Every finding on record at Isabella County Medical Care Facility

Based on interview and record review, the facility failed to educate and provide informed consent of psychotropic medications for 3 residents (R1, R69, and R70) out of 5 reviewed. Findings include: R69 Review of an admission Record revealed R69 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and depression. Review of R69's Physician's Orders active 3/18/2026 revealed R69 was taking fluoxetine HCI (used to treat depression, anxiety, and several other mental health conditions) and bupropion HCI (used to treat depression and other mental health conditions). Further review of the medical record revealed no consents on file to verify whether the facility had reviewed the risks and benefits of these medications with the resident and/or resident representative. Email correspondence received from the Nursing Home Administrator on 3/18/2026 at 10:07 AM confirmed the facility did not have a consent on file for R69's fluoxetine HCI or bupropion HCI. R70 Review of an admission Record revealed R70 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and depression. Review of R70's Physician's Orders active 3/18/2026 revealed R70 was taking Ativan (used to treat anxiety) and sertraline HCI (used to treat depression, anxiety and other mental health conditions). Further review of the medical record revealed no consents on file to verify whether the facility had reviewed the risks and benefits of these medications with the resident and/or resident representative. Email correspondence received from the Director of Nursing on 3/18/2026 at 10:40 AM confirmed the facility did not have a consent on file for R70's Ativan or sertraline HCI. R1 Review of an admission Record revealed R1 admitted to the facility on [DATE] with pertinent diagnosis which included dementia, major depressive disorder, agitation, and restlessness. Review of an Order Summary on 3/17/2026 revealed R1 had active orders for hydroxyzine HCL (medication used for anxiety and tension), 10 milligrams (mg) by mouth at bedtime for agitation and restlessness. Further review of an Order Summary revealed an active order for Escitalopram Oxalate (medication used to treat depression), 10 mg by mouth one time a day for depression. During an interview on 03/17/2026 at 1:39 PM, the Director of Nursing (DON) stated that informed consents or risk versus benefits are only completed for residents that are on anti-psychotropic medications. The DON stated the facility had not completed risk versus benefits or offered informed consent for psychotropic medications (anti-depressants, anti-anxiety, hypnotics, and anti-psychotics) besides anti-psychotics. During an interview on 03/17/2026 at 2:16 PM, Social Services Coordinator (SSC) H stated that paper consents are obtained for residents with active orders for antipsychotics. SSC H stated that an informed consent is typically completed in a progress note in the resident Electronic Medical Record (EMR). SSC H could not provide any documentation that collaboration was completed with R1 regarding the use of psychotropic medications. Review of facility policy Use of Psychotropic Medication dated 05/22 revealed .The indications for initiating, withdrawing, or withholding medications(s), as well as the use of non-pharmacological approaches, will be determined by. assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. the attending physician, or other prescribing clinician, will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team .

Based on interview and record review, the facility failed to ensure that monthly pharmacy reviews were conducted for 5 of 5 residents (R3, R16, R28, R46, & R66) reviewed for monthly pharmacy medication regimen reviews, resulting in residents medications not being reviewed and the potential for an adverse outcome from medications and/or lack of assessment and monitoring of medications. Findings include: A review of the facility's Drug/Medication Regiment Review for All Residents policy, last revised 8/22, revealed the Medication Regimen Review (MRR) is a thorough evaluation of the medication regiment of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) and potential risks associated with medication. The policy further revealed the medication regimen of each resident must be reviewed by a licensed pharmacist at least once a month. R3 A review of R3's Admission Record, dated 1/17/25, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Admission Record revealed multiple diagnoses that included severe dementia with psychotic disturbance, late onset Alzheimer's Disease, visual hallucinations, and atrial fibrillation (an irregular rapid heart rate that commonly causes poor blood flow). A review of R3's medical records (electronic and paper), dated 11/16/23 to 1/16/25, failed to reveal monthly pharmacy medication regimen reviews for December 2023, March 2024, June 2024, October 2024, and November 2024. During an interview on 01/16/25 at 02:50 PM, the Director of Nursing (DON) stated they have not had a change in pharmacy or issues with their pharmacy. She stated she did not know why R3's pharmacy reviews were missing and/or not conducted for December 2023, March 2024, June 2024, October 2024, and November 2024. She stated she would see if she can locate the documentation. The surveyor requested copies of any documentation that the DON can locate, if available. The DON verbalized understanding and stated she would get the documentation to the surveyor as soon as possible, if she can locate anything. During an interview on 01/16/25 at 03:35 PM, the DON stated she could not find any of R3's missing pharmacy reviews. She stated she also called the pharmacy and they do not have them. The DON it appears that the pharmacist did not conduct a monthly medication regiment review for R3 during the months of December 2023, March 2024, June 2024, October 2024, and November 2024. The DON further stated they have changed pharmacists and the new one is more organized. R16 A review of R16's Admission Record, dated 1/16/25, revealed R16 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R16's Admission Record revealed multiple diagnoses that included diabetes mellitus type 2, seizures, depression, and anxiety. A review of R16 medical records (electronic and paper), dated 2/1/24 to 1/16/25, failed to reveal monthly pharmacy medication regimen reviews for March 2024, June 2024, October 2024, and November 2024. During an interview on 01/16/25 at 02:50 PM, the DON stated they have not had a change in pharmacy or issues with their pharmacy. She stated she did not know why R16's pharmacy reviews were missing and/or not conducted for March 2024, June 2024, October 2024, and November 2024. She stated she would see if she can locate the documentation. The surveyor requested copies of any documentation that the DON can locate, if available. The DON verbalized understanding and stated she would get the documentation to the surveyor as soon as possible, if she can locate anything. During an interview on 01/16/25 at 03:35 PM, the DON stated she could not find any of R16's missing pharmacy reviews. She stated she also called the pharmacy and they do not have them. The DON it appears that the pharmacist did not conducted monthly medication regiment review for R16 during the months of March 2024, June 2024, October 2024, and November 2024. The DON further stated they have changed pharmacists and the new one is more organized. 28101 R28 Review of R28's face sheet dated 1/17/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: dysphasia following cerebral infarction (swallowing problems after a stroke), diabetes mellitus 2, bipolar disorder, cognitive communication deficit, and muscle weakness. He was not his own responsible party. Record review for R28 revealed the monthly pharmacy reviews for March, June and November 2024 were missing. During an interview with the Director of Nursing (DON) on 1/17/25 at 9:08 AM, she confirmed that the reviews for R28 for March, June and November 2024 were missing. R46 Review of R46's face sheet dated 1/17/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included dementia, cognitive communication deficit, and post traumatic stress disorder. She was not her own responsible party. Record review for R46 revealed that the pharmacy reviews were missing for February, June and November 2024. During an interview with the Director of Nursing (DON) on 1/17/25 at 9:08 AM, she confirmed that the reviews for R46 for February, June and November 2024 were missing. R66 Review of R66's face sheet dated 1/17/25 revealed he was [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Parkinson's disease, tremor, adjustment disorder, and dementia. He was not his own responsible party. Record Review for R66 revealed the pharmacy reviews for March, June and October 2024 were missing. During an interview with the Director of Nursing (DON) on 1/17/25 at 9:08 AM, she confirmed that the reviews for R66 for March, June and October 2024 were missing. The DON said the facility was not aware the Pharmacist had not completed all the monthly reviews in 2024 until 1/16/25 when the survey team requested pharmacy reviews.

Based on interview and record review, the facility failed to follow their policies and procedures and provide documentation justifying psychotropic medication for 1 (Resident #2), out of 5 residents reviewed for psychotropic medications, resulting in the potential for unnecessary medication orders/administration. Findings include: Review of a policy titled Use of Psychotropic Medication last revised on 5/22 revealed: PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Resident #2 (R2) Review of a Face Sheet revealed R2 admitted to the facility on [DATE] and is on hospice and has a diagnosis of dementia. Review of a physician order with a start date of 9/1/23 for R2 revealed Ativan 0.5 mg (milligrams) tablet every 6 hours as needed for anxiety and dyspnea was ordered with no stop date. Review of Medical Records for R2 revealed there was no thorough documentation about medical justification by the prescribing practitioner for the ongoing use of PRN (as needed) Ativan that was ordered with no stop date. In an interview on 11/15/23 at 3:21 PM, Unit Manager I reported she is aware of the need for the practitioner to provide documentation for PRN Ativan that is ordered for longer than 14 days and was not able to find documentation in R2s chart to justify the continued order. In an interview on 11/16/23 at 10:00 AM, the Director of Nursing (DON) reported the PRN Ativan order fell through the cracks and acknowledged the appropriate documentation from the physician was missing from the medical record.

Based on observation, interview, and record review, the facility failed to store medications in safe temperature ranges for 1 medication refrigerator (1st floor) of 3 medication refrigerators reviewed, resulting in the potential for medications to become ineffective. Findings included: During a review of medications being stored in the first floor medication refrigerator on 11/15/23 at 8:31 AM, the refrigerator temperature log was reviewed with Registered Nurse (RN) A. The temperature log revealed, If the temperature deviates from 36 degrees to 46 degrees notify Infection Control and Maintenance. Temperatures were recorded once a day from January 1, 2023, to November 15, 2023. Temperatures ranged from 34 degrees to 42 degrees. The sheet recorded 16 times where the refrigerator was 34 degrees and on 5 dates there was no recorded temperature. RN A said she was not aware of the low temperatures or if anyone had been notified of the low temperatures. RN A said she was aware that the refrigerator did freeze over at times and maintenance did defrost the refrigerator. Insulin (diabetic medication), Trulicity (blood sugar regulation medication) and suppositories (medication for bowel care) where stored in the refrigerator at the time of the observation. During an interview with the Nursing Home Administrator (NHA) and Pharmacist B on the telephone on 11/15/23 at 10:15 AM the first floor medication refrigerator log was reviewed. Pharmacist B confirmed the safe storage range for all medications was 36 to 46 degrees Fahrenheit. He also confirmed it was a concern if the refrigerator was getting down to 34 degree and was having issues with intermittent freezing requiring defrosting. During an interview with the Director of Nursing (DON) on 11/16/23 at 8:53 AM, she reported she was not aware of the first floor medication temperatures dropping below the recommended temperature until yesterday. She said the maintenance staff reported they defrosted that refrigerator last July and yesterday they turned the dial down one setting and placed 2 thermometers in the refrigerator. Maintenance staff checked that refrigerator this morning at it was 38 degrees. Review of the facility provided information labeled, Food and Drug Administration regarding Insulin Storage and Switching Between Products in an Emergency revealed. According to the product labels from all three U.S. insulin manufactures, it is recommended that insulin be stored in a refrigerator at approximately 36 degrees F (Fahrenheit) to 46 degrees F. Unopened and stored in this manner, these products maintain potency until the expiration date on the package. Do not use insulin that has been frozen.

Based on observation, interview, and record review, the facility failed to maintain confidentiality of resident medical records for 8 residents (Resident #10, Resident #19, Resident #28, Resident #52, Resident #54, Resident #62, Resident #65, and Resident #117), resulting in the potential for disclosure of residents' personal and confidential information to unauthorized individuals and the potential for residents' privacy of protected health information/personally identifiable information (PHI/PII) and Health Insurance Portability and Accountability Act (HIPAA) information being violated. Findings include: During an observation on 08/17/21 at 11:30 AM, the 2 South Medication Cart computer screen was open and visible to anyone walking by the nurse's station. Resident #52's Treatment Administration Record (TAR) information (i.e. Resident # 52's name, date of birth (DOB), latest vital signs, room number, physician's name, and treatments) and Resident #52's picture were displayed and visible to anyone walking by. Staff were not visibly present in the area. During an interview on 08/17/21 at 12:45 PM, Licensed Practical Nurse (LPN) E stated the computer screen on the medication cart should be on the hide screen (clicked to a cover/screen saver page), the screen should be lowered/closed, or the computer should be logged off before she walks away from it. During an interview on 08/18/21 at 9:15 AM, Registered Nurse (RN) D stated she always double hides (clicks onto the cover/screen saver page and minimizes the screen) the computer screen on her medication cart before walking away from the cart. She stated she does not leave the computer screen open and she covers her paperwork before she walks away from the medication cart because of HIPAA. During an interview on 08/18/21 at 10:30 AM, the 2 South Medication Cart computer screen was open on top of the cart and visible to anyone walking by the nurse's station. Resident #10's, Resident #19's, Resident #28's, Resident #52's, Resident #54's, Resident #62's, Resident #65's, and Resident #117's personal health information/personally identifiable information (name, room number, and medical record number) and pictures were displayed and visible to anyone walking by. Staff were not visibly present in the area. During an interview on 08/19/21 at 09:40 AM, LPN C stated when she walks away from her medication cart, she will hide the screen so resident information cannot be viewed by someone walking by. She stated if the medication cart is behind the nurse's station, she will leave the display screen up, but the information is hidden. She also stated if the medication cart is in the hallway, she will hide the screen and then lower or close it. She stated she would never leave resident information exposed on the computer screen when she walks away from it. She stated, That would be a HIPAA violation. A review of the Centers for Disease Control and Prevention (CDC)'s web site, dated 9/14/18, revealed, The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient ' s consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA . A major goal of the Privacy Rule is to ensure that individuals ' health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public ' s health and well-being . The following types of individuals and organizations are subject to the Privacy Rule and considered covered entities: Healthcare providers: Every healthcare provider, regardless of size of practice, who electronically transmits health information in connection with certain transactions. These transactions include claims, benefit eligibility inquiries, referral authorization requests, and other transactions for which HHS has established standards under the HIPAA Transactions Rule (http://www.cdc.gov/phlp/publications/topic/hipaa.html). A review of the HIPAA Journal, 8/20/21, revealed, Under HIPAA, protected health information [PHI] is considered to be individually identifiable information relating to the past, present, or future health status of an individual that is created, collected, or transmitted, or maintained by a HIPAA-covered entity in relation to the provision of healthcare, payment for healthcare services, or use in healthcare operations (PHI healthcare business uses). Health information such as diagnoses, treatment information, medical test results, and prescription information are considered protected health information under HIPAA, as are national identification numbers and demographic information such as birth dates, gender, ethnicity, and contact and emergency contact information. PHI relates to physical records, while ePHI is any PHI that is created, stored, transmitted, or received electronically (https://www.hipaajournal.com/what-is-considered-protected-health-information-under-hipaa/). A review of the HIPAA Journal, dated 8/20/21, revealed, PHI is any health information that can be tied to an individual, which under HIPAA means protected health information includes one or more of the following 18 identifiers. If these identifiers are removed the information is considered de-identified protected health information, which is not subject to the restrictions of the HIPAA Privacy Rule. 1. Names (Full or last name and initial), 2. All geographical identifiers smaller than a state . 3. Dates (other than year) directly related to an individual . 8. Medical record numbers, 17. Full face photographic images and any comparable images, and 18. Any other unique identifying number, characteristic, or code except the unique code assigned by the investigator to code the data (https://www.hipaajournal.com/what-is-considered-protected-health-information-under-hipaa/). A review of the facility's Medication Administration policy and procedure, revised 11/19, revealed, Procedure . 6. Close or minimize eMAR (electronic medical record) when leaving vicinity, to protect resident information.

Based on observation, interview, and record review, the facility failed to properly store and label medications for 1 of 3 medication carts reviewed (2 South Medication Cart), resulting in the potential for misappropriation and residents receiving the wrong medications. Findings include: During an observation on 8/17/21 at 12:25 PM, the 2 South Medication Cart, including the narcotics drawer, was observed to be unlocked. Staff were not visibly present in the area. During an interview at the 2 South Medication Cart on 08/17/21 at 12:30 PM, Licensed Practical Nurse (LPN) E stated, Oh. The cart is unlocked. She stated that the top drawer of the medication cart was the narcotics drawer, contains narcotics (such as [MEDICATION(S)] (Roxanol), [MEDICATION(S)], and ativan), and verified that it was unlocked and had been left unattended. During an observation on 8/17/21 at 12:30 PM, the 2 South Medication Cart was inspected with LPN E. The following interview and observations were made: - 1 bottle of dorzolamide 2.23% ophthalmic solution (an eye drop medication for glaucoma) was observed in a box labeled with Resident #117's name. However, the individual bottle was not labeled with Resident #117's name. Therefore, if the bottle became separated from the box, the nurse would not know which resident the bottle belonged to. - 1 bottle [MEDICATION(S)] (Xalatan) 0.0005% ophthalmic solution (an eye drop medication for glaucoma) was observed in a box labeled with Resident #117's name. However, the individual bottle was not labeled with Resident #117's name. Therefore, if the bottle became separated from the box, the nurse would not know which resident the bottle belonged to. - The bottom drawer of the medication cart was observed to have a white, powdery, sticky substance caked to the bottom of the drawer. - LPN E stated the dorzolamide and [MEDICATION(S)] bottles should be labeled with Resident #117's name in case they are separated from the boxes. She stated, The bottles should be labeled. She stated if they were separated from the boxes, she would not know who the medication belonged to. She stated, I'd just have to throw them out. - LPN E verbally confirmed these findings at the time of discovery. During an interview on 08/19/21 at 09:40 AM, LPN C stated the vials/bottles in the medication cart should be individually labeled, even if they come in a box. She stated if a medication vial/bottle was not individually labeled, she would dispose of it and notify the pharmacy because she would have no idea whose medication it was if it was not in the box with the resident's name on it. During an interview on 08/19/21 at 09:50 AM, LPN B stated the medication vials/bottles need to be individually labeled, even if they are in a box with the resident's name on it. She stated the reason for them being labeled was if she has two residents with the same medication, she would know which vial/bottle goes with which resident if they are separated from their respective boxes. A review of the Director of Nursing (DON)'s e-mail, dated 8/18/21 at 11:01 AM, revealed, All of our medication carts are double locked for narcotics. Back-up narcotics are also under double lock. A review of the facility's Medication Administration policy, revised 11/19, revealed, Med (medication) Cart: . Med Cart is locked when unattended.

Based on observation, interview, and record review, the facility failed to maintain proper infection control techniques during a dressing change for 1 of 2 residents (Resident #54), resulting in the potential for the spread of illness and disease. Findings include: A review of Resident #54's Admission Record, dated 8/19/21, revealed Resident #54 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of Resident #54's wound dressing changes on 8/18/21 at 2:20 PM, performed by Licensed Practical Nurse (LPN) E, the following interview and observations were made: - After entering Resident #54's room, LPN E placed her supplies (e.g. foam dressing, a jar of Magic Butt cream, a vial of normal saline solution) on top of Resident #54's bedside table. These supplies were placed on top of items that were already on the table (e.g. Resident #54's call light, phone, juice/water glass). When she opened the supplies and took them out of their respective containers, they were still on top of these items. - LPN E placed a dirty linen bag on top of Resident #54's bed (on the left side of the bed next to his pillow). She placed the dirty linen (e.g. wash clothes, towel) in this bag after she cleaned Resident #54's buttocks, sacral area, and wounds with them. - After LPN E cleaned Resident #54's wounds with normal saline solution, she removed her gloves and scrubbed her hands with soap and water for 5 seconds (counting from the time the soap was applied to her hands to the time the soap was rinsed off her hands). - After LPN E applied Magic Butt cream (a combination formula used to heal rashes/skin breakdown/ fungal infections caused by incontinence) to Resident #54's wounds and covered the wounds with a foam dressing, she removed her soiled gloves and scrubbed her hands again for 5 seconds with soap and water (counting from the time the soap was applied to her hands to the time the soap was rinsed off her hands). She then stated she was out of gloves in the bathroom. - After LPN E washed her hands, she came back out of Resident #54's bathroom and pulled up his pants with her bare hands. LPN E then noticed Resident #54's pants were partially up on the right side and needed to be pulled up on the left side. She had him turn to his left to pull up his pants. As Resident #54 turned, he put his face right next to the open dirty linen bag laying next to his pillow with used wash clothes and a used towel in it. She then had him turn onto his back and pulled up his blanket. - After LPN E had Resident #54 adjusted and settled in bed, she gathered up her used/dirty supplies, grabbed the dirty linen bag and tied it up, turned off his room light, and closed his room door with her bare, unsanitized hands. She then took the dirty linen bag to the dirty linen room, opened the door with her bare hands, put the bag in there, closed the door, and then sanitized her hands. After LPN E had finished doing all of these things, she went to the nurse's station, sanitized her hands with an alcohol-based hand sanitizer, and stated, I won't ask you how I did. I know I messed it up pretty bad. During an interview on 08/19/21 at 10:00 AM, the Director of Nursing (DON) stated her expectation is that the nurses set up a sterile/clean field to put their supplies on when they do a dressing change. She stated it was unacceptable to place supplies on items on top of a resident's bedside table when they do dressing changes. She also stated she would hope that nurses put the dirty linen bag somewhere besides next to the resident's head or pillow when they are doing a dressing change. She stated putting the dirty linen bag in the trash can on the floor to drop dirty linen/supplies into would be acceptable, but the dirty linen bag should not be on the resident's bed. A review of the facility's Clean Dressing Change policy and procedure, dated 11/18, revealed, Steps in the Procedure . 2. Set up clean field with needed supplies for wound cleansing and dressing application: a. If the surface is soiled, wipe clean. b. Place a disposable tray or another barrier on the surface . d. Wash and dry hands. e. Open dry, clean dressing(s), gauze by pulling corners of the exterior wrapping outward. Place on clean field . A review of the Centers for Disease Control and Prevention (CDC) instructions on when and how to wash your hands, reviewed 6/10/21, revealed, Washing your hands is easy, and it ' s one of the most effective ways to prevent the spread of germs. Clean hands can stop germs from spreading from one person to another and throughout an entire community-from your home and workplace to childcare facilities and hospitals. Follow these five steps every time. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice. Rinse your hands well under clean, running water. Dry your hands using a clean towel or air dry them (https://www.cdc.gov/handwashing/when-how-handwashing.html).

Based on interview and record review, the facility failed to implement a mechanism to convey Resident Council concerns and concern resolutions to the group, resulting in staff not informing the Resident Council of group concerns potentially affecting all facility residents. Findings include: In an interview conducted 8/18/21 at 3:37 PM, Activities director (AD) M reported she is the Resident Council facilitator. AD M reported that due to COVID 19 restriction the Resident Council has been performed by completing one-on-one resident interviews using a questionnaire. AD M reported the form covers all the issues typically addressed at a Resident Council meeting. AD M reported when the resident interviews are completed the shared concerns are summarized and forwarded to the department to which the concern is directed. AD M reported that the department head will treat as an individual concern and will respond individually to the resident that raised the issue. On 8/19/21 at 9:15 AM, Resident #26 reported she is the Resident Council President. Resident #26 reported group Resident Council meetings had been suspended due to the COVID 19 pandemic. Resident #26 acknowledged that staff were asking if residents had concerns but was not aware that this was being done in lieu of Resident Council meetings. Resident #26 reported that she was not aware what the collective resident concerns were or what was done to resolve the concerns. Resident #26 was handed six months of Resident Council summaries provided to the survey team by AD M. Resident #26 reported she has never seen a Resident Council summary and did not sign off on the summaries. Resident #26 indicated that the summaries were inaccurate and did not reflect the actual concerns of the Resident Council as a group. Resident #26 reported that two weeks ago she had told AD M that a group meeting should be held in a large room where residents could be socially distanced. Resident #26 indicated that she felt the facility residents would benefit from group discussion and stated, we need to meet. On 8/19/21 at 12:25 PM, a follow up interview was conducted with AD M. AD M reported that she had not been asked by anyone to have a group Resident Council meeting in a socially distanced setting. AD M reported greater resident participation using this method and was considering continuing this in the future. AD M also reported that no one had voiced to her they did not like the current process of Resident Council with individual interview and collective review of concerns. AD M indicated the Resident Council President, and the committee, is not informed of the results of the resident interviews and that this is, definitely an area we can improve on. The facility policy Grievances/Concerns, revised 4/17, read, All grievances will be investigated within three (3) business days following receipt of the grievance. Results of the investigation will be provided to the resident and/or family member within seven (7) business days. Resident and/or family member voicing the grievance has the right to obtain a written decision regarding the grievance. The facility policy, Resident Council Meetings, revised 5/17, read, 4. The Activity Director should communicate concerns involving other departments, to the appropriate department manager. In addition, the Activity Director should follow-up, as necessary, to address the resident requests or concerns, and should follow up with the council to evaluate the effectiveness of facility actions. 5. The facility shall act upon concerns and recommendations of the council, make attempts to accommodate recommendations to the extent practicable and will communicate its decisions to the council.

Based on observation and record review, the facility failed to install and maintain backflow prevention devices in the kitchen and dining rooms resulting in the potential contamination of the equipment and the domestic water supply. This deficient practice affects all 95 residents in the facility. Findings include: On 10/30/19 at 10:24 AM, the kitchen chemical closet mop sink was observed to have a shutoff valve, from a chemical dispenser, downstream from the atmospheric vacuum breaker (a backflow prevention device used in plumbing to prevent backflow of non-potable liquids into the drinking water system). This plumbing arrangement allows for the water faucet handle to remain in the on position, resulting in the atmospheric vacuum breaker being under constant pressure, which may damage the device and cause the device to fail if a backflow event were to occur. There was no pressure relief device attached directly to the utility sink faucet to prevent damage to the atmospheric vacuum breaker. The water fixture was observed to be on at the time of the inspection. Additionally, the shield for the atmospheric vacuum breaker was observed to be missing. On 10/30/19 at 10:32 AM the ice machine drain lines, located on the second floor central dining room and the third floor central dining room, were observed to be directly connected and not provided with an air gap to prevent backflow of solid, liquid, or gas contaminants. According to the 2012 Michigan Plumbing Code, incorporating the 2012 edition of the International Plumbing Code, Section 608 Protection of Potable Water Supply, 680.1 General. A potable water supply system shall be designed, installed and maintained in such a manner as to prevent contamination from nonpotable liquids, solids or gases being introduced into the potable water supply through cross connections or any other piping connection to the system .

Based on observation, interview and record review, the facility failed to treat 3 residents (Residents #70, 71 and 68) of 19 reviewed for dignity, and 6 of 11 residents in confidential resident council in a dignified manner by failing respond timely to call lights, waking residents in the night for care and staff not identifying themselves during care resulting in the potential for feelings of inferiority, depression, and loss of self-worth. Findings include: Review of facility policy Resident Rights with a most recently revised date of 05/17 revealed: The resident has the right to a dignified existence . A confidential group meeting with 11 alert and oriented residents was completed on 10/30/19 at 10:00 AM. 6 residents stated there was an issue with staff not being well identified. It was stated some staff don't wear name tags, other staff have name tags that are turned around, it was also stated staff don't introduce themselves when they come to your room or at the beginning of their shift. Other residents agreed there is a lot of new staff and we don't know who comes in and is taking care of you. One resident stated they have had staff act offended when I asked who they are coming into my room and another stated staff will come in first thing in the morning, wake me up and I don't know who they are. Residents stated: we have talked about sticker name tags to see names better but didn't happen, and another stated they also suggested staff have white boards to sign in either in resident rooms or at the nurse station. The lack of identification was noted to make residents nervous you don't know who to look for if you need help and frustrated that when staff don't introduce themselves it feels that staff aren't friendly and don't care about you. 5 of 11 residents also complained of call light wait times. Resident complained of waiting for more than 20 minutes at least once a day. Others stated it depends on who is working, 2nd and 3rd shift are more difficult to get help. It was also stated new workers have been taking a bit to learn and can be slow. Residents were concerned new staff did not have enough training before working and new staff are already training other workers before they know what they are doing. Residents stated the call light wait times make them feel terrible, it's frustrating, I'm mad, it's scary, and I've wet myself. Residents also revealed concerns about being woke up in the middle of the night. It was stated that 3rd shift staff can make a lot of noise and this is disrespectful, it makes it difficult to sleep. 4 residents revealed that they had been woke up for care in the middle of the night and it was frustrating. Review of resident council minutes with a date of 5/8/19 revealed the concern: Council members stated that they would like staff members to introduce themselves during shift change so they are aware of who their aide is; name tags are often times flipped around and cannot read the name. Staff reminded during Hump Day Huddle to introduce themselves during shift change. Review of resident council minutes with a date of 7/10/19 revealed a concern: 2 council members agreed that at times the call lights are not being answered in a timely manner. Review of resident council minutes with a date of 8/14/19 revealed a concern: Council member stated that staff are not introducing themselves during shift change and discussed the noise level at the nurses station during shift change. Review of resident council minutes with a date of 9/11/19 revealed a concern: Council members stated that call lights are not getting answered in a timely manner, most often during the 3-11 shift and .the staff are still not introducing themselves during shift change. They stated that it might help if they had a board where the staff write their CNA, Nurse, and date. Review of resident council minutes with a date of 10/9/19 revealed: (NHA) discussed with the council of making name tags for all residents like they have on our memory care unit. Resident #70 Review of the Face Sheet reflected Resident #70 initially admitted to the facility on [DATE] and most recently admitted on [DATE]. Resident #70 is their own responsible party. Review of Resident #70's orders revealed Change O2 tubing every 14 days . with the directions every night shift every 14 day(s). During an interview on 10/31/19 at 11:32 AM Resident #70 stated she had been awakened at least twice in the last month to have her oxygen tubing changed. Resident #70 stated it startled her and she said what the heck are you doing? Resident #70 stated that the night shift nurse changes her oxygen tubing, but she is usually up until 11 PM and she is always up at 4 or 5 in the morning anyways. However, staff will come in at 1 or 1:30 AM. Resident #70 stated she would even stay up later if she needed to since she does not sleep much as it is. Resident #70 stated she has told the nursing staff before that she does not want it done in the middle of the night, but it still happens. An interview was completed with Registered Nurse (RN) F on 10/31/19 at 03:02 PM. RN F stated that Resident #70 had talked to them before about not being woke up in the night to change her oxygen tubing. RN F stated they knew this was Resident #70's preference but was not aware if it was in her care plan. Resident #71 Review of the Face Sheet reflected Resident #71 initially admitted to the facility on [DATE] and most recently admitted on [DATE]. Resident #71 does not make his own medical decisions. On 10/31/19 at 11:38 AM an interview was completed with Family Member G. Family member G stated that they are always getting the new staff, and the when they have been there the staff do not introduce themselves when they come in. Resident #71 confirmed staff did not introduce themselves to him when they come in. Resident #71 stated he has gotten used to it. Family Member G and Resident #71 were asked if staff wore name tags when they entered his room, Family Member G stated he is blind. Resident #68 According to the MDS, dated [DATE], Resident #68 had multiple [DIAGNOSES REDACTED]. This same assessment revealed Resident #68 required extensive assistance of one staff person for transferring, dressing, and other hygiene needs. Resident #68 was cognitively intact and their own responsible party. During an interview on 10/31/19 at 11:10 AM, Resident #68 indicated that she did not like to be woke up for medications. I asked (facility) staff a long time ago to change the medication administration time, they (facility) have never changed it. I don't want to wake up so early, they are too busy on shift change at 7 am. Breakfast is at 8 am, I would like the medication around 6:30 or 7 am. Review of Resident #68's Medication Admin Audit Report (MAAR), dated 10/25/19 to 10/31/19, revealed Resident #68 received the medication Trospium Chloride before 6:30 AM five out of the previous seven days. During an interview on 10/31/19 at 1:04 PM, Registered Nurse (RN) L stated that she was familiar with Resident #68 and reported, (Resident #68) told me she doesn't want to be woke up before six. I did not call the doctor or put in the care plan. I am not sure when her med (medication) is scheduled, it is early, we have an hour either way to give meds. No problem with getting med to (Resident #68) at 6:30 (am), (medication administration time) should be her preference. It (preferences) would be located in care plans or MAR (medication administration record) per home routine. During an interview on 10/31/19 at 12:56 PM, RN M stated that she was familiar with Resident #68 and reported, Sometimes (Resident #68) does complain about being woke up for meds, if she is awake, she doesn't mind. We could always call the doctor about changing her med times. During an interview on 10/31/19 at 12:46 PM, the DON reported that changing medication administration time is not a problem and that if resident concerns are voiced to staff, they take the concern to the Unit Coordinator and the Unit Coordinator would call the pharmacy or make the appropriate changes.

Based on observation, interview and record review, the facility failed to address Resident Council grievances according to 7 of 11 of the residents in a confidential group interview, resulting in unresolved resident concerns, unmet care needs and decreased feelings of self-worth. Findings include: Review of facility policy Resident Rights with a most recently revised date of 05/17 revealed: The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the residents may have. A confidential group meeting with 11 alert and oriented residents was completed on 10/30/19 at 10:00 AM. 7 residents discussed concerns with various issues that had been discussed in resident council but had not yet been resolved. 6 residents stated there was an issue with staff not being well identified. It was stated some staff don't wear name tags, other staff have name tags that are turned around, it was also stated staff don't introduce themselves when they come to your room or at the beginning of their shift. Other residents agreed there is a lot of new staff and we don't know who comes in and is taking care of you. One resident stated they have had staff act offended when I asked who they are coming into my room and another stated staff will come in first thing in the morning, wake me up and I don't know who they are. Residents stated: we have talked about sticker name tags to see names better but didn't happen, and another stated they also suggested staff have white boards to sign in either in resident rooms or at the nurse station. The lack of identification was noted to make residents nervous you don't know who to look for if you need help and frustrated that when staff don't introduce themselves it feels that staff aren't friendly and don't care about you. 5 of 11 residents also complained of call light wait times. Resident complained of waiting for more than 20 minutes at least once a day. Others stated it depends on who is working, 2nd and 3rd shift are more difficult to get help. It was also stated new workers have been taking a bit to learn and can be slow. Residents were concerned new staff did not have enough training before working and new staff are already training other workers before they know what they are doing. Residents stated the call light wait times make them feel terrible, it's frustrating, I'm mad, it's scary, and I've wet myself. 7 Residents also revealed concerns about snack issues not being followed up on. Residents reported they are not always being offered snacks, and when they are, it was not the variety of items they had requested in resident council. It was reported we are supposed to have new snack carts on all floors, but we are still waiting on them. Residents stated: we have been talking about it for 3-4 months and we don't know what is happening. Review of resident council minutes with a date of 5/8/19 revealed the concern: Council members stated that they would like staff members to introduce themselves during shift change so they are aware of who their aide is; name tags are often times flipped around and cannot read the name. Staff reminded during Hump Day Huddle to introduce themselves during shift change and Council members stated that they are not always offered a snack. Staff reminded during Hump Day Huddle of what and when snacks are to be offered. Review of resident council minutes with a date of 6/12/19 revealed the concern: Council members stated that snacks are not always being offered, and .discussed with council the variety of snacks that are offered and what the residents would like to see offered. Review of resident council minutes with a date of 7/10/19 revealed a concern: 2 council members agreed that at times the call lights are not being answered in a timely manner and .the facility is going to be trying a new HS snack process, which will involve a cart with items that rotate to provide variety and Council member offered some suggestions for the snack cart rotation. Review of resident council minutes with a date of 8/14/19 revealed a concern: Council member stated that staff are not introducing themselves during shift change and Council members inquired about the new HS snack system. Council was informed that the facility is still working out some of the kinks. Review of resident council minutes with a date of 9/11/19 revealed a concern: Council members stated that call lights are not getting answered in a timely manner, most often during the 3-11 shift and .the staff are still not introducing themselves during shift change. They stated that it might help if they had a board where the staff write their CNA, Nurse, and date. Review of resident council minutes with a date of 10/9/19 revealed: (NHA) discussed with the council of making name tags for all residents like they have on our memory care unit. On 10/31/19 at 11:38 AM, an interview was completed with Family Member G. Family member G stated that they are always getting the new staff, and the when they have been there the staff do not introduce themselves when they come in. Resident #71 confirmed staff did not introduce themselves to him when they come in. Resident #71 stated he has gotten used to it. Family Member G and Resident #71 were asked if staff wore name tags when they entered his room, Family Member G stated he is blind. During an observation on 10/30/19 at 11:00 AM, CNA J was caring for a resident, CNA J had no name tag on. During an interview on 10/30/19 at 2:18 PM, Family Member K stated, Half of the staff do not wear name tags, there are so many, and they keep changing. During the Quality Assurance task on 10/31/19 at 10:45 AM, the Nursing Home Administrator (NHA) was asked how she ensured the resident council concerns were resolved. The NHA said she had been having the department leader attend the meetings to address the concerns. The NHA said they recently found out that concerns raised during the resident council were no longer being documented on concern forms. The NHA was not aware when the practice of using the concern forms stopped but they were just starting to go back to using the concern forms so that they could ensure the concerns were resolved. The NHA said she was aware to the resident's concern about not being able to read staff names on their name tags and NHA had started a pilot program of using green tags for staff on the first floor. The NHA had not implemented a facility wide intervention to resolve the name tag concern at the time of the survey.

Based on interview and record review, the facility failed to provide written notice of transfer for 5 Residents ( #22, #47, #77, #80 and #71) of 5 residents reviewed for transfers, potential for residents or their responsible party not being fully notified of the reasons for the transfer, circumstances requiring the transfer, and location of the transfer. Findings include: Review of Resident #47's face sheet, dated 11/1/19, revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #47's electronic medical record revealed she was transferred to the hospital in (MONTH) 2019 and returned to the facility on [DATE]. The Director of Nursing (DON) was asked for a copy of the written transfer and bed hold notification for Resident #47 on 10/31/19 at 11:33 AM. The DON said staff have been verbally going over the information, but they do not keep a copy of the information. On 11/1/19 at 8:46 AM, the DON said she had started staff education on the transfer and bed hold form. Resident #77 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #77 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS), reflected a score of 15 out of 15 which represents Resident #77 was cognitively intact. According to the medical record, Resident #77 transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. There was no evidence of a transfer notice provided to the resident/resident representative. Resident #22 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #22 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 0 out of 15 which represents Resident #22 had severe cognitive impairment. According to the medical record, Resident #22 transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. There was no evidence of a transfer notice provided to the resident/resident representative. Resident #80 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #80 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 9 out of 15 which represents Resident #80 had moderate cognitive impairment. According to the medical record, Resident #80 transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. There was no evidence of a transfer notice provided to the resident/resident representative. Resident #71 Review of the Face Sheet reflected Resident #71 initially admitted to the facility on [DATE] and most recently admitted on [DATE]. Resident #71 does not make his own medical decisions. According to the medical record, Resident #71 transferred to the hospital on [DATE] and 7/7/19. There was no evidence of a transfer notice being provided to the resident or resident representative. On 10/31/19 at 11:38 AM, an interview was completed with Family Member G. Family Member G stated they did not receive any paperwork regarding a bed hold or a transfer notice when Resident #71 transferred to the hospital. Family Member G stated the facility had verbally discussed the hospital transfer, but there was no paperwork provided related to the transfers. Review of facility provided Transfer Notice with no created or revised date revealed: Please take notice that due to the circumstances noted below, the resident will be transferred from our facility IMMEDIATELY or as soon as appropriate arrangements for transfer can be made. Fields to be completed include: date, resident name, representative information, transfer location, reason for transfer, reason for urgency, information regarding appeal rights and contact information for the ombudsman. Per an email from the DON on 10/31/19 at 1:41 PM, regarding bed hold and transfer notices: Unfortunately, we did not retain copies for our medical record. I did do education with the nurses on this in July.

Based on interview and record review, the facility failed to provide written notice of bed-hold for 5 Residents ( #22, #47, #71, #77 and #80) of 5 residents reviewed for transfers, resulting in the residents or their responsible party not being fully notified of the bed hold policy should they decide to return to the facility after their hospitalization . Findings include: Review of Resident #47's face sheet, dated 11/1/19, revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #47's electronic medical record revealed she was transferred to the hospital in (MONTH) 2019 and returned to the facility on [DATE]. The Director of Nursing (DON) was asked for a copy of the written transfer and bed hold notification for Resident #47 on 10/31/19 at 11:33 AM. The DON said staff have been verbally going over the information, but they do not keep a copy of the information. On 11/1/119 at 8:46 AM, the DON said she had started staff education on the transfer and bed hold form. Resident #77 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #77 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS), reflected a score of 15 out of 15 which represents Resident #77 was cognitively intact. According to the medical record, Resident #77 transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. There was no evidence of a bed hold provided to the resident/resident representative. Resident #22 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #22 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 0 out of 15 which represents Resident #22 had severe cognitive impairment. According to the medical record, Resident #22 transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. There was no evidence of a bed hold provided to the resident/resident representative. Resident #80 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #80 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 9 out of 15 which represents Resident #80 had moderate cognitive impairment. According to the medical record, Resident #80 transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. There was no evidence of a bed hold provided to the resident/resident representative. Resident #71 Review of the Face Sheet reflected Resident #71 initially admitted to the facility on [DATE] and most recently admitted on [DATE]. Resident #71 does not make his own medical decisions. According to the medical record, Resident #71 transferred to the hospital on [DATE] and 7/7/19. There was no evidence of a bed hold policy being provided to the resident or resident representative. On 10/31/19 at 11:38 AM, an interview was completed with Family Member G. Family Member G stated they did not receive any paperwork regarding a bed hold or a transfer notice when Resident #71 transferred to the hospital. Family Member G stated the facility had verbally discussed the hospital transfer, but there was no discussion or paperwork provided related to the bed hold policy. Review of facility provided policy Bed Hold Guidance Policy with a revised date of 11/28/16 revealed: when a resident is transferred to a hospital, the resident's responsible party for financial matters will be contacted by telephone the following regular business day regarding a bed hold A resident and/or family member or legal representative may have the bed held by either submitting the signed Bed Hold Agreement OR by giving verbal consent . Review of facility provided policy Bed Hold Notice Upon Transfer with a revised date of 2/2017 revealed: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or resident representative written notice which specifies the duration of the bed-hold policy. Per an email from the DON on 10/31/19 at 1:41 PM, regarding bed hold and transfer notices: Unfortunately, we did not retain copies for our medical record. I did do education with the nurses on this in July.

This citation pertains to intake MI 634. Based on interview and record review, the facility failed to update a resident representative for two Residents (#233 and #241) out of five residents reviewed for representative notifications. This deficient practice resulted in a lack of communication between staff and a resident representative, resident representative missing a doctor appointment, and unanswered care concerns. Findings include: Resident #233 According to the Minimum Data Set (MDS) Assessment, dated 7/25/19, Resident #233 had medically complex conditions including end stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT], diabetes, and [MEDICAL CONDITION] (abnormal heart rhythm). During this same assessment when staff asked, How important is it to you to have your family or a close friend involved in discussions about your care?, Resident #233 responded that it was Very important. Staff assessed Resident #233 as having a Brief Interview of Mental Status (BIMS) score of 9 out of 15 indicating Resident #233 was moderately cognitively impaired. Resident #233 was their own responsible party. During an interview on 10/31/19 at 3:37 PM, Family Member (FM) K reported that facility staff did not tell her that Resident #233 had a doctor appointment that day and that she had missed the opportunity to attend the appointment. Review of Resident #233's medical record revealed an Authorization for Release /Disclosure of Health Information, signed by Resident #233 on 7/19/19, indicating information regarding his care could be released to multiple family members including FM K. During an interview on 11/1/19 at 9:00 AM, Resident #233 recalled prior day events accurately regarding doctor appointment and costume party event. Resident #233 reported he wants FM K notified of his doctor appointments. Resident #233 stated FM K was not at his doctor appointment the day prior and that he would have liked her to have been there. During an interview on 11/01/19 at 10:40 AM, Unit Manager (UM) Z revealed that the [MEDICAL TREATMENT] unit notified the facility on 10/25/19 that Resident #233 had an appointment for a more permanent [MEDICAL TREATMENT] shunt assessment scheduled for 10/31/19. UM Z stated she had not notified the family as she thought the [MEDICAL TREATMENT] staff had contacted the family. Resident #241 According to the Admission Record, printed by the facility on 10/29/19, Resident #241 newly admitted to the facility with multiple [DIAGNOSES REDACTED]. Staff listed FM K as an emergency contact. A BIMS assessment, dated 10/23/19 revealed a score of 13 out of 15 indicating Resident #241 was cognitively intact. Resident #241 was their own responsible party. During an interview on 10/30/19 at 2:18 PM, FM K reported that she had attended Resident #241's care conference on 10/21/19 and there was no nurse in attendance to answer several care concerns. FM K reported she had wanted to know about Resident #241's fluid restriction, bathroom safety, and medication changes. Review of Resident #241's medical record revealed an Authorization for Release /Disclosure of Health Information, signed by Resident #241 on 10/14/19, indicating information regarding her care could be released to multiple family members including FM K. During an interview on 11/01/19 at 8:58 AM, Resident #241 stated she wanted FM K notified of doctor appointments and to be kept updated on her care needs. Review of Resident #241's care conference notes, dated 10/21/19, read, Care conference held with resident and her (2) daughters. See assigned Acknowledgement of Care Conference form in the medical record. Copy of medication list and care plan provided. Discharge plan is uncertain, family has scheduled a meeting with (name of another company) on 10/24/19. Review of Acknowledgement of Care Conference form, dated 10/21/19, revealed there was no clear indication of who attended the care conference nor that the resident representative, FM K, had unanswered care concerns. During an interview on 10/31/19 at 11:27 AM, Social Worker (SW) O reported attending Resident #241's care conference on 10/21/19. SW O stated that FM K voiced concerns about fluid restriction and perineal care and that a Certified Nursing Assistant had come into the meeting and answered some questions. SW O verified that there were no nurses at this care conference and that she had to talk to a nurse after the meeting regarding Resident #241's fluid restrictions. Additional documentation was requested by Social Worker O indicating FM K was updated following the care conference regarding Resident #241's fluid restrictions and care concerns. The facility did not provide any additional documentation. The facility reported no concern forms for Resident #241 since admission.

This citation pertains to intake MI 634. Based on observation, interview, and record review, the facility failed to implement care planned interventions for one Resident (#241) out of 19 residents reviewed for implementation of care plans. This deficient practice resulted in this resident not having safety measures implemented while in the bathroom and the potential for falls and injury. Findings include: According to the Admission Record, printed by the facility on 10/29/19, Resident #241 newly admitted to the facility with multiple [DIAGNOSES REDACTED]. A Brief Interview of Mental Status (BIMS) assessment, dated 10/23/19 revealed a score of 13 out of 15 indicating Resident #241 was cognitively intact. Resident #241 was their own responsible party. During an interview on 10/29/19 at 3:01 PM, Resident #241 reported being left alone in the bathroom on multiple occasions. During an interview on 10/30/19 at 2:18 PM, Family Member (FM) K stated that staff had left Resident #241 alone in the bathroom. Review of Resident #241's Fall Risk care plan, accessed 10/31/19, revealed the intervention Do not leave me unattended in the bathroom (CNA, RN, LPN). This intervention was not followed by a K indicating the intervention was listed on Resident #241's Kardex. A review of Resident #241's Kardex confirmed no such intervention was listed. During an interview on 10/31/19 at 2:09 PM, Certified Nursing Assistant (CNA) N stated, We always leave (Resident #241) in the bathroom, she uses the call light when she is done. CNA N demonstrated access to Resident #241's Kardex and stated, This doesn't say. Sometimes she takes herself (to the bathroom). That same day at 2:35 PM, the Director of Nurses (DON) agreed Resident #241's Kardex did not instruct staff to stay with Resident #241 while in the bathroom. The DON also reported that the CNA's have access to the full care plan, including the safety interventions, and that Resident #241 should have a yellow wrist band indicating she is a fall risk and not to leave her alone in the bathroom. An observation on 11/01/19 at 8:58 AM, revealed Resident #241 had a yellow wrist band on the right wrist. During a follow up interview on 11/1/19 at 10:40 AM, Unit Manager (UM) Z stated that she expects staff to access the residents Kardex for care guidance.

Based on observation, interview, and record review, the facility failed to provide safety interventions while in the bathroom for one Resident (#241) and follow their policy for reporting an incident causing a skin abrasion for one Resident (#233) out of 19 residents reviewed for safety. This deficient practice resulted in potential for fall and injury for Resident #241 and a delayed reporting of a transfer resulting in an injury for Resident #233. Findings include: Resident #241 According to the Admission Record, printed by the facility on 10/29/19, Resident #241 newly admitted to the facility with multiple [DIAGNOSES REDACTED]. A Brief Interview of Mental Status (BIMS) assessment, dated 10/23/19 revealed a score of 13 out of 15 indicating Resident #241 was cognitively intact. Resident #241 was their own responsible party. During an interview on 10/29/19 at 3:01 PM, Resident #241 reported staff left her alone in the bathroom on multiple occasions. During an interview on 10/30/19 at 2:18 PM, Family Member (FM) K stated that staff had left Resident #241 alone in the bathroom. Review of Resident #241's Fall Risk care plan, accessed 10/31/19, revealed the intervention Do not leave me unattended in the bathroom (CNA, RN, LPN). This intervention was not followed by a K indicating the intervention was listed on Resident #241's Kardex. A review of Resident #241's Kardex confirmed no such intervention was listed on that document. During an interview on 10/31/19 at 2:09 PM, Certified Nursing Assistant (CNA) N stated, We always leave (Resident #241) in the bathroom, she uses the call light when she is done. CNA N demonstrated access to Resident #241's Kardex and stated, This doesn't say (that she can be left alone). Sometimes she takes herself (to the bathroom). That same day at 2:35 PM, the Director of Nurses (DON) agreed Resident #241's Kardex did not instruct staff to stay with Resident #241 while in the bathroom. The DON also reported that the CNA's have access to the full care plan, including the safety interventions, and that Resident #241 should have a yellow wrist band indicating she is a fall risk and not to leave her alone in the bathroom. An observation on 11/01/19 at 8:58 AM, revealed Resident #241 had a yellow wrist band on the right wrist. During a follow up interview on 11/1/19 at 10:40 AM, Unit Manager (UM) Z stated that she expects staff to access the residents Kardex for care guidance. Resident #233 According to the Minimum Data Set (MDS) Assessment, dated 9/24/19, Resident #233 had medically complex conditions including end stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] and diabetes. This same assessment indicated Resident #233 required extensive assistance of a staff member for moving in bed, transferring, dressing, and other hygiene needs. Staff assessed Resident #233 as having a Brief Interview of Mental Status (BIMS) score of 7 out of 15 indicating Resident #233 was severely cognitively impaired. Resident #233 was their own responsible party. During an interview on 10/31/19 at 3:37 PM, Family Member (FM) K reported that she had witnessed a staff member transferring Resident #233 without a gait belt earlier this afternoon. It was reported that during this transfer Resident #233's foot got caught in the foot pedal causing a scratch and then bleeding. The staff member took Resident #233 to the costume party and did not reported the incident. FM K reported Resident #233's injury was not assessed until later when they returned from the costume party and after FM K told the nurse about the incident. During an observation and interview on 11/1/19 at 9:00 AM, Resident #233 was noted to have a scratch on the left outer calf and a band aid was in place. Resident #233 stated that the injury occurred yesterday when I was rushing to get to the costume party, Resident #233 could not recall if staff used a gait belt during the transfer or what had caused the injury. During an interview on 11/01/19 at 9:18 AM, Unit Manager (UM) Z was unaware of the above incident and consulted progress notes. UM Z stated that there was no incident report regarding the incident occurring 10/31/19 with Resident #233. Review of Resident #233's progress notes revealed on 10/31/19, Resident #233 had a scratch on his left calf and a band aid was applied. There was no indication of how the scratch occurred. During an interview on 11/01/19 at 10:40 AM, Unit Manager (UM) Z stated that she had talked with both Certified Nursing Assistant CC and the nurse assigned to Resident #233 regarding the incident, no incident report was completed, and that staff were coming in to the facility today to complete an incident report. UM Z stated that she expects staff to complete an incident report with this type of injury. During an interview on 11/1/19 at 12:26 PM, CNA CC stated that sometimes the residents Kardex and care plan does not always match, that she uses the most extensive interventions, and notifies the Unit Manager. CNA CC stated she transferred Resident #233 on 10/31/9 when the scratch occurred. CNA CC reported a gait belt was used, that the foot pedals had been removed from the wheelchair, and that Resident #233 got his feet tangled up and the scratch probably occurred from underneath where the foot pedals rest. CNA CC stated she had reported the incident to the nurse, it was noted, and stated, I am sure she wrote an incident report. Review of facility policy, Reporting and Monitoring of Incidents, revised 8/18, read, in part, Purpose: To maintain a complete record from the medical chart of any accident or incident that occurs on facility premises. To report any changes in the condition of the resident to his/her Attending Physician and/or responsible family member(s). To study and evaluate accidents/incidents as part of a comprehensive quality assurance and improvement process to prevent reoccurrence. And, Policy: The facility shall conduct a professional review of unusual occurrences for the reduction of morbidity and mortality and improve resident care. A confidential Incident Report Form is filled out by the department head/manager/licensed nurse gaining input from the staff member(s) involved as soon as possible after the incident occurs.

Based on interview and record review, the facility failed to maintain communication between facility staff and [MEDICAL TREATMENT] staff for one Resident (#233) out of one resident reviewed for [MEDICAL TREATMENT] communication. This deficient practice resulted in incomplete [MEDICAL TREATMENT] communication forms and the potential for unmet care needs relating to [MEDICAL TREATMENT] care. Findings include: According to the Minimum Data Set (MDS) Assessment, dated 9/24/19, Resident #233 had medically complex conditions including end stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] and diabetes. This same assessment indicated Resident #233 required extensive assistance of a staff member for moving in bed, transferring, dressing, and other hygiene needs. Staff assessed Resident #233 as having a Brief Interview of Mental Status (BIMS) score of 7 out of 15 indicating Resident #233 was severely cognitively impaired. Resident #233 was their own responsible party. During an interview on 10/29/19 at 10:49 AM, Resident #233 reported attending [MEDICAL TREATMENT] offsite on Mondays, Wednesdays, and Fridays. Review of Resident #233's Nutrition care plan, revised 10/21/19, read, in part, Weigh at same time of day and record 3 days a week post [MEDICAL TREATMENT]. Staff did not document post [MEDICAL TREATMENT] weights on 10/22/19 or on 10/25/19. Review of facility policy, Managing [MEDICAL TREATMENT] Care, revised 9/19, read, in part, A [MEDICAL TREATMENT] communication form will be utilized for [MEDICAL TREATMENT] treatments, to provide communication between facility and [MEDICAL TREATMENT] center. Review of Resident #233's DIAIS COMMUNICATION FORM, dated 9/27/19 through 10/25/19, revealed 10 incomplete communication forms with no progress notes indicating communication between facility and [MEDICAL TREATMENT] staff occurred. DIAIS Communication forms, dated 9/27/19, 10/11/19, and one with no date, was missing a [MEDICAL TREATMENT] assessment and a post [MEDICAL TREATMENT] assessment completed by the facility upon Resident #233's return to the facility after [MEDICAL TREATMENT]. There were no progress notes indicating staff had contacted [MEDICAL TREATMENT] staff for a report regarding Resident #233 and staff did not document completing a post [MEDICAL TREATMENT] assessment, including obtaining vital signs. On 10/2/19, 10/4/19, 10/7/19, 10/14/19, there was no post [MEDICAL TREATMENT] assessment completed by facility staff on the DIAS Communication forms and there was no progress note indicating staff assessed Resident #233 upon return from [MEDICAL TREATMENT]. On 10/23/19 and 10/25/19 the communication forms did not have a [MEDICAL TREATMENT] assessment and there were no progress notes indicating facility staff contacted [MEDICAL TREATMENT] staff for a report of Resident #233's condition during and immediately following treatment. During an interview on 11/01/19 at 10:40 AM, Unit Manager (UM) Z stated the facility identified a concern with [MEDICAL TREATMENT] communication the middle of (MONTH) this year, the facility has educated staff, and that the audits are in place. UM Z stated that she expects facility staff to call [MEDICAL TREATMENT] staff, obtain missing information, and to complete the DIAS communication forms. The UM performs one to one staff education when staff do not meet expectations. During an interview that same day at 12:55 PM, the Director of Nursing (DON) stated that she expects staff to contact the UM if [MEDICAL TREATMENT] staff do not complete the appropriate assessment on the DIAS communication forms.

Based on observation, interview, and record review, the facility failed properly identify and dispose of refused medications and maintain a clean environment for medications under refrigeration. This deficient practice resulted in Resident #71's medications being returned to the medication cart, relabeled and held for storage and the central medication room medication refrigerator contained opened food items. Findings include: Resident #71 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #71 admitted to the facility with the following [DIAGNOSES REDACTED]. Brief Interview for Mental Status (BIMS), reflected a score of 5 out of 15 which represents Resident #71 had severe cognitive impairment. During an observation and interview on 10/29/19 at 9:00 AM, Registered Nurse (RN) C placed 7 prescribed medications into a small portion of applesauce and attempted to administer it to Resident #71. Resident #71 took 2 of the 7 medications in the cup and refused to take the other 5. RN C labeled the cup with Resident #17's name and returned the small container of applesauce with the 5 remaining medications to the top drawer of the medication cart. When asked if it she could determine which medications Resident #71 took and which ones remained, RN C stated, No. RN C stated that she would reattempt after Resident #71's spouse came in. The facility provided a copy of the Medication Administration policy dated 7/2018 for review. The policy reflected, 15. Refused or withheld meds: Meds refused or withheld will be properly documented on the medication administration record. If a refused meds have been put in applesauce or pudding, they are considered unadministrable and may be disposed . During an interview on 10/30/19 at 11:50 AM, the Director of Nursing stated that it was not the policy nor practice of the facility to return refused medications to the medication cart and hold them for later dispensing. The facility provided a copy of 1 to 1 In-Service dated 10/30/19 for review. The in-service reflected that RN C received the following education, If a resident refuses some or all of their medication, the medication not administered needs to be documented as not given in the medical record. The refused mediation must be disposed of and cannot return to the med cart. During an observation and interview on 10/31/19 at 9:10 AM, Licensed Practical Nurse (LPN) AA showed this surveyor the medication storage refrigerator for the central medication room. The refrigerator had an opened container of yogurt, applesauce, and a bottle of wine. LPN AA stated, Only unopened food may be stored in the medication refrigerator. During an interview on 10/31/19 at 9:27 AM, the DON stated, Staff should not store opened food in the medication refrigerator. The facility provided a copy of the Medication & Vaccine Refrigerator Guidelines dated 7/2019 for review. The guidelines reflected, Alcohol, yogurt, Med Pass, apple sauce and supplements may be stored unopened for med pass use for resident palatability .

Based on observation, interview, and record review, the facility failed to thoroughly clean and sanitize a glucometer after each use, this deficient practice affects all diabetic residents receiving blood glucose monitoring from the 2 East Medication cart. This deficient practice resulted in the potential for infection transmission. Finding include: During a medication pass observation on 10/30/19 at 11:50 AM, Registered Nurse (RN) DD cleaned a glucometer machine after testing a resident's blood sugar. RN DD used a super sani wipe and wiped the front and back of the glucometer. RN DD then placed the glucometer in a paper cup. RN DD stated that the glucometer must remain wet for one full minute. A follow up interview on 10/31/19 at 11:38, RN DD clarified that the glucometers are cleaned and sanitized by wiping both sides and keeping the machine wet for one minute, the glucometer was reported as being good to use after that. An interview on that same day at 11:40 with RN EE stated that the glucometers are cleaned and sanitized using the first sani wipe to clean and a second sani wipe to disinfect. The glucometers need to air dry for two minutes. Manufacturers guidelines, revised 2/16, and the facility policy for cleaning glucometer, unknown date, reflected glucometers are cleaned and sanitized by using a sani wipe and wiping the entire surface of the meter three times horizontally and three times vertically, then to disinfect the glucometer, a second sani wipe is used to wipe the entire surface of the meter three times horizontally and three times vertically to remove blood-borne pathogens. The exterior of the glucometer should remain wet for two minutes.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program related to facility rounding, offensive odors in the entry between the dementia unit and business office area, and staff finger nails for one (#89) Resident, and for all residents residing on the 2nd Floor within the facility, resulting in offensive odors noted for three days, and the potential for the transfer of pathogenic organisms and cross contamination between residents and staff. Findings include: Record review of the facility infection control surveillance report forms for: Housekeeping, Laundry, Maintenance and Activities departments were dated for the month of (MONTH) (YEAR). The Infection Preventionist was not able to provide or find any other rounding surveillance records when requested the previous six months. Record review of the facility 'Infection Preventionist' policy dated 1/2018, revealed the responsibilities of the infection preventionist include but not limited to: (a.) Develop and implement an ongoing infection prevention and control program to prevent, recognize and control the onset and spread of infections to provide a safe, sanitary and comfortable environment. (b.) Establish facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff and visitors. Infection Prevention rounding: Observation on 10/29/18 during the entrance tour of the recertification survey, revealed there to be an offensive odor of urine located in the corridor between the dementia care unit entrance and the business offices. Observation of the area revealed there to be large wheeled plastic bins with laundry in them. The odors seem to be coming from the bins. Observation on 10/30/18 at 07:30 AM, of the 1st floor dementia unit kitchenette area, revealed a broken corner appliance garage with wooden roll down cabinet door with broken wood slat pieces sticking out. Surveyor was able to roll up the wood roller door and the bottom three inches of the wood slatted door were broken folding under itself. Observation on the way into and out of the secured dementia unit revealed the large wheeled bins and odors of urine to still be noted in the corridor. Interview and rounding tour on 10/31/18 at 10:00 AM, with the Registered Nurse (RN) Infection Control Preventionist V, the State surveyor accompanied the Infection Control Preventionist V through the corridor to the secured dementia unit where the broken roll down cabinet appliance garage was viewed. Coming back out of the dementia unit the Infection Control Preventionist V was asked what the offensive odors were in the corridor and reviewed the large wheeled bins of clean or dirty linens and agreed that the odors were offensive. Infection Control Preventionist V was asked about rounding and stated Rounding- yes, I started surveillance sheets with all departments. Staff Finger Nails: Record review of the facility 'Dress Code' policy dated 3/2017, revealed that all resident care staff's hands and fingernails must be clean and fingernail length may not exceed 1/8 inch in length beyond the finger. Light and colored nail polish is acceptable. Observation on 10/30/18 at 08:38 AM, of the 2nd floor Central hall dining room revealed Certified Nurse Assistant (CNA) B with estimated inch long black finger nails with ring finger nail painted a different color, to be Applying food protectors to residents in dining room, serving meal trays from the kitchenette window to residents and assisting with feeding a female resident. CNA B during the observation did not wash hands or use gloves between applying clothing protectors around resident necks touching resident clothing and hair area at back of neck, serving meal trays and then assisting a female resident with her meal. Observation on 10/30/18 at 11:11 AM while getting on the elevator with Assistant Director of Nursing F (ADON F) and Certified Nurse Assistant B, revealed that CNA's finger nails were an estimated one inch in length as she held the elevator door open. In an interview on 10/31/18 at 8:07 AM, with Assistant Director of Nursing F, ADON F agreed that nails on CNA's should be shorter. The ADON F acknowledged that she did see the fingernails on the elevator and that they are an infection control issue with the CNA touching clothing protectors and residents around the necks and serving food trays without washing her hands. In an interview on 10/31/18 at 10:22 AM with Registered Nurse (RN) Infection Control Preventionist V, discussion of Assistant Director of Nursing (ADON) F observed long nails of Certified Nurse Assistant (CNA) B with estimated 1-inch long nails. Registered Nurse (RN) Infection Control Preventionist V, stated that Hand Hygiene is the most important to prevent spreading of infection from cross contamination. Discussion on the last hand Hygiene education and surveillance was a couple of months ago. We had had conversations on long nails. Nail length is in the dress code policy and should be an 1/8 of an inch or shorter for direct care workers. Resident #89 According to the MDS assessment, dated 10/14/18, Resident #89 had multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #89 was moderately cognitively impaired. During a dining observation on 10/29/18 at 8:19 AM, CNA N was observed passing meal trays in the 3 South Dining Room to nine residents. CNA N was noted to have fingernails approximately an inch long and painted a gray color. During an interview on 10/29/18 at 9:10 AM, it was determined that Resident #89 was able to accurately recall what he had eaten for breakfast that day, that he had recently been in the hospital and could not recall why he had been hospitalized . When asked about the cares he receives from the caregivers in the facility, Resident #89 stated, Those nails. Resident #89 denied being scratched by the nails but indicated he was concerned about the nails and provided no further information. Family Member O stated, . (Resident #89) is concerned for the CNA's safety with the long nails and (Resident #89) is concerned he might break them (the nails) while the CNA's are performing his cares. Resident #89 nodded agreement with Family Member O's statements.

Based on observation, interview and record review, the facility failed to ensure supervision or assistive devices for 3 residents (sampled Residents #1, #2 and #4), who were assessed to be at risk for falls of 9 residents reviewed for falls and who had previous falls at the facility of a total sample of 16 residents, resulting in a fracture, head injury, hospitalization and severe pain. Findings Include: Resident #2: Review of the Face Sheet, Minimum Data Set ((MDS) dated [DATE], nurses' and physician note's, dated 5/17 through 8/1/17, and hospital records, dated 5/26/17, revealed Resident #2 was a [AGE] year-old male, confused and unable to make his own healthcare decisions, admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #2 fell at the facility on 5/26/17 and was transferred to the hospital for evaluation which revealed a fracture of his left shoulder with head injury. Review of the Fall Triggers and Fall Scene Investigation Report, dated 7/25/16, revealed Resident #2 had fallen in the bathroom with the conclusion revealing he had a UTI (urinary tract infection). Resident #2 had a known history of falling at the facility. Review of Resident #2's psychosocial care plan dated 5/8/17 (prior to 5/26/17 fall), stated Problem: yelling/swearing in anger; physical aggression (hitting, kicking, etc.) placing feet firmly on ground (removing from foot rests) in effort to stop staff from pushing W/C (wheelchair). Observations of Resident #2 were made on 8/1/17 at 9:00 a.m. and 11:05 a.m., he was in his bed, mouth breathing and was unable to respond to questions when asked by this surveyor. The resident was receiving hospice services at the time of the investigation (8/1/17 through 8/3/17). Review of the facility Accident/Incident report, dated 5/26/17, revealed on 5/26/17 at 11:20 a.m., Resident #2 was observed by staff in his room on the floor. Review of the Accident/Incident report (5/26/17), stated observed patient on floor of bed on left side with head distal to this nurse, moderate amount of bright red blood noted by head, lacerations to left head above left eye, transferred to (hospital). CNA (staff member H) transported patient from bathroom to bedroom in wheelchair after toileting. Patient put feet down while wheelchair was in motion and fell forward. Patient to have leg peddles on when transporting in wheelchair. Review of the Root Cause Analysis (dated 5/26/17), stated Resident planted his feet on the floor while being transported in the W/C (wheelchair), facility wide in service regarding W/C pedal management. Review of the facility nurses' notes, dated 5/26/17, stated Transferred to emergency room , fall related, major injury. During an interview done on 8/1/17 at 12:05 p.m., staff member H (Nursing Assistant/CNA) stated in the hallways we know the peddles need to be on, but if in the bathroom, we are not told to put the peddles on, the policy (foot pedals) was made after the fall (the fall on 5/26/17). He (the resident) needed to go to the bathroom, we got him off the toilet, cleaned him up. I was getting him ready to leave his bathroom, he was in the wheelchair, he drug his feet down on the floor. He stopped his wheelchair. I got down eye level and told him I needed him to pick his feet up and he did it again and he fell forward. He was dragging his feet down before. If you put foot pedals on when he is in the bathroom, it would start his behaviors and it would last all day long. I was behind his chair, he fell on his shoulder. It has been three weeks since he's been up out of bed, since the resident's return from the hospital after his fall, he had been bed bound. During a phone interview done on 8/1/17 at 2:05 p.m., staff member I (Charge Nurse, RN) stated I was in another room when I came in he was on the floor, the aide (CNA, staff member H) was pushing him out of the bathroom and he fell forward. When this surveyor asked staff member I if the residents fall (on 5/26/17) could have been prevented, she stated yes, I am being honest, yes, he should have had the foot pedals on (had the foot pedals on the wheelchair). During an interview done on 8/1/17, staff member C (Assistant Director of Nursing/ADON) stated we don't have a foot rest policy. Review of the Internal Memo dated 5/26/17, stated Message regarding attention: Wheelchair pedals MUST be on wheelchairs when residents are being transported unless care planned otherwise. Review of the hospital Discharge Summery, dated 6/9/17, revealed Resident #2 was admitted to the hospital from the facility after a fall on 5/26/17 and discharged from the hospital back to the facility on [DATE] (a total of 14 days) and stated The patient (Resident #2) is a [AGE] year-old white male who was admitted to the hospital after he fell , sticking his forehead, left shoulder and left hand. The patient was on anticoagulation and had significant bleeding. The patient had x-rays performed and was evaluated by the orthopedic surgery for [REDACTED]. Presently, the patient was found to have a urinary tract infection as well as severe anemia. He was dehydrated, did not eat well, but within the last couple of days he has improved. He does have protein calorie malnutrition. Review of the hospital records, dated 5/28/17, stated The patient is a [AGE] year old white male who was admitted after falling, having hypoxia (low oxygen), confusion, sticking his head requiring sutures. The patient was in his room and found on the floor after he had fallen out of his wheelchair, struck on the corner of a nightstand. He has a large laceration over the left anterior frontal scalp. He has multiple contusions and bruises over his knees, left shoulder, left hand and arms. Review of the hospital records, dated 6/2/17, stated UTI (urinary tract infection), with multidrug resistant Pseudomonas and MRSA, status [REDACTED]. The patient (Resident #2) had fallen, breaking his left acromion with severe pain and bruising in the left shoulder. Review of the hospital record, dated 6/2/17, stated The patient is a [AGE] year old male who has become more and more confused. The patient had fallen, breaking his left acromion with severe pain and bruising in the left shoulder. Review of the hospital x-ray, dated 5/26/17, stated high riding humeral head compatible with chronic rotator cuff tear, nondisplaced fracture base of the acromion (fracture of the left shoulder). Review of the physician order, dated 6/5/17 (return from the hospital) stated readmit, Dx (diagnosis): UTI, Fx (fracture) of the acromion left shoulder, shoulder sling while up, change drsg. (dressing from head injury) daily. Review of the facility physician note, dated 6/12/17, stated Pt. (patient) quiet, he took some meds today, recently dc'd (discharged ) from hospital. Review of the facility Disciplinary Report for staff member H (Nursing Assistant/CNA) stated CENA (CNA) transferred resident with 1 assist knowingly, resident 11 (2) assist for transfers. Review of the facility written education for staff member H (CNA), dated 6/1/17 (for incident of fall on 5/26/17), stated in order to prevent a similar occurrence from happening again, I plan to implement (the facility's) wheelchair footrest policy now and in the future. Review of the facility Training Checklist (orientation CNA checklist) dated 11/23/14, revealed staff member H (CNA) was trained and skill checked on resident transfers. Resident #1: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected that Resident #1 was an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS, dated [DATE], for the Brief Interview for Mental Status (BIMS), reflected a score of 7 out of 15 which represented moderate cognitive impairment. Resident #1 limited required staff assistance with all activities of daily living. According to the incident dated 2/14/17 at 7:05 AM, Resident #1 was found on the floor in her room. Resident #1 sustained 2 lacerations to the forehead that measured 5.8 cm and 1.9 cm. Resident #1 was sent to the ER for further evaluation and closure of the lacerations. On 8/3/17 at approximately 12:00 PM, the ADON C and the NHA A were interviewed regarding the fall. The facility provided an investigation of the fall which reflected that the facility identified a staffing concern related to the incident. The ADON A stated that the fall happened at shift change and they discovered that there was no CNA assigned to care for Resident #1 from 11 PM - 7 AM. The ADON A stated that the nurse had provided pain medication around midnight and no CNA had checked Resident #1 after midnight and before the fall at 7:05 AM. The ADON C and NHA A stated that all residents should be checked at least every 2 hours. Resident #4: Resident #4 according to the admitting and discharge record dated 8/1/2017 had [DIAGNOSES REDACTED]. Brief interview for mental status from the minimum (MDS) data set [DATE] was 14 indicating cognitively intact. Review of the medical record revealed the resident experienced falls in the facility on 5/21/2017, 5/27/2017, 6/21/2017, and 6/22/2017. After the fall on 5/27/2017 the facility implemented a chair alarm for resident #4 as noted on the corrective action section of the 5/27/2017 incident report. Per the incident reports on 5/21/2017 and 5/27/2017 resident #4 had self-transferred. The incident report dated 6/21/2017 at 7:50 AM, indicated that the resident self-transferred from recliner chair to her walker and then self-ambulated from the day/common/living room area (located across from the nurses' station at the opposite end of the hall from the resident's room) to her room's bathroom (room 102-A). For the fall event that occurred on 6/21/2017 the incident report dated 6/21/2017 indicated in the corrective action section to make sure alarm and dysom are in recliner chair, and on the post fall assessment and investigation form on page 2 dated 6/21/2017 N/a (not applicable) was indicated for the questions of If an alarm was used, was it functional prior to the fall? and Did staff respond to the alarm?. In an interview with Unit Coordinator Registered Nurse J on 8/22/2017 in the conference room at 8:22 AM, she reported that the chair alarm should have been in place in the recliner chair in the day room on 6/21/2017 and on any chair resident #4 sat in anywhere in the facility. Registered Nurse J confirmed the chair alarm was in effect from 5/27/2017 through 7/28/2017 and resident #4's preferred places to sit were a recliner in the day room as well as the recliner in her room. The minimum (MDS) data set [DATE] indicated self-performance for transfer required extensive assistance which meant staff was to provide weight-bearing support, self-performance for walking in corridor (with walker) required limited assistance which meant staff was to provide guidance, and self-performance for toilet use required extensive assistance which meant staff was to provide weight-bearing support. The fall in room 102 a-no injury form account of event completed by registered nurse J dated 6/22/2017 indicated staff intervened after resident #4 had self-ambulated to the bathroom, self-toileted, self-lowered to the floor, and then she had pulled the bathroom call light for help. No documentation of staff supervision or assistance was available to indicate staff helped resident from recliner chair to her walker, to her bathroom, or with toileting. The chair alarm intervention put in place by the facility was not on the recliner chair on 6/21/2017. The resident proceeded to self-transfer and then self-ambulate to her bathroom where she fell . Staff intervened when she pulled the call light in her bathroom, but couldn't respond to a chair alarm in the day room as it was absent. The chair alarm, if it had been in place, had the potential to alert staff and ultimately decrease the fall risk.

This citation pertains to MI# 278 Based on observation, interview and record review, the facility failed to prevent a fall during a Hoyer lift transfer to 1 out of 4 total sampled residents (#101) resulting in serious injury, fracture and necessitating emergency room treatment. Findings include: Record review of Resident #101's 'Accident/Incident Report' dated [DATE] at 10:10 AM revealed the nurse was called to Resident #101's room by Certified Nurse Assistant (CNA) #4. "The nurse entered room and observed Resident #101 lying on his right side facing the doorway. Resident's right waist observed over the top of the legs of the mechanical lift. Resident's head at the foot of the bed and noted blood on the floor under his head, quarter size moon shaped laceration noted to the right post side of head. Pressure applied, bleeding stopped ". The accident/incident report noted major injury and treatment ordered. Observation on [DATE] at 8:50 AM revealed room #318 ( Resident #101's room) was located at the far end of the hall away from the nursing station. Observation of room #318 revealed a private room with adjoining bathroom and a window facing the north street side of the building and hard smooth flooring. Record review of Resident #101's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with unclear speech that was sometimes understood, he had signs and symptoms of delirium behavior that were continuously present and had altered level of consciousness (lethargic, stuporous) that did not fluctuate. His functional status assessment was a transfer of total dependence (full staff performance every time) with support of one person assist. Functional status from the assessment regarding his balance during transitions of moving from surface to surface (transfer between bed and chair or wheelchair) , "as not steady, only able to stabilize with staff assistance". Active [DIAGNOSES REDACTED]. Record review of Resident #101's care plans with print date of [DATE] revealed the resident to be a total lift and 2 people assist with medium sling. Interdisciplinary care plan interventions form noted that on [DATE] Resident #101 was changed to a total lift with one assist and discontinued the two assist. Record review of Resident #101's updated care plan dated [DATE] related to debilitated state noted the approach for nurse aide to transfer with total lift and 1 assist with medium sling. Record review of Resident #101's cardex care guide with multiple dates (carded multiple dates) revealed a total lift with one person assist. An interview on [DATE] at 10:15 AM with Certified Nurse Assistant (CNA) #4 revealed that on [DATE] at 10:10 AM CNA #4 washed Resident #101 and got the resident dressed. CNA #4 stated that she got the lift sling, a beige medium size and the mechanical lift machine. CNA #4 stated that she placed the sling under Resident #101 and pulled the sling leg portions through his legs and crossed them. CNA #4 stated that she was the only CNA in the room and that Resident #101 was a one person mechanical lift transfer. CNA #4 demonstrated how she used the mechanical lift on [DATE] with Resident #101. She showed how she hooked up the black straps at the shoulders, the beige straps at the legs, she used the remote control to activate the lift while giving Resident #101 the thumbs up as he was lifted off the bed and pulled the lift away from the bed. CNA #4 explained that when she pulled the lift away from the bed, the sling rotated, Resident #101 faced her with his feet pointed toward her. CNA #4 stated that Resident #101 suddenly started to fall forward; the right side leg sling hung down; it was not hooked to the sling bar. CNA #4 continued that the resident slid right out of the sling, landed hard on his right shoulder and hitting his head on the floor. His legs laid across the lift and started saying, "Help me, Help me". CNA #4 could not recall if she checked the strap that needed to be hooked to the sling bar. CNA #4 explained to this surveyor that the sling strap must have been resting on top of the sling bar hanger. CNA #4 stated, " I had transferred Resident #101 before lots of times". CNA #4 stated that she had cared for Resident #101 for 2 ,[DATE] years on and off. CNA #4 stated that she started screaming for help. CNA #4 stated that Registered Nurse #5 came into the room, assessed him and removed the lift machine from under him. CNA #4 stated that another CNA came with a bath blanket which they placed under Resident #101 and did a four person lift from the floor to the gurney. CNA #4 stated that no back board or neck brace were used during transfer post trauma. CNA #4 stated that Resident #4 complained of left shoulder pain and there was blood on the floor coming from his head. CNA #4 stated that Resident #101 was immediately taken on the gurney to the hospital next door. Record review of Resident #101's Certified Nurse Assistant charting on [DATE] at 2:56 PM revealed, "... transfers the resident required one person physical assist to transfer the resident, with no self-performance. Total mechanical lift during transfer the strap came un hooked from EZ lift causing resident to fall out. Licensed staff notified ". An interview on [DATE] at 10:55 AM with Registered Nurse #5 revealed that she had just finished her morning medication pass around 10:00 AM, was sitting at the nursing station when she heard someone yell for help. RN #5 went down the East hall to room #318. RN #5 stated that she walked into the room, saw Resident #101 facing the doorway, lying on the floor with the legs of the hoyer lift machine under him at the waist on his right side with his shoulder and head on the floor. RN #5 noted there was blood on the floor coming from his head. RN #5 stated that gauze and pressure were applied to the head wound and the lift was removed from under the resident. RN #5 stated that Resident #101 was rolled onto a blanket and fireman style lifted on a gurney and taken to the emergency room by staff. RN #5 stated that assessed Resident #101, applied gauze to the back of the head for a laceration the size of a quarter and a swelling the size of a goose egg. RN #5 stated that Resident #101 came back from the emergency room at 1:30 PM with laceration to head with staples and a fractured left humorous (arm). Record review of the 'EZ Way Smart Lift' manufactures 'Operator's instructions' manual (undated) revealed step by step instructions on how to transfer a resident from a bed to a wheelchair. It stated, Step #3 Attaching the sling to the lift, step #4) Make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars. Patient is now ready to be lifted. Record review of Resident #101's 'emergency room physicians record' dated [DATE] at 10:52 AM revealed fall during lift assist transfer, pain right side and both shoulders. History of present illness noted, 'Pt. c/o (complained of) roll out of Hoyer (mechanical) lift at (facility). Complained of right and left shoulder pain and right rib pain and scalp laceration. Fall description of 3 feet from Hoyer (mechanical) lift". Record review of x-rays dated [DATE] for unilateral ribs impression: "Multiple right rib fractures involving right third through ninth ribs are noted in the lateral aspects and which are most likely old fractures. Underlying acute fractures cannot be entirely excluded. Review of left shoulder x-ray dated [DATE] impressions old/acute fracture dislocation of left humorous neck". Record review of Hospice 'Clinical Note-Nursing' dated [DATE] by the hospice nurse visit from [DATE] at 11:45 PM through [DATE] at 1:30 AM revealed the following vital signs: temperature of 98.1, pulse 96, respirations 36 and blood pressure ,[DATE]. Pain assessment of nonverbal signs for pain, "grimace with movement of left UE (upper extremity) by furrow on brow. Current pain medication regimen Roxinal (morphine pain medication) last dose given at 8:20 AM. Plan of care listed the problem, change of respiratory status after fall sustained yesterday ([DATE]) ". In an interview on [DATE] at 1;00 PM with Director of Nursing Registered Nurse #2 revealed that the facility did not have a mechanical lift policy, but followed the manufacturer's operating instructions. Record review of Hospice 'Death Event Record' dated [DATE] revealed that Resident #101 was pronounced deceased by facility staff at 6:35 AM and that the body was released to the funeral home. Record review of Resident #101's 'Certificate of Death' dated [DATE], signed by the attending physician at the long term care facility revealed cause of death as Alzheimer's. No autopsy was performed. ( )