Every finding on record at Covenant Village of the Great Lakes

Based on interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include: On 3/24/26 at 1:14 PM, a review of the facility provided document entitled Legionella Policy, dated 12/21/2022, found that the the Water Management Program will be reviewed at least once a year . The document also states that, .our facility has a water management program, which is overseen by the water management team. A review of the provided document entitled Water Management Program, dated September 2020, found multiple Water Management Plan Team members that are former employees of the facility. A further review of the program found under the heading Control Measures - Domestic Water, found control measure DWM06 is to Monitor disinfectant level in the water supply and distal faucets. On 3/24/26 at 3:30 PM, an interview with Maintenance Supervisor (MS) JJ found the control limits are completed as they come up in their maintenance system, but the vendor is the one who takes the samples and would have the updated documents. MS JJ stated he would reach out to the vendor for additional documentation.On 3/26/26 at 7:32 AM, an email was sent to MS JJ requesting additional documentation.On 3/26/26 at 8:17 AM, a reply email from MS JJ found the facility would be educating staff and reinstituting the free chlorine monitoring.On 3/26/25 at 12:35 PM, a reply email from the Nursing Home Administrator (NHA) was received with documents showing work orders on maintaining the chlorine residual in the cooling towers, but no documentation showing tests done for free chlorine residual from the domestic water supply used by residents. A review of the updated document entitled Water Management Plan dated March 24th, 2026, found only two team members listed (one vendor contact and one facility staff) when their Legionella Policy states that: The water management team will consist of the following personnel: a. Facilities Maintenance Co-Lead, b. Infection Preventionist Co-Lead, c. Healthcare Administrator, d. Director of Nursing, e. Medical Director (or designee);.

Based on observation, interview and record review the facility failed to revise a person-centered care plan for 1 resident (Resident #7) of 12 residents reviewed for care plan revision resulting in an inaccurate reflection of the resident's current care needs. Findings include:Resident #7(R7)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R7 admitted to the facility on [DATE] with pertinent diagnoses including depression, anxiety and history of COVID. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which indicated R7 was cognitively intact.During an observation on 3/24/2026 at 10:02 AM, it was noted that there was no contact precaution signs or enhanced barrier precaution signs outside R7's door or inside the room.During an interview on 3/24/2026 at 10:08 AM, R7 stated that she was sick earlier this month with an infection but she was feeling better now.Review of R7's progress note dated 2/24/2026 revealed .Nurse Practitioner II into eval (evaluate) resident's culture and sensitivity (diagnostic procedure to identify infectious germs from body samples and determine the most effective antibiotic medication to treat it) with new order to d/c (discontinue) previous antibiotic and to start nitrofurantoin for tx (treatment) of UTI (Urinary Tract Infection).Contact precautions initiated.Review of R7's progress note dated 2/28/2026 revealed Resident (R7) continues on antibiotics for UTI without side effects noted. Resident (R7) continues on isolation.Review of R7's progress note dated 3/1/2026 revealed . Resident (R7) continues on contact isolation till (until) tomorrow.Review of R7's Care Plan revealed Problem: Isolation-Contact Isolation-Due to ESBL (Extended spectrum beta lactamase enzymes are produced and can cause severe infection) in urine. Status: Active (Current). Goal: No cross contamination to visitors and employees by March 5. Status: Active (Current). Goal date: 5/25/2026.Intervention: Follow transmission-based precautions. Problem: Infection (R7) has active infection in urine. Status: Active (Current). Interventions.Personal Protective Equipment if indicated. Status: Active (Current).During an interview on 3/26/2026 at 10:10 AM, Assistant Director of Nursing (ADON) who was also the Infection Preventionist (IP) S stated that R7 had ESBL in her urine and was under contact precautions until 3/2/2026. ADON/IP S said that R7 was no longer under contact precautions since her infection was resolved. ADON/IP S also stated that the contact isolation and active infection in urine care plans should have been deleted/resolved. ADON/IP S said that Minimum Data Set (MDS) nurse M was the main one doing nursing care plans and now Director of Nursing (DON) B and her were helping out. During an interview on 3/26/2026 at 10:37 AM, MDS M stated that she initiated nursing care plans and then ADON/IP S and DON B help with updating them. MDS M said she tries to update care plans when changes occur and to resolve care plans but if she didn't catch it right away, she updated them at the quarterly review. During an interview on 3/26/2026 at 10:52 AM, Nursing Home Administrator A was told that the infection care plans for R7 weren't updated and she nodded.

Based on observation, interview, and record review the facility failed to prevent the development and worsening of pressure ulcers in 2 residents (Resident #13 and Resident #43) of 2 residents reviewed for pressure ulcers resulting in the development of a facility acquired pressure ulcer for Resident #13 and the potential worsening of an existing pressure ulcer for Resident #43.Findings include:Review of a Face Sheet revealed Resident #13 was a female, with pertinent diagnoses which included: other abnormalities of gait and mobility, difficulty in walking not elsewhere specified, other lack of coordination, and pressure area of left buttock stage 3 (full thickness skin injury with exposure of subcutaneous [under all the layers of the skin] fat). Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 2/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #13 was moderately cognitively impaired. Further review of said MDS revealed Resident #13 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) for Roll left and right (The ability to roll from lying on back to left and right side, and return to lying on back on the bed.) and sit to stand (The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.) Review of a Wound Care note dated 2/24/26 revealed, .Chief Complaint/Nature of Presenting Problem: Wound on left buttock History Of Present Illness: (Resident #13) is seen today because staff noted a new wound on her left buttock. At this time (Resident #13) is sitting in her wheelchair in her room. She admits that the wound is a little painful. She offers no other complaints today.WOUND 1 Type: Pressure Location: Left buttock Size (cm) (centimeter): 0.8x0.9x0.1cm Base: 100% granulation (pink-red moist tissue filling an open wound as it begins to heal) Stage (Pressure): Stage 3.Plan:.Resident has an APM (alternating pressure mattress) mattress and a pressure relieving cushion in her wheelchair, staff to continue to assist resident with frequent turning when in bed, advised resident that she should lay down a couple of times during the day to help get pressure off her bottom. Review of Resident #13's Resident Care – Touchscreen Summary (a document directing the care of the resident for the nursing staff) prior to the development of the stage 3 pressure ulcer on her left buttock on 2/24/26 revealed, .Precautions – Skin Pressure reducing seat cushion Float heals (sic) Heel protectors – Right Heel protectors – Left. Review of Resident #13's Resident Care – Touchscreen Summary after the development of the stage 3 pressure ulcer on her left buttock on 2/24/26 revealed, .Precautions – Skin Pressure reducing seat cushion Special mattress Float heals (sic) Heel protectors – Right Heel protectors – Left Proper positioning Other (describe) turn q (every) 2 hours and lay in bed in between meals. In an interview on 3/25/26 at 10:08 AM, Licensed Practical Nurse (LPN) Q reported prior to the development of Resident #13's stage 3 pressure ulcer on her left buttock, pressure ulcer preventative interventions included 2 hour turns (reposition every 2 hours) and with her incontinence care. LPN Q reported Resident #13 did not want to lay down in her bed and would sit up in her chair a lot of the day. LPN Q reported now we have it so she will lay down after meals. LPN Q did not address how the facility performed offloading from the wheelchair if the resident chose to not lay down. In an interview on 3/25/2026 at 10:12 AM, Certified Nurse Aide (CNA) F reported prior to the development of Resident #13's stage 3 pressure ulcer on her left buttock, pressure ulcer preventative interventions included putting a wedge cushion underneath Resident #13 while in bed to keep her off her bottom. CNA F reported the facility was also using barrier cream on her bottom. CNA F reported sometimes Resident #13 would refuse repositioning and sometimes she didn't want to lay down because she wanted to attend activities. CNA F reported Resident #13 also wears pressure relieving boots while in bed to prevent pressure ulcers on her heels. CNA F did not address how the facility performed offloading from the wheelchair if the resident chose to not lay down. In an interview on 3/25/26 at 10:18 AM, Director of Nursing (DON) B reported Resident #13's stage 3 pressure ulcer on her left buttock was determined to be from pressure and the facility assumed it was from sitting. DON B reported Resident #13 sometimes refused to lay down to get pressure off of her bottom. DON B reported Resident #13 liked to sit in her chair. DON B did not address how the facility performed offloading from the wheelchair if the resident chose to not lay down. In a follow up interview on 3/25/26 at 10:55 AM, DON B was queried as to what interventions were in place prior to the development of Resident #13's stage 3 pressure ulcer on her bottom to prevent a pressure ulcer from developing. DON B reported Resident #13 had a cushion on her wheelchair and staff encouraged her to reposition, which Resident #13 would do. DON B reported other than repositioning and the cushion, that was what the facility was doing when Resident #13 was in her wheelchair. DON B reported the repositioning would be documented in the electronic medical record. In an interview on 3/25/26 at 10:51 AM, Resident #13 reported the staff would come in and offer to reposition her when she was in bed and get her off her bottom. Resident #13 reported she liked to be in her chair after meals. Resident #13 reported she wouldn't refuse to lay back down after meals because it doesn't matter to her where she is. Resident #13 did not report facility staff would help her with removing pressure while seated in her wheelchair. In a follow up interview on 3/25/36 at 2:02 PM, CNA F reported there was not a place in the electronic medical record to document that a resident was turned and repositioned. CNA F was queried as to what interventions the facility implemented to prevent pressure injury for Resident #13 since her preference was to sit in her wheelchair a lot of the time. CNA F reported the facility had put a cushion on her wheelchair, but she would not have been repositioned in her wheelchair because she had a regular wheelchair and queried how could you reposition them in a regular wheelchair? CNA F reported they did remind Resident #13 to shift in her wheelchair. CNA F reported Resident #13's preference was to stay up in her wheelchair in the afternoon after lunch to play BINGO. In an interview on 3/25/26 at 3:23 PM, CNA D reported until Resident #13's stage 3 pressure ulcer on her left buttock appeared, staff were turning and repositioning her every 2 hours but if Resident #13 wanted to be in the wheelchair, she was in the wheelchair. CNA D reported there was nowhere to document turning and repositioning of the resident. CNA D reported sometimes Resident #13 refused to get out of her wheelchair. CNA D did not address how the facility performed offloading from the wheelchair if the resident chose to not lay down. In a follow-up interview on 3/26/26 at 8:38 AM, Resident #13 reported since the stage 3 pressure ulcer developed on her left buttock, staff were making sure that she lay down after meals. Resident #13 also reported they reposition her in bed every 2 hours and they put pillows underneath her to keep pressure off her bottom. Resident #13 was queried as to what other options of treatment or what education did staff provide when she would refuse to lay down to get out of her wheelchair. Resident #13 reported she would never refuse to lay down or anything even before her wound developed. In an interview on 3/26/26 at 8:57 AM, CNA O reported they try and lay Resident #13 down after meals and put her on her side to get her off her bottom. CNA O reported when Resident #13 refused to lay down, she tried to educate her that it is important to get off her bottom. CNA O reported Resident #13 is one of the residents that likes to stay up in her wheelchair all day. CNA O reported when Resident #13 would refuse to lay down, she would tell the nurse that she had refused and then the nurse would go and educate Resident #13 and the nurse could then document the refusal in the progress notes. In an interview on 3/26/26 at 9:48 AM, Registered Nurse RN G reported if a resident was at risk for pressure ulcers and they refused to lay down, she would reapproach the resident, but they did have the option to refuse. RN G reported she would educate the resident of the risk of refusal but if they still refused, staff would have to let them stay up and just make sure the documentation was in place in the progress notes to support the refusal. RN G did not address how the facility performed offloading from the wheelchair if the resident chose to not lay down. In a follow-up interview on 3/26/26 at 9:19 AM, CNA F reported that the intervention to lay Resident #13 down after meals happened after she developed the stage 3 pressure ulcer on her left buttock. CNA F reported in the medical field, everybody gets busy and the resident may be up for 3 or 4 hours. CNA F reported she thought Resident #13's pressure ulcer developed because she was staying in her chair too long and being in her wheelchair all day. CNA F reported CNAs did not document refusals of the resident to lay down. In an interview on 3/26/26 at 10:28 AM, Physician's Assistant (PA) GG reported by the time she was made aware of Resident #13's pressure ulcer on her left buttock, it was a stage 3. PA GG reported any event where the resident has pressure to the area, even more than a couple hours, could lead to a pressure injury. PA GG reported even one event when Resident #13 was up in her wheelchair longer than a couple hours could lead to a pressure ulcer. PA GG reported she knew Resident #13 had been reluctant to lay down during the day in the past and had been refusing to lay down. PA GG reported if Resident #13 did refuse, there really is not much the facility could have done. PA GG reported she believed Resident #13's pressure ulcer developed from sitting in her wheelchair. PA GG stated I think it is definitely more of a chair issue and her not wanting to lay down during the day. PA GG did not address how the facility performed offloading from the wheelchair if the resident chose to not lay down. In a follow-up interview on 3/26/26 at 12:18 PM, CNA D reported prior to Resident #13 developing the stage 3 pressure ulcer on her bottom, she did not believe she was encouraged to lay down after meals. CNA D reported Resident #13 sits in the wheelchair so there was not much they could really do. CNA D reported Resident #13 would refuse to lay down when staff encouraged her to lay down and she would just tell the nurse because there was nowhere for CNAs to document the refusal. In an interview on 3/26/26 at 12:35 PM, Former CNA (FCNA) HH reported she did not ever recall that Resident #13 refused to get into bed to get out of the wheelchair. In a follow-up interview on 3/26/26 at 12:49 PM, CNA F was queried what would she do if Resident #13 refused to get out of her wheelchair and lay down. CNA F stated, what else can you do, it is her choice, we leave her in the chair. In an interview on 3/26/26 at 1:03 PM, Assistant Director of Nursing ADON S reported when a resident refused to get out of their wheelchair and lay down, she would expect staff to reapproach the resident, ask someone else to ask her, and to help the resident to reposition in their wheelchair or stand in the bathroom to take pressure off their bottom. In a follow-up interview on 3/25/26 at 3:18 PM, ADON S was asked for documentation of turning and repositioning for Resident #13 and ADON S reported there was not anything specific in the charting and documentation for CNA charting that confirms that Resident #13 was repositioned every 2 hours. On 3/26/26 at 9:57 AM, Nursing Home Administrator A was requested, via electronic mail, to provide this surveyor with any documentation that (Resident #13) was offered to lay down and refused for the period of 1 month prior to the development of the pressure ulcer. In a follow-up interview on 3/26/26 at 11:30 AM, DON B reported refusals (to lay down) should be documented in the medical record. In electronic correspondence on 3/26/26 at 2:43 PM, NHA A responded to this surveyor's request of 3/26/26 at 9:57 AM with the following response, Unfortunately our system is not set up to document refusals if there is not an order in place, which there wasn't at the time frame requested. I do not have documentation when (Resident #13) was offered to lay down in between meals and she refused to lay down. Review of Resident #13's Care Plan prior to the development of the stage 3 pressure ulcer on her left buttock on 2/24/26 and as provided by the facility revealed the focus of, (Resident #13 is at risk for skin breakdown related to occasional incontinence, impaired mobility r/t (related to) dx (diagnosis) of Parkinson (a disorder of the central nervous system that affects movement, often including tremors) & glaucoma (an eye disorder that damages the optic nerve) & chronic back pain which can affect this as well & needs staff assistance for mobility. (no implementation date) and care planned interventions in entirety which included Calculate calorie needs/fluid requirements. Adjust based on weight, tolerance, and hydration status; Check for incontinence: change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier; Check skin for areas of redness. Report any changes to the nurse; Dietary Consult; Do NOT massage skin over pressure areas; Keep fluids next to (Resident #13) at all times. Provide cues/assist (Resident #13) to drink fluids with medications and between meals; Monitor laboratory results for abnormal findings.; Nutritional supplements as recommended; Perform complete assessment of skin. Note areas of redness; Elevate/float heels off bed or Heel Protector boots while in bed per (Resident #13)'s preferences; Resident to wear a sports bra to protect breasts from gait belt with transfers.; APM mattress for skin injury prevention (no implementation dates). (Note there was no documentation in the care plan that Resident #13 preferred to stay in her wheelchair and there was not adequate interventions in place for Resident #13 who preferred to sit in her wheelchair for extended periods of time to relive pressure to her buttocks.) According to the National Pressure Ulcer Injury Advisory Panel, Pressure Ulcer Prevention (Black, J. PhD, RN, FAAN), (Resources for Faculty on Pressure Ulcer Prevention - National Pressure Injury Advisory Panel) Nursing Interventions: .Instruct the patient to change position in the chair every hour or more, Stand up if possible. For patients who use a wheelchair for mobility: Use a chair cushion, ask physical therapy for suggestions on which one . Instruct the patient to change position every 15 minutes . Reposition the patient in the chair every 1 hour Resident #43 Review of a Face Sheet revealed Resident #43 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses which included: rhabdomyolysis (a rare and life-threatening condition where your muscles break down and release toxins into your blood and kidneys), muscle weakness, and abnormalities of gait (walking pattern) and mobility. On 3/24/26 at 12:12 PM, Resident #43 was observed laying supine (on her back) in bed. Heel protectors (a boot shaped padded device designed to protect the heels by offloading pressure) blue and orange in color were observed in the reclining chair in the room. Resident #43's heels rested directly in contact with the mattress of the bed. When queried, Resident #43 replied I have no idea what is supposed to happen with those boot things. Review of Wound Care provider noted for Resident #43 dated 3/24/26 revealed .Hospital records indicate wounds present on her back, bottom and left elbow.on admission to facility noted wounds to both elbows, her back and her bottom. Wound 1 Type: pressure Location: Left buttock.Wound 2 Type: pressure Location: coccyx. Wound 3 Type: pressure Location Right elbow.Wound 4 Type: pressure Location Left elbow. Additional Wounds Section: Wound 5 pressure left heel 5.0 x 3.0 cm non-blanchable (refers to skin redness that does not fade when pressure is applied, indicating a potential tissue damage and compromised blood flow) purple discoloration DTI (deep tissue injury) no drainage peri-wound (around the wound) skin intact.Wound 6 pressure Right heel 1.5 x 4.0 cm non-blanchable purple discoloration DTI no drainage peri-wound skin intact. On 3/25/26 at 09:10 AM, Resident #43 was observed laying supine in bed. Heel protectors blue and orange in color were observed in the reclining chair in the room, in the same position as observed the day before. Resident #43 was observed sleeping in bed, and her heels rested directly in contact with the mattress of the bed. Review of Nursing admission Evaluation for Resident #43 dated 3/17/26 revealed .Skin color: normal.Pressure injuries to bilateral (both) elbows, left buttock and natal (groove that separates the two buttocks) fold.Wound details: left buttock pressure injury.left elbow pressure injury.right elbow pressure injury.proximal natal fold pressure injury.bilateral heels intact, blanchable, but mushy. Review of Braden Scale Risk Evaluation for Resident #43, authored by Director of Nursing (DON) B dated 3/17/26 revealed .Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitations lead to almost constant friction.Risk level: Very High Risk. Review of Baseline Care Plan for Resident #43 dated 3/19/26 revealed .Resident receives the following services: wound care. There were no interventions noted related to wound care, or pressure injuries. On 3/25/26 at 11:59 AM, Resident #43 was observed laying supine in bed. Assistant Director of Nursing (ADON) S and Registered Nurse (RN) G were observed removing the blanket covering Resident #43, and her heels were noted to be resting directly on the mattress. Heel protectors blue and orange in color were observed in the reclining chair in the room, in the same position as observed earlier that day and the day before. On 3/25/26 at 12:09 PM, RN G removed Resident #43's sock on her right foot, inspected her heel and then applied skin prep wipe (protective wipes used to form a protective barrier that helps preserve skin integrity). The outer side of Resident #43's right heel was noted to have what appeared to be a large fluid filled blister, purple in color. ADON S was observed visually inspecting Resident #43's right heel, touching and prodding the heel, reapplying her sock and applying the heel protector she retrieved from the reclining chair. RN G then removed the sock from Resident #43's left foot and applied skin prep wipe. Resident #43's left heel was noted to also have what appeared to be a large fluid filled blister purple in color. ADON S was observed also visually inspecting Resident #43's left, heel, touching and prodding the heel, and reapplying her sock and applying the heel protector she retrieved from the reclining chair. Review of Care Plan Report for Resident #43 dated 3/25/26 revealed Resident #43 was admitted with multiple pressure injuries: bilateral heels, elbows, and sacrococcygeal area.Goal.Promote patient's progression of pressure wounds healing.use pillows, pads or wedges to reduce pressure on heals and pressure points. In an interview on 3/25/26 at 1:20 PM, Resident #43 reported she had worn the heel protectors on and off since she was admitted to the facility. Resident #43 stated sometimes they put them on, sometimes they don't. Resident #43 reported she did not wear them that day until the nurse put them on when they looked at her heels, and she did not wear them at all the day before. Resident #43 reported she did not mind wearing the heel protectors, she stated they felt like feet pillows. In an interview on 3/25/26 at 1:35 PM, Certified Nurse Assistant (CNA) R reported she provided morning care to Resident #43 at about 9 am, and she was pretty sure she was wearing her heel protector boots at that time. CNA R reported she applied her heel protectors when she was done with care. In an interview on 3/25/26 at 3:30 PM, CNA K reported Resident #43 did not have any interventions in place for pressure wounds that she was aware of, and she did not wear heel protector boots. In an interview on 3/26/26 at 8:52 AM, CNA O reported she was unsure what interventions were in place for Resident #43 related to pressure wounds, but she did not think she had heel protector boots. CNA O reported if someone had wounds on their heels they would always 'float' them off the bed with a pillow. CNA O reported she had assisted the wound provider on Tuesday, 3/24/26 and knew that purple areas were found on Resident #43's heels that day. In an interview on 3/26/26 at 11:04 AM, RN G reported Resident #43 did not have a baseline care plan related to wounds. RN G reported she was not aware Resident #43 had pressure injuries on both of her heels until she observed them yesterday. RN G reported there should have been interventions in place for prevention of pressure wounds and/or the worsening of existing pressure wounds related to the wounds Resident #43 admitted to the facility with. RN G reported without interventions, the wounds can break down further, could open, and get worse. In an interview on 3/26/26 at 11:39 AM, Clinical Reimbursement Manager/Registered Nurse (CRM/RN) M reported baseline care plans have 4 main topics ADLs (activity of daily living), fall risk, pain, and nutrition and should be created by the admitting nurse. CRM/RN M reported she added additional information to the baseline care plan to create the comprehensive care plan, and she had 14 days to complete the care plan. CRM/RN M reported wound care, or wound prevention was not part of the baseline care plan. CMR/RN M reported a resident's existing wound or wound development risk would be important information for the nursing team to know; if interventions were not in place or staff did not know about a wound, it could get worse. CMR/RN M reported a resident care summary would have information regarding a resident's needs for pressure wound interventions. CMR/RN M confirmed Resident #43's care summary indicated she required wound care, but no specific interventions were noted. Additionally, CMR/RN M confirmed she had created Resident #43's that day, and it was a basic pressure injury care plan, and it did not list heel protectors. Review of March 2026 Physician Order Sheet for Resident #43 revealed .Dressing Change, Notes: Pressure injury: Skin prep to bilateral heels, encourage use of heel off loading boots with a start date of 3/25/26.Wound care: Heel Right: Notes Cleanse heel with NS/Wound cleanser, pat dry, apply skin prep to heel, one time daily, ordered on 3/25/26.Wound care: Heel Left: Notes Cleanse heel with NS/Wound cleanser, pat dry, apply skin prep to heel, one time daily, ordered on 3/25/26. Review of Clinical Notes Report revealed .clinical Notes . authored by Director of Nursing (DON) B on 3/17/26. has multiple wounds to bilateral elbows, mid spine, natal fold, and left buttock. Heels are intact, blanchable (refers to skin or tissue that temporarily turns white or pale when pressure is applied and quickly return to its original color once pressure is released; indicating circulation is intact and blood flow is normal to the affected area) but mushy. In an interview on 3/26/26 at 12:42 PM, DON B reported Resident #43's heels were intact but mushy when she admitted to the facility. When asked, DON B reported Resident #43's heels were like 'mashed potatoes with skin over them. DON B reported Resident #43 had heel boots and pillows for offloading. When queried regarding how heel boots were implemented DON B stated we walk down to laundry and grab a pair, we add it to the care summary, the care plan, and we tell the resident what we are doing and why. DON B reported heel boots were put in place for Resident #43 shortly after she arrived. In an interview on 3/26/26 at 12:47 PM, ADON S reported Resident #43's care summary was completed on 3/19/26 and it was noted she had multiple pressure injuries, barrier cream and to be repositioned side to side. ADON S stated there is nothing specific about heels or heel boots. Review of facility policy Prevention of Pressure Injuries with a revision date of April 2020 revealed .review the resident's care plan and identify the risk factors as well s the interventions designed to reduce or eliminate those considered modifiable.Assess the resident on admission.for existing pressure injury risk factors.inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living).inspect pressure points.heels.

Based on observation, interview, and record review the facility failed to develop a person-centered baseline care plan for 1 (Resident #46) of 12 residents reviewed for person-centered baseline care plan resulting in the potential for unmet care needs.Findings include:Resident #46Review of a Face Sheet revealed Resident #46 was a female who was admitted to the facility on [DATE] and had pertinent diagnoses which included: centrilobular emphysema (a chronic condition that causes shortness of breath), chronic respiratory failure, and dependence on oxygen.On 3/24/26 at 1:24 PM, Resident #46 was observed sitting in her bed, with a nasal cannula (a device that delivers extra oxygen through a tube into the nose) present in her nose, with an oxygen concentrator (machine that draws in air, filters out nitrogen, and delivers a steady stream of oxygen-enriched air) running at 2L (liters). Resident #46 appeared to be short of breath.In an interview on 3/25/26 at 10:41 AM, Resident #46 was sitting in her bed with a nasal cannula present in her nose and the oxygen concentrator running at 2L. Resident #46 reported she always wore oxygen, even in the shower. Resident #46 reported when she did not have the oxygen, she was very winded and was not able to do anything until she caught her breath again.On 3/25/26 at 9:00 AM, Resident #46 was observed sitting in her bed with a nasal cannula present in her nose and the oxygen concentrator running at 2L. Resident #46 reported she had a chronic lung condition, and she had to always wear oxygen. Resident #46 reported she had her machine (oxygen concentrator) set at 2L at home, but she would adjust the dial if she needed more when she was moving around. Review of March 2026 Physician Order Sheet for Resident #46 revealed .Oxygen (O2) at 2 L/min (liters per minute) per nasal cannula Notes 2L continues, 4 L with activity, titrate (continuously measure and adjust the balance) to 1 L. with an order date of 3/20/2026.Review of Nursing admission Evaluation-Respiratory for Resident #46 dated 3/20/26 revealed Rhythm: labored; oxygen therapy: yes.In an interview on 3/25/26 at 1:35 PM, Certified Nurse Assistant (CNA) R reported each resident has a resident care summary that the CNAs can review that provides specific instructions for providing resident care. CNA R reported Resident #46 does wear oxygen, but she was unsure of the liter flow rate. CNA R reported the information would be in the resident care summary. When queried, CNA R reported she did not have access to review physician orders for residents.Review of Resident Care-Touchscreen Summary for Resident #46 reviewed on 3/26/26 revealed .Toileting -care oxygen @ (at) 4L for activity & (and) 2L at rest. Review of Baseline Care Plan for Resident #46 reviewed on 3/25/26 revealed .Resident receives the following services: Oxygen. There were no interventions noted.Review of Care Plan for Resident #46 reviewed on 3/25/26 revealed Problem.Nursing - Respiratory Status: No noted problem was listed. Goals: Resident #46 will be free of respiratory distress: Active. There were no interventions noted.In an interview on 3/26/26 at 10:41 AM, Registered Nurse (RN) G reported baseline care plans are within the admission assessment section of the medical records. RN G reported oxygen use was not part of the baseline care plan. RN G reported baseline care plan topics were pre-determined within the computer program and did not include a respiratory specific care plan. RN G reported the admitting nurse would enter a physician order for oxygen use for a resident, but CNAs do not have access to review physician orders. RN G reported if a resident's needs were not on the resident care summary, a CNA would not have access to the information. RN G reported CNAs would need specific information regarding a resident's oxygen needs because CNAs exchange portable oxygen tanks, and the liter flow rate would need to be set. In an interview on 3/26/26 at 11:39 AM, Clinical Reimbursement Manager/Registered Nurse (CRM/RN) M reported baseline care plans have 4 main topics ADLs (activity of daily living), fall risk, pain, and nutrition and should be created by the admitting nurse. CRM/RN M reported she added additional information to the baseline care plan to create the comprehensive care plan, and she had 14 days to complete the care plan. CRM/RN M reported respiratory status and oxygen use would need to be put directly on the resident care summary. CMR/RN M reported a resident's oxygen use would be important information for the nursing team to know; it would be part of the resident's daily needed care. CMR/RN M reported she was out of the office when Resident #46 admitted to the facility and the team was 'still learning that piece' when queried about who covered her role in her absence. CMR/RN M reported Resident #46's care summary indicated she used oxygen, but no specifics were mentioned. Additionally, CMR/RN M confirmed Resident #46's respiratory care plan did not have any interventions listed.In an interview on 3/26/26 at 12:32 PM, Director of Nursing (DON) B reported CRM/RN M was responsible to create a baseline care plan for a resident within 48 hours of admitting to the facility, and the baseline care plan would include basic information about how to care for a resident. DON B reported oxygen use would be a physician order and added to the resident care summary.In an interview on 3/26/26 at 12:36 PM, Assistant Director of Nursing (ADON) S reviewed the care plan for Resident #46 and confirmed there were no interventions related to her oxygen use. ADON S reviewed Resident #46's resident care summary and reported she had added .Toileting -care oxygen @ 4L for activity & 2L at rest. and it did appear oxygen use was only during toileting; however, the resident required the adjusted oxygen use at all times.Review of facility policy Care Plans - Baseline with a date of March 2022 revealed .a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident.the baseline care plan includes instructions needed to provide effective, person-centered care of the resident.initial goals based on admission orders.physician orders.

Based on interview and record review, the facility failed to ensure the Infection Preventionist completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards and infectious disease outbreaks in a vulnerable population of 29 residents. Findings include: Findings include: During the entrance conference interview on 3/4/25 at 10:30 AM, Nursing Home Administrator (NHA) A stated, The (Director of Nursing (DON) B is the Infection Control Preventionist (ICP). During an interview on 3/4/25 at 2:20 PM, DON/ICP B stated, (Assistant Director of Nursing (ADON) C) is the Infection Control Preventionist. During an interview and record review on 3/4/25 at 2:25 PM, ADON C stated, I do a lot with infection control but (DON B) is the Infection Control Preventionist. Requested on 3/4/24 at 3:44 PM of the NHA A, the ICP Infection Control certificate by 4 PM on 3/4/25. As of 4:05 PM, the certificate has not been received. During an interview and record review on 3/5/25 at 3:39 PM, DON/ICP B stated, I am the Infection Control Preventionist. I started November 1 last year (2024). I am not certified in Infection Control. I started taking the course end of February this year. I've not had time to finish the modules plus I have to take a test to get the certificate.

Based on interview, and record review, the facility failed to develop policies and procedures to include current standards of practice in regard to pneumococcal immunizations, resulting in the potential for eligible residents to not be offered either the PCV15 (15-Valent Pneumococcal Conjugate Vaccine) or PCV20 (20-Valent Pneumococcal Conjugate Vaccine), therefore increasing the risk of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Review of the policy Pneumococcal Vaccine revised March 2022 indicated all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (See current vaccine information statements at https://www.cdc.gov/vaccines/hcp/vis/index.html for educational materials.) Provision of such education is documented in the resident's medical record. It was noted there was no recommendations in regard to the PCV15 and PCV20 immunizations to reflect current CDC guidance. In an interview on 3/5/2025 at 2:29 PM, Director of Nursing (DON) B reported she was unaware of the types of pneumococcal vaccines that were available for residents and the CDC recommendations in regard to PCV15 and PCV20 immunizations, and if the policy had been updated to reflect the current guidance. It was noted an updated policy/procedure was not provided prior to survey exit, 3/5/2025 at 5:30 PM. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Recommendations, page dated 10/24/2024, revealed .CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults [AGE] years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown .If PCV15 is used, this should be followed by a dose of PPSV23 one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak .If PCV20 is used, a dose of PPSV23 is NOT indicated . Retrieved from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html

Based on interview and record review, the facility failed to provide showers per resident preference in 1 (Resident #17) of 1 resident reviewed for self determination, resulting in dissatisfaction with care and the potential for poor hygiene, skin breakdown, and infection. Findings include: Review of an Admission Record revealed Resident #17 was a female, with pertinent diagnoses which included: encounter for palliative (hospice) care, muscle weakness, unsteadiness on feet, and difficulty walking. Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 12/18/24, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #17 was cognitively impaired. Further review of said MDS revealed Resident #17 required substantial/maximal assistance with shower/bathe self (the ability to bathe self, including washing, rinsing, and drying self .) In an interview on 3/3/25 at 12:22 PM, Resident #17 reported she did not receive showers as frequently as she felt she should. Resident #17 reported she had been getting a shower once a week and felt that she should have been receiving them twice a week. Review of the North Hall Shower Schedule revealed Resident #17 was scheduled to receive a shower twice a week, on Monday evening shift and Thursday evening shift. On 3/4/25 at 10:51 AM, the facility was requested to provide this surveyor with shower sheets for Resident #17 for the last 3 months (12/5/24 - 3/3/25). On 3/5/25 at 12:38 PM, the facility provided, electronically, copies of Resident #17's shower sheets and a copy of an unnamed report with codes entered next to dates for the same requested period. There was no legend to describe the codes. Review of Resident #17's completed shower sheets revealed Resident #17 received 8 showers out of 25 shower opportunities (2 times per week for 12.5 weeks). In an interview on 3/5/25 at 1:12 PM, Assistant Director of Nursing (ADON) C reported she had realized the previous week that there had been an issue with Resident #17's showers. ADON C reported Resident #17 was supposed to have received showers from facility staff on Mondays and from hospice staff on Thursdays. ADON C reported facility staff thought that hospice staff was giving Resident #17 her showers on both Mondays and Thursdays and were consequently not giving Resident #17 her Monday showers as they should have been. ADON C reported the result was that Resident #17 had been receiving 1 shower a week (from hospice), instead of the 2 showers per week that she was scheduled to receive. ADON C reported because she just updated the shower schedule to reflect which staff was supposed to give Resident #17 showers on which days and had educated facility staff, Resident #17 should start receiving 2 showers per week starting the week of 3/3/25. In an interview on 3/5/25 at 1:34 PM, NHA A was queried for additional information related to the unnamed report with codes entered next to dates submitted with Resident #17's shower sheets. NHA A initially reported the unnamed report should have been additional documentation of Resident #17's showers; however, it was the wrong report. NHA A was requested to provide any additional documentation as evidence of Resident #17's showers for the last 3 months. No additional documentation was submitted prior to survey exit.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure appropriate PPE was worn during foley catheter care and brief change for two of 12 residents (R5 and R16) reviewed for infection control, resulting in the potential for the spread of disease to a vulnerable population. Findings include: R5 According to R5's Face Sheet, the resident had diagnoses that included chronic multifocal osteomyelitis (infection of bone) of left ankle and foot, neuromuscular dysfunction of bladder and retention of urine, pressure ulcer of right and left buttock stage 2, and pressure ulcer of right heel stage 4. Review of R5's Care Plan, Skin Breakdown, dated 10/2/2022, indicated the resident had a supra pubic catheter (device to collect urine) and multiple pressure ulcers. Review of R5's Care Plan, goal date 6/10/2025, indicated the resident had osteomyelitis to multi focused areas of left foot and was actively on Enhanced Barrier Precautions. During an observation and record review on 3/03/25 at 11:40 AM, there was signage inside the alcove between R5 and roommate that declared, Enhanced Barrier Precautions with two-pictures of a gown, a pair of gloves, and goggles next to a full hand sanitizer. On the inside of the room's door were 2-boxes of gloves. A 3-drawer dresser had nothing in the first 2 drawers with 4-yellow gowns in bottom drawer. No eye covering was available. R16 According to R16's Face Sheet the resident had diagnoses that included neuromuscular dysfunction of bladder. Review of R16's Care Plan, indicated the resident's Enhanced Barrier Precautions related to foley catheter use had been discontinued. It was noted the Care Plan provided by the facility did not have a start/end date or revision history date(s). During an observation on 3/03/25 11:45 AM, signage inside the alcove between R16 and roommate that declared, Enhanced Barrier Precautions with two-pictures of a gown, a pair of gloves, and goggles. The signage did not indicate what PPE had to be worn. On inside of room's door were 2-boxes of gloves with a 3-drawer dresser with each drawer containing blue gowns. No goggles were available. Hospice aide (Aide) L was providing morning cares for the resident lying partially clothed on the bed. On the resident's right inner thigh was a leg strap attached to a foley catheter (indwelling urine collection device). Aide L was wearing gloves was not wearing a gown. Aide L stated, (R16) is not on any precautions. I did not see any EBP signs. I should be wearing gloves because I am touching her (R16's) catheter, soiled brief, and body. I make sure I don't splash urine on me. Aide L did not change gloves while moving from soiled brief to body. During an observation on 3/4/25 at 2:05 PM, there was signage inside the alcove between R16 and her roommate that declared, Enhanced Barrier Precautions with two-pictures of a gown, a pair of gloves, and goggles. On top of the isolation cart was a rolled up blue gown with the strings torn as if a person had worn the gown and ripped it off. During an observation and interview, on 3/4/25 at 2:15 PM, Director of Nursing/Infection Control Preventionist (DON/ICP) B stated while observing EBP signage and isolation cart outside of R5's room, I do not really know what the resident is on as far as precautions or why. I am not sure what PPE Enhanced Barrier Precautions require. I'll look in the cart (isolation) and see what is in here, that should tell us what staff needs. The DON/ICP observed the top two drawers of the cart were empty with 4-yellow gowns in the bottom of the cart. The DON/ICP stated, Night staff is supposed to stock the carts with supplies. I will have to look to see what the resident needs. During an observation, interview, and record review, on 3/4/25 at 2:20 PM, DON/ICP B stated, looked at the EBP sign and isolation cart outside of R16's room. On top of the isolation cart was a rolled up blue gown. DON B stated, If that gown is soiled, it should be put in the garbage. Staff should not have left it here. I don't know if the goggles are to be worn for Enhanced Barrier Precautions for a foley catheter. You will have to ask (ADON C) about this, she is the Infection Control Preventionist. During an interview and record review on 3/4/25 at 2:25 PM, Assistant Director of Nursing (ADON) C stated, The facility has done a lot of training of staff on infection control. Last year, Corporate, sent the facility the policy on Enhanced Barrier Precautions and a CDC (Centers for Disease Control) directive of Enhanced Barrier Precautions. I also made the signs that indicate the resident is on Enhanced Barrier Precautions. I give the staff the option of wearing goggles for Enhanced Barrier Precautions. I can't find the CDC signage on Enhanced Barrier Precautions. Hospice staff should know before coming here to take care of a resident if the resident requires PPE for Enhanced Barrier Precautions by looking at the Care Plan. Hospice knows how to open the Care Plans, and they should know what PPE to wear for Enhanced Barrier Precautions before they even come here. The facility does not train them, they should just know. Training of agency and hospice staff is done by word-of-mouth and no signature page is taken to prove the training was done. The facility follows CDC guidelines on infection control. ADON C did not reply when asked if she knew where to obtain the CDC Enhanced Barrier Precautions signage. During an interview on 3/5/25 at 2:29 PM, DON/ICP B stated, Enhanced Barrier Precautions (EBP) expectations of ancillary staff that care for residents on EBP are the hospice nurses are to communicate to the hospice aides the precautions and care needs of each hospice resident. The charge nurse on 3rd shift should be checking the CNAs are doing their job of filling the isolation carts. No one from day management checks the carts to make sure they have been stocked. All hospice staff checks with facility staff when they enter the facility to be reminded what residents are on EBP. Review of facility's policy Enhanced Barrier Precautions dated August 2022, revealed, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray .examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); . EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization . EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk .Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. 9. Staff are trained prior to caring for residents on EBPs. 10. Signs are posted indicating the type of precautions and PPE required. 11. PPE is available inside or outside of the resident rooms.

Based on interview and record review, the facility failed to maintain a complete and accurate medical record related to Advance Directives / Code Status for 1 (Resident #17) of 1 resident reviewed for accurate medical records, resulting in the potential for the resident's care wishes not being honored as desired. Findings include: Review of a Face Sheet revealed Resident #17 was a female. Review of Resident #17's paper-based medical chart on 3/4/25 at 8:35 AM revealed Resident #17 had a signed DO NOT RESUSCITATE (DNR) order in place. There was a red page in the front of the chart that read DNR. Review of Resident #17's Electronic Medical Record (EMR) Clinical tab Ribbon indicated that Resident #17 was DNR. Review of a current Physician Order for Resident #17 revealed, 8/15/24 12:00 AM Full Code Active (Current) In an interview on 3/5/25 at 9:39 AM, this surveyor, along with Licensed Practical Nurse (LPN) R, reviewed Resident #17's paper-based medical chart and EMR advance directives documentation. LPN R confirmed Resident #17's paper-based chart and EMR Ribbon indicated Resident #17 was a DNR. LPN R confirmed Resident #17's physician order was for a Full Code. In an interview on 3/5/25 at 9:47 AM, Assistant Director of Nursing (ADON) C reported all documentation related to a resident's advance directives should match so that everyone can be certain of what someone's last care wishes were.

Based on observation, interview, and record review the facility failed to ensure adaptive dining equipment was provided consistently for 1 (Resident #179) of 2 residents reviewed for nutrition resulting in difficulty drinking, feelings of worry, and the potential for dehydration. Findings include: Resident #179 Review of Resident #179's face sheet, printed 3/5/25, included diagnoses of Muscle weakness, Osteoarthritis (cartilage that cushions the ends of bones in joints gradually deteriorates), Need for assistance with personal care, and Dysphagia, oropharyngeal phase (difficulty in swallowing). Review of the social services progress note, dated 2/25/25, noted Resident #179's brief interview for mental status score was 15 which indicated the resident was cognitively intact. Review of Resident #179's Occupational Therapy Evaluation, dated 2/24/25, stated, Patient (R179) will improve ability to safely and efficiently perform eating tasks with Setup or Clean-up Assistance with use .a 2-handled mug. During an observation on 03/03/25 at 10:26 AM, Resident #179 was seated in her room with her tray table in front of her that had two beverages; a double handled cup with spout lid containing what looked like juice and a disposable foam cup (no handles) with lid and straw which contained what appeared to be water. During an observation and interview on 03/03/25 at 10:45 AM, Resident #179 still had the same two beverages in front of her and confirmed it was juice in the dual handled cup and water in the disposable foam cup. Resident #179 reported the dual handled cup was helpful and would prefer if the facility would put her water in a dual handled cup with lid. Resident #179 reported the facility usually only gave her the dual handled cup with spout lid for her juice and her water was usually in a foam cup (no handles). During an observation and interview on 03/03/25 at 11:56 AM, Certified Nurse Aide T delivered Resident #179's lunch to her room. The lunch tray was delivered with three beverages: cranberry juice (in a two handled cup with spout lid), water (in a two handled cup with spout lid), and a coffee in a regular mug with plastic disposable lid. Resident #179 reported the coffee mug with one handle would spill and was not as easy to drink from than the two handled cups. On the bedside table along with the lunch tray was a disposable zero handled foam cup of water with disposable lid and straw. Resident #179 reported it was much easier to drink from the two handled cups, she was working with the therapy department with dining, and the therapy department had started the adaptive dining devices including the dual handled cup. Resident #179 reported she had to be real careful and that any cup that didn't have two handles could slip from her hands easily. Resident #179 reported she was worried about dropping a drink, it was easy to let it go (drop a cup), and she preferred not to have that happen. During an observation on 03/03/25 at 03:03 PM, Resident #179 was in her bed with bedside table next to her. On the bedside table was a disposable foam cup with lid and straw (no handles) and a plastic clear 2 handled cup with spout lid filled with cranberry juice. During observations and interviews which began on 03/04/25 at 07:46 AM, Resident #179 was observed in bed attempting to eat her breakfast. The coffee was delivered in a mug with disposable lid (one handle). On the tray table there was a disposable foam cup with lid and straw (no handles). Registered Nurse (RN) Y was observed doing range of motion with Resident #179's arms and RN Y reported Resident #179 was stiff in the morning. RN Y proceeded to leave the resident's room. Resident #179 continued to attempt to eat breakfast, but stated, I can't feed myself as she struggled to bring the built-up curved spoon to her mouth and was shaky. The tray ticket on the table stated, 2 handled cup and included Preferences .Regular Coffee (1 cup). At 07:55 AM, RN Y reported Resident #179 has fine motor issues and has some weakness. At 07:58 AM, Resident #179 was observed trying to drink the coffee (with the one handle), but she was unsuccessful. Resident #179 took her right hand and grabbed the coffee mug handle, then attempted to grab the mug with her left hand but she was observed unable and stated, I can't do it. Resident #179 was unable to pick up the mug and drink her coffee and gave up trying. Resident #179 reported she likes to drink coffee but hasn't been able to with the cup. The water on her bedside table in the disposable foam cup, lid, and straw was dated 3/4 and still had the paper over the straw tip. There were no handles on that water. During an observation on 03/04/25 at 09:51 AM, Resident #179 was laying in her bed with the tray table next to her. The tray table had one beverage in a dual handled cup with spout lid but the bedside water in the disposable foam cup (no handles) still had the paper over the straw with none of the beverage consumed. During an observation on 03/04/25 at 11:53 AM, Resident #179 was served a coffee in a mug with one handle and disposable lid. Resident #179 still had a disposable foam water cup dated 3/4 which had no handles. During an observation on 03/04/25 at 12:39 PM, Resident #179 was sitting upright in her wheelchair watching television with her tray table next to her that was holding a dual handled cup with spout lid with juice and a disposable zero handled foam cup with disposable lid and straw. During an interview on 03/04/25 at 12:43 PM, Dietary Aide P reported they don't put coffee in a dual handled cup, but they could. During an interview on 03/04/25 at 12:57 PM, Dietary Manager H reported Resident #179 was supposed to get the dual handled cup for all beverages. Dietary Manager H confirmed coffee could be put in the dual handled cups and that the dual handled cups could handle both hot and cold liquids. Dietary Manager H confirmed certified nurse aides can see the kardex (key resident information reference) which indicated a two handled cup should be used for Resident #179 for all liquids. During an interview on 03/04/25 at 01:29 PM, Director of Therapy J reviewed Resident #179's occupational therapy notes and confirmed occupational therapy had recommended dual handled cups for liquids for ease of drinking and to get it to her (Resident #179) mouth with control. Review of the Assistance with Meals policy, revised March 2022, stated, Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as . and/or specialized cups. Review of Resident #179's Occupational Therapy note, dated 2/24/25, stated, Eating: Pt's (Patient/Resident #179) self-feed skills significantly impacted due to limited shoulder AROM (active range of motion) bilaterally (both sides). Pt (patient) requires setup assist for placing all utensils and plate within her functional reach .Pt then able to bring food to mouth, however effortful. Pt manages beverage with bilat (both hands) hands, would benefit from double handled cup for improved ease. Review of the Resident Summary Template (able to be viewed by staff to see various care needs for the resident) (also known as the CENA (Competency-Evaluated Nursing Assistant)) Template, signed 2/28/25, stated, .2 handled cup with lid. Review of Resident #179's nutrition care plan, print date 3/5/25, stated, (R179) is at nutrition risk d/t (due to) limited arm mobility with .need for adaptive equipment . Review of the dietary progress note, dated 2/28/25, stated, .Receiving mechanical soft ground diet, 2 handled cup .

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice for physician orders were followed for 1 of 8 residents (R9) reviewed for professional standards of care, resulting in the lack of following orders, and the potential for the worsening of a condition and a delay in treatment. Findings include: Review of R9's Physician Order dated 12/320/2024, revealed, Slow Fe 137 mg (45 mg iron) tablet, extended release, 1 tablet oral (by mouth/PO) .one time daily .iron deficiency . It was noted that there was no documentation of physician stating it was allowable to interchange with a stock medication. Review of R9's Medication Profile dated 12/30/2024 included Slow Fe 137 mg (45 mg iron) tablet, extended release (table extended release). Notes: Indication: Iron deficiency anemia .1 tablet PO (by mouth) .class (of medication) minerals and electrolytes-iron. During an observation, interview, and record review on 3/05/25 at 11:16 AM, Licensed Practical Nurse (LPN) R prepared medications to be administered to R9. Among the medications ordered to be administered included Slow Fe 137 mg (45 mg Iron) 1-tab whole PO. The LPN pulled 1 tab Fe 325 mg (65 mg essential iron stating, The facility's doctor allows nurses to give the stock medication. The doctor writes on the order Okay to give stock med. The LPN reviewed the order and stated, I do not see where the physician said it was okay to give the stock med but that is what the nurses have been doing. Review of facility policy Medication Orders revised November 2014, revealed, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders .a current list of orders must be maintained in the clinical record of each resident .

Based on observation, interview, and record review, the facility failed to develop and implement person-centered comprehensive care plans for 2 (Resident #7 and #17) of 15 residents reviewed for care plans, resulting in an incomplete reflection of the residents' care needs and the potential for a lack of resident-centered care planned goals and interventions. Findings include: Resident #7 Review of a Face Sheet revealed Resident #7 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) with diabetic polyneuropathy (nerve damage or malfunction of many nerves in the body). Review of a Physician Order for Resident #7 revealed, Start Date 7/28/2023 Lantus U-100 Insulin 100 unit/mL (milligram) subcutaneous (under the skin) solution 15 units Subcutaneous One Time Daily Starting 07/28/2023 Status Active (Current) Review of a Physician Order for Resident #7 revealed, Start Date 1/15/2024 insulin aspart U-100 100 unit/mL subcutaneous solution .Notes: Indication: DMII (type 2 diabetes) Sliding Scale Insulin: Insulin Units < (less than) 60 or > (greater than) 450 Notify MD (medical doctor); 151-200, 1 Units; 201-250, 2 Units; 251-300, 3 Units; 301-350, 4 Units; 351-400, 5 Units; 401-450, 6 Units .per scale Subcutaneous Three Times Daily Starting 01/15/2024 Active (Current) A review of Resident #7's current Care Plan was conducted on 1/26/24 at 10:02 AM and revealed no care planned focus, goals, or interventions related to Resident #7's insulin use. In an interview on 1/26/24 at 10:37 AM, Assistant Director of Nursing (ADON) J reported if a resident was on insulin, they should have a separate care plan specific for that medication. ADON J reviewed Resident #7's current Care Plan with this surveyor and reported there was no separate care plan for Resident #7's insulin use. ADON J reported (Minimum Data Set Registered Nurse (MDSRN) F lead the care planning process for the residents because she completed the MDS Assessments, but other disciplines contributed to care plans as well. In an interview on 1/26/24 at 1:04 PM, MDSRN F reported when a resident admitted to the facility, she opens up (starts) the basic care plans for care needs and safety (collectively known as baseline care plan) within 24-48 hours of admission and if, at that time, she can tell that the resident is on a high risk medication, she will open those care plans as well. MDSRN F reported she also tried to go through the care plans when the resident's quarterly and annual MDS assessments were completed. MDSRN F reported definitive responsibility for who reports what on the care plans has never been assigned. MDSRN F reported if a resident was prescribed insulin, they should have a care plan specific to insulin use. MDSRN F reported it was important to have a care plan specific for insulin because the resident needed to be monitored more closely because their blood sugars could become too high or too low quickly. 45410 Resident #17 Review of an Admission Record revealed Resident #17 admitted to the facility on [DATE] with pertinent diagnoses which included peripheral vascular disease and a left heel pressure ulcer. Review of a Minimum Data Set (MDS) assessment for Resident #17, with a reference date of 12/27/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #17 was cognitively intact. Review of a current Care Plan problem for Resident #17, dated 1/25/2024, revealed a pressure ulcer to left posterior ankle related to pressure from a brace. In an observation of wound care and interview on 1/25/2024 at 2:11 PM in Resident #17's room, care of Resident #17's left heel and ankle wounds was performed by the wound physician assistant. Assistant Director of Nursing (ADON) J reported Resident #17 admitted with the left heel wound, but developed the left ankle wound from a prafo (pressure relief ankle foot orthosis) boot that she was admitted with to prevent drop foot. In an interview on 1/26/2024 at 10:00 AM, ADON J reviewed Resident #17's Electronic Medical Record and reported she could not find a care plan for the care of the prafo boot Resident #17 admitted with. ADON J reported a care plan should have been developed specifically to direct the care of Resident #17's prafo boot. In an interview on 1/26/2024 at 1:57 PM, ADON J reported she further reviewed Resident #17's Electronic Medical Record and was unable to find a care plan for the prafo boot Resident #17 admitted with. ADON J reported the facility has some work to do regarding care plans and who completes these when she is not at the facility.

Based on observations, interview, and record review the facility failed to provide activities of daily living to a dependent resident, including incontinence care, removal of facial hair and nail care in 1 (Resident #15) of 13 sampled residents resulting in the potential for the reasonable person to experience feelings of embarrassment and diminished self-esteem. Findings include: Review of an Admission Record revealed Resident #15 had pertinent diagnoses which included: muscle weakness, anxiety, and dementia (loss of memory and abstract thinking). Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 10/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #15 was severely cognitively impaired. During an observation on 1/24/24 at 1:17 PM., Resident #15 was sitting in her wheelchair at a table in the dining room. Resident #15 was noted to have food debris on her face and hands, long fingernails soiled with dirt and debris, and facial hair on her upper lip and chin. During an observation on 1/24/24 at 3:14 PM., Resident #15 was laying in bed sleeping. Resident #15 was noted to have food debris on her face and hands, long fingernails soiled with dirt and debris, and facial hair on her upper lip and chin. Review of Resident #15's Care Plan revealed problems .I need staff assist for all cares .interventions .I need extensive assistance with bathing, incontinent care, and grooming .I need extensive assist with UB/LB ADLs (upper body/lower body activities of daily living) .I have an electric razor and I like to have my face clean shaven . During an observation in the resident room on 1/25/24 at 9:46 AM., Resident #15 was positioned on her back in bed with noted facial hair and long fingernails soiled with dirt and debris, fully dressed under the covers. Resident #15's pants were wet to the touch with a noted odor of urine. During an observation in the resident room on 1/25/24 at 12:31 PM., Resident #15 was positioned on her back in bed with noted facial hair and long fingernails soiled with dirt and debris, fully dressed under the covers. Resident #15's pants were wet to the touch with a noted odor of urine. During an interview on 1/25/24 at 12:35 PM., Certified Nurse Assistant (CENA) O reported that Resident #15 needed staff to provide her care. CENA O reported that Resident #15's care included her facial hair removed, nail care, and incontinent care. CENA O reported that she should obtain Resident #15's care needs from the electronic health record, Kardex. CENA O reported that Resident #15 should be checked and changed every 2 to 3 hours for incontinence and positioning. During an observation in the resident room on 1/25/24 at 1:45 PM., Resident #15 was positioned on her back in bed with noted facial hair and long fingernails soiled with dirt and debris, fully dressed under the covers. Resident #15's pants were wet to the touch with a noted odor of urine. During an interview on 1/25/24 at 2:04 PM., Licensed Practical Nurse (LPN) M reported that nail care for residents was the responsibility of all nursing staff. LPN M reported that Resident #15 was dependent on staff for her care. During an observation in the resident room and interview on 1/25/24 at 2:06 PM., LPN M was asked to observe Resident #15. LPN M reported that Resident #15 was positioned on her back in bed with noted facial hair and long fingernails soiled with dirt and debris, fully dressed under the covers, Resident #15's pants were wet to the touch with a noted odor of urine. LPN M stated I will find an aide, and exited Resident #15's room without providing any care to Resident #15. During an observation in the resident room on 1/25/24 at 2:18 PM., Resident #15 was positioned on her back in bed with noted facial hair and long fingernails soiled with dirt and debris, fully dressed under the covers. Resident #15's pants were wet to the touch with a noted odor of urine. During an observation in the resident room and interview on 1/25/24 at 2:22 PM., CENA O was asked to observe Resident #15. CENA O reported that Resident #15 was positioned on her back in bed with noted facial hair and long fingernails soiled with dirt and debris, fully dressed under the covers. Resident #15's pants were wet to the touch with a noted odor of urine. CENA O reported that Resident #15 should be checked, changed, and repositioned every 2-3 hours and that she had not provided any care to Resident #15 during the shift. CENA O reported that staff should complete nail care and remove facial hair with an electric razor for Resident #15. CENA O reported that nail care and shaving should be completed for residents on their scheduled shower days. Noted written on the white board in Resident #15's room was her shower schedule, Tuesday, and Friday. Review of Shower Sheet for Resident #15 dated 1/19/24 revealed resident was given a shower but did not have her facial hair shaved due to the shaver not charged and fingernails were not cleaned/cut. During an interview on 1/26/24 at 9:01 AM., Director of Nursing (DON) B reported that the expectation was nail care be completed during a resident's shower time and when needed. DON B reported that nail care was a standard of care and could be completed by either CENAs and/or Nurses. DON B reported that facial hair in females was to be removed daily as needed. During an observation in the resident room on 1/26/24 at 10:35 AM., Resident #15 was positioned on her back in bed, with the head of the bed elevated to about forty-five (45) degrees and leaning to the left, wearing a hospital gown with noted facial hair and long fingernails soiled with dirt and debris, and the over the bed table present over the bed and directly in front of the resident. During an observation in the resident room on 1/26/24 at 11:47 AM., Resident #15 was positioned on her back in bed, with the head of the bed elevated to about forty-five (45) degrees and leaning to the left, wearing a hospital gown with noted facial hair and long fingernails soiled with dirt and debris, and the over the bed table present over the bed and directly in front of the resident. During an observation in the resident room on 1/26/24 at 12:45 PM., Resident #15 was positioned on her back in bed, with the head of the bed elevated to about forty-five (45) degrees and leaning to the left, wearing a hospital gown with noted facial hair and long fingernails soiled with dirt and debris, and the over the bed table present over the bed and directly in front of the resident. During an observation in the resident room on 1/26/24 at 1:15 PM., Resident #15 was positioned on her back in bed, with the head of the bed elevated to about forty-five (45) degrees and leaning to the left, wearing a hospital gown with noted facial hair and long fingernails soiled with dirt and debris, and the over the bed table present over the bed and directly in front of the resident. Personal hygiene affects patients' comfort, safety, and well-being. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities . promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition.

Based on observations, interview, and record review the facility failed to provide bed mobility and incontinence care for the prevention of skin breakdown in 1 (Resident #15) of 13 sampled residents resulting in the potential for skin breakdown and/or the development of pressure ulcers. Findings include: Review of an Admission Record revealed Resident #15 had pertinent diagnoses which included: muscle weakness, anxiety, and dementia (loss of memory and abstract thinking). Review of a Minimum Data Set (MDS) assessment for Resident #15, with a reference date of 10/1/23 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #15 was severely cognitively impaired. Resident #15 is dependent on staff for bed mobility and turning. During an observation in the resident room on 1/25/24 at 9:46 AM., at 12:31 PM, at 1:45 PM, and at 2:18 PM, Resident #15 was positioned on her back in bed. Resident #15's pants were wet to the touch with a noted odor of urine. During an interview on 1/25/24 at 12:35 PM., Certified Nurse Assistant (CENA) O reported that Resident #15 needed staff to provide her care. CENA O reported that Resident #15 should be checked and changed every 2 to 3 hours for incontinence and positioning. Review of Care Plan for Resident #15 revealed problems .I need staff assist for all cares .interventions .I need extensive assistance with bathing, incontinent care, and grooming . problem . I am at risk for skin breakdown related to incontinence, impaired mobility . I will not develop any skin breakdown . encourage me to sit in my chair for meals . provide incontinent care as needed . Review of Resident #15's Braden Scale Risk Evaluation (medical evaluation used to measure a resident's risk for developing a pressure ulcer) dated 7/15/2023 revealed .not always communicate needs to be turned .occasionally moist skin requiring an extra linen changed once a day .ability to walk severely limited or nonexistent .very high risk (for skin break down) During an observation and interview on 1/25/24 at 2:06 PM., LPN M was asked to observe Resident #15. LPN M reported that Resident #15 was positioned on her back in bed. Resident #15's pants were wet to the touch with a noted odor of urine. LPN M stated I will find an aide LPN M exited Resident #15's room without providing any care. During an observation and interview on 1/25/24 at 2:22 PM., CENA O was asked to observe Resident #15. CENA O reported that Resident #15 was positioned on her back in bed with Resident #15's pants were wet to the touch with a noted odor of urine. CENA O reported that Resident #15 should be checked, changed, and repositioned every 2-3 hours and that she had not provided any care to Resident #15 during the shift. During an interview on 1/26/24 at 9:01 AM., Director of Nursing (DON) B reported that the expectation was dependent residents should be checked, changed, and repositioned every 2 hours as standard of care and could be completed by either CENAs and/or Nurses. DON B reported that Braden Assessment score should be completed every quarter. During an observation in the resident room on 1/26/24 at 10:35 AM., at 11:47 AM, at 12:45 PM., and at 1:15 PM, Resident #15 was positioned on her back in bed, the head of the bed elevated to about forty-five (45) degrees and leaning to the left, wearing a hospital gown and the over the bed table present over the bed and directly in front of the resident. During an interview on 1/26/24 at 10:45 AM., Certified Nurse Assistant (CENA) Q reported that Resident #15 needed staff to provide her care. CENA Q reported that Resident #15 should be checked and changed every 2 to 3 hours for incontinence and positioning. Personal hygiene affects patients' comfort, safety, and well-being. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities . promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744). Elsevier Health Sciences. Kindle Edition. Review of facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol with a revision date of April 2018, revealed .nursing staff will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility . Review of facility policy Prevention of Pressure Injuries with a revision date of April 2020, revealed .review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable . Prevention . Skin care . 1. Keep skin clean . 2. Clean promptly after episodes of incontinence .Mobility/repositioning .reposition all residents with or at risk of pressure injuries on an individualized scheduled .choose frequency for repositioning based on the resident's risk factors .

Based on observation, interview, and record review the facility failed to implement gait belt use for safety during a transfer in 1 (Resident #10) of 13 residents reviewed for transfer status resulting in the potential for injury during transfer. Finding include: Review of an Admission Record revealed Resident #10 had pertinent diagnoses which included: muscle weakness, Alzherimer's disease, and dementia (loss of memory and abstract thinking). Review of a Minimum Data Set (MDS) assessment for Resident #10, with a reference date of 10/9/23 revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated Resident #15 was severely cognitively impaired. Review of Care Plan for Resident #10 revealed .I need 2 people stand/pivot assist for transfers . with gait belt . I do not ambulate (walk) . During an observation in the resident room and interview on 1/24/24 at 1:31 PM., Certified Nurse Assistant (CENA) Q was prepared to transfer Resident #10 from her wheelchair into her bed alone. CENA Q placed her hand under Resident #10's arms and around her back to pick Resident #10 up to transfer her from her wheelchair to her bed. Resident #10 was yelling, and CENA Q did not complete the transfer of Resident #10 from her wheelchair to her bed. CENA Q did not place a gait belt (a safety device placed on someone to be used to assist with movement) on Resident #10 prior to transfer. There was a gait belt visualized on the bathroom door in Resident #10's room during this time. CENA Q reported she needed a second person to complete the transfer and left the room. During an observation in the resident room and interview on 1/24/24 at 1:46 PM., Certified Nurse Assistant (CENA) Q and CENA K were preparing to transfer Resident #10 from her wheelchair to her bed. CENA Q and CENA K positioned themselves on each side of Resident #10 and placed one arm under each of Resident #10's arms. CENA K and CENA Q picked up Resident #10 with one hand under Resident #10's arms and one hand holding the back of Resident #10's pants. CENA K and CENA Q did not use a gait belt to complete the transfer of Resident #10 from her wheelchair to her bed. There was a gait belt visualized on the bathroom doon in Resident #10's room during this time. During an interview on 1/25/24 at 12:08 PM., CENA Q reported that every resident transfer without a lift should be done with a gait belt. CENA Q reported that resident specific transfer information was in the Kardex (summary of care needs for specific resident). During an interview on 1/25/24 at 12:15 PM., CENA O reported that every resident transfer using one or two people should be done with a gait belt. CENA O reported that resident specific transfer information was in the Kardex. During an interview on 1/26/24 at 9:01 AM., Director of Nursing (DON) B reported that his expectation was that a gait belt be used with all transfers not using a lift. DON B reported that resident specific information about transfer status was in the Kardex. A gait belt provides a secure way to steady or guide patients who need assistance with ambulation when transferring or walking. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 25912-25913). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to clean a CPAP (continuous positive airway pressure) mask (a treatment used for sleep apnea - pressurized air is provided through a mask to prevent collapse of the airway) according to the facility policy for 1 (Resident #25) of 1 resident reviewed for respiratory care, resulting in the increased potential for respiratory infection and respiratory distress. Findings include: Resident #25 Review of an Admission Record revealed Resident #25 admitted to the facility on [DATE] with pertinent diagnoses which included left femur fracture and obstructive sleep apnea. Review of a Minimum Data Set (MDS) assessment for Resident #25, with a reference date of 1/5/2024, revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #25 was cognitively intact. Review of a current obstructive sleep apnea Care Plan intervention for Resident #25, active 1/25/2024, directed staff to clean CPAP per physician orders. Review of Resident #25's January 2024 Treatment Administration Record revealed documentation of daily cleaning of Resident #25's CPAP mask from January 1st through January 12th, but no documentation of the cleaning of the CPAP mask from January 13th through January 25th. In an observation and interview on 1/25/2024 at 10:29 AM in Resident #25's room, Resident #25's CPAP mask was observed sitting on her bedside table and not covered. Resident #25 reported her mask had not been washed at the facilily that she was aware of since her admission. In an interview on 1/26/2024 at 9:41 AM, Assistant Director of Nursing (ADON) J reported there was an order to clean Resident #25's mask from her date of admission that dropped off on 1/12/2024. ADON J reported there was no documentation that Resident #25's CPAP mask had been cleaned from January 13th through January 25th. ADON J reported CPAP masks should be cleaned daily. Review of facility policy/procedure CPAP/BiPAP Support, revised March 2015, revealed .Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses .

This citation is related to intake #MI00135955. Based on interview and record review, the facility failed to document resident concerns according to facility policy for 1 resident (Resident #182) of 13 residents reviewed for resolution of grievances, resulting in the potential for a decline in the physical, mental, and psychosocial well being of residents. Findings include: Resident #182 Review of a Face Sheet revealed Resident #182 admitted to the facility on [DATE] with pertinent diagnoses which included fractured vertebra and back pain. Review of a Minimum Data Set (MDS) assessment for Resident #182, with a reference date of 3/24/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #182 was cognitively intact. Further review of same MDS assessment revealed Resident #182 required assistance with toileting. In a telephone interview on 1/25/2024 at 4:35 PM, Resident #182 reported she was forced to use a dirtly toilet several times while at the facility and was denied a shower afterwards. Resident #182 reported she discussed her concerns with a male and female nurse. Resident #182 reported after a few days her roommate was moved to another room. Review of Resident #182's Progress Note, dated 3/21/2023 at 12:45 PM, revealed Social Worker EE documented she was contacted by a resident advocacy group regarding Resident #182's concerns and the Health Care Administrator and Director of Nursing spoke to Resident #182 about the concerns and had plans to address the concerns with staff and provide education. In an interview on 1/26/2024 at 8:54 AM, Social Worker EE reported she remembered Resident #182 had concerns after speaking to the advocacy group but she could not remember the nature of the concerns. Social Worker EE reported she communicated the concerns to the Nursing Home Administrator (NHA) and the Director of Nursing. Social Worker EE reported the concerns were not documented as a grievance. In an interview on 1/26/2024 at 9:07 AM, NHA A reviewed Resident #182's progress note documentation and reported she did not remember the nature of the resident concerns. NHA A reported Resident #182's concerns should have been documented as a grievance. NHA A reported she would review her daily notes and look for grievance documentation. In an interview on 1/26/2024 at 10:29 AM, NHA A reported she was able to review emails and determine that Resident #182 was concerned over a weekend that her roomate had explosive diarrhea causing a dirty toilet. NHA A reported the facility should have documented this concern as a grievance. NHA A reported the facility did not find a grievance related to this concern. Review of facility policy/procedure Grievances, updated 10/28/2016, revealed Residents and resident representatives have a right to voice all grievances without discrimination or reprisal . If an employee receives a verbal complaint, he/she will request that the resident or resident representative complete the grievance form and offer assistance in completing it . The completed form will be routed to the Grievance Officer for evaluation and action . The following information should be maintained in one central file in the Administration Offices . The original grievance form . Corrective measures and summary of the findings and conclusions . Any corrective actions as a result of the grievance .

Based on interview and record review, the facility failed to complete and transmit a death tracking assessment and transmit the data to CMS for 1 (Resident #6) of 13 sampled residents. Findings include: Review of a Face Sheet revealed Resident #6 was a female, originally admitted to the facility on [DATE]. Further review of said Face Sheet revealed Resident #6 expired at the facility on [DATE]. Review of a Progress Note dated [DATE] at 4:42 PM revealed, Entered resident room to notice resident has no b/p (blood pressure), no resp (respirations) and no heart rate, verified by Assistant Director of Nursing (ADON) J, Paged Dr on call and (hospice name omitted). Review of Resident #6's electronic medical record revealed no evidence that a death tracking assessment was completed for Resident #6. In an interview on [DATE] at 1:27 PM, Minimum Data Set (MDS) Coordinator, Registered Nurse) (MDSRN) F reported she was responsible for completing the MDS Assessments, including the Death in the Facility tracking assessments, at the facility. MDSRN F reviewed Resident #6's electronic medical record with this surveyor and reported that that a Death in the Facility tracking assessment had not been completed for Resident #6 but should have been since the resident expired at the facility. MDSRN F reported it got missed. According to the MDS 3.0 Resident Assessment Manual the Death in Facility Tracking Record, must be completed when the resident dies in the facility or when on LOA, must be completed within 7 days after the resident ' s death, which is recorded in item, and must be submitted within 14 days after the resident ' s death .

Based on interview and record review, the facility failed to promote resident dignity for 2 residents (Resident #13 and #184) of 4 residents reviewed for dignity, resulting in feelings of diminished self worth and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well being. Findings include: Resident #13 Review of a Face Sheet revealed Resident #13 admitted to the facility on [DATE] with pertinent diagnoses which included pulmonary embolism (blood clot in the lungs) and a urinary tract infection. Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 1/18/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #13 was cognitively intact. In an interview on 1/24/2024 at 11:53 AM, Resident #13 reported there is an aide that often fails to bring her water when she requested it. Resident #13 reported this makes her feel disrespected. In an interview on 1/25/2024 at 2:45 PM, Resident #13 reported her aide that morning came into her room that morning after breakfast, stated I'm gonna take a break, sat down in her bedside chair without asking permission, and used her cell phone for about 20 minutes. Resident #184 Review of a Face Sheet revealed Resident #184 admitted to the facility on [DATE] with pertinent diagnoses which included back pain and one side weakness following a stroke. Review of a Minimum Data Set (MDS) assessment for Resident #184, with a reference date of 1/24/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #184 was cognitively intact. Further review of same MDS assessment revealed Resident #184 required assistance with toileting. Review of a current activities of daily living Care Plan intervention for Resident #184, dated of 1/16/2024, directed staff to provide assistance with toileting as her needs indicated. In an interview on 1/25/2024 at 1:24 PM, Resident #184 reported her aide that morning answered her call light at about 9:00 AM when she needed to use the bathroom, turned her call light off, stated she had other people to take care, and left the room. Resident #184 reported the aide returned to her room about 40 minutes later to assist her but she was unable to hold her urine and had wet herself. Resident #184 reported this made her feel degraded and humiliated. Resident #184 reported this same aid used her personal cell phone in her room while whe was waiting to get off the toilet. Resident #184 reported this aide was on her phone frequently while in her room on a regular basis. In an interview on 1/25/2024 at 1:44 PM, Certified Nursing Assistant (CNA) P reported she turned Resident #184's call light off that morning and left the room to care for another resident. CNA P reported when she returned to assist Resident #184, Resident #184 had wet herself. CNA P reported staff were not permitted to use personal cell phones while working. In an interview on 1/25/24 at 1:49 PM, Licensed Practical Nurse (LPN) T reported staff were not allowed to use personal cell phones while working. LPN T reported when she saw aides using personal cell phones, she spoke to them about it not being appropriate. In an interview on 1/25/24 at 4:20 PM, Nursing Home Administrator (NHA) A reported staff were not allowed to use personal cell phones in patient care areas. Review of facility policy/procedure Employee Use of Cellular, Smart Phones and Similar Devices, revised 2/1/2024, revealed .To assure attention to work responsibilities and minimize distractions, employees are not permitted to make or receive personal calls or text messages . when on work time or in resident areas . This includes the use of personal cellular or smart phones . or similar device .

Based on interview and record review the facility failed to ensure a Pre-admission Screening/Annual Resident Review (PAS/ARR) Level I screening for a Level II OBRA evaluation (DCH-3878) was completed for a resident who remained at the facility greater than 30 days following an exempted hospital stay for 1 (Resident #1) of 15 sampled residents reviewed, resulting in the potential for the resident to not receive appropriate mental health treatment and services. Findings include: Review of a Face Sheet revealed Resident #1 was a female, originally admitted from the hospital to the facility on [DATE], with pertinent diagnoses which included: bipolar disorder unspecified, generalized anxiety disorder, and depression unspecified. A review of Resident #1's Pre-admission Screening/Annual Resident Review (PAS/ARR) Level I (Form DCH-3877) dated 8/1/23 and completed by (hospital name omitted) revealed, .Section II .1. (Yes box checked) The person has a current diagnosis of (X) Mental Illness .2. (Yes box checked) The person has received treatment for (X) Mental Illness .DISTRIBUTION: If any answer to items 1 - 6 Section II is YES, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record . A review of Resident #1's Mental Illness/Intellectual Disability/Related Condition Exemption Criteria Certification Level 2 (Form DCH-3878) dated 8/1/23 and completed by (hospital name omitted) revealed, .HOSPITAL EXEMPTED DISCHARGE: Yes, I certify that the patient under consideration: (X) 1. Is being admitted after a hospital stay, AND (X) 2. Requires nursing facility services for the condition for which he/she received hospital care (X) 3. Is likely to require less than 30 days of nursing services . In an interview on 1/25/24 at 2:36 PM, this surveyor queried Social Worker (SW) EE if Resident #1 had been referred for a Level II screening since she remained at the facility for greater than 30 days. SW EE reported realized today that she (SW EE) had not submitted the paperwork for Resident #1 to receive a Level II screening as required. SW EE reported the Level I screen (Form DCH-3877) that the hospital completed should have been submitted to the (local CMHSP name omitted) and a Level II screen requested because Resident #1 had remained at the facility beyond 30 days. SW EE reported she was the one responsible for tracking and coordinating the Level I and Level II screens for the residents. SW EE reported she had not submitted the paperwork as required, so Resident #1 did not have a Level II screening but should have had one.

This citation pertains to intake MI 034 Past non-compliance was accepted for this citation. Plan identified below. Based on observation, interview and record review the facility failed to prevent the elopement of 1 (Resident #1) of 2 residents reviewed for elopement, from a total sample of 5 residents, resulting in an Immediate Jeopardy when (Resident #1) who had been assessed as an elopement risk and wore a Roam Alert bracelet, and who eloped from the facility, unbeknownst to staff despite an elopement alarm sounding and pager notifications, allowing Resident #1 to elope from the facility on 9/5/16 at 9:22 a.m., was observed outside the facility at approximately 9:30 a.m. and was brought back into the facility at approximately 10:30 a.m. when facility staff were finally able to redirect Resident #1 back into the building. This deficient practice placed Resident #1, who was assessed as being at risk for elopement, at risk for serious harm, injury and or death from hazards outside the facility. Findings: Resident #1 was a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was severely cognitively impaired, wandered daily, was unsteady during transitions and walking, only able to stabilize with human assistance, used a walker with ambulation and needed extensive assistance from one person for ambulation, transfers, dressing, personal hygiene, bathing and toilet use. Review of an Admission Data Collection & Documentation document dated 7/6/16 did not reflect Resident #1 was at risk for elopement. Another formal Elopement Risk Assessment was not completed for Resident #1 until 9/8/16, after she successfully eloped from the facility. Review of clinical notes indicated that Resident #1 demonstrated exit seeking behaviors on 7/15/16 and a Roam Alert device was applied to her walker and checked for placement and functioning every shift starting on 7/15/16. Review of a Care Plan, undated, indicated Resident #1 Has been having exit seeking behaviors-stating that she has to get home, her mom is waiting for her, has been asking staff for the door and to be let out the door with resulting need for a WanderGuard. The goal of the Care plan was to prevent Resident #1 from leaving facility unattended. During an observation on 9/15/2016 at 9:00 a.m., the route Resident #1 may have taken outside the facility was walked in the presence of the Director of Nursing and Administrator (DON/NHA) A and the Maintenance Supervisor (MS) E. Several hazards were observed including access on the sidewalk to a parking lot, a side walk that eventually leads to a very busy 5 lane 45 mph thoroughfare, and a grassy slope that leads to a marshy area/ravine. Review of a Facility Report revealed Resident #1 was observed outside the facility at approximately 9:30 a.m. Resident #1's Roam Alert was triggered at 9:22 a.m. Resident #1 walked along the back side of the building moving north from the sidewalk to the grass. The alert system sounded but was not heard. The facility has an automated alert and call light system. The alert for the resident was sounding when triggered. Staff did not hear the alarm as they were providing care in another room. The pager alert was sounding to the Charge Nurse pager. The Charge Nurse did not have the pager on her person. During an interview on 9/15/16 at 8:35 a.m., NHA/DON A reported that there were 5 staff on duty the day the elopement occurred and it was determined that Licensed Practical Nurse (LPN) C and Certified Nursing Assistant (CNA) B did not have their pagers on their persons. Three other staff on duty on the morning of 9/5/16 were wearing pagers but did not respond to the Roam Alert page because the door that triggered the alert was not on the unit they were assigned. During a telephone interview on 9/15/16 at 4:09 p.m., LPN C reported that she had been assigned to care for Resident #1 on the day the elopement occurred. LPN C reported that one staff person had called in for the day and she was helping CNA B get residents out of bed and ready that morning. LPN C reported there was no indication Resident #1 was actively exit seeking prior to her elopement from the facility and admitted she did not hear the audible door alarm sounding and was not wearing her pager and knew she should have been. An attempt were made to contact CNA B for a statement on 9/15/16 at 12:16 p.m. and a return call was not received. Review of a Roam Alert-Call History Report dated 9/4/16-9/6/16 confirm that Resident #1 had not been attempting to elope from the facility prior to her successful attempt on 9/5/16 at 9:22 a.m. The Nursing Home Administrator/Director of Nursing A was informed on 9/15/16 at 1:15 p.m. that an Immediate Jeopardy (IJ) had been identified at F-323 which began on 9/5/16 at 9:22 a.m., due to the facilities failure to prevent the elopement of 1 resident (Resident #1) who was a known elopement risk and wore a Roam Alert bracelet and still, unbeknownst to staff, eloped from the facility despite an audible alarm sounding and pager notifications that staff did not respond to, allowing Resident #1 to elope from the facility on 9/5/16 at 9:22 a.m. This deficient practice placed Resident #1, who was assessed as being at risk for elopement at risk for serious harm, injury and or death from hazards outside the facility. On 9/21/16 the surveyor verified the following interventions had been put into place and were effective to remove the immediacy: On 9/5/16: -Resident #1 was assessed and no injury was identified. Close observation initiated. -A facility wide head count was conducted and all residents were accounted for. -Initial training regarding use of pagers for both licensed and CNA staff was completed. On 9/6/16: -Continued close observation of Resident #1. -Continued training of facility staff by Charge Nurses to CNAs regarding the recognition of residents at risk for elopement and responding to alarms. -Volume increased on door alarms to full volume. -Door code changed, out of an abundance of caution. On 9/7/16: -Close observation of Resident #1 continued. -Electrical contractors were in the facility at 7:00 a.m. to evaluate system and ensure its function. No malfunctions were identified. -Investigation findings revealed LPN C and CNA B did not have pagers on at the time Resident #1 eloped from the facility. It was determined 2 of 5 staff on duty were not wearing their pagers and 5 of 5 staff did not respond to either the audible alarm or pager notifications. -Training was completed by the Director of Facilities Management and Field Support Engineer regarding Code W (elopement response), including missing resident search kit and missing resident log. This training included the necessity for all staff to respond to roam alert pages regardless of their assignment. On 9/8/16: -Reassessment of all residents in the facility with there being no recognition of other residents at risk for wandering/elopement. On 9/21/16 the surveyor reviewed documentation, conducted interviews and made observations the preceding interventions were completed prior to the abbreviated survey. A determination of past non-compliance with the compliance date of 9/16/16, due to the external enunciators being installed on 9/16/16 to ensure that the existing door alarms could be heard throughout the facility, was approved by the State Agency as of 9/8/16.

This citation pertains to intakes MI 696 Based on observation, interview and record review the facility failed to prevent the elopement and ensure the safety of one resident (Resident #101), who had been identified as an elopement risk and who eloped from the facility on 10/02/15 at approximately 5:30 PM, unbeknownst to facility staff. Resident #101 was thought to have exited the building via the staff parking lot exit door with a group of visitors. Resident #101 was returned to the building at 5:50 PM by an Assisted Living staff member. This deficient practice places 1 other resident, who is identified to be at risk for elopement, at risk for serious harm, injury and/or death. Resident #101 Review of the Face Sheet, dated 10/01/15, reflected that Resident #101 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) test had not been completed at the time of the elopement. According to the Admission Data Collection & Documentation assessment, dated 10/01/15, Resident #101 had poor safety awareness and was assessed as a high elopement risk. On 10/14/15 at 1:35 PM an observation and interview was attempted with Resident #101 in his room. Resident #101 was sitting in the wingback chair next to his bed speaking with the Occupational Therapist. Resident #101 was not able to answer either her or my questions appropriately. He would respond with sentences not applicable to the question nor was able to stay on the topic of his sentences. Review of hospital admission History and Physical, dated 9/27/15, print date 10/01/15 at 16:12 EDT (military time for 4:12 PM) reflected On Wednesday (9/23/15), family states that patient wandered away from the house in the evening. Police ultimately found patient a few blocks from home, but patient had fallen and was complaining of pain. The hospital admission History and Physical documentation was found in Resident #101's chart at the nursing station in the facility. Resident #101's son confirmed this when interviewed via telephone on 10/15/15 at 2:15 PM, adding that the incident described by the hospital documentation had occurred between 3 and 4:00 AM and that Resident #101 had been found on on a stranger's porch. This information placed Resident #101 at even higher risk for elopement from the facility. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 10/14/15 at 9:20 AM. NHA stated that the facility only had two Departure Alert System bracelets, which were in use at the time Resident #101 was admitted , so Resident #101 was placed on a 1:1 status. The NHA stated at 6 AM on 10/02/15, the day shift nurse transitioned Resident #101 to every 15 minute checks from 1:1. Review of the 15 Minute Check log reflected the last documented 15 minute check was at 2 PM on 10/2/15. The NHA stated that the policy for the facility is to keep all new admissions on 15 minute checks for 3 days after admission. Neither the NHA nor the DON knew why the 15 minute checks had been stopped. In a telephone interview on 10/14/15 at 11:30 AM, Licensed Practical Nurse (LPN) C stated that Resident #101 was assigned to her for her tour of duty on 10/2/15. LPN C stated that she was unaware Resident #101 was assessed as a high elopement risk upon admission the day before. LPN C stated It was about 5:50 PM when the south nurse (Nurse D) asked if I had seen (Resident #101's name). They said there was an older man outside on Lake Michigan Drive (also known as M-45, a heavy traffic highway) hitchhiking. LPN C stated she had gone to look for Resident #101 in the building and somebody said they brought him back. In a telephone interview on 10/14/15 at 12:10 PM, Certified Nursing Assistant (CNA) E stated she had .never met him (Resident #101) before. CNA E stated that she had not been told Resident #101 was neither a high elopement risk nor that he was to be on every 15 minute checks. CNA E stated The missing resident procedure was not activated that night because no one knew he (Resident #101) was missing. In a telephone interview on 10/14/15 at 12:25 PM, Assisted Living Nurse F stated she was notified that .there was a man hitchhiking on the street. Assisted Living Nurse F stated she and another staff member ran out the front doors on Level 2 of the facility, but didn't' see anyone. Assisted Living Nurse F stated she then ran back inside, grabbed her car keys and jacket. Assisted Living Nurse F stated that she parked in the staff parking lot outside the doors on the first level of the facility and as she was running to her car, .I told the first floor (skilled unit) nurses that someone was hitchhiking on the street and the nurse said 'Oh shoot!' Assisted Living Nurse F stated she got her car, drove around the facility then happened to see .two cars pulled over on each side of the street (street name) with an elderly gentleman .he was standing in the street but up by the curb talking to the girls from the one car. Assisted Living Nurse F stated I seen his wrist band and that he was in room 108 so I got him in my car and brought him back. Review of the facility's Wandering Residents Health and Wellness Policy No. ADM 65, Nursing Operations, implementation date July 1, 2009, reflected under Policy Interpretation and Implementation, Implementation of Monitoring Schedule, number 6. .A monitoring schedule will be implemented to ensure resident safety. Review of the Elopements Health and Wellness Policy No. ADM 22, Nursing Operations Implementation date: July 1, 2009 did not reveal how the facility staff would be made aware of a missing resident. Under Reporting Practices Number one reflects It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. Neither the Elopements Health and Wellness Policy No. ADM 22, Nursing Operations Implementation date: July 1, 2009 nor the Wandering Residents Health and Wellness Policy No. ADM 65 Nursing Operations Implementation Date: July 1, 2009 outlined a guideline for the notification of the facility staff of a missing resident. During an interview conducted with the NHA on 10/15/15 at approximately 4:00 PM, the NHA stated that prior to Resident #101's elopement, the staff would have been notified by one staff member verbally informing another. It is unclear which route Resident #101 had taken the evening he eloped from the facility. One purported route placed him on Lake Michigan Drive NW (M-45) and a second route placed him along Thornridge Drive adjacent to the facility. Calls received by the facility from anonymous motorists were unclear as to which road/street Resident #101 traversed to end up in the street in front of the house where he was located by Assisted Living Nurse F. Either route was approximately 2 city blocks long as estimated on 10/14/15 at approximately 10:15 AM when the NHA, DON and this surveyor walked the Thornridge Drive route. The home in front of which Resident #101 was found was observed to be less than 1/8th of a city block from Lake Michigan Drive NW (M-45). On 10/15/15 at 2:50 PM, an observation was made of Resident #101 ambulating in the hallway without assistance. His gait was observed as moderately unsteady. When staff observed Resident #101 ambulating without assistance they tried to redirect him with his walker. Resident #101 refused. Resident #101 came to the nursing station and began speaking with this surveyor. Resident #101's conversation was disjointed and jumped from topic to topic. Staff attempted to redirect Resident #101 to sit down while talking as he was not steady standing, Resident #101 adamantly refused. On 10/15/15 at 12:02 PM, the Nursing Home Administrator (NHA) was notified of Immediate Jeopardy that began on 10/02/15 at 5:30 PM and was identified on 10/15/15 due to the facility's failure to supervise and monitor Resident #101 when he eloped from the facility. A written plan of removal was requested at that time. On 10/15/15 at 4:00 PM the surveyor verified the following: -Resident #101 had a reassessment for elopement risk and the medical record updated based on current assessment. -Resident #101's Wandering Alert Device transmitter was placed as ordered by the physician and was functional. -On 10/02/15 all residents were reassessed for elopement risk and one other resident was identified as requiring a Wandering Alert Device. -The Wandering Alert Device on the additional resident identified as high elopement risk was correctly placed and functional. - On 10/02/15 at 10:30 PM education was initiated for the facility staff education regarding completion of Missing Resident Action Plan and testing and documenting the Wandering Alert Device functionality and placement. No staff member will be allowed to work past 10/02/15 without receiving the education. -Four Wandering Alert Devices were present and ready for use in the facility including two Wandering Alert Device testing units as of 10/15/15. -The facility will forward racking and trending of audits to the NHA for presentation at facility QAPI at least monthly for review and further recommendations. -On 10/02/15, the facility developed and began educating facility staff on how to respond once a missing resident is suspected. On 10/15/15 the facility submitted the following past non-compliance packet which was accepted. Description of Occurrence (why and how did it happen): AP was observed on sidewalk in front of Covenant Faith & Hope houses without signing out of center or notifying staff. Plan of Correction: In-depth analysis of how the event occurred. Patient (AP) was admitted to the center for short term rehabilitation stay. Upon admission, was assessed to be high risk for wandering and 1:1 initiated throughout the evening. AP was transitioned to every 15 minute checks. AP was visiting with son by the door, but had gone into the dining room for meals. Nursing staff were in the process of assessing another patient for wandering risk and use of alerting wander device when notified by the AL nurse of a potential elopement. AP was observed by staff and directed back to the center. One on one initiated, resident assessment completed without any changes to skin, pain or function. How facility identified resident(s) affected and residents with potential to be affected by the same practice. All residents were reassessed to determine wander risk, with only one other individual identified at risk. Corrective action taken for resident affected. · Assessed upon return to center - no changes noted in skin, pain, or ADL function. 1:1 placed with individual, and reassessed in the morning for wander risk. Wandering alert device placed on resident. Activity and social services assessments completed, care plans updated. · Social work visits and continues with high family involvement/visits · Offered phone calls to wife, but AP declining at this time · AP added to High Risk for Wandering binder · Care conference with family on discharge planning and community re-entry support Measures or systemic changes made to ensure that practice will not occur and affect others. · Wander assessments and intervention options · Wander alert devices stock. · Visitor education on door safety · Door Code cards to communicate changes in codes non-verbally · Resident pictures uploads into computer · Missing Resident policy review and drills practiced · Tips for managing behaviors of residents with dementia cheat sheet · Activity programming and supplies for staff led behavioral interventions Center risk assessment completed - o Door codes changed, o Alarming door alerts placed on doors without wander guard o Wander door guards in place and functioning o Window guards to prevent windows opening as an exit o Patio gate reviewed and locked for additional security Education o Tips for managing behaviors of residents with dementia o Missing resident plan o Completed wandering risk assessments with intervention o Identifying individuals at risk for wandering o Door safety and code safety o Use of alarming devices, checking alarm device function, and documenting place and functioning. All staff was educated prior to the start of their shift, and by Monday 10/5/15 only PRN staff and one staff member on vacation were remaining to be trained. All nursing staff, including all PRN, was educated by 10/8/15. How facility monitors its corrective actions to ensure practice was corrected and will not recur. The Director of Nursing (DON) or designee is responsible for maintaining ongoing compliance. The DON or designee will monitor completion of audits of facilities maintenance weekly door checks and the nursing staff daily checks of door function and alert. Further the DON or designee will ensure all residents are reviewed for wandering risk upon admission, with placement and function of wander alert devices documented in the TAR daily. DON or designee to complete daily audits for the first month to ensure ongoing compliance is maintained. Results to be reviewed at QAA for determination of next steps to maintain compliance. Date of completion of plan of correction. October 8, 2015 The Immediate Jeopardy was removed on 10/15/15, this surveyor verified that the facility had corrected the deficient practice as of 10/08/15 and had sustained compliance as of 10/15/15.

This citation pertains to MI 423. Based on observation, interview and record review the facility failed to transfer 1 of 3 residents reviewed for transfers (#301) from a total sample of 3 residents with the appropriate mechanical lift resulting in Resident #301 developing acute back and shoulder pain requiring emergency treatment and an increase in pain medication. Findings include: Based on the Minimum Data Set Assessments ((MDS) dated [DATE] and 12/31/14, Resident #301 was an alert and oriented [AGE] year old female whose [DIAGNOSES REDACTED]. Resident #301 was readmitted to the facility on [DATE] after a hospital stay. Based on the above MDS Resident #301 had a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated the resident was independent in decision making and her memory was intact. Based on the above MDS Resident #301 was totally dependent on two or more staff for transfers and did not ambulate. On 2/3/15 the Electronic Medical Record (EMR) Vital Signs section reflected Resident #301 weighed 291 pounds. On 2/3/15 at 4:03 PM Family Member "A" was interviewed by telephone. Family "A" stated that on 12/25/14 at around 2:00 PM Resident #301 asked two CNAs (Certified Nurse Aides) to transfer her from the chair to the bed. Family "A" stated the two CNAs used the sit to stand mechanical lift (a lift used when a resident can bear weight on their legs and where the resident has their feet on a platform with a strap around the calf area and a sling secured around the waist/lower chest area which is attached to the machine and raises the resident to a standing position). Family "A" stated Resident #301 told the CNAs twice that the chest sling was 'not right' and Family "A" stated they could see the sling was not tight enough but the CNAs 'did not listen'. Family "A" stated that while Resident #301 was being lifted to a standing position the chest sling looked loose and Resident #301's back was arched and she was leaning backward (not standing up straight). Family "A" stated Resident #301 told the CNAs to stop three times during the transfer but they did not stop. Family "A" stated that when Resident #301 was positioned over the bed she was lowered to sitting position on the bed and one CNA took her shoulders and one CNA took her feet and "threw" her into bed and left the room. Family "A" stated Resident #301 then asked if they had heard her back crack. Family "A" stated they had not heard anything except Resident #301 crying out in pain. Family "A" stated they talked the facility into sending Resident #301 to the emergency room for evaluation and treatment. Family "A" stated Resident #301 received 4 shots in the upper back around the shoulders and had X-rays done. Family "A" stated the emergency room Doctor told them there was a lot of muscle spasm in the back and legs. Family "A" stated that after Resident #301 returned to the facility the low back pain continued and now Resident #310 can't move her legs or move her toes. Family "A" stated they had not seen the sit to stand lift used for Resident #301 before or after 12/25/14 and that the facility was using the Hoyer lift (a mechanical lift which has the whole body in a sling and transfers a resident in a sitting position with no standing required). Family "A" stated that after the 12/25/14 sit to stand transfer both the family member and Resident #301 discussed it with a therapy staff member who Family "A" declined to identify. Family "A" stated the Physical Therapy (PT) staff stated the sit to stand lift was to be used by the therapy staff only and not by the floor staff. Family "A" stated they did not report the incident to anyone except the PT staff member. On 2/4/15 at 8:45 AM Resident #301 was interviewed in her room with Family "A" present. Resident #301 stated that on 12/25/14 around 7:00 PM she requested to be transferred from the chair to the bed as she had been up most of the day, Resident #301 stated the two aides got the sit to stand lift and put the belt around her waist but it was not tight enough, then when they lifted her up the belt slipped up toward her shoulders and she heard a crack and felt sharp pain in her mid back just below the shoulders. Resident #301 stated she told the CNAs to stop at least three times but the did not. Resident #301 stated that while she was in the lift she was not putting any weight on her legs. Resident #301 stated the CNAs "threw me in bed and left" without repositioning her. Resident #301 stated she was in excruciating pain throughout her whole back and the pain pills did not help so she talked her husband into to taking her to the hospital where she got four shots for pain in the arms (Family "A" corrected her to say the shots were in the back up by the shoulders) and had X-rays which revealed no fractures. Resident #301 stated she was still in pain on return to the facility later that night and has remained "sore" with pain in her whole spine and shoulders. Resident #301 stated the 12/25/14 transfer was the only time the floor staff had used the sit to stand lift during her current stay at the facility. Resident #301 stated she had used the sit to stand lift in therapy before the 12/25/14 transfer and the therapist had told her the the sit to stand lift was to be used only in therapy. Resident #301 stated that when she told Physical Therapy Assistant (PTA) "B" what had happened PTA "B" was "mad" and said only therapy was to use the sit to stand lift with Resident #301. Resident #301 was not able to recall when she discussed the incident with PTA "B". Resident #301 stated one of the CNAs was CNA "C" but she could not recall who the second CNA was. The nursing notes by Registered Nurse "G", dated 12/25/14 at 4:08 PM, reflected "...she (Resident #301) was transferred to her bed and was able to stand in order to facilitate the transfer. She stated she heard her back 'click' and was in intense pain and asked to go to the hospital because as she said 'You do not have anything strong enough to touch this pain here.' She continued to rate her pain at a 10 out of 10..." The care plan for ADL (activities of daily living) Deficit, printed 12/24/14, reflected the intervention "T/F (transfer) with Hoyer lift ext (extensive) assist X (times) 2". The "ADL Plan of Care", dated 12/25/14 7:00 AM-12/25/14 11:01 PM) reflected "sling lift", "total dependence" and "2 or more person physical assist" under the "Transfers" section. On 2/4/15 at 4:35 PM the Director of Nursing stated the "sling lift" was the Hoyer lift. On 2/4/15 at 8:45 AM during and interview in her room Resident #301 was observed seated in her wheelchair with her left leg and foot on the leg/foot rest and her right leg on the leg rest but her foot did not reach the foot rest (approximately 4 inches between the foot and the foot rest). Resident #301 was able to move her right foot up and down and side to side an inch or two but could not move her toes or lift her leg. When Family "A" removed the left leg rest the leg and foot dangled freely and Resident #301 was unable to produce any movement. On 2/4/15 at 11:10 AM PTA "B" was interviewed privately. PTA "B" stated she worked as needed in the therapy department, mostly weekends, and had worked with Resident #301. PTA "B" stated she was told that at the hospital Resident #301's legs were weak and the sit to stand lift had been used but the Physical Therapist at the facility had prescribed the Hoyer lift for transfers on the nursing unit at the facility. PTA "B" stated she had used the sit to stand lift with Resident #301 during her therapy session on 12/24/14 to assess her standing ability. PTA "B" stated there was a CNA from the unit present and the CNA was told the sit to stand lift was for use in therapy only and to continue with the Hoyer lift on the unit. PTA "B" stated any communication to the nursing unit for treatment changes was written on a communication form and given to the unit nurse, the MDS assessment nurse and the Director of Nursing who then made changes in "AccuNurse" a computer based program where the CNAs would obtain information related to Residents' care needs and activity status. PTA "B" stated that on 12/26/14 Resident #301 waved her into the resident's room and said "guess what?" and told PTA "B" that two CNAs had transferred the resident with the sit to stand lift on 12/25/15 on the second shift. PTA "B" stated Resident #301 was unable to name the CNAs but stated she would know them if she saw them and stated one was a male and the other was female. PTA "B" stated Resident #301 told her she had not reported the incident to anyone in the facility. PTA "B" stated she told Resident #301 she should tell the nurse and also stated she (PTA "B") looked for the nurse but was unable to find the nurse. PTA "B" stated she did not see Resident #301 again until 1/15/15 at which time Resident #301 could not move her legs and had decreased sensation. PTA "B" stated that Resident #301 told her "I've lost my legs" and was scared and afraid. PTA "B" stated Resident #301 tried to move her legs that day and could not. On 2/4/15 at 11:45 AM Physical Therapist "D" was interviewed privately. PT "D" stated she had been the primary PT for Resident #301 since her admission on 12/22/14. PT "D" stated she completed a therapy evaluation for Resident #301 on 12/23/14 and at that time deemed the resident was to have a Hoyer lift for transfers and was dependent for bed mobility. PT "D" stated that on 12/23/14 during the initial evaluation Resident #301 was able to; raise her feet to fully straighten her knees while in a seated position, flex her ankles up and down and lift her knees slightly while seated. The verbal statements of PT "D" were supported by the "PT Treatment Plan", dated 12/23/14 and signed by PT "D". PT "D" stated that on 12/30/14 Resident #301's legs were noticeably weaker and she was unable to lift her knees at all, could raise her feet only half way to straighten her knees and move her ankles one-half the distance she did on 12/23/14. PT "D" stated Resident #301 gradually progressed to no movement in her legs on 1/12/15. PT "D" stated she spoke with Resident #301's physician on 12/31/14 and the physician wanted to order an MRI but Resident #301 declined related to feelings of claustrophobia. PT "D" stated the physician then wanted to schedule a CT scan with contrast dye which had to be coordinated with the dialysis physician. PT "D" stated Resident #301 had told her the floor staff used the sit to stand lift to transfer her but did not recall when except that other therapy staff including PTA "B" already knew about the transfer. PT "D" stated she had mentioned the sit to stand transfer to her supervisor, Certified Occupational Therapy Assistant (COTA) and Rehabilitation Director "E". PT "D" provided a copy of the communication form from therapy to nursing, dated 12/23/14, which read "transfer with Hoyer lift and 2 person assist" and was signed by PT "D". On 2/4/15 at 3:25 PM CNA "F" was interviewed by telephone and stated she was one of the two CNAs who had transferred Resident #301 with the sit to stand lift on 12/25/14 on the 2:00 PM-10:30 PM shift. CNA "F" stated that when Resident #301 requested to be put in bed from her wheelchair CNA "F" initially took the Hoyer lift into the room but the resident stated she wanted to use the sit to stand lift not the Hoyer lift. CNA "F" stated she got the sit to stand lift and with another CNA, who's name or sex she could not recall, transferred Resident #301 to the bed. CNA stated the chest sling was buckled securely and when Resident #301 was lifted about half way up the resident began screaming. CNA "F" stated Resident #301 was then seated on the side of the bed, removed from the lift sling and laid down in the bed without further repositioning and CNA "F" went to get the nurse. CNA "F" could not recall who the nurse was. CNA "F" stated the chest sling was secure and did not move during the transfer. CNA "F" stated she did not hear any (cracking) noises during the transfer. CNA "F" stated Resident #301 had been a Hoyer lift transfer prior to 12/25/14 and CNA "F" had been told on 12/25/14 by other CNAs that the resident wasn't a Hoyer transfer any longer. When asked how she would know the transfer status of a resident CNA "F" stated she would ask other CNAs, the nurse or therapy staff. CNA stated she did not know how to access the "AccuNurse" computer program to see the "ADL Plan of Care" used by the CNAs when giving care to residents. In addition, CNA "F" stated she had not been trained to use any of the lifts at the facility. As of 5:20 PM on 2/4/15 the Administrator could not provide any documentation of CNA orientation or a skills evaluation for CNA "F" who was hired on 10/6/14. The hospital "Final Report", dated 12/19/14, reflected Resident #301 was having "a lot of back pain" and was likely causing depression. The facility physician History and Physicals, dated 11/27/14 and 12/24/14, reflected "chronic pain" as a diagnosis. The physician orders [REDACTED]. After the emergency room visit the pain medication was increased to Hydrocodone 37.5 mg/Acetaminophen 325 mg, 2 tablets every 6 hours for 3 days and Flexeril (a muscle relaxant) 10 mg three times daily as needed for 3 days for muscle spasms. On 12/29/14 the Hydrocodone 37.5 mg/acetaminophen 325 mg, was decreased to every 12 hours and on 1/22/15 Robaxin (a muscle relaxant) 750 mg twice daily and 1 dose as needed at at lunch time was added. RN "G" and CNA "C" were not available for interview during the survey. ( )

This citation pertains to Intake Number MI 282. Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being in 1 of 3 sampled residents (Resident #102), from a total of 6 sampled residents, resulting in an Immediate Jeopardy when Resident #102, who had a history of [REDACTED]. This deficient practice placed 7 residents, identified with swallowing difficulties, at risk for serious harm, injury, and/or death. Findings include: Review of the Medical Record revealed Resident #102 was admitted to the facility on [DATE]. Per the admission "physician's orders [REDACTED]. The Minimum Data Set (MDS), observation end date of [DATE], revealed, Resident #102 had "Active [DIAGNOSES REDACTED]. Per the MDS, Section K - Swallowing/Nutritional Status, completed and signed by Certified Dietary Manager (CDM) #11 on [DATE], Resident #102 had no "Signs and symptoms of possible swallowing disorder". Per the "Speech Therapy" policy and procedure, dated [DATE], "The purpose of this procedure is to identify, assess and treat speech and language problems including swallowing disorders. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident...d) Dysphagia - difficulty in chewing or swallowing..." Review of the Aspiration Care Plan revealed Resident #102 had no interventions in place to prevent aspiration until [DATE] (24 days after his first admission to the facility and 2 days after his readmission from a hospitalization after a choking event on [DATE]). Per the facility's "Prevention of Aspiration Policy", dated ,[DATE], "Purpose: Prevention of aspiration and compensate for swallowing difficulties. Policy: The dietary and nursing department will be responsible for proper altered diet. Procedure: 1. Monitor for signs and symptoms of aspiration: Shortness of Breath, coughing, Nasal drainage, wet gurgling voice after swallow, respiratory changes; 2. If found to have signs and symptoms of aspiration charge nurse can down grade diet x 3 days, then notify Med (physician or physician assistant) Speech Therapy, and Dietary...". The "Facility Incident Report - 24 Hours", received date [DATE], indicated that on [DATE] at "approximately 12:36 PM, Resident #102 had a "Choking issue - CPR administered. Resident is at hospital". Per the "Facility Incident Report - 5 Working Days", received date [DATE], "on Wednesday, [DATE], (Resident #102) was eating his ordered no-added-salt diet in the dining room...At approximately 12:36 PM, (Licensed Practical Nurse (LPN) #3) heard a female voice call Nurse, Nurse...observed (Resident #102) appeared to be trying to cough and/or breathe but she noted no air exchange. (LPN #3) ...began to administer the [MEDICATION NAME] Maneuver which successfully expelled a meat debris [MEDICATION NAME](LPN #3) then noted (Resident #102) to slump over, visibly drooling with no visible respirations. (LPN #3) immediately called for assistance and quickly removed (Resident #102) from the dining room to his own room ...When efforts to arouse (Resident #102) were not successful and pulse was lost, his code status was determined and CPR (cardiopulmonary resuscitation) with rescue breathing was begun with intermittent suctioning during the resuscitation...prior to arrival of EMS (Emergency Medical Service), after only ,[DATE] minutes of resuscitation, pulse and respirations were re-established...EMS...transferred (Resident #102) to the hospital". In an interview on [DATE] at 4:00 PM, Registered Nurse (RN) #18 stated he was working the second shift on [DATE] and did "part of the admission orders Aspiration precautions" and the diet order of "NAS (no added salt)/Gluten free (no wheat products)". RN #18 stated "Aspiration precautions" were placed on the "Treatment Administration Record" and explained that "Aspiration precautions come up for us (licensed nurses) every shift. It is our jobs to let the nurse aides know that". When asked if he had instructed the nurse aides that Resident #102 was on "Aspiration precautions", RN #18 stated, "No, I can't remember doing that". In an interview on [DATE] at 3:30 PM, Licensed Practical Nurse (LPN) #10 confirmed she had transcribed some of the information sent from the hospital on the Admission order form. LPN #10 stated, "We read orders to our doc (physician) over the phone. I didn't write on here (the Admission order form) who I called". In an interview on [DATE] at 9:38 AM, Physician Assistant (PA) #31 told this Surveyor she, "doesn't sign verbal (Admission) orders", and that she was present at the facility on [DATE]. PA #31 stated, "I initialed the med's (transfer medication list) so I looked at the admission paperwork...but I don't sign them. I don't see it noted, by the nurse, that I approved them (admission orders [REDACTED] In an interview on [DATE] at 2:40 PM, Certified Nurse Aide (CNA) #14 stated that prior to [DATE], while eating "sometimes (Resident #102) coughs". CNA #14 stated she did not report Resident #102's coughing while eating to the licensed nurses. In an interview on [DATE] at 11:43, CNA #12 stated, "Before (the choking incident on [DATE]), I always reminded him (Resident #102) to eat slow because he had a hard time swallowing and he like to eat fast". In an interview on [DATE] at 10:50 AM, LPN #10 stated, "(Resident #102) always eats too fast, coughs. He's one to start coughing and keep eating." In an interview on [DATE] at 2:55 PM, Speech-Language Pathology Therapist (SLP) #15 stated, "When (Resident #102's) chart came in, I saw the (Admission) orders sheet, looked at the diagnoses, and the diet order...The wife (#13) was saying he was having trouble with swallowing bread. I did not see Aspiration Precautions (written on the admission orders . In an interview on [DATE] at 11:54 AM, Resident #102's wife #13 stated, "It might be a good thing for them (the facility) to check (for swallowing difficulties) when elderly people are admitted ". Regarding the incident on [DATE], wife #13 stated, "It was such a scare. I saw no one (no staff in the dining room). I got up and hit him on the back. I'm calling for help, threw my arms up in the air yelling help, help. No one came. Elderly people were in there (the dining room) eating. No one came to my help. I ran down the hall to find someone. I yelled my head off. I was scared to death! No one was at the (South) nurses' desk, behind the (structural) post (adjacent to the Dining Room); that's the first place I looked. No one near the nurses' desk...I went out there (pointed to the North section of the Dining Room). I went to the entrance of the hall before I saw someone; a female, possibly a nurse aide, come out of a room. I was so glad to see someone. She came, took one look at him, and ran for help... I yelled for help for ,[DATE] minutes! He was feeding himself. I was cutting up his chicken. It was probably the chicken he choked on. He is a fast eater". Wife #13 stated she was told to sit in a chair in the hallway outside of Resident #102's room while the facility staff assisted Resident #102. Wife #13 stated, "When they came out, someone said (one staff to another) 'You just saved that man's life'." In a telephone interview on [DATE] at 9:15 AM, this Surveyor asked Medical Director #30 if staff should have initiated CPR (Cardiopulmonary Resuscitation) in the dining room rather than transport him to his room first, Medical Director #30 stated, "Yes, they should have". On [DATE] at 9:07 AM, Resident #102 was observed sitting in his room, in a wheelchair with an oxygen tank attached to the back, dressed in street clothes. As Resident #102 spoke, it appeared he was missing teeth. He was unable to recall the choking incident on [DATE] and resulting hospitalization . Resident #102 and was disoriented to time and place. On [DATE] at 12:00 PM, Resident #102 was observed sitting at a Dining Room table. Wife #13 was sitting on his right side and Certified Nurse Aide (CNA) #18 was sitting on his left side, watching Resident #102 and Wife #13. Wife #13 handed a cup of liquid to Resident #102 and he met her hand half way, put the cup to his lips, took a small sip, and returned the cup to his wife's hand. On [DATE] at 9:45 AM, Administrator #1 was notified of the Immediate Jeopardy that was identified on [DATE] at 4:30 PM and began on [DATE], at approximately 12:35 PM, when Resident #102, who had a history of [REDACTED]. On [DATE] the Surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy. 1. On [DATE], Resident #102's Care Plans were reviewed and updated as necessary by the Interdisciplinary Team which including Speech-Language Therapist, Nursing, Social work, and Dietary, and includes instructions for nursing staff to offer frequent drinks of nectar thickened water throughout each shift. 2. On [DATE], the Speech-Language Therapies evaluated Resident #102 and initiated treatment. On [DATE], Resident #102 began treatment from Speech-Language Therapy with goal to increase his oral and pharyngeal strength. 3. On [DATE] Speech-Language Therapy evaluated and instructed Resident #102's wife on how to feed Resident #102 and instructed on how to give nectar thickened water in the presence of staff only and successfully completed return demonstration. 4. On [DATE], Speech-Language Therapy and Dietary re-evaluated and verified that the diet order for Resident #102 was for nectar thickened liquids and pureed diet. Resident #102's bedside water container now includes nectar thickened water, and is kept out of Resident #102's reach. 5. On [DATE], specific written feeding instructions, for Resident #102, were placed on the table where Resident #102 consumes meals, intended for staff and Wife #13's use. The instructions included for Resident #102 to have 1:1 supervision by staff unless his wife is with him, at which time a CNA is to be no more than 5 feet away. 6. On [DATE], Resident #102's feeding instructions were added to AccuNurse, an automated, verbally activated Care Plan. 7. On [DATE], the Speech-Language Therapist, Nursing and dietary assessed and identified 8 of the total 33 residents that were at risk for for aspiration and individualized instruction cards were placed at their tables. 8. On [DATE], the Speech-Language Therapist updated Care Plans on all 8 residents identified at risk for aspiration. 9. On [DATE], the Dietary Manager #11 and RN #4 reviewed all 33 residents' charts for order inconsistencies with attention to Dysphagia, Aspiration precautions, and diet orders. 10. As of [DATE], the facility's "Prevention of Aspiration Policy" was updated to include "Prevention of Obstructed Airway Techniques" (Aspiration precautions): Cut food into small pieces, chew food slowly and thoroughly, especially if resident is wearing dentures, avoid laughing and talking during chewing and swallowing, avoid excessive intake of alcohol before and during meals, feed the resident slowly, do not give liquids when mouth is full of food, give the proper diet as ordered by the physician, provide thickened liquids according to physician orders. 11. On [DATE], 53 of the total 71 employees had received the in-service on the following information: a). Emergency procedures at mealtimes (AccuNurse paging system will continue to be utilized). Emergency Procedures at Mealtime include the [MEDICATION NAME] maneuver, the resident will not be removed from the dining room, proper feeding techniques, assistance at mealtimes, and prevention of Obstructed Airway Techniques. b). Residents at risk for choking will be placed on the "Residents at Risk for choking" list that will be maintained by the charge nurse and available to all nursing and dietary staff at mealtimes. Nursing is to monitor residents for proper positioning, correct diet, and signs and symptoms of swallowing difficulties/aspiration throughout meals. c). Speech Therapy in regards to swallowing which included that any resident admitted with a [DIAGNOSES REDACTED]. d). Use of suction machine, and new Admission Order Policy and Procedure for transcribing admission orders [REDACTED] e). Residents assessed as at risk for aspiration will dine in the corner where the North and South Dining Rooms meet to increase visibility by licensed staff positioned there during meals. f). As of [DATE], no food or fluids are to be served to any resident until a licensed nurse is present in the Dining Room. There Will always be a licensed nurse in the dining area while any resident is still consuming food. CNA's and Dietary staff will also be in the dining room. At minimum, there will always be a staff member in the dining area who is CPR and [MEDICATION NAME] maneuver certified. g). Nurse aides will report any issues or concerns to the licensed nurse present in the dining room/the licensed nurse will document the findings and notify the physician. The remaining 18 staff members will be in-serviced by the Director of Nursing prior to working any further shift. Although Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity of no actual harm but potential for more than minimal harm, due to all staff had not received the in-service and sustained compliance had not been verified by the State agency. ( )