 does not have a diagnosis of Alzheimer's and it was not clear in her clinical record the necessity for the antipsychotic medication. Resident #138: On 2/13/2025 a review was conducted of Resident #138's clinical record, and it indicated he admitted to the facility on [DATE] with diagnoses that included, Dehydration, Adult Failure to Thrive, Guillain- Barre Syndrome, Depression and Dysphagia. Further review yielded the following: Physician Orders: Duloxetine HCL (hydrochloride) Oral capsule delayed release sprinkle 30 MG (milligram)- Give 1 capsule at bedtime for mental health. Give with 60 mg duloxetine to equal 90 mg. Ordered on 2/11/2025. Duloxetine HCL (hydrochloride) Oral capsule delayed release sprinkle 60 MG-Give 1 capsule at bedtime for mental health. Give with 30 mg duloxetine to equal 90 mg at bedtime. Ordered on 2/11/2025. Progress Notes: 2/11/2025 at 22:28: Duloxetine HCl Oral Capsule Delayed Release Sprinkle 30 MG Give 1 capsule by mouth at bedtime for Mental health Give with 60 mg duloxetine to equal 90 mg. Resident #138 has the appropriate diagnosis to be administered his depression medication but the indication listed was mental health, it is unknown how or why this occurred. On 2/13/2025, Social Worker F was queried regarding the residents psychotropic medications and varying concerns. Resident #6: Social Worker J stated the Cymbalta is treating the resident's diagnosis of depression and she was unsure as to why it was indicated for antianxiety. Resident #91: Social Worker J reported she had not been monitoring duplicate therapy for facility residents and stated she did not have the rationale within the charting regarding why both were needed. Resident #137: Social Worker J reviewed the diagnosis list and stated the resident does not have a diagnosis of Alzheimer's and did not have an answer as to why that was listed as the indication. Resident #138: Social Worker J explained he is utilizing Duloxetine for his diagnosis of depression and mental health should not have been utilized as an indication for usage. She further stated she does not monitor the indications for usage for residents' psychotropic medication usage. Review was completed of the facility policy entitled, Psychotropic Medication Assessment and Monitoring, revised April 2019. The policy stated, .Psychotropic medications are only prescribed when necessary to treat a specific diagnoses and documented condition .

Based observation, interview and record review, the facility failed to 1) Ensure 1 resident (Resident #93) had the ordered Cervical collar (C-collar) on while up in wheelchair, 2) Ensure 1 resident (Resident #138) had accurate admission documentation, and 3) Ensure 1 resident's (Resident #137) wound care was done per physician's orders, resulting in the potential for increased cervical damage, decreased wound healing, and incomplete admission assessment. Findings Include: Resident #93: Review of the Face Sheet, physician orders, progress notes and nursing notes dated 1/28/25 through 2/13/25, care plans dated 2/12/25 and Kardex (dated 2/13/25), revealed Resident #93 was [AGE] years-old, alert with confusion and communication deficit, admitted for rehab on 1/28/25, and was dependent of staff for assist with Activities of Daily Living (ADL). The resident's diagnosis included, Acute kidney failure, dehydration, history of stroke, diabetes, chronic kidney disease, heart failure, cognitive communication deficit, muscle weakness, and spinal stenosis, cervical region (neck area). During medication pass done on 2/13/25 at 1:00 p.m., it was observed the resident's C-collar (due to cervical stenosis and not having surgery-collar prescribed) was sitting on her room dresser next to the door. At this time the resident was sitting in her wheelchair. During an interview done on 2/13/25 at 1:00 p.m., Nurse, LPN I stated yes, she is supposed to have it (the C-collar) on when sitting up. Review of the physician order dated 2/6/25, stated Aspen collar (type of C-collar) to be worn while sitting up and walking. Review of the facility ADL care plan dated 2/12/25, stated aspen collar on for all transfers (while in the up-right position). Resident #93 attended Resident Council on 2/13/2025 at 11:30 AM, the resident was observed to not have on her C-collar for the duration of the hour long meeting. Resident #93 was hunched over in the wheelchair, with her head angled down and chin almost touching the top of her chest. Review of the facility Kardex dated 2/13/25, revealed the resident was to wear the C-collar during transfers and toileting (while in the up-right position). Review of the facility Physical Therapy Evaluation for Resident #93 dated 1/29/25, stated Aspen collar when up. 38471 Resident #137: On 2/12/2025 at 10:09 AM, Resident #137 was observed resting in bed, she shared she was recently admitted but resided at home with her husband prior too. When asked if she had any wounds on her body, she stated on her toe and pulled up the blanket. Resident #137 had a wound dressing on her right great toe that was dated 2/10 with initials LS. The resident was not certain if the dressing had been changed since her admission to the facility. On 2/12/2025 at approximately 1:00 PM, a review was completed of Resident #137's medical records and it indicated she admitted to the facility on [DATE] with diagnoses that included, Pulmonary Embolism, Chronic Kidney Disease, Syncope and Collapse, Dementia and Hypertension. Further review yielded the following: Physician Orders: Wound to R (right) toe, change daily and prn (as needed). Cleanse well with NS (normal saline), pat dry, apply xeroform gauze to wound bed, cover with 2 x 2 gauze and wrap with kerlix. Ordered on 2/10/2025 to begin on 2/11/2025. Admission Assessment- 2/10/2025 Skin- .right great toe, shearing to skin on top of great toe. February 2025 TAR (Treatment Administration Record): TAR was marked off by Nurse K as completed on 2/11/2025. The nurses' initials do not match what was written on Resident #137's wound dressing. On 2/13/2025 at 2:20 PM, Wound Nurse J stated Resident #137 admitted on [DATE] and she completed her initial skin assessment yesterday (as upon admission she will completed a secondary comprehensive skin assessment). When asked if she recalled the date and initials on the wound dressing prior to the assessment, she reported she could not recall. Wound Nurse J was asked if the facility would expect dressing changes to be completed per the order and she stated yes that is the expectation. Nurse J was asked if there were any nurses with the initials observed on 2/10/2025 and she reported she was not sure. Nurse J was informed of the observations made on 2/10/2025, she stated the facility would investigate it. On 2/13/2025 at 3:55 PM, Nurse K was queried regarding Resident #137's dressing change that was documented as completed on 2/11/2025 on the TAR. Nurse K explained on 2/11 she entered the resident's room to complete the dressing change and had her sign admission paperwork as she was refusing for other staff members. Resident #137 signed the admission consents, but she refused the dressing change to her toe. Nurse K stated she forgot to go back and strike it out in the TAR. Resident #138: During initial tour on 2/12/2025, Resident #138 was observed resting in bed, he shared he was just readmitted to the facility and slept amazing. Observed his right upper arm which had an IV in place, Resident #138 was uncertain what it was used for in the hospital and if they will utilize it at the facility. Review was conducted of his admission skin assessment and admission progress note and the IV was not noted. On 2/12/2025 at 3:23 PM, Wound Nurse J and MDS (Minimum Data Set) Nurse L shared they completed a skin assessment on Resident #138 and in his right arm upper arm was a peripheral IV. Upon removing the IV they found it was not inserted into his body and the internal catheter was folded into the dressing. They were asked if this should have been listed on his admission assessment and they stated it should have. On 2/13/2025 a review was conducted of Resident #138's clinical record, and it indicated he admitted to the facility on [DATE] with diagnoses that included, Dehydration, Adult Failure to Thrive, Guillain- Barre Syndrome and Dysphagia. Further review yielded the following: Progress Notes: 2/11/2025 at 20:39: Resident admitted from Covenant for weakness, failure to thrive. Resident has 18 french Foley with 30cc (cubic centimeters) of H20 (water), for retention following with urology. Resident alert x 4, active bowel sounds in all 4 quadrants . 2/12/2025 at 13:56: right upper arm peripheral IV dressing removed, internal catheter notes on dressing, puncture site healed. Review was completed of the facility policy entitled, Skin Management Facility Guidelines, reviewed January 2022. The policy stated, Conduct baseline head to toe skin assessment on each resident upon admission, readmission .complete follow ups on all areas of identified skin impairments .

Based on observation, interview and record review, the facility failed to ensure 2 of 4 medication carts were clean and sanitized for a census of 34 residents who receive medications, resulting in the potential for cross contamination. Findings Include: [NAME] Hall Medication Cart: During observation done on 2/12/25 at 11:27 a.m. on [NAME] Hall, the fourth medication drawer down was noted to have an excessive amount of dried on liquid medications on the bottom of the drawer. The Pro-State bottle had dried on drips on the sides and it had leaked onto the bottom of the drawer; no staff member had cleaned it up. Also, crushed meds-like substances and small pieces of paper were found in the corners of the fourth drawer along with the Milk of Magnesia bottle that had dried on medication drippings on the sides. During an interview done on 2/12/25 at 12:00 p.m., Nurse, LPN G stated I don't know who is supposed to clean the cart (medication cart). During an interview done on 2/13/25 at approximately 9:00 a.m., the Director of Nursing said she did not think the facility had a medication cart cleaning policy. Review of the facility Cleaning Medication Storage Areas policy dated January 2010, revealed how to clean the refrigerators, medication rooms and floors, and how to clean the top of medication and treatment carts only. No documentation of who was to clean the inside of medication carts was found. [NAME] Hall Medication Cart: During observation done on 2/12/25 at 12:00 p.m., on [NAME] Hall, the fourth medication drawer down was noted to have black colored dust, small pieces of papers and crushed-like meds on the bottom of it. During an interview done on 2/12/25 at 12:00 p.m., Nurse, LPN H stated We clean it (the medication cart) on our own.

This Citation pertains to Intake Number MI00144619. Based on observation, interview and record review the facility failed to prevent the development and/or worsening of pressure injuries and complete accurate documentation and timely implementation of wound care treatments for two residents (Resident #201 and Resident #205) of two residents reviewed for wounds, resulting in Resident #201's Stage II pressure ulcers worsening, untimely initiation of treatment orders and inconsistent wound assessment documentation and the development of an avoidable Stage II pressure sore behind Resident #205's ear. Findings Include: Resident #201: On 9/17/2024 at approximately 1:00 PM, a review was conducted of Resident #201's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Right Femur Fracture, Atrial Fibrillation, Kidney Disease, Heart Failure, Reduced Mobility, Stage II Pressure Ulcer of Sacral Region. Resident #201 required staff assistance for her Activities of Daily Living and was able to make her needs known. On 9/16/2024 at 1:30 PM, an interview was conducted with Family Member L regarding Resident #201's wound progression during her time at the facility. It was reported the resident needed to be repositioned multiple times a day but that was not occurring. They continued the facility was not appropriately managing the wound and while Resident #201 was admitted with a pressure sore it worsened during her stay at the facility, as the wound did not receive the appropriate treatment. Family Member L stated while they do recall Resident #201 being evaluated by the physician, they do not recall them assessing the wound. They further stated upon discharge the resident had to be readmitted to the hospital due to the wound. Review was completed of Resident #201's medical records, and it revealed the resident was admitted with two wounds and an area of discoloration to her coccyx area. It was found the documentation of the location of the wounds and specific treatments were not consistent within the progress notes, wound notes and Treatment Administration Record TAR). It was difficult to ascertain which wounds were actively assessed and treated. Progress Notes: 2/2/2024 at 12:01: Wound care following resident for stage II pressure injuries to left upper buttock . 2/5/2024 at 11:15: Wound care following resident for stage II pressure injuries to right upper buttock and coccyx . 2/8/2024 at 10:54: Resident has areas of pressure to coccyx and rt buttock . 2/12/2024 at 11:37: Wound care following resident for stage II pressure injuries to left upper buttock. Wound not progressing. Previous wound to coccyx has resolved . 2/26/20241 at 10:33: Wound care following for stage II pressure injuries to left upper buttock. Wound not progressing < wound bed to upper left buttock slough. Wound to lower left buttock no change . 3/4/2024 at 08:57: Wound care following resident for unstageable pressure injury to left upper buttock. Wound is not progressing., wound bed to upper left buttock slough. Wound to lower left buttock no changes . Practitioner Progress Notes: 2/2/2024 at 9:04 AM: . Unable to visualize coccyx wound . 2/5/2024 at 10:21 AM: .Unable to visualize coccyx wound . 2/16/2024 at 9:32 AM: .Unable to visualize coccyx wound . Skin Assessments: 2/1/2024 (admission): .Sacrum: Stage 2.3 x 0.5-inch purple/red open area with noted sheering proximal to wound; Left buttock: 15 x 11 discoloration (purple) to left buttock); Left buttock: 6 x 7 inch 2 open area . 2/2/2024: .Coccyx: open area treatment in place; Right buttock: shearing, treatment applied . During Resident #201's time at the facility the practitioners assigned to her team never physically assessed her wounds. On 9/16/2024 at 3:45 PM, an interview was held with Wound Nurse B regarding the progression and resolution of Resident #201's wounds. Nurse B reviewed the resident's record and stated the resident was admitted with a Stage II Sacrum wound, a Stage II Left buttock wound and left buttock discoloration. As the wound nurse perused the chart, she was able to ascertain Resident #201's coccyx wound healed on 2/12/2024 (although there were treatment orders after this date for coccyx wound treatment). As we attempted to follow the other wounds throughout the wound notes and subsequent treatment orders, we were unable to do so, due to the significant inaccuracies. It was found there was no treatment order for Resident #201's left buttock wound until 2/27/2024 (twenty-six days after admission) The following treatment orders were reviewed per wound in Resident #201's March 2024 TAR. Stage II Pressure Ulcer to Sacrum: Cleanse open area to sacrum with Normal Saline and cover with comfort foam dressing q-3 (every 3 days) days and PRN ((as needed). Initiated on 2/2/2024 and discontinued on 2/3/2024. Resident #201 received this treatment twice. Cleanse open area to sacrum with normal saline and cover with comfort foam dressing q-3 and PRN. Order initiated on 2/4/2024 and discontinued on 2/12/2024. Resident #201 received this treatment twice. Cleanse coccyx with wound cleanser, pat dry, apply Medihoney to wound and cover with comfort foam dressing. Change daily and PRN. Order initiated on 2/14/2024 and discontinued on 2/20/2024. Resident #201 received this treatment six times although the wound assessment notes stated this wound resolved on 2/12/2024. Cleanse coccyx with wound cleanser, pat dry, apply Medihoney to wound and cover with comfort foam dressing. Change every 3 days and PRN. Order initiated on 2/21/2024 and discontinued on 2/26/2024. Resident #201 received this treatment one time, although the wound assessment notes stated this wound resolved on 2/12/2024. Cleanse coccyx with wound cleanser, pat dry, apply Medihoney to wound and cover with comfort foam dressing. Change every 3 days and PRN. Every 24 hours as needed when missing or soiled. Order initiated on 2/20/2024 and discontinued on 2/26/2024. Resident #201 received this treatment one time although the wound assessment notes stated this wound resolved on 2/12/2024. Left Buttock: Cleanse open area to left buttock with wound cleanser, pat dry, apply Medihoney to wound and cover with comfort foam dressing. Change every 3 days and PRN. Order initiated on 2/27/2024 and discontinued on 3/11/2024. Resident #201 received this treatment once. Right Buttock: Cleanse wound on right buttocks with NS (normal saline), pat dry and cover with comfort foam dressing. Change q3 days and PRN. Order initiated on 2/9/2024 and discontinued on 2/12/2024. Resident #201 received this treatment once. Based on the TAR, Resident #201 was not receiving the appropriate wound treatments to manage her wounds as wound treatments indicated on the TAR did not align with the wound documentation. Pressure Ulcer Healing Assessment: 2/5/2024: Stage 2 Pressure injury to right upper buttocks;Right Buttock: 5.2 x 3.5 x 0.1 ; Stage II Coccyx: Pressure; 0.5 x 0.3 x 0.2; Stage II 2/12/2024: 1. Left Buttock: 6.1 x 3.6 x 0.1; Stage II 2. Left Buttock (b): 2.7 x 3.7 x UTD (slough wound bed) Stage II pressure injury to coccyx: 0 x 0 x 0 - pressure injury healed (it can be noted it was labeled anatomically as left buttock but the header identified location as coccyx. 2/20/2024: 1. Left Buttock: 0.8 x 1.0 x 0.1; Stage II 2. Left Buttock: 1.0 x 0.6 x 0.1; Stage II 2/26/2024: 1. Left Buttock: 1.8 x 1.3 x 0.1; Stage II 2. Left Buttock: 3.9 x 2.5 x UTD: Stage- Unstageable 3/6/2024: Left Buttock: 2.2 x 1.3: Unstageable From the wound documentation it would appear Resident #201 admitted with one left buttock wound and a second left buttock wound developed during her stay at the facility. The location of the wounds was not specific and were labeled anatomically and descriptively the same. The documentation varied so much that the facility itself was unable to explain the progression of the wounds, the certainty of documented resolved wounds, the accuracy of wound treatment orders and wound assessments. Resident #205: On 9/17/2024 at approximately 2:45 PM, a review was completed of Resident #205's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included COVID-19, Acute Respiratory Failure with Hypoxia, Congestive Heart Failure and Diabetes. Resident #205 was cognitively intact and able to make her needs known. The admission skin assessment denoted the following areas: Cellulitis on right lower font and left lower front leg, excoriation underneath bilateral breasts and abdominal fold was reddened. Further review yielded the following: Progress Notes: 8/20/2024 at 20:50: Patient admitted .for a fall and bilateral lower extremity cellulitis. Patient refused to let me remove her ace wraps tonight. Excoriation of bilateral breast and abdomen noted, Desenex powder applied. Patient is A&O x 4 (alert and oriented) and bed bound. Patient oriented to room, TV remote, call light, bed remote, and telephone .Placed on 2L (liters) of oxygen for low O2 (oxygen) level, was previously on oxygen at the hospital . 9/6/2024 at 12:51: Res (resident) with stage II pressure ulcer noted to top of right ear measuring 0.3 cm (centimeter) x 0.3 cm x 0.1 cm .Res is dependent on 02. Order placed to add foam ear protectors to 02 tubing .Pressure relieving interventions evaluated. Foam ear protectors added to 02 tubing . Pressure Ulcer Healing Assessment: 9/6/2024: Onset date: 9/6/2024; Site: Right ear; 0.3 cm x q3 x 0.1 cm; Stage: II . Skin Assessments: 9/10/2024: .Open areas behind right ear from oxygen tubing . On 9/17/2024 at 3:27 PM, an interview was conducted with Wound Nurse B regarding the development of Resident #205's pressure ulcer. Nurse B stated the wound developed from the O2 tubing rubbing against the back of her ear. The resident initially complained of pain in the area and upon assessment they found the wound and added foam ear protectors and a hydrocolloid dressing. Nurse B was asked if the ear protectors are readily available in the facility, and she stated they were. It can be noted Resident #205 did not have any preventive measures in place prior to the development of the Stage II pressure ulcer. On 9/17/2024 at approximately 4:25 PM, Resident #205 was observed watching television in their room. The resident was observed to not have the foam ear protectors affixed to the oxygen tubing and when asked where they were she pointed to the bedside table. Resident #205 stated they had been off for awhile, but denied being in any current discomfort. On 9/17/2024 at approximately 1:00 PM, an interview was conducted with the administrator regarding Resident #201 and #205 pressure injuries. The wound assessment, progress notes and TAR was reviewed for Resident #201, and it was evident there were discrepancies across the three. It was also pointed out the treatment for the left buttock not being implemented until 27 days after admission. It was explained Resident #205's pressure injury was avoidable given the foam ear protectors were accessible to facility staff upon their admission. The administrator expressed understanding of the stated concerns. Review was completed of the facility policy entitled, Skin Management, reviewed January 2022. The policy stated, .Residents admitted with skin impairments will have: Appropriate interventions implemented to promote healing; A physician order for treatment; treatment record initiated; Wound location and characteristics documented .The licensed nurse (wound care nurse) will monitor all pressure ulcers, and will document on the Treatment Record in PCC verifying the completion of the treatment as ordered by the physician .

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 27 residents. Findings include: 1. On 2/21/24 at 1:28 PM, one condiment bottle was observed with wet debris on its interior, and two spatulas and two serving utensils were observed with an accumulation of dried food debris on their food contact surfaces while stored on the clean, ready for use, storage rack. At this time upon further inspection of the utensil holding containers the surveyor observed an accumulation of dust and dried food debris on the interior of four such containers. On 2/21/24 at 1:32 PM, upon interview with General Manager, staff D, regarding the current state of the utensils and their containers they stated, we keep cleaning logs, and this is part of a daily task for staff. I'll take them to be redone. At this time the surveyor requested a copy of the cleaning logs mentioned by staff D to review. On 2/21/24 at 1:44 PM, an accumulation of dust and debris was observed on the walls, and on the refrigeration lines in the walk-in cooler. At this time the surveyor inquired with staff D on the frequency in which the cooler is expected to be cleaned to which they stated, I'm surprised to see it. We do it throughout the week. On 2/21/24 at 1:46 PM, an accumulation of dark colored dust and debris was observed on and around two ceiling heat vents above stainless steel food preparation tables adjacent to the walk in coolers. At this time the surveyor inquired with General Manager, staff D, on the current state of the vents to which they stated, I think they were just done, but that would be more of a maintenance question. On 2/21/24 at 1:49 PM, the six burner stove top's temperature controlling knobs were observed heavily soiled. Upon observation staff D, began removing the knobs and stated to the surveyor, we'll send them through the dish machine and put them back on before our next meal. On 2/21/24 at 4:27 PM, review of electronic documents dated 2/19 - 2/25, titled dietary worksheets revealed that the facility has a system in place to ensure a clean and sanitary environment in the kitchen. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils directs that: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2. On 2/21/24 at 1:37 PM, five cutting boards were observed soiled and discolored with deep cut marks and grooves on the boards food contact surface. Upon observation the surveyor inquired with the General Manager, staff D, on the current state of the cutting boards to which they stated, We might have some new ones somewhere. If not I'll order more. On 2/21/24 at 1:53 PM, the cold line cooler's cutting board was observed discolored with deep cut marks and grooves on the board's food contact surface. At this time staff D flipped the cutting board over to view the condition of the other side revealing a buildup of mold/ mildew on its surface. At this time the surveyor asked staff D on the facility's expectation on the frequency for items like this to be cleaned and sanitized to which they stated, daily, but obviously it wasn't done. On 2/21/24 between 1:54 PM and 1:59 PM, staff D was observed by the surveyor removing the cutting board from the cooler, placing it by the dishwashing area, then cleaning and sanitizing the stainless steel surface of the cold line that the cutting board was in contact with. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-501.12 Cutting Surfaces directs that: Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.

Based on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facility's census of 27 residents and its staff resulting in an increased potential for harm. Findings include: On 2/21/24 at 3:28 PM, the lack of Personal Protective Equipment (PPE), and soap available for use at the hand washing sink in the short term rehab's laundry room were observed. At this time the surveyor inquired with Maintenance Manager, staff E, on the current state of the room to which they stated, we'll get some soap and PPE in this room. On 2/21/24 at 3:40 PM, the lack of PPE available for use, and paper towel at the handwashing sink were observed in the primary building's laundry soiled linen room. At this time the surveyor inquired with staff E on the current state of the room to which they stated, I'll make sure it gets paper towels and I can probably add some storage hooks for the PPE by the door. On 2/21/24 at 3:45 PM, four cabinets, with two shelves per cabinet, were observed containing assorted types of food and personal items in the primary building's laundry soiled linen room. At this time upon interview with General Manager, staff D, on the storage of items such as these in soiled linen rooms they stated, I'm removing them all right now. On 2/21/24 between 3:46 PM and 3:49 PM, staff D was observed by the surveyor removing the items from the cabinets and taking them out of the room.

Based on observation, interview, and record review the facility failed to ensure proper storage of medications for one resident (Resident #171), and 1 of 3 medication carts reviewed, resulting in the increased likelihood for residents, visitors, and/or staff to access the medications. Findings include: During an observation and interview on 2/22/24 at 12:36 PM, the Superior pod medication cart was located just inside the open door of the charting room on Superior pod unlocked. No staff were observed on the unit. Continued to observe Medication cart unlocked at 12:47 PM with no Nurse observed on the unit. During continued observation, Licensed Practical Nurse (LPN) G returned to the Superior pod at 12:55 p.m. and reported had been off the unit on break. LPN G reported medication carts should remain locked at all times unless in use. LPN G verified the Superior medication cart was unlocked and should have been lock before leaving the unit for break. During an interview on 2/22/24 at 1:30 PM, Director of Nursing (DON) B reported would expect nurses to lock medication cart if not in use to make sure medications remain secured. Resident #171 (R171): In an observation and interview on 2/21/2024 at 10:30 AM, Resident #171 (R171) was observed in her room lying in bed, and upon approaching R171's bedside 18 medications were observed to be left at her bedside which included tablets and pill. Four were observed on the bedside table, 12 were observed on the over the bed table, and two were observed to be on the floor at the head of the bed. R171 stated that she did not know what the medications were, nor could she identify any of the pills or tablets. R171 said she went to take the medications and spilled the whole medication cup, and said she was not able to reach the two medications that were on the floor. R171 stated that the nurse always left her medications with her and would leave her room. Immediately following the observation and interview with R171, Registered Nurse (RN) C was asked to identify the tablets and pills in R171's room. RN C was able to state what each of the tablets and pills were. RN C was asked what the facility policy and procedure was for leaving medications at the the beside. RN C said medications were not to be left at a residents bedside, and said R171 did not want to take the medications until she was done eating so she left the medications with R171. RN C said she should have brought medication out of R171's room when she left. RN C also stated that R171 was no assessed to be able to self administer her medications. In an interview on 2/22/2024 at 7:24 AM, Director of Nursing (DON) B stated that her expectation was that no medications should ever be left at a residents bedside, and that RN C should have brought the medications out of R171's room with her. Record review of the facility's policy and procedure titled, MEDICATION PASS GUIDELINES dated September 2023, revealed under, Procedure, 6. Observe that the resident swallows oral drugs. Do not leave medications with the resident to self administer unless the resident is approved for self-administration of the medication.

Based on observation, interview, and record review, the facility failed to ensure that accurate advance directive information was in place for one resident [Resident #8 (R8)] of one resident reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised [DATE]), revealed, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence. Further review of this Act revealed, Sec. 4. A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall be in substantially the following form: DO-NOT-RESUSCITATE ORDER This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________. (Type or print declarant's or ward's name) Use the appropriate consent section below: A. DECLARANT CONSENT I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. _______________________________________ _______________ (Declarant's signature) (Date) _______________________________________ _______________ (Signature of person who signed for (Date) declarant, if applicable) _______________________________________ (Type or print full name) B. PATIENT ADVOCATE CONSENT I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Patient advocate's signature) (Date) _______________________________________ (Type or print patient advocate's name) C. GUARDIAN CONSENT I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Guardian's signature) (Date) _______________________________________ (Type or print guardian's name) _______________________________________ _______________ (Physician's signature) (Date) _______________________________________ (Type or print physician's full name) ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not) received an identification bracelet. ______________________________ ______________________________ (Witness signature) (Date) (Witness signature) (Date) ______________________________ ______________________________ (Type or print witness's name) (Type or print witness's name) THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT. Resident #8(R8): Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R8 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included recent fall with fracture right hip, atrial fibrillation, kidney failure, hypertension and anxiety. The MDS reflected R8 had a BIMS (assessment tool) score of 10 which indicated her ability to make daily decisions was moderately impaired. The Face Sheet reflected R8 was her own responsible person. Review of the Electronic Medical Record(EMR) on [DATE] at 1:19 PM, reflected R8 had a Do Not Resuscitate Physician order, dated [DATE]. Continued review of the EMR reflected a document titled, Advance Care Planning Form, signed by R8 on [DATE], reflected R8 did not want CPR(Cardiopulmonary Resuscitation). The form included one facility representative signature, dated [DATE] and a physician signature dated [DATE]. The form did not have include two witness signatures nor was the form compliant with the verbiage required per the Michigan Do Not Resuscitate Act. During an interview on [DATE] at 2:05 PM, Social Worker(SW) F reported oversees the facility DNR accuracy. SW F verified the facility form, Advance Care Planning Form was updated on ,d+[DATE]. SW F reported was unaware of need for two witness signatures required for DNR order. SW F verified R8 was own responsible person and the facility Advance Care Planning Form, was the only DNR document the facility used and had one witness signature. During an interview on [DATE] at 2:10 PM, Nursing Home Administration(NHA) A reported the facility used the Advance Care Planning Form as the DNR order. NHA A reported was involved with the recent form revision in [DATE] and was not aware of the required verbiage per the Michigan Do Not Resuscitate Act or the required need for two witnesses signatures. NHA A reported the facility currently had five residents with DNR wishes including R8. NHA A reported planned to develop and implement required DNR document for current residents and moving forward.

Based on observation, interview and record review, the facility failed to prevent a fall for one (#1) of four residents sampled, resulting in Resident #1 sustaining a fall from the side of the bed, with no alarm sounding and with a short cast to the right ankle, resulting in a head injury of a large swollen mass on the right temple and a nondisplaced fracture to the distal third of the right clavicle. Findings include: Record review of facility 'Safety-Patient' policy, revision date of 12/2017, pages 3-4, revealed interventions: initiate the following precautions for every patient: (1.) (g.) Utilize proper or non-slip footwear when getting patients up. (h.) Keep beds in low position and locked at all times. Bed controls Lock-out feature may be utilized for confused patients. (l.) provide visual safety checks every hour. (3.) If patient is confused, impulsive, has had a stroke or [MEDICAL CONDITION] or demonstrates poor judgement: (a.) Initiate bed/chair alarms Observation and record review on 11/15/18 at 10:55 AM with Licensed Practical Nurse (LPN) D of the unit supply closet revealed there to be a supply of square alarm chair pads and longer bed-width alarm pads with alarm boxes noted in the closet. Record review of the alarm pad instructions packaged with each alarm pad revealed: This system does not prevent falls or injury from falls and is not a substitute for patient care, caregiver rounding and a comprehensive fall management protocol in your facility. Testing Alarm and Chair Sensor Pad: Always check sensor pads when connecting them to an alarm. You can check a sensor pad by attaching it to the sensor input on the alarm, activating the alarm and placing pressure on the sensor pad. When the pressure is released, the alarm should sound. Repeat this pressure/release test in several different areas along the entire length of the sensor pad to ensure entire sensor pas is functioning properly. If the alarm and/or sensor pad do not function properly, remove the alarm and sensor pad from service and replace them with a properly functioning alarm and/or pad. Do not use the alarm or sensor pad if it does not activate each time weight is removed from the sensor pad Make sure sensor pad lays flat on bed surface, directly under patient's weight Record review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed an elderly female with Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating that the resident was cognitive. Medical [DIAGNOSES REDACTED]. Record review of Resident #1's 'Safety Checks' were ordered on [DATE] for every-hour safety checks. Bed Alarm was ordered on [DATE] Record review of Resident #1's 'Occupational Therapy Transitional Care Unit Daily Note', dated 7/6/18 at 2:04 PM, revealed surgical procedures of ORIF (Open Reduction and Internal Fixation) of right hip 6/20/18 and right ankle fracture 5/15/18. Precautions included: falls, non-weight bearing on right lower extremity, bed/chair check, ORIF hip precautions; short cast right lower extremity. Therapist noted confused/mild, recognizes care giver/family, judgement/safety: impaired. Follows directions: Follows 1 step 51-75% of the time. Memory: impaired. Record review of Resident #1's Fall Risk care plan start date of 6/25/18 included: bed side rails up x 2, bed and chair alarm, perform safety checks. Record review of Resident #1's 'Current Summary- Fall Event' form, dated 7/7/18 at 8:40 AM, revealed that the type of event was a fall from the bed with injury. The patient was found by a nurse on the floor laying on her right side. Patient stated that she hit her head. Swollen mass noted on right side of the head above the temple. Patient also stated that her right shoulder was sore. No obvious bleeding noted at the time. Vitals were obtained. Staff asked how patient fell . She stated that her feet came out from under her as she was trying to scoot back on the bed. Fall was not witnessed, and once the patient fell , the roommate rang the call light. The roommate did not see the fall. Under the section of 'Fall Event Details' Resident #1 was noted to be a high risk per her last fall assessment and had a history of [REDACTED]. Injury Details included head injury of a large swollen mass on the right temple and a nondisplaced fracture noted to the distal third of the right clavicle. Fall event summary reported that when facility spoke with Licensed Practical Nurse (LPN) who found Resident #1, she stated alarm was not sounding upon entering the room. Record review of Resident #1's care 'Flowsheet', dated from 7/7/18 at 05:00 AM (nightshift), documented that the adult safety checks of side rails up were documented as checked up till 05:30 AM. The shift ended at 6:00 AM. The day shift Certified Nurse Assistant (CNA) did not document any checks on bed side rails or that bed/chair alarms were in place or functioning from 7/7/18 at 6:00 AM the start of the day shift until 1:38 PM when the resident was up in a chair. Resident #1 sustained a fall from the bed at 8:40 AM. The Certified Nurse Assistant C, who no longer works for the facility, was contacted via telephone and did not return the surveyor's call for an interview. The Licensed Practical Nurse H was contacted via telephone and did not return the surveyor's call for an interview. An interview on 11/15/18 at 10:35 AM with Licensed Practical Nurse (LPN) D revealed that she was in the hallway when LPN H stated that she needed help because she had a resident on the floor. They went to the room and Resident #1 was on the floor between the wall by the entrance and the bed. Resident #1 stated that she was trying to scoot herself back on the bed and fell . Resident #1 was seated at the edge of the bed for breakfast and she had on a slipper sock on one foot and a short cast on the right foot. LPN D stated that she did not hear any alarms sounding at the time of the fall. LPN D stated that the bed position was estimated to be up at hip height if standing next to the bed. In an interview on 11/15/18 at 12:44 PM the Director of Nursing (DON) B, stated that the fall occurred on a Saturday and that she wasn't there. The DON B stated that Resident #1 had a bed/chair alarm in place upon admission on 6/25/18. The DON B stated that she did the investigation and that Resident #1 had been sitting on the edge of the bed for meals for several days prior to the fall. DON B stated that CNA's/staff are to check alarms, verify connections and that alarm is on/functioning at the beginning of their shift and during the shift when residents move or their position changes. The DON B reviewed the safety device flowsheets with the surveyor and discussed that the flowsheet checks stopped on 7/7/18 at 5:30 AM and started again at 8:00 PM. There were no day shift safety checks documented.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 618. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THE SAFETY OF ONE (RESIDENT #101) OF 6 SAMPLED RESIDENTS REVIEWED FOR SAFETY, FROM A TOTAL SAMPLE OF 7 RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #101 ON 11/26/2012, WHEN SHE SUSTAINED BLISTERED BURNS ON HER RIGHT HAND AND FINGERS, ACCOMPANIED BY "VERY SEVERE ...BURNING " PAIN, AFTER SHE WAS EXPOSED TO UNSPECIFIED HIGH TEMPERATURES FROM A MOIST HOT COMPRESS THAT WAS IMPROVISED AND APPLIED BY FACILITY STAFF IN A MANNER NOT CONSISTENT WITH CURRENT STANDARDS OF PRACTICE FOR AN UNKNOWN AMOUNT OF TIME AND WITHOUT BEING MONITORED FOR COMPLICATIONS DURING AND SUBSEQUENT TO THE HOT PACK THERAPY. THIS DEFICIENT PRACTICE PLACED RESIDENT #101, AS WELL AS ANY OTHER RESIDENT WHO RECEIVED HOT COMPRESS THERAPY AT RISK FOR SERIOUS INJURY, HARM, IMPAIRMENT AND/OR DEATH. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET, DATED 12/10/2012, RESIDENT # 101 WAS admitted to the facility on [DATE]. THE MINIMUM DATA SET (MDS), dated [DATE], INDICATED THAT RESIDENT #101 WAS AN [AGE] year-OLD ALERT FEMALE WHO WAS ABLE TO COMMUNICATE VERBALLY BUT REQUIRED EXTENSIVE ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. SHE HAD SEVERAL [DIAGNOSES REDACTED]. ACCORDING TO THE INCIDENT REPORT, DATED 11/29/2012, ON 11/26/2012 FACILITY STAFF ATTEMPTED TO START AN INTRAVENOUS INFUSION (METHOD FOR DELIVERING MEDICINES OR SUBSTANCES INTO THE BODY BY WAY OF A CATHETER OR NEEDLE) INTO A VEIN ON RESIDENT #101'S RIGHT HAND, BUT FAILED. RESIDENT #101'S HAND BEGAN SWELLING AND SHE DEVELOPED A HEMATOMA (A LOCALIZED COLLECTION OF BLOOD, USUALLY CLOTTED, IN TISSUE). DURING AN INTERVIEW ON 12/12/2012 AT 9:51 A.M., REGISTERED NURSE (RN) #1 SAID THAT ON 11/26/2012 AT SOME TIME CLOSE TO 5:00 P.M., RESIDENT #101'S FAMILY MEMBER CAME TO HER AND ASKED HER TO LOOK AT RESIDENT #101'S HAND. RN #1 SAID THAT WHEN SHE ASSESSED RESIDENT #101'S HAND, THERE WAS A "...SLIGHT..." AMOUNT OF SWELLING AND BRUISING DESCRIBED AS "...DARKENED SKIN..." ON THE BACK OF RESIDENT #101'S RIGHT HAND. RN #1 SAID SHE COULD NOT IMMEDIATELY REMEMBER WHETHER SHE SHOULD APPLY A HOT COMPRESS OR A COLD COMPRESS, BUT DECIDED TO USE A HOT ONE TO EASE THE DISCOMFORT AND SWELLING. ACCORDING TO NURSING ASSISTING: ESSENTIALS FOR LONG-TERM CARE, BY BARBARA ACELLO, (2005) BEFORE USING A HOT COMPRESS, "...YOU SHOULD KNOW...THE LENGTH OF TIME THE APPLICATION IS TO STAY IN PLACE..." AND THE "...PROPER TEMPERATURE OF THE APPLICATION..." LOCALIZED HEAT APPLICATIONS SHOULD INCLUDE THE USE OF PROTECTIVE COVERS AND STAFF SHOULD "...CHECK THE RESIDENT'S SKIN UNDER THE APPLICATION EVERY 10 MINUTES..." FOR SIGNS OF REDNESS THAT COULD INDICATE A THERMAL INJURY OR BURN. ACCORDING TO THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION ARTICLE, DANGERS OF MICROWAVE-HEATED COMPRESSES BY ALFRED SOFFER, JUNE 14, 2004, VOLUME 164, NO. 11, MICROWAVE HEATED HOT PACKS OFFER CONVENIENCE, DEEPER PENETRATION AND MORE PROLONGED RETENTION OF HEAT THAN WARM WATER SOAKS OR TOWELS, BUT UNFORTUNATELY, THIS TYPE OF THERAPY HAS FREQUENTLY RESULTED IN SERIOUS SECOND- AND THIRD-DEGREE BURNS. "...MICROWAVE OVENS HEAT QUICKLY, DEEPLY AND UNEVENLY: READINGS CAN BE MISLEADING, PAVING THE WAY FOR SERIOUS INJURIES..." ACCORDING TO IATROGENIC BURNS: BEWARE OF MICROWAVES!, US NATIONAL LIBRARY OF MEDICINE NATIONAL INSTITUTES OF HEALTH, AUGUST 17, 2008, MICROWAVE-HEATED COMPRESSES AND GEL PACKS CAN CAUSE SEVERE BURNS. "...MICROWAVE OVENS HEAT DEEPLY AND UNEVENLY AND DANGEROUS TEMPERATURES CAN QUICKLY BE REACHED...BURNS ARE SOMETIMES CAUSED BY LENGTHY CONTACT WITH AN OBJECT THAT IS NOT HOT ENOUGH TO CAUSE PAIN OR EVEN DISCOMFORT. THE HEAT PERCEIVED BY THE USER DOES NOT REFLECT THE QUANTITY OF HEAT ACTUALLY TRANSFERRED..." IN THE SAME INTERVIEW ON 12/12/2012, RN #1 SAID SHE HAD NEVER PREPARED A HOT COMPRESS BEFORE, BUT SHE HAD SEEN THE CERTIFIED NURSE ASSISTANTS IN THE FACILITY MAKE THEM "...MANY TIMES..." SO SHE FELT CONFIDENT THAT SHE COULD. RN #1 SAID SHE MOISTENED A TOWEL WITH WATER AND THEN REMOVED THE EXCESS WATER FROM THE TOWEL. RN #1 SAID SHE THEN FOLDED THE TOWEL, PLACED IT INTO A BLUE INCONTINENCE PAD AND HEATED IT IN THE MICROWAVE FOR "...A FEW MINUTES..." RN #1 CLARIFIED THAT THE ASSEMBLED WET TOWEL COMPRESS WAS HEATED FOR "...MAYBE 2 MINUTES..." IN THE MICROWAVE AND THEN PLACED ON RESIDENT #101'S HAND. RN #1 SAID SHE DID NOT KNOW WHAT THE TEMPERATURE OF THE HOT PACK WAS WHEN IT WAS PLACED ON RESIDENT #101'S HAND AND THAT SHE DID NOT RETURN TO ASSESS THE EFFECTS OF THE HOT PACK. IN AN INTERVIEW ON 12/10/2012 AT 1:36 P.M., CERTIFIED NURSE ASSISTANT (CNA) #1 SAID THAT RN #1 "...DID NOT HOW TO MAKE IT (THE HOT COMPRESS) RIGHT. SO I WENT IN AND MADE ONE FOR HER..." CNA #1 SAID SHE MADE THE HOT PACK BY FOLDING A TOWEL, WETTING IT WITH WATER, AND MICROWAVING IT. CNA #1 SAID SHE THEN TOOK THE OLD HOT PACK OFF RESIDENT #101'S HAND AND PLACED THE NEW ONE ON RESIDENT #101'S HAND. CNA #1 SAID RN #1'S HOT COMPRESS WAS TOO THICK, SO SHE (CNA #1) TOOK IT OFF AND PUT A THINNER COMPRESS ON. CNA #1 SAID SHE DID NOT KNOW WHAT THE TEMPERATURE OF THE HOT PACK WAS WHEN IT WAS PLACED ON RESIDENT #101'S HAND AND "...I HONESTLY DON'T KNOW HOW LONG IT WAS ON FOR..." CNA #1 SAID AT THE TIME SHE CHANGED THE COMPRESS, RESIDENT #101'S HAND LOOKED BLUE, AND THAT THERE WAS "...NO REDNESS..." BUT THAT SHE (CNA #1) DID NOT RETURN TO ASSESS THE EFFECTS OF THE HOT PACK. ACCORDING TO THE NURSE'S NOTE, DATED 11/26/2012 AT 5:33 P.M., RESIDENT #101 SAID THE HEAT WASN'T WORKING AND THAT "...HER (#101) FINGER NAILS WERE EVEN HURTING ..." DURING AN INTERVIEW ON 12/12/2012 AT 10:35 A.M., LICENSED PRACTICAL NURSE (LPN) #1 SAID THAT ON 11/26/2012 AT 5:33 P.M., SHE WENT TO RESIDENT #101'S ROOM AND ASSESSED HER (#101) HAND. LPN #1 SAID RESIDENT #101 COMPLAINED OF PAIN "...IN HER HAND, EVEN (IN) HER FINGERNAILS..." LPN #1 SAID THAT RESIDENT #101'S HAND WAS "...VERY WARM..." TO TOUCH, AND "...REDDENED WITH SOME BRUISING..." LPN #1 SAID THAT RESIDENT #101 DESCRIBED HER PAIN AS "...SEVERE..." SO SHE (LPN #1) REAPPLIED THE HOT COMPRESS AND THEN CALLED THE DOCTOR. LPN #1 SAID RESIDENT #101'S PHYSICIAN ORDERED THE REMOVAL OF THE HOT COMPRESS AND ORDERED A COLD COMPRESS FOR RESIDENT #101'S HAND. ACCORDING TO FACILITY RECORDS THE COMPRESS WAS REMOVED AT 5:38 P.M. ACCORDING TO THE MDS dated [DATE], RESIDENT #101 SUFFERED FROM BURNS CLASSIFIED AS "...SECOND OR THIRD DEGREE..." AND THAT RESIDENT #101 WAS "...ALMOST CONSTANTLY..." IN PAIN DESCRIBED AS "...VERY SEVERE, HORRIBLE..." THAT HAD MADE IT HARD FOR RESIDENT #101 TO SLEEP AT NIGHT. ACCORDING TO THE NURSE'S NOTES, DATED 11/27/2012, RESIDENT #101'S REDDENED HAND WAS FOUND TO HAVE FORMED BLISTERS. THE FLUID FILLED BLISTERS FURTHER DEVELOPED AND, ACCORDING TO PHOTOGRAPHS TAKEN BY THE FACILITY, DATED 11/29/2012, MEASURED APPROXIMATELY 5 CM BY 2.5 CM ON THE BACK OF HER RIGHT HAND, 1.75 CM BY 0.75 CM ON THE BACK OF HER FIRST FINGER, AND 1.5 CM BY 1 CM ON THE BACK OF HER SECOND FINGER. ACCORDING TO THE NURSE'S NOTES, DATED 11/28/2012, SMALL BLISTERS OF UNDOCUMENTED SIZES WERE ALSO FOUND ON THE BACKS OF HER THIRD AND FOURTH FINGERS. ACCORDING TO RESIDENT #101'S UNDATED CARE PLAN, RESIDENT #101 SUFFERED FROM A BURN WITH "...VERY SEVERE...BURNING..." PAIN IN HER RIGHT HAND. DURING AN INTERVIEW ON 12/10/2012 AT 1:00 P.M., RESIDENT #101'S PHYSICIAN (MD) #1 SAID SHE SAW RESIDENT #101'S HAND INJURY THE NEXT DAY (11/27/2012) AND DETERMINED THAT IT WAS EITHER A BURN OR A SOFT TISSUE INJURY THAT WAS MADE MUCH WORSE AND BLISTERED AS A RESULT OF THE HEAT THAT WAS APPLIED TO RESIDENT #101'S HAND. MD #1 SAID, " ...OR (IT COULD BE THAT) THE INJURY WAS A COMBINATION OF BOTH (BURN OR SOFT TISSUE INJURY)..." MD #1 SAID THAT WHEN HEAT WAS TO BE USED ON A WOUND, A TEMPERATURE CONTROLLED DEVICE SHOULD BE USED, SUCH AS A K-PAD (AN ELECTRICAL UNIT THAT HEATS WATER PUMPED THROUGH PLASTIC PAD PROVIDING LOCALIZED HEAT). MD #1 SAID, "...I DON'T KNOW I WOULD EVER USE A WET TOWEL HEATED IN A MICROWAVE..." TO TREAT RESIDENTS. IN AN INTERVIEW ON 12/11/2012 AT 9:39 A.M., RESIDENT #101'S PHYSICIAN (MD) #2 SAID SHE SAW RESIDENT #101'S INJURY A FEW DAYS LATER AND SAID SHE BELIEVED IT TO SIMPLY BE A BURN, FROM THE HOT PACK. MD #2 SAID THAT SHE TREATED THE INJURY WITH MEDICATIONS COMMONLY USED TO TREAT SECOND DEGREE BURNS AND IT RESPONDED WELL TO THE MEDICATION. MD #2 SAID THAT THE INJURY WAS DEFINITELY A HEAT RELATED INJURY, ALTHOUGH IT WAS POSSIBLE SOME OF THE SOFT TISSUE INJURY WAS A THERMAL INJURY THAT DIRECTLY RESULTED FROM THE HEAT THAT WAS APPLIED TO THE HEMATOMA AND WAS NOT SIMPLY A BURN. ON 12/10/2012 AT 11:47 A.M., THE NURSE MANAGER/DIRECTOR OF NURSING (DON) #1 SAID SHE WAS UNSURE WHY A MICROWAVED TOWEL WAS IMPROVISED AS A HOT PACK. DON #1 SAID, "...WE USUALLY WARN PEOPLE NOT TO WARM TOWELS IN A MICROWAVE. THEY (MICROWAVED TOWEL) MAY OVERHEAT..." DON #1 SAID THAT TOWELS SHOULD BE HEATED ONLY WITH WARM TAP WATER, OR THAT NURSES COULD USE COMMERCIALLY AVAILABLE PADS THAT PUMP WARM WATER THROUGH THEM FOR HEAT THERAPY. DON #1 SAID SHE WAS ADVISED BY THE FACILITY'S RISK MANAGEMENT DEPARTMENT THAT MICROWAVES CREATED INCONSISTENT HEATING AND POCKETS OF HIGHER TEMPERATURE AREAS THAT CAN CAUSE BURNS. DON #1 SAID SHE INVESTIGATED THE INCIDENT AND WAS UNSURE HOW LONG THE HOT COMPRESS WAS ON RESIDENT #101'S HAND, BUT THAT IT "...COULD BE UP TO 38 MINUTES, WE BELIEVE...AT ONE POINT (RESIDENT #101) WAS assessed with [REDACTED].#1 WAS ASKED TO PROVIDE ANY POLICIES THAT DESCRIBE HOW STAFF WERE INSTRUCTED TO PREPARE, TEST AND MONITOR MOIST HOT COMPRESSES OR OTHER HOT PACKS. DON #1 SAID, "...WE HAVE NO POLICY..." RELATED TO HOT PACK THERAPY, TO ASSESSMENTS, TO DURATION OF THERAPY, OR HOW TO MAKE A HOT PACK OR WARM COMPRESS. IN AN INTERVIEW ON 12/12/2012 AT 10:35 A.M., LPN #1 SAID SHE WAS TRAINED TO MAKE HOT PACKS FROM WET MICROWAVE OVEN-HEATED TOWELS BY OTHER FACILITY STAFF MEMBERS, WHO WERE WORKING ON THE FLOOR DURING HER ORIENTATION. LPN #1 SAID THAT THERE WAS A TOWEL OR BLANKER WARMER AVAILABLE FOR USE, "...BUT WHEN YOU DON'T HAVE TIME, YOU USE THE MICROWAVE..." DURING AN INTERVIEW ON 12/10/2012 AT 2:00 P.M., THE ADMINISTRATOR (ADM) #1 SAID THERE WAS NO POLICY RELATED TO THE USE OF MICROWAVES IN PATIENT CARE, AND THERE WAS NO POLICY RELATED TO HOW TO PREPARE A HOT PACK AT THE FACILITY. ADM #1 SAID THE FACILITY BEGAN REVIEWING THE STANDARDS OF CARE RELATED TO HOT PACK USE BEFORE THIS INCIDENT OCCURRED. ADM #1 CLARIFIED THAT "...A FEW WEEKS..." BEFORE RESIDENT #101'S INJURY THE CLINICAL NURSE SPECIALIST BECAME AWARE THAT IT WAS THE PRACTICE IN THE FACILITY TO MAKE HOT PACKS FROM MICROWAVED WET TOWELS FOR VARIOUS USES. ADM #1 SAID THAT ACCORDING TO THE CLINICAL NURSE SPECIALIST, MICROWAVES CREATED INCONSISTENT HEATING BUT IT WAS NOT UNTIL AFTER RESIDENT #101'S INJURY THAT SHE "...CALLED A STOP THE PROCESS..." ON 12/10/2012 AT 1:36 P.M., CNA #1 SAID SHE LEARNED TO MAKE HOT PACKS FROM OTHER STAFF ON THE FLOOR DURING HER ORIENTATION. CNA #1 SAID SHE WAS TOLD IT WAS QUICKER THAN USING THAN THE "PADS," BECAUSE "...IT HEATS FASTER..." CNA #1 SAID THAT SINCE THE INCIDENT WITH RESIDENT #101, SHE (CNA #1) WAS TOLD TO NOT USE THE POWERFUL MICROWAVE IN THE DINING ROOM, BUT THAT SHE COULD USE A DIFFERENT MICROWAVE TO MAKE HOT PACKS,. CNA #1 CLARIFIED TWO ADDITIONAL TIMES DURING THE COURSE OF THE INTERVIEW THAT SHE WAS STILL USING THE SAME METHOD TO MAKE HOT PACKS, BUT WAS NOW SIMPLY USING A DIFFERENT MICROWAVE. ON 12/12/2012 AT 1:46 P.M. AN IMMEDIATE JEOPARDY SITUATION WAS IDENTIFIED AT F-323. THE ADMINISTRATOR WAS INFORMED ON 12/13/2012, AT 1:10 P.M., OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 11/26/2012 WHEN THE FACILITY FAILED TO ENSURE THAT RESIDENT #101 WAS TREATED WITH A HOT COMPRESS THAT WAS REGULATED TO A SAFE TEMPERATURE FOR A SAFE AMOUNT OF TIME AND WAS MONITORED FOR COMPLICATIONS DURING AND SUBSEQUENT TO THE HOT PACK THERAPY, PLACING RESIDENT #101 AT HIGH RISK FOR SERIOUS HARM, INJURY OR DEATH. ON 12/17/2012, THE SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY ON 12/13/2012: ON 12/10/2012, THE SURVEYOR CONFIRMED THAT ON 12/10/2012 THE FACILITY IDENTIFIED 14 OTHER RESIDENTS IN THE FACILITY WITH MODERATE TO SEVERE PAIN. ON 12/10/2012, THE SURVEYOR CONFIRMED THAT FACILITY STAFF MEMBERS WERE NOTIFIED BY EMAIL ON 11/28/2012 THAT THE MICROWAVE WAS NOT TO BE FOR WARMING ANYTHING OTHER THAN FOOD. ON 12/10/2012, THE SURVEYOR CONFIRMED THAT RESIDENT #101 WAS discharged on [DATE]. ON 12/17/2012, THE SURVEYOR CONFIRMED THAT ON 12/5/2012 AT 2:00 P.M., DON #1 VERIFIED THAT NO OTHER RESIDENTS IN THE FACILITY WERE RECEIVING ANY FORM OF HEAT THERAPY. ON 12/17/2012, THE SURVEYOR CONFIRMED THAT ON 12/13/2012, SIGNS WERE PLACED ON EACH OF THE FACILITY'S MICROWAVE OVENS INDICATING THAT "...THE MICROWAVE OVEN IS TO BE USED FOR FOOD AND BEVERAGES ONLY, AND IS NOT TO BE USED FOR HEATING NON-FOOD ITEMS..." ON 12/17/2012, THE SURVEYOR CONFIRMED THAT ON 12/13/2012, THE CARE OF THE KITCHEN ON THE TRANSITIONAL CARE UNIT POLICY WAS REVISED AND APPROVED TO INCLUDE THE FOLLOWING STATEMENT: "...MICROWAVE OVENS ARE TO BE USED FOR HEATING FOOD AND BEVERAGES ONLY, AND ARE NOT TO BE USED FOR HEATING NON-FOOD ITEMS. NO PATIENT CARE DEVICES OR OBJECTS SHALL BE WARMED IN A MICROWAVE OVEN, INCLUDING, BUT NOT LIMITED TO IRRIGATION FLUIDS, COMPRESSES, WASH CLOTHS, TOWELS AND BLANKETS..." ON 12/17/2012, THE SURVEYOR CONFIRMED THAT ON 12/13/2012, A WARM MOIST COMPRESSES POLICY AND PROCEDURE WAS DEVELOPED AND APPROVED TO DEFINE THE CORRECT POLICY AND PROCEDURE FOR APPLICATION OF WARM MOIST COMPRESSES. ON 12/17/2012, THE SURVEYOR CONFIRMED THAT AS OF 12/13/2012, THE FACILITY'S DIRECTOR OF NURSING WAS TO BE PAGED PRIOR TO THE APPLICATION OF ANY WARM COMPRESSES TO ENSURE THAT ALL WARM COMPRESSES WERE ADMINISTERED ACCORDING TO POLICY AND PROCEDURE. ON 12/17/2012, THE SURVEYOR CONFIRMED THAT ON 12/13/2012, IN-SERVICING BEGAN FOR THE REGISTERED NURSES, LICENSED PRACTICAL NURSES, AND CERTIFIED NURSE ASSISTANTS REGARDING THE MICROWAVE ONLY BEING USED TO WARM FOOD AND BEVERAGES AND THE POLICY AND PROCEDURE FOR APPLICATION OF WARM COMPRESSES. ON 12/17/2012, THE SURVEYOR CONFIRMED THAT THE STAFF MEMBERS PROVIDING CARE TO RESIDENTS WERE NOT ALLOWED TO WORK UNTIL THEY HAD COMPLETED THESE IN SERVICES. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 11/26/2012 WAS REMOVED ON 12/13/2012. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. ( )