Every finding on record at Kalkaska Memorial Health Center

This deficient practice pertains to Intake 3005509.Based on observation, interview, and record review, the facility failed to prevent, detect, and respond to an elopement resulting in the likelihood of serious harm, injury, impairment, or death for one Resident (#1) of three residents reviewed for elopement.Findings include:Resident #1 (R1)Review of the FRI submitted to the State Agency (SA) on 4/30/26 at 9:44 PM, included an investigation report which read, in part: On Thursday 4/30/26 at approximately 8:23 PM LPN (Licensed Practical Nurse) A was alerted by [Hospital Name] reception desk who was notified by the [City Name] Police Department that they had picked up (R1) kneeling alongside the road near the (local restaurant/grocery store).Time the resident was last seen by facility staff members 4/30/26 at 6:40 PM by Certified Nurse Aide (CNA) B.(R1) was observed via camera footage to have exited the facility on 4/30/26 at 7:09 PM. He walked from his chair located near the nurses' station facing the doors on [unit name] that exit into the lobby area. He then proceeded through the next 2 sets of double doors onto the sidewalk of the [unit name] (R1) wearing a (name brand elopement alert device) bracelet on his left wrist. He exited out of the door furthest from the (name brand elopement alert device) sensor with his left arm on the other side of his body from the sensor. The alarm did not sound and was not activated.once outside (R1) proceeded to walk to the left of the exit/building.when resident (R1) approached the stop sign.he cut across the grass area in front.and continued walking down the street passing the stone house and [Hospital Name] entrance of the hospital. He was then lost from camera view. The investigation indicated R1 was located in a compromised position near a roadside that has constant road traffic and the speed limit increases to 55 miles per hour. This road also serves as the main road in and out of the city the facility is located.The Immediate Jeopardy began on 4/30/26 at 7:09 PM when R1 eloped from the facility undetected and was found kneeling alongside a busy street and had been missing for approximately one hour and fourteen minutes. R1 was discovered by an external entity emergency personnel after a phone call was placed by a community member around 7:45 PM. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 5/13/26 at 3:14 PM. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 4/30/26 and the deficient practice was corrected and monitored since 5/1/26, prior to the start of the survey and was determined to be past noncompliance.Review of R1's electronic medical record (EMR) revealed admission to the facility on 9/10/25 with diagnoses including Alzheimer's disease, schizophrenia, and dementia with agitation. Review of R1's Minimum Data Set (MDS) assessment revealed a score of 3/15 for the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of R1's Elopement Evaluation, dated 3/16/26, revealed a score of 2, indicating R1 was, at risk of elopement.Review of R1's Physician Orders for April 2026, revealed the following orders: Elopement Evaluation one time a day q (every) 3 months on 15th (active 3/15/26) Resident is at risk for elopement, verify placement of (name brand elopement alert device) q shift. If (name brand elopement alert device) is missing replace if you are unable to replace initiate a 1:1 (one to one) until one is obtained (start date 11/19/25; discontinued 5/2/26). Review of the April Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed ten missed documentations of wander guard placement, including the night of 4/30/26 for R1. On 5/13/26 at approximately 12:45 PM, the location where R1 was sitting at the time of the elopement was observed near the front entrance of the facility. Where R1 was sitting was approximately 10-15 feet away from the set of doors that led to a lobby area. All three doors observed did not have a delayed egress. A witness statement from LPN A was reviewed by this Surveyor as she was unavailable for interview during the survey. LPN A wrote, I came on shift at 18:00 (6:00 PM), received report from 200 hall nurse, then 100 hall nurses. While counting the 200-hall cart I observed (R1) sitting by the nurses' station outside the day room.At approximately 8:23 PM.reception called and this nurse answered the phone.stated that dispatch had just phoned and that the police had (R1) with them.it was verified that the patient was (R1).A witness statement from LPN B was reviewed by this Surveyor as he was unavailable for interview during the survey. LPN B wrote, (R1) was observed sitting in front of nurse's station in chair at shift change from around 6:00 PM. Resident observed again sitting chair while (nurse) doing narcotic count of 200 and 300 cart at 6:20 PM.I did not see (R1) exit the doors and I did not hear the (name brand elopement alert device) alarm.Review of R1's EMR revealed the following progress notes highlighting a history of exit-seeking behavior:1. 2/12/26 at 2:39 AM: At approximately 2100 (9:00 PM), patient was observed packing his clothing into a paper gift bag in his room. When asked why he was doing so, patient replied to CNA that he was going somewhere tomorrow. Pt (patient) left room with his things in a bag and was stopped at nurses' station and asked where he was going. (R1) became frustrated and said that the clothing was his things, and he was 'tired of it'. 2. 4/19/26 at 7:45 PM: (R1) has had increased wandering during shift and has expressed multiple times to staff that he is leaving. During shift resident was opening doors and attempting to follow visitors out of the building. 3. 4/20/26 at 10:33 PM: (R1) agitated and stating he is going to head out the doors.He attempted to go through entry doors and was redirected towards his room. (R1) then set alarm off at end of 300 hall exit doors. (R1) yelled at staff and paced around unit.4. 4/21/26 at 4:14 AM: (R1) came out and sat at the chairs in front of the nurse station. Staff asked him how he was doing and resident became agitated. (R1) stated 'I want the f*** out of this place. (R1) then started following CNA down to a room they were going into.5. 4/22/26 at 6:14 AM: Recent reports of (R1) sundowning at night by staff, it was reported that he was yelling out and threatening to beat staff up, he was also wandering more and going into other rooms.staff report that he is easily angered lately which is not usual for him. Res (resident [R1]) recently had melatonin d/c'd (discontinued) due to him sleeping well. PA [Physician Assistant] will be restarting this med (medication).Will follow up with res and staff in 1 week to see any effect from the melatonin. Review of R1's EMR revealed the following progress note written on 5/1/26 at 2:50 AM:Approx. (approximately) 2023 pm (8:23 PM) [Staff Name] from reception called and told this nurse that dispatch called and the police department brought in (R1). [Staff Name] stated he had an ID bracelet on and thought he might be one of our residents. [Staff Name] stated the police found him on the roadside confused. This nurse informed 300 hall nurses of incident, and this nurse and 300 hall nurses went to the E.D. (Emergency Department) and verified that it was (R1) our resident.DON (Director of Nursing) contacted by 300 hall charge nurses immediately. On 5/13/26 at 11:00 AM, an interview was conducted with Registered Nurse (RN) C, who stated she was R1's morning nurse on 4/30/26 and started working at the facility around 3/10/26. RN C was asked of R1's Physician Order to check the placement of his (name brand elopement alert device). RN C stated she assumed the order was meant for nurses to see if R1 had his (name brand elopement alert device) on his wrist. RN C confirmed she never checked the functioning of R1's (name brand elopement alert device).An interview was conducted with the DON and Nursing Home Administrator (NHA) on 5/13/26 at 11:35 AM. The DON and NHA stated checking the (name brand elopement alert device) for function was a task for CNAs. When asked for documentation of R1's (name brand elopement alert device) was being checked for placement and function, the DON and NHA stated they were unable to pull those records from R1's EMR. The NHA confirmed the maintenance department had also not performed a monthly checking system of the (name brand elopement alert device). The DON and NHA also confirmed R1's(name brand elopement alert device) did not properly sound on 4/30/26 when R1 eloped from the facility.Review of the facility's Alarm Use policy dated 5/23/25 read, in part, It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being.The use of alarms does not eliminate the need for adequate supervision of the resident. Types of alarms include:.Wander/elopement alarms - includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exits an area or building.Each resident shall be assessed for fall and elopement risk upon admission and periodically thereafter as part of the comprehensive assessment process.Resident directed approaches shall be implemented in accordance with the resident's needs, goals, and preferences.Supervision shall be provided to the resident in accordance with the resident's plan of care. When alarms are utilized, additional monitoring shall be provided, including but not limited to: Verifying alarms are used in accordance with the resident's care plan, verifying alarms are working properly.The (name brand elopement alert device) battery will be checked daily and this will be documented. The Immediate Jeopardy that began on 4/30/26 was removed on 4/30/26 when the facility:1) The front door which does not alarm if exit is attempted unless the (name brand elopement alert device) is functioning was immediately placed on 1:1 staff supervision for any resident attempting to exit. 2) Head count was conducted and confirmed by DON upon notification of the incident. 3) R1 was moved to secure units with delayed exit doors which alarm upon return from ED.The deficient practice was corrected on 5/1/26 after the facility: 1) Residents assessed to be an elopement risk and able to exit without staff assistance moved to a secured unit with alarming doors and delayed exit. 2) Resident care plans updated to reflect elopement risk and need for secured unit. 3) Education to all staff on new elopement risk policy and procedure.

This citation pertains to intake 2692547Based on observation, interview and record review the facility failed to monitor and assess three residents (R1, R2, and R3) for safety with hot liquid beverages. This deficient practice resulted incomplete assessments for safety of handling hot liquid beverages for R2 and R3, and resulted in harm when R1 sustained second degree burns from a hot coffee spill . Findings include:R1Review of R1's Electronic Medical Record (EMR) revealed admission to the facility on 9/12/25 with diagnosis including Alzheimer's disease, vascular dementia with behaviors, and weakness. R1's 10/1/25 Brief Interview for Mental Status (BIMS) score was a 4/15 indicating severe cognitive impairment.Review of the 'Facility Reported Incident' read, in part, On December 5th, 2025, at approximately 10:30 AM, (R1) was attending an activity in the activity room located on the Legacy unit. During the activity the residents were having coffee and using the Keurig located in the activities room for the brewing. The coffee was prepared and handed to (R1) across the table by the activities staff member. This was served in a regular cup, with no lid or ice added per (R1s) dietary instruction on his card. (R1) then knocked the cup over causing it to spill into his lap, left arm and left thigh area.An interview was conducted with the Activity Aide/Staff A on 1/2/26 at 12:30 PM. Staff A stated on 12/5/25 she had prepared R1 a cup of coffee from the Keurig, placed it on the table, and assisted R1 to the table using the wheelchair. Staff A confirmed that they had not placed a lid on R1's cup of coffee. Staff A then turned her back to R1 to continue making coffee for different residents but heard R1 say something. Staff A stated that she turned back and realized R1 had spilt coffee on himself.An interview was conducted with the Nursing Home Administrator (NHA) on 1/2/25 at approximately 10:30 a.m. The NHA confirmed staff do not take temperatures of hot liquid beverages that are dispensed through the Keurig machine in the activity room. The NHA stated that the activities director was asked to temperature check the Keurig and obtained temperatures of 178.7 and 177.6 just after brewing.On 1/2/25 at approximately 1:15 p.m., an interview and observation was conducted with R1, who stated he couldn't remember exactly what happened, but knew that it hurt. R1 revealed his abdomen which showed a 10 centimeter (cm) by 3 cm burn.Review of the facility's Hot Liquid Safety in Long Term Care and Swing Beds. Effective 7/17/24 read in part, .Food Service Responsibilities: A) Serve hot beverages between 140 degrees Fahrenheit and 160 degrees Fahrenheit.LTC (long term care) Staff Responsibilities.Provide education to staff members to monitor the individual needs of residents who need extra assistance.General safety precautions when serving hot liquids include, but are not limited to:.All residents will be provided a hard plastic lid on their cup of choice that has a handle.R2Review of R2's EMR revealed admission to the facility on 3/24/18 with readmission on [DATE] and diagnoses including vascular dementia. R2's 11/4/25 BIMS score was 8/15 indicating mild cognitive impairment.R2 was noted by the NHA to use the Keurig machine located in the activity department during coffee hour activities.Review of R2 Hot Liquid Evaluation revealed a completed assessment on 7/29/25 with no further assessments since the survey exit date of 1/2/25R3Review of R3's EMR revealed admission to the facility on 9/28/23 and readmission on [DATE] with diagnosis including rheumatoid arthritis. R3's 12/2/25 BIMS score was 13/15 indicating they were cognitively intact.Review of R3's assessments revealed no completed hot liquid assessment since admission or readmission to the facility.Review of the facility's Hot Liquid Safety in Long Term Care and Swing Beds. Effective 7/17/24 read in part.All residents should be assessed for their ability to handle and consume containers of hot food and beverage on admission, quarterly, annually, and when there is a significant change in the resident's status.

Based on interview and record review, the facility failed to notify a resident's Power of Attorney (POA; a legal document that authorizes a trusted person, called an agent, to make legal, financial, and/or medical decisions on their behalf) of a change in condition in a timely manner for one Resident (#3) of three residents reviewed for notification of changes. This deficient practice resulted in an 8-hour delay in notifying the POA of the resident's significant change in condition and the potential for delays in treatment.Resident #3 (R3)A review of the Electronic Medical Record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses including dementia with unspecified severity and other behavioral disturbance. On 5/9/25, R3 was given a BIMS (Brief Interview for Mental Status) score of 5 out of 15 indicating severe cognitive impairment. R3 also had a POA for medical care and financial decisions appointed to their daughter.The progress notes on 10/5/25 at 1:21AM indicated R3 was found by staff sitting on floor next to bed. Resident (R3) stated he went to sit up at edge of bed and slipped off.resident (R3) while sitting at bedside stated his left hip hurt.received order for x-ray for bilateral hips and pelvis . R3 was taken for x-rays at the hospital and diagnosed with displaced fractures of the left superior and inferior pubic rami (a break in two of the bones that form the front part of the pelvis).On 10/16/25 at 12:50PM, a phone interview was conducted with the POA for R3, who stated they had not been called the night R3 fell. The POA stated they would have liked to have been there for their father stating they believed R3 must have been confused, and scared. The POA felt that her presence would have calmed R3 and alleviated any fears. The POA stated the facility called on the morning of 10/5/25 after the day shift nurse came on.Certified Nursing Assistant (CNA) D stated they were working the night R3 fell. During a phone interview on 10/16/25 at 1:54PM, CNA D stated nursing staff were supposed to notify families when there is a change in condition.A phone interview was conducted on 10/16/25 at 2:27 PM with LPN F who was working the night R3 fell, stated they did not call R3's POA.A review of the facility's Post Fall Documentation indicated R3 fell on [DATE] at 10:45PM. The section labeled Document family member notified along with time/date indicated R3's POA was notified on 10/5/25 at 7:05AM. This documentation lacked any family/POA notifications at time of R3's fall. This resulted in the guardian not being informed of the resident's significant change in condition for over 8 hours, potentially delaying decision-making and necessary interventions.The NHA stated, during an interview at 2:40 PM on 10/5/25, the facility does not have a specific policy about notifications for change in condition.

This citation pertains to intake: 2621196Based on interview and record review, the facility failed to follow fall interventions for one Resident (#4) of five residents reviewed for falls. This deficient practice resulted in a fall with major injury requiring surgery. Findings include: Resident #4 (R4)Review of R4's Electronic Medical Record (EMR) revealed admission to the facility on 6/25/24 with diagnosis including above right knee amputation, dementia, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of R4's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating R4 was cognitively intact. Section GG of the MDS showed R4 required max assistance for toileting and transfers. R4's Fall Risk Evaluation dated 11/21/24 showed a score of 13, indicating a high risk for falls.Review of R4's Progress Note dated 9/9/25 and 9/10/25 read, in part, Approx. (approximately) 9:40 p.m. this nurse called to (R4's room) resident was laying on the floor on her back, resident stated she was on the toilet and stood up by herself to grab a brief and lost her footing and fell.Resident assessed and c/o (complaint of) right hip pain, this nurse phoned E.D (Emergency Department) and gave report.and this nurse sent resident to the E.D. for x-rays and evaluated [sic].fall was unwitnessed. 9/10/25 Approx. 12:20 a.m.,.E.D. called this nurse and resident does have a fractured right hip and is being transferred to [Hospital Name].A witness statement from Certified Nurse Aide (CNA) A dated 9/9/25 read, in part, I had gone into (R4's) room and told her I would be in ASAP (as soon as possible) to get her in the bathroom. It was super busy and I was way behind. I was also trying to get help to turn [Resident room number].I didn't want (R4) to have to wait any longer so I put her in the bathroom and went to [Resident room number] with CNA B. CNA B walked out and went straight to (R4) and found her on the floor.Review of R4's Care Plans read, in part, .The resident is AT risk for falls r/t (related to ) deconditioning dx (diagnosis) right AKA (above knee amputation).Do not leave alone in BR (bathroom) date initiated 10/10/24When CNA A was asked by facility staff if they were aware of R4's care plan intervention to not leave alone in the bathroom, CNA A stated she was not.An interview conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 9/19/25 at approximately 10:45 a.m. confirmed that CNA A did not follow R4's care plans which contributed to R4's fall and fracture.

Based on interview and record review, the facility failed to ensure written consent and education was provided prior to administration of psychotropic medications for 5 Residents (#3, #8, #9, #40, & #72) of 5 residents reviewed for psychotropic consents. Findings include:Resident #9 (R9) A review of R9’s Electronic Medical Record (EMR) indicated R9 was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbance. Review of R9’s orders indicated a physician order on 12/1/25 for “RisperiDONE (an atypical antipsychotic thought to work on certain parts of the brain) 0.5 mg (milligrams) Give 1 tablet by mouth two times a day for dementia w(with)/ BPSD (Behavioral and Psychological Symptoms of Dementia) replaces 1 tab daily d/t (due to) failed GDR (Gradual Dose Reduction) w/ relapsed verbal/physical agitation.” Further review of R9’s EMR indicated R40 had a legal guardian (a person appointed by a court to make decisions and care for another individual who is unable to do so themselves, whether due to age (minor) or incapacity (due to disability or other reasons)) responsible for her care within the facility. The EMR revealed psychotropic medications were initiated or continued without documentation of signed informed consents. There was no evidence in the EMR indicating risks, benefits, and alternatives to this medication were discussed with R9 and/or their guardian, and no consent forms were present in the clinical records. Resident #40 (R40) A review of R40’s EMR indicated R40 was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbance. Review of R40’s orders indicated a physician order on 7/22/25 for “RisperiDONE Tablet 0.25 MG Give 1 tablet by mouth in the morning for dementia w/ bpsd replaces 0.5mg d/t stable bpsd and weakness w/ dysphagia ADR (Adverse Drug Reaction) AND Give 3 tablet by mouth at bedtime for dementia w/ bpsd give 0.75mg total.” Further review of R40’s EMR indicated a Durable Power of Attorney (DPOA, a legal document that allows a person to designate another person to make medical decisions on their behalf if they become unable to do so themselves due to illness, injury, or other circumstances.) was activated and in place for decision making in R40’s care within the facility. The EMR revealed psychotropic medications were initiated or continued without documentation of signed informed consents. There was no evidence in the EMR indicating risks, benefits, and alternatives to this medication were discussed with R40 and/or their DPOA, and no consent forms were present in the clinical records. On 7/30/25 at 10:32 AM, requested medication consents for R9 and R40 from the NHA (Nursing Home Administrator) and the DON (Director of Nursing), no medication consents were provided. Resident #8 (R8) Review of R8’s Minimum Data Set (MDS) assessment, submitted 5/2/2025, revealed initial admission to the facility 8/3/2020 with diagnoses including dementia with behavioral disturbance, anxiety disorder, and major depressive disorder. Review of R8’s July 2025 medication administration record (MAR) revealed the resident was actively prescribed and receiving the following medications Cymbalta Oral Capsule Delayed Release Particles [an anti-depressant medication], 20 mg [milligrams] with a start date of 11/7/24. Alprazolam 0.25 mg tablet [an anti-anxiety medication] with a start date of 4/22/25. Olanzapine 15 mg tablet [an antipsychotic medication] with a start date of 3/18/24. A review of R8’s EMR revealed no informed consent for Cymbalta, Alprazolam, nor Olanzapine. On 7/30/25 at 10:32 AM, psychotropic medication consents were requested for R8 from the NHA (Nursing Home Administrator) and the DON (Director of Nursing). No medication consents were provided by the time of survey exit. Resident #72 (R72) Review of the EMR revealed R72 was admitted to the facility on [DATE] and had diagnoses including Parkinson’s disease, dementia with psychotic disturbances, and major depressive disorder. Review of R72’s July 2025 MAR revealed the resident was actively prescribed and receiving the following medications: Wellbutrin XL (anti-depressant medication) 300 mg daily. Start date: 4/1/2024. Nuplazid (anti-psychotic medication) 34 mg daily at bedtime. Start date: 3/11/2025 Trazodone HCL (anti-depressant medication) 100 mg daily at bedtime. Start date: 1/27/2025 During review of R72’s EMR no informed consent for the Wellbutrin, Nuplazid or Trazodone could be located. Review of the physician’s progress note revealed no indication the medication regimen was discussed with the resident nor were there any informed consents completed for R72’s actively prescribed psychotropic medications to the resident/resident representative Resident #3 (R3) Review of the MDS assessment, submitted 5/16/2025, revealed R3 was admitted to the facility on [DATE] with diagnoses including psychotic disorder with delusions and major depressive disorder. Review of R3’s July 2025 MAR (medication administration record) revealed the resident was actively prescribed and receiving the following medications: Effexor XR (anti-depressant medication)150 milligram (mg) daily. Start date: 4/01/2024. Effexor XR 75 mg daily, give with Effexor XR 150 mg for total of 225 mg. Start date: 7/02/2025. Lurasidone HCL (anti-psychotic medication) 80 mg daily. Start date: 4/01/2024. Trazodone HCL (anti-depressant medication) 25 mg daily at bedtime. Start date: 7/01/2025. During review of R3’s EMR no informed consent for the Effexor, lurasidone or trazodone could be located. On 7/30/2025 at 2:41 p.m., the Nursing Home Administrator (NHA) presented a physician’s medication review, dated 4/02/2024. Review of the physician’s progress note revealed no indication the medication regimen was discussed with the resident or of informed consent for R3’s actively prescribed Effexor, lurasidone or trazodone being provided to the resident or her representative. During an interview on 7/30/2025 at 2:26 p.m., the Director of Nursing (DON) and the NHA were asked what the facility’s procedure was for obtaining informed consent for psychotropic medications. The NHA reported the facility had no formal process related to informed consent and discussions with resident and/or resident representatives related to medications were not consistently documented. The NHA confirmed no informed consent was obtained prior to starting psychotropic medications and no information was consistently being provided to residents in writing of the need for psychotropic medications, the potential side effects of the medications or alternative treatments available.

Based on observation, interview, and record review, the facility failed to follow physician orders for an upper extremity orthotic for one Resident (#1) of two residents reviewed for range of motion, positioning, and mobility.Findings include:Resident #1 (R1)Review of R1's electronic medical record (EMR) revealed a most recent admission to the facility on 5/24/25 with diagnoses including cerebral infarction (stroke) and hemiplegia (paralysis) affecting the left side. Review of R1s Minimum Data Set (MDS), dated [DATE], revealed a score of 14 on the Brief Interview for Mental Status (BIMS) assessment, indicative of intact cognition.On 7/29/2025 at 10:59 AM, an interview was conducted with R1 who confirmed he suffered a stroke with resulting deficits to the left side of his body. R1's left hand appeared to be edematous with minimal active movement. When asked about interventions for his left arm, R1 stated he was prescribed a left shoulder sling when out of bed for pain management due to a history of shoulder subluxation (when the head of the upper arm bone slips partially out of the shoulder socket).Review of R1's EMR revealed the following physician order, initiated 5/29/25: [Brand name] Sling should be worn when out of bed only.On 7/30/2025 at 11:47 AM, R1 was observed propelling himself in a wheelchair through the hall with his right arm and leg. R1's left arm was observed laying in his lap, without a sling, appearing edematous. When R1 was asked where his sling was, R1 stated, She [certified nursing assistant (CNA)] didn't put it on me. On 7/30/2025 at 3:09 PM, a follow-up interview was conducted with R1 regarding the location of the sling. R1 stated he hadn't seen this sling since he moved from a different unit on the facility approximately a month prior. When asked if R1 refused to wear the sling he admitted , I don't particularly like it, but I wouldn't refuse it. R1 confirmed he had continued discomfort in the left shoulder.On 7/31/2025 at approximately 7:23 AM, R1 was again observed wheeling down to the dining room for breakfast without a sling applied to his left upper extremity. R1's left arm was laying his lap, appearing edematous. On 7/31/2025 at 9:21 AM, an interview was conducted with Nurse Practitioner (NP) E regarding R1's left upper extremity sling. NP E verified she prescribed the left shoulder sling for increased comfort and support due to the flaccidity of R1's arm. When asked the potential outcomes of not wearing the sling when out of bed, NP E stated, increased pain in the left shoulder, for one. On 7/31/2025 at 9:52 AM, an interview was conducted with CNA F regarding orthotic care needs for R1. CNA F stated R1 had a left arm rest on his wheelchair but was unaware of any other care planned interventions for R1's left upper extremity. On 7/31/2025 at 9:55 AM, an interview was conducted with CNA G who was unaware of any care planned interventions for R1's left upper extremity.On 7/31/2025 at 9:56 AM, an interview was conducted with Registered Nurse (RN) H who stated she was unaware of any care planned interventions or orders for R1's left upper extremity.Review of R1's plan of care revealed no interventions for his left upper extremity.Review of R1's EMR revealed the following progress notes:5/21/25 at 1:20 PM: .Patient may benefit [NAME] [sic] shoulder sling on the left upper extremity.5/28/25 at 10:23 AM: .[R1] is having pain in the left shoulder for which he finds wearing his sling helpful .On 7/31/2025 at 11:14 AM, an interview was conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) who verified orthotics should be provided as indicated by the physician order. The NHA and DON were also made aware the sling was not care planned properly, and the NHA and DON acknowledged it should have been.Review of the facility policy titled, Safety Device Use in Long Term Care, revised 2/18/25, read, in part: Purpose: To provide a process for safety devices used to maximize the independence and the maintenance of health and safety of an individual by reducing the risk of falls and injuries associated with the resident's medical symptoms. Posture devices:. these devices are used to enable a resident maintain proper body alignment. since most of the residents who will have a need for enablers are somewhat dependent on staff and restorative measures to maintain their current level of function, it is important that residents are visually checked regularly.

Based on observation, interview and record review, the facility failed to follow nursing standards of practice for wound care for one Resident (R5) of two Residents reviewed for pressure injuries. Findings include: Review of R5's Electronic Medical Record (EMR) revealed admission to the facility on 1/22/25 with diagnosis including peripheral vascular disease, unstageable pressure ulcer to left heel, and type 2 diabetes. R5 received a 15/15 on the Brief Interview for Mental Status (BIMS) score, indicating she was cognitively intact.On 7/29/25 at 11:05 a.m., R5 was observed sitting in her recliner chair with her left leg placed on top of a folded pillow and a blanket covering her. R5 stated that she was feeling well and confirmed that she had a pressure ulcer on her left heel and was heading to a doctor's appointment at 2:45 p.m. for the wound.On 7/30/25 at 9:54 a.m. an interview was conducted with Registered Nurse (RN) I who stated that R5 will be receiving a wound dressing change at 3:00 p.m. today. An interview with R5 confirmed this Surveyor could observe the wound dressing change. On 7/30/25 at 3:45 p.m. this Surveyor observed the wound dressing change for R5 with RN I and Nurse Technician/Staff J. RN I stated Staff J would be performing the wound dressing change. Staff J confirmed the physician order for R5, gathered supplies and sanitized prior to donning Personal Protective Equipment (PPE) which included gloves and a gown. Staff J entered R5's room and placed a barrier pad underneath residents left lower leg/foot area, removed R5's left shoe, and removed the wrap covering R5's wound placing it in the trash can. It was observed that gauze was still attached to the wound area on R5's left foot. Staff J then took a syringe with saline solution and began to soak the gauze and slowly began to peel it back exposing the wound bed. Once the gauze was fully off the wound bed, Staff J placed it in the trash can and began to apply the new gauze soaked with betadine on the wound. Staff J did not remove her soiled gloves or sanitize hands during the wound observation. After the observation, an interview was conducted with Staff J who confirmed her gloves should have been replaced after taking off R5's shoe and old gauze pad.An interview was conducted with the Nursing Home Administrator (NHA) on 7/31/25 at 10:30 a.m. who confirmed the observation of Staff J not removing soiled gloves was not the facility's standard of practice. Review of the Center for Disease Control and Prevention (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/26/24 read, in part, .When to change gloves and clean hands.If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs.

This deficient practice pertains to Facility Reported Incident (FRI) MI00152479. Based on observation, interview, and record review, the facility failed to prevent, detect, and respond to an elopement resulting in the likelihood of serious harm, injury, impairment, or death for one Resident (#1) of four residents reviewed for elopement. Findings include: The Immediate Jeopardy began on 4/11/25 at 7:17 PM when R1 eloped from the facility undetected and was wandering near a busy street and ambulance garage for approximately 19 minutes. R1 was discovered by external entity emergency personnel wandering near the entrance/exit to the ambulance bays. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 5/1/25 at 4:16 PM. This surveyor confirmed by observation, interview, and record review that the immediacy was removed on 5/2/25 at 11:14 AM, however, noncompliance remains at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA). Resident #1 (R1): Review of R1's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, major depressive disorder with psychotic symptoms, and borderline personality disorder (a mental health condition marked by extreme mood fluctuations, instability in interpersonal relationships, and impulsivity). Record review of R1's most recent St. Louis University Mental Status (SLUMS) examination, dated 4/16/25, revealed a score of 19/30, indicative of dementia. Review of R1's MDS Assessment Sections E and G, dated 3/25/25, indicated R1 exhibited wandering behavior occurring 4 to 6 days per week and was independent with mobility. Review of R1's plan of care identified the following focus, initiated 8/10/24: Risk of Wandering/Elopement Identified with an intervention which read, Wanderguard (an electronic wristband used to notify staff of a resident exiting alarmed doors) in place on walker for elopement concerns . Review of R1's Elopement Evaluation, dated 3/11/25, revealed a score of 5, indicating R1 was, at risk of elopement. Review of the FRI submitted to the SA on 4/21/25 at 7:37 PM, included an investigation report which read, in part: .On 4/11/2025 [Licensed Practical Nurse (LPN) B] called and alerted LTC (long term care) on call manager [Registered Nurse (RN) C] that [R1] had eloped from the facility . Camera footage was obtained, and it was discovered that at 7:17 pm [R1] exited her room and walked to the right and down the hallway. Only a few doors down, [R1] approached the fire exit door which is labeled to hold for exit. [R1] was observed to hold the door until its release, she went through the door and walked to the right - through the second exit door outside of the building. (The door did alarm however it is the far end of the building and staff did not hear the alarm until they were halfway down the hall heading towards [R1's] room) . At 7:23 pm [Certified Nursing Assistant (CNA) D] reported .to [R1's] room .and noted the alarm on the door sounding, she immediately checked the exit (6 minutes after [R1] had exited.) [CNA D] did not see [R1] and she went to inform [RN A] . [RN A] was about to page a missing adult alert when EMS [emergency medical services] called to ask if a resident was missing . [R1] returned to long term care at 7:36 pm . During review of the camera footage we [facility] were able to determine that [R1] did not take her walker which had her Wanderguard attached to it . On 5/1/25 at approximately 9:30 AM, the location of R1's room at the time of the elopement was observed in a back hall, around a corner from the nurses' station where it could not be visualized. Approximately 20 feet from R1's room were a set of doors that led to a vestibule between two units of the facility. Inside the vestibule, a delayed exit door was observed leading to the outside of the facility which read, Keep pushing. This door will open in 15 seconds. Alarm will sound. According to the clinical census, R1's room was in the same location from 11/27/24 - 4/16/25. On 5/1/25 at 3:03 PM, an interview was conducted with LPN L regarding care-planned interventions in the event R1 became exit-seeking. LPN L stated R1 refused to wear a Wanderguard around her wrist so the device was attached to her walker. However, LPN L revealed R1 rarely utilized a walker when walking throughout the facility. LPN L confirmed the set of doors that led to the vestibule where R1 eloped on 4/11/25 were equipped with a Wanderguard sensor, but had not alerted staff of R1's exit because she was not using her walker (which had the Wanderguard attached). Review of R1's EMR revealed the following progress notes highlighting a history of exit-seeking behavior: 1. 10/19/24 at 5:46 PM: Pt [patient (R1)] very agitated all shift Pt [R1] was told she needed to stay in the building. She then tried to exit out the front doors. I encouraged her to call her son which she did. She stood in the front entrance of the building with RN and security while the son was on the phone for over 1.5 hrs [hours] while we tried to coax her back into the building . 2. 11/17/24 at 9:53 PM: [R1] was up wandering around the halls . The resident started to walk out the first double doors by the nurse's station. This nurse quickly closed the med cart and followed resident to prevent an elopement. Resident was easily redirected back inside. This nurse suggested making resident a one-on-one, however, the on-call manager initiated every 15 minute checks. Staff were performing this duty when a CNA saw resident beeline it towards the double doors . 3. 11/26/24 at 11:30 AM: This morning [R1] was going to a dental appointment, and this nurse received a call from the transporter that resident was not being safe, she had taken off down the road after she had verbal confrontation with the transporter . 4. 12/26/24 at 5:07 PM: [R1] attempted to leave facility . 5. 12/28/24 at 5:34 PM: .One episode of exiting seeking where she [R1] was walking out the front door . 6. 3/8/25 at 6:11 PM: [R1] very agitated today with exit seeking behaviors. Resident up walking without assistance. Resident tried to leave the building, this RN stood at the door holding it shut and attempted to redirect . 7. 3/22/25 at 6:54 PM: [R1] successfully exited the facility today. She was unaccompanied and walked out the front door. A CNA saw her leave and she was brought back inside . 8. 3/23/25 at 8:00 PM: Approx. [approximately] 2000pm [8:00 PM] this nurse heard the door alarm going off in the front lobby area. Upon entering the room resident was between the first set of doors and second set of double doors leading to the outside . 9. 3/27/25 at 6:14 PM: [R1] experienced some exit seeking behaviors and agitation this afternoon . 10. 4/9/25 at 11:28 PM: At approx. [approximately]. 2000 [8:00 PM], [R1] attempted to leave the facility. This nurse was talking with resident, trying to redirect her, while she was walking toward the exit . Review of R1's EMR revealed the following progress note written on 4/11/25 at 9:47 PM: At approx. [approximately] 1925 [7:25 PM] staff found resident was not in her room. Staff checked all rooms and common areas and did not find resident. At 1930 [7:30 PM] this nurse was about to call a missing adult code when EMS called asking if we were missing a resident. Staff went over to EMS and brought resident back into facility .Resident has a one on one with staff tonight, as she continues to threaten to leave . On 5/1/25 at approximately 12:05 PM, security footage from 4/11/25 was reviewed with Security Officer F which revealed the following events: 1. At 7:17 PM, R1 was observed exiting the facility via a delayed egress door. 2. At 7:23 PM, CNA D was observed shutting off the sounding alarm, glancing out the door window, and returning to the unit. 3. At 7:27 PM, a group of 4 staff members were observed looking out the door window. 4. At 7:36 PM, R1 was observed entering the facility via the main doors with a staff escort. On 5/1/25 at 1:22 PM, a phone interview was conducted with CNA D who verified she first discovered R1 was not in her room on 4/11/25. CNA D stated she was attempting to deliver R1 a snack in an effort to distract her from exit-seeking behaviors when she noticed the room was empty. CNA D recalled hearing the door alarm sounding and subsequently peaked outside through the window, but did not see anybody. When asked why she did not complete a more thorough search before disengaging the alarm, CNA D replied, I just thought there was no way she went outside . I just figured she was in another resident's room. CNA D stated she notified LPN B R1 was not in her room and began searching facility rooms. CNA D stated after searching inside the facility for several minutes, she told LPN B about the alarm sounding. When asked about R1 behaviors prior to the elopement, CNA D confirmed R1 had been verbalizing her desire to leave the facility but does not recall the implementation of any interventions as it was difficult to ascertain if R1 was, serious [about leaving the facility]. CNA D stated she did not recall receiving education or a de-briefing following R1's elopement from facility management. On 5/1/25 at 5:23 PM, a phone interview was conducted with LPN B regarding R1's elopement on 4/11/25. LPN B stated CNA D initially asked if she knew R1's whereabouts. When LPN B was informed R1 was not in her room, facility staff began searching room-to-room. LPN B stated RN A was the charge nurse on duty and began looking for the facility elopement policy because she was unfamilar with elopement protocol. LPN B stated she realized the urgency of the situation and decided to call the on-call manager for further direction instead of looking for the policy. LPN B recalled after several minutes of searching rooms, CNA D had relayed to her, The door alarm was going off, but I didn't see anybody, so I reset it. LPN B stated a group of staff members looked around the exit but did not see anybody. LPN B said, eventually, the facility received a call from EMS with a description of a person who matched R1. LPN B did not recall if R1 was exhibiting exit seeking behaviors earlier that day. LPN B verified she did not receive any education or participate in an in-service following the elopement. On 5/2/24 at 1:37 PM, an interview was conducted with CNA E regarding R1's behaviors on 4/11/25. CNA E recalled telling an on-duty nurse that staff, should keep an eye on R1 as she was repeatedly asking CNA E to let her outside earlier in the shift. CNA E was not aware of any additional interventions put into place following these vocalizations. Review of R1's EMR revealed the following progress note, written 4/11/25 at 6:04 PM (approximately 80 minutes prior to R1's successful elopement): .[R1] having increased agitation and exit seeking. [R1] attempted to leave facility today, door was held closed by this RN which worsened agitation and [R1] became physically aggressive slapping RN in the face and pulling hair. Security was called and [R1] redirected back into the building by 2 CNAs . On 5/1/25 at 11:19 AM, the alarmed door from which R1 eloped, was opened by the NHA to demonstrate the reprogramming of fire alarm exits alerts to staff pagers to this Surveyor. After several minutes of no response to the alarm by staff, the NHA interviewed the floor staff to investigate the lack of response. CNA H stated she received the page but was on lunch break, so she did not respond. CNA I stated she was providing cares to another resident, but verified she received the alert on her pager. CNA G stated she assumed a different staff member was responding to the alert. LPN J was observed standing at a medication cart and did not offer a reason for not investigating the door alarm. All staff verified the notification came to their pager. The NHA stated, They should have responded. Review of the facility policy titled, Elopement precautions, long-term care, revised 2/24/25, read, in part: .Residents with psychiatric disorders .are prone to elopement . Purposeful wandering, including exit-referenced behavior, may predict elopement in residents with dementia . Residents at risk for elopement typically: have significant short-term memory impairment; manifest exit-seeking behaviors, such as verbalizing a desire to go home, staying close to entrance or exit doors, or actually trying to leave . .Preventing elopement: Make sure that the resident is properly assigned to a unit and room based on the elopement risk because a resident at risk for elopement may require a room that's located away from exits, close to the nurses' station, or in a secured unit that requires computer-coded entry and exit to ensure the resident's safety . .Responding to Elopement: Arrange a staff huddle to update staff on the status of the search and gather information that may have been missed during the initial data-gathering process. Use this time to reinforce safety procedures to prevent future elopement . The Immediate Jeopardy which began on 4/11/25 was removed on 5/2/25 at 11:14 AM when the facility took the following actions to remove the immediacy: The facility will immediately change the following: IMMEDIATE ACTION: As of May 1st, 2025, all staff will be educated immediately within 24 hours that they acknowledge and understand that in the event they hear an exit door alarming, they observe the alarm on the facility monitors or a page is obtained stating that an exit door has been opened or is alarming they will respond immediately to investigate. If staff are caring for a resident when this alert is obtained, they will ensure their resident is safe and then respond promptly. Staff that have not signed stating understanding within 24 hours will not be permitted to work until education has been obtained. Any staff who are found not to be compliant will be reeducated immediately. Door alarms were set off and [the NHA] and [Director of Quality and Compliance K] verified that notifications were sent to staff pagers and facility monitors. Resident #1 will be moved to the locked unit in LTC within 24 hours once appropriate notifications have been made due to her noncompliance to wear a wanderguard and her risk of elopement. Until this move occurs she will be placed on 1:1 monitoring when out of her room. All residents who score a 1.0 or higher on the elopement assessment have been reassessed to ensure proper interventions are in place. As of 5/2/2025 the likelihood for serious injury, serious harm, serious impairment or death no longer exists. NEW PROCEDURES / PROCESSES FOR RESPONSE TO EXIT DOORS ALARMING AND RESIDENTS ASSESSED TO BE AN ELOPEMENT RISK. Any resident in the facility that is deemed to be an elopement risk a wanderguard will be placed and care planned for that resident. Any resident that is refusing to wear a wanderguard will be moved to the locked unit in long term care for increased supervision and safety. If a bed is not available in the locked unit, the resident will be placed on 1:1 supervision until an appropriate room is available.

This citation pertains to intake MI00150384. Based on record review and interview, the facility failed to notify the legal guardian of one Resident (#6) of one resident reviewed for notification of change in condition. Findings Include: Resident #6 (R6) A review of the medical record indicated R6 had a court appointed guardian, who was listed as the #1 emergency contact and a private caretaker who was listed as #2 emergency contact. A nurse's note on [DATE] at 6:33 PM charted by Registered Nurse (RN) A read in part: . (R6) deceased at 1333 (1:33 PM) today. (R6) had a bed bath at 1100. (R6) was wearing O2 (Oxygen) at 4 LPM (Liters Per Minute) via nasal cannula. (R6) was not awake during bath. (R6) resp (respiratory) were reg (regular) but he was blue when HOB (Head of Bed) was flat. O2 sat 72 on 4 LPM (R6) is on Hospice care for Pulmonary Hypertension. (R6) was bladder scanned at 1015 this am for 275 cc (cubic centimeters). (R6) was not (straight) cathed (catheterized) (a tube placed in body to drain urine). at 1330 (1:30 PM) Nurse and CENA (Certified Evaluated Nursing Assistant) went into (R6) room and found him sitting on the floor beside the bed leaning against the bed with O2 off. no resp rate or HR (Heart Rate) noted. (R6) was pronounced Dead at 1333. (R6) bed was in the lowest position and there was a mattress beside his bed that he was care planned to have due to his climbing out of bed and crawling to the door. the mattress was moved out of the way by him we think when he got out of bed. he was put back to bed with a hoyer lift and caregiver, guardian and sister called. Hospice also called. Guardian here to see him. organ donation called and they checked to see if tissue or eyes could be donated. they called back late afternoon and denied them. medical examiner called and told per hospice Dr. Medical examiner released the body. Morge (sic) called, and body picked released with glasses, stuffed cat and FBI hat at 1830(6:30 PM). belongings will be picked up by . his care giver on another day. While conducting an interview with RN A on [DATE] at 1:41 PM, RN A stated they had called the private caretaker, but was not the one who had contacted the guardian. RN A stated they believed it was nurse B who had called the guardian. This contradicts the nursing note that RN A had charted on [DATE]. During a phone interview on [DATE] at 1:43 PM, with R6's guardian C stated that the facility had not called to alert her to R6's death. Guardian C stated they had received a text message from the NHA that had said sorry for your loss, but the text didn't state who it was for, causing confusion to Guardian C. Guardian C stated the caregiver then texted asking if guardian C had received a phone call, to which guardian C responded they had not. The caregiver then asked guardian C to call them, at which time the caregiver notified guardian C of R6's death. On [DATE] at 2:02 PM a phone interview was conducted with nurse B regarding the death of R6. Nurse B stated they were a nurse float on [DATE]. Nurse B stated they were told not to call the guardian by someone, that person would call the guardian. Nurse B could not remember who that was. This revealed that there was no clear protocol in place to ensure responsible parties were contacted upon a resident's death. On [DATE] at 3:45 PM, the facility provided a Transfer and Discharge policy, that did not include protocols to perform upon a resident's death. The NHA (Nursing Home Administrator) and the Director of Compliance and Quality Assurance, Staff D, could not locate a policy related to notifications of a death. However, the NHA and Staff D provided a Death Checklist of Procedure. The NHA and Staff Dindicated the nurses were expected to follow this procedure guide. The fifth task in the Death Checklist of Procedure stated: Charge nurse to notify and ask emergency contact located in My Unity under census, resident information and then related parties if he/she plans to come in, would like body released to funeral home and if belongings should be left in room or proved to the funeral home.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 81 residents. Findings include: On 8/26/24 at approximately 9:45 AM, a Lexan container was observed in the walk in cooler (WIC) with a label identifying the contents as beef tenderloin, with a production date of 7/14 and use by date of 7/16. An interview with Kitchen Manager (KM) A was conducted at this time and was learned the container had been pulled from the freezer. KM A could not identify the date the product had been removed from the freezer and therefore did not know when the product was to be discarded if not used. KM A reviewed slacking logs which were explained to be documentation of the dates food was removed from the freezer to be thawed (slacked) to be used at a later date. KM A stated there was no documentation as to the date when the product had been removed, and stated it would be discarded. On 8/26/24 at approximately 9:55 AM, the walk in freezer (WIF) was observed to have a two gallon Lexan container labeled fajita meat with a prep date of 5/04 and another labeled meat loaf with a prep date of 4/30. KM A was requested to review documentation to demonstrate the products had been properly cooled. KM A reviewed the kitchen documentation for the dates identified and reported the documentation did not include the two products. The FDA Food Code 2017 states: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. Pf (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first-prepared ingredient. (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method APPROVED by the REGULATORY AUTHORITY for refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; On 08/26/24 at approximately 10:10 AM, staff were observed making ham salad sandwiches in the kitchen. The task was identified as placing a ground ham meat mixed with mayonnaise from a large container (approximately 1 gallon in volume) onto bread. At approximately 11:36 AM ham sandwiches were observed in a stainless steel hotel pan waiting to be served at the noon meal. An interview with Food Service Worker (FSW) B was conducted at this time and learned the sandwiches observed were those which were being made about an hour and half earlier. The temperature of the meat filling (ham salad) was measured with a metal probe Super Pen thermometer and found to be 54 F to 56 F. At approximately 12:10 PM the sandwiches were again measured with the same thermometer and found to be between 54 F and 58 F. An interview with FSW B was conducted at this time who was asked what the plan was for the sandwiches not served at the meal. FSW B stated they would be placed in a refrigerator and used at a later time/meal. At 12:30 PM an interview with KM A was conducted with the sandwich temperature observation and interview information from FSW B shared. KM A stated the sandwiches, due to the temperature deficiency, should not be stored following the noon meal. The FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above;P or (2) At 5 C (41 F) or less. On 8/27/24 at approximately 1:45 PM, staff were observed in the dish room conducting dish washing activities with the high temperature mechanical dish machine. When the dish machine was opened, following a completed cycle of washing, rinsing and sanitizing, steam was released which quickly rolled out from under the capture hood. Some of this steam was observed to contact a ceiling mounted air deflector from the cooling system. The steam was observed being condensing then dripping onto the floor, near the clean end of the three compartment sink. It was confirmed the exhaust hood motor was in the ON position. An interview with KM A at this time revealed the dish machine was just about a year old, and she did not know if any modifications to the exhaust had been made. KM A agreed the steam should be captured by the hood to prevent the condensation and dripping into the clean area. The FDA Food Code states: 4-204.11 Ventilation Hood Systems, Drip Prevention. Exhaust ventilation hood systems in FOOD preparation and WAREWASHING areas including components such as hoods, fans, guards, and ducting shall be designed to prevent grease or condensation from draining or dripping onto FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. On all days of the survey, it was observed that the marble type counter top to the right of the steam table (standing behind looking into the dining room) had two large cracks running the entire depth and thickness of the surface. This area could no longer be properly cleaned and sanitized. On 8/27/24 at approximately 2:40 PM an interview with KM A was conducted who agreed the counter needed to be replaced. The FDA Food Code 2017 states: 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2 and 4-501.12 Cutting Surfaces. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced.

Based on observation, interview, and record review, the facility failed to ensure an appropriate therapeutic diet was implemented for two Residents (#67 and #70) of 2 residents reviewed for nutrition and hydration. This deficient practice resulted in the potential for unmet nutritional needs. Findings include: Resident #67 (R67): Review of R67's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including malignant neoplasm of the cerebellum (brain cancer), failure to thrive, and severe protein-calorie malnutrition. Review of clinical census data revealed R67 signed with hospice services on [DATE]. On [DATE] at approximately 11:32 AM, R67 was observed laying in bed with an emaciated (abnormally thin looking) appearance including sunken cheeks, a visible ribcage, and little muscle bulk. R67 was not alert and was unresponsive to questioning. R67 expired on [DATE] at 11:35 AM. Review of R67's EMR revealed a physician order, initiated [DATE], which read: NPO [nothing by mouth, including food and liquid] diet, NPO texture, NPO consistency. Review of a Health Status Note, written by Physician Assistant (PA) F on [DATE], read, in part: Hospice RN [Registered Nurse] in today and feels [R67] is transitioning and now entering final hours to day or two of life . not safe to give anything PO [by mouth] outside of comfort meds . change diet to npo. On [DATE] at 12:12 PM, an interview was conducted with PA F who verified she changed R67's diet order to NPO on [DATE]. PA F stated she was notified by hospice staff R67 was no longer alert and unsafe to consume food or water. PA F stated, I later found out his level of consciousness was fluctuating significantly, so staff were comfort feeding him as he was awake and alert. When asked if R67 had an available source of nutrition from the time the NPO order was initiated on [DATE] until his death on [DATE], PA F confirmed the diet order should have been written in a way that better reflected R67's cognitive status and subsequent ability to safely consume food and beverage. On [DATE] at 12:30 PM, an interview was conducted with Registered Dietitian (RD) A who stated she was involved in R67's care as a food service director. RD A stated as a standard of practice, R67's diet order should have been contingent on his level of consciousness in order to make decisions on nourishment intake more resident-centered in R67's last days of life. Review of R67's (State)-POST (Physician orders for Scope of Treatment), dated [DATE] read, in part: .Medical Interventions .Comfort-Focused Treatment . Primary goal of maximizing comfort. May include pain relief through use of medication, positioning, wound care, food and water by mouth . 34568 Resident #70 (R70): Review of R70's EMR revealed admission to the facility on [DATE] with diagnoses including dementia, malignant neoplasm of liver, bile duct, and colon. R70 was admitted on [Hospice Name] services on [DATE] on a regular diet. Review of R70's (State) POST signed on [DATE] read, in part, .DO NOT attempt Resuscitation/CPR (No CPR, allow Natural Death) .Comfort-Focused Treatment: Primary goal of maximizing comfort. May include pain relief through use of medication, positioning, wound care, food and water by mouth, and non-invasive respiratory assistance . Review of R70's progress notes from [DATE] - [DATE] read: [DATE] .patient having increased abdominal distention and discomfort. Family was worried he was constipated .Hospice feels the distention is related to tumor burden . [DATE] .Patient still requiring 1:1 care due to fall risk and risk of injury .Resident only able to eat soft foods and his intake is significantly decreased . [DATE] .Call lights and fluiods [sic] within reach. Staff and this nurse providing 15-minute checks . [DATE] .RN from Hospice here, (R70) has been obtunded all day today .Plan: 1) D/C all oral meds (medications) except for palliative meds d/t (due to) unable to take PO any longer 2) change to NPO 3) continue oral hygiene Q2 hrs (every 2 hours) [DATE] .Resident's diet was also changed to NPO due to his decreased responsiveness. Staff will continue to monitor [DATE] .Resident pronounced at 02:54 a.m. Review of R70's Food Intake from [DATE] - [DATE] revealed the following: ,d+[DATE]% of food acceptance - 6 times ,d+[DATE]% of food acceptance - 8 times ,d+[DATE]% of food acceptance - 24 times ,d+[DATE]% of food acceptance - 65 times Resident refused - 1 time Review of R70's Fluid Intake from [DATE] - [DATE] revealed the following: ,d+[DATE] mLs (milliliters) - 22 times ,d+[DATE] mLs - 32 times ,d+[DATE] mLs - 46 times >800 mLs - 26 times Resident refused - 0 times On [DATE] at 10:46 AM, an interview was conducted with the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Director of Compliance and Quality Assurance G who verified R70 and R67 lived for 2 and 13 days after an NPO diet order was initiated, respectively. All parties confirmed R70's and R67's diet orders should have reflected their level of consciousness to ensure they could safely consume food and beverage per their request while simultaneously following physician orders. Review of facility policy titled, Caring for Patients at End of Life, revised [DATE], read, in part: .Decisions to prolong life with the support of advanced medical interventions and technologies or to allow the natural dying process can create ethical challenges for physicians and decisional burdens for patients and/or their loved ones. These challenges can be minimized through the application of ethical principles: Respect for patient autonomy: protect the patient's rights to self-determination per their end-of-life care goals and medical standards .

Based on observation, interview and record review, the facility failed to follow menus developed by the registered dietitian for 10 residents, of a total 78 residents. This deficient practice has the potential to result in nutritional deficiency to these 10 residents. Findings include: On 10/3/23 at 12:10 PM, observations were made of the noon meal service in the area designated as Greenhouse North. (GH=N). A foil pan of commercially prepared macaroni and cheese was sitting on the counter, carrots were being cooked on a stove top, and commercially canned fruit cocktail was observed in small serving dishes. An interview with Certified Nurse Aide (CNA) B was conducted at this time and learned she and other CNAs assigned to the GH-N were responsible for preparing meals and the macaroni and cheese, carrots and fruit cocktail were being served for the lunch meal. A review of the menus provided by the facility was conducted and learned the meal was planned to be both Macaroni & Cheese, meat loaf, french style green beans, orange slices and lemon dessert. The meat loaf and lemon dessert were not offered. On 10/3/23 at approximately 1:30 PM, an interview with Registered Dietitian (RD) A was conducted and learned GH-N was supposed to follow the same menus as the rest of the facility and was surprised the meat loaf and lemon dessert were not prepared and offered, as well as the vegetable substitute. At approximately 2:00 PM an interview was conducted with CNA B who stated the staff on GH-N did not necessarily follow the facility menus and prepared what the residents wanted. CNA B did not know if the changed menus were reviewed by the facility RD. On 10/4/23 at approximately 8:15 AM, an interview was conducted with RD A who stated the changes to the menus were not approved and they were not aware of the changes. Further review of the past meal service documentation (untitled food documentation) revealed within the past three days none of the facility menus had been followed for either the noon or evening meals as follows: Sunday 10/1/23 Lunch: Facility menu planned: Beef roast, roasted potatoes; carrots&onions; fresh apple slices; sherbet. Turkey noodle soup was the only food item documented as being served. Sunday 10/1/23 Dinner: Facility menu planned: Hot Dog on bun; Turkey salad sandwich; Baked Beans; Yellow beans; tossed salad; watermelon; red velvet cake. Cheese burger and fries were the only documented foods served. Monday 10/2/23: Lunch: Facility menu planned: Taco Salad/tacos; tuna salad sandwich; fresh sauteed zucchini; pineapple tidbits; butterscotch pudding. Meatloaf, mashed potatoes, and cauliflower were documented as being served. Monday 10/2/23 Dinner: Facility Menu Planned: Rolled Lasagna; Bologna sandwich; cheese breadstick; mixed vegetables; pear halves; lemon ice: Cream of broccoli soup and egg salad sandwich were documented as being served. Tuesday 10/3/23 Lunch: Facility Menu Planned: Meatloaf; Mac&Cheese; French style Green beans; fresh orange slices; Coconut cake. Ham and Macaroni &Cheese; fruit cocktail and carrots were documented as being served. Tuesday 10/3/23 Dinner: Facility menu planned: Chicken tenders; roast beef sandwich; American fried with onions; beet salad; fruit cocktail; sugar cookies; No entry for food served was located. On 10/4/23 at approximately 2:00 PM, an interview was conducted with the Nursing Home Administrator and Director of Nursing who stated this practice was not acceptable.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to ensure a staff person washed their hands after being potentially contaminated. B. Failing to ensure the dish machines used for the washing, rinsing and sanitizing of food contact surfaces were tested for proper sanitizing. This deficient practice was observed on a Green House unit housing 10 of the 78 facility residents, with this unit preparing the meals for only these 10 residents. Findings include: A. On 10/4/23 at approximately 7:35 AM Certified Nurse Aide (CNA) B was observed entering the kitchen area, wearing gloves. CNA B disposed of an item by pushing her gloved hand down into the garbage can, coming into contact with the swinging lids of the can, then proceeded over to the oven and began preparing pancakes for the residents. CNA B failed to remove her gloves and wash her hands. The FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. B. On 10/4/23 at approximately 9:30 AM an interview was conducted with CNA C. CNA C acknowledged the nursing staff were responsible for the preparation and service of all meals on the Green House unit. When asked about the testing of the dish machine to ensure proper sanitizing, CNA C stated it was no longer conducted, stating further, There used to be strips down here, but I haven't seen them in a long time. The FDA Food Code 2017 states: 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing. (B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature.

This citation relates to Intakes #MI00135793, #MI00133897. Based on observation, interview, and record review, the facility failed to prevent falls and accidents/equipment safety for two Residents (#1, #2) of three residents reviewed for falls. This deficient practice resulted in a rib fracture with pain for Resident #1, and right knee effusion (swelling and irritation) with pain for Resident #2, with the potential for medical, psychosocial, and functional decline or adverse outcomes. Findings include: Resident #2: Review of Resident #2's Face sheet revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including diabetes, heart failure, obesity, kidney transplant, peripheral vascular disease [narrowing of arteries reducing blood flow], kidney disease, paraplegia [paralysis of legs], and depression. Review of Resident #2's Care Plan, revealed Resident #2 required 1-to-2-person assistance with a standing mechanical lift and green sling. The Care Plan further revealed Resident #2 required extensive assistance with dressing and bathing, and limited assistance with grooming, with cognition designated as alert and confused. The interdisciplinary fall care plan revealed, I am at increased risk for a fall r/t [related to] BLE [bilateral lower extremity] weakness . Review of Resident #2's accident and incident report, dated 12/09/22 at 8:00 am., received from the Director of Nursing (DON) revealed, On 12/09/2022 at 0400 (4:00 a.m.), [Resident #2] had his call light on .[Certified Nurse Aide (CNA) T] went to answer it and found [Resident #2] on the floor between his bed and the wall. [Resident #2] said he was ok .It was noticed his bed locks [on the facility bed] were not locked .An investigation was completed .[Resident #2] has multiple diagnoses including diabetic neuropathy [nerve damage], osteomyelitis [bone infection], and hypokalemia [low potassium]. [Resident #2] is his own person. [Resident #2's] BIMS [Brief Interview for Mental Status assessment] score is at a 14 [scoring cognitively intact at the time of the incident]. [Resident #2] has a history of falls .On 12/09/22, at 0400, [Resident #2] had his call light on. [CNA T] walked into the room .[CNA T] did see his hand and heard someone say, 'I am down here.' .[Resident #2] was on the floor between the bed and the wall. [Resident #2] told [CNA T] he was trying to reposition himself in bed and his leg fell off the bed when he slipped through the bed and wall .[CNA T] reported he was ok .and was assisted back to bed with a total lift and did not complain of pain. The bed was not locked but it was in the lowest position, per Licensed Practical Nurse (LPN) EE. LPN EE assessed Resident #2 and he did not complain of pain [initially] but later in the day he did complain of right leg pain. He did receive PRN [as needed] Tylenol [Over the Counter (OTC)] pain medication and an ice pack to the area .the x-ray did show no evidence of fracture but did show effusion to the right knee .Physical Therapy was ordered for the knee effusion. An RCA [Root Cause Analysis meeting] was held, and it was found some of our beds are unlocking easier than they should be .We [nursing management] identified this .We found some [of the beds] are hard to lock but easy to unlock .We have also placed a bariatric bed in [Resident #2's] room . Review of the facility's RCA report, dated 12/13/22, revealed Resident #2 rolled out of bed onto the floor between the bed and the wall on 12/09/23. The flow diagram showed Resident #2 had been checked on at 2:00 a.m. (2 hours prior to the incident) and rolled out of bed when his right leg slipped off the edge of the bed, and CNA T found him on the floor, with no complaints of pain. Team reviewed with nursing staff it is in their scope of practice to ensure resident beds are locked when they are caring for residents. It was found some beds were becoming easily unlocked by touch, and this was addressed by having restorative staff checking all beds, maintenance doing repairs, and ensuring housekeeping and other staff were aware beds were unlocking easily. Resident #2 was to be evaluated for a bariatric bed, cradle mattress and a trapeze per this meeting. During an interview on 04/20/23 at 4:45 p.m., Registered Nurse (RN) I confirmed Resident #2 had complained of leg pain at the time of the incident on 12/09/22, and an x-ray was ordered. RN I recalled the x-ray being negative (for a fracture) and showing he had a knee effusion. During an interview on 04/20/23 at 5:00 p.m., Physical Therapist (PT) S, with the Rehabilitation Director, Physical Therapist Assistant (PTA) Q and a treating therapist, PTA R present, was asked about Resident #2's functional status before the fall, and any change of condition, increased pain, and therapeutic interventions after the fall. PT S and PTA R reported Resident #2 required the standing lift with staff, and in therapy he typically required moderate to maximal assistance for full transfers, due to performance inconsistencies and medical illnesses/infections. PTA R reported Resident #2 did have some right lower extremity weakness and paralysis prior to the incident and reported Resident #2's cognition fluctuated with frequent infections, which caused some intermittent confusion and altered mental status. Surveyor reviewed clinical condition of knee effusion with physical therapy team, who concurred knee effusion was a swollen knee with excess fluid, which likely occurred from the trauma of the fall, which caused irritation from cartilage being injured and potentially muscle injury. Physical Therapy was treating him at the time of injury, and did not address the knee injury, as Resident #2 did not use this leg as it was paralyzed. PT S reported Resident #2 described the injury occurring when Resident #2 was rolling in bed to turn his call light off and over rolled between the bed and the wall, and he ended up straining his knee and may have twisted his leg on his way to the ground. PT S reported they would expect the facility beds to be locked at all times, including Resident #2's bed. PT S reported Resident #2 was at baseline after the injury, and PT was still able to ambulate Resident #2 with assistance, as PT staff continued to lock his right knee during ambulation, and his transfers remained the same subsequent to the incident/injury. During an interview on 04/21/23 at 8:44 a.m., CNA T confirmed the incident occurred on 09/12/22 at 4:04 a.m., and reported she walked into Resident #2's room to check on him and saw his hand and he said, Somebody help me. CNA T reported Resident #2 stated he was trying to position himself in the bed, his right leg slid off between the wall and bed, and the bed moved because of the pressure of his leg slipping off, and he slipped off the bed onto the floor. CNA T denied Resident #2 having pain at the time of the occurrence, and immediately notified their nurse and obtained vitals. CNA T reported Resident #2's mood was positive, and they were not distressed about the incident. Surveyor asked CNA T why Resident #2's bed was unlocked. CNA T responded, I take full responsibility for the bed being unlocked. When you're going room to room, I should have checked the bed at shift [change] report when I arrived .at 10:00 p.m CNA T acknowledged there were multiple opportunities for them to check the bed, and reported they received a verbal reeducation. CNA T reported some of the beds would become unlocked easily if one accidently struck the brake unintentionally with their foot, but had not reported the concern. CNA T stated after the incident maintenance checked the beds to make sure they were locked. CNA T reported after the incident they had been educated to check the beds and make sure they were locked at the beginning of their shift. CNA T confirmed this was their oversight, and there were no ill intentions. During an interview on 04/21/23 at 9:00 a.m., the Nursing Home Administrator (NHA), with the DON present, reported an RCA had been completed, and the bed checking process was updated, with restorative services newly involved in bed checks by doing monthly checks, and maintenance staff addressed any concerns as needed. The NHA and DON reported they understood the concern with Resident #2's bed being unlocked and Resident #2 becoming injured as a result. During an observation on 04/21/23 at 11:35 a.m., Resident #2's hospital bed was observed in their room. There were no concerns with the locking mechanism, and none were reported by staff. The DON confirmed there were no concerns found with beds of this type. Resident #2 was at the hospital during this observation. Review of the document, Federal Resident Rights and Facility Responsibilities, dated 2017, provided by the DON, revealed on page 18, Safe environment. The resident has the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safety. The facility must provide .i. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . The DON reported there was no policy respective to equipment/bed safety checks. Resident #1: Review of Resident #1's Minimum Data Set (MDS) assessment, dated 03/22/23, revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including diabetes, arthritis, dementia, anxiety and depression. Resident #1 was independent with bed mobility, transfers, and walking in her room, and set-up for toileting, and supervision and set up for walking in corridor (facility). Resident #1 was unable to participate in the Brief Interview for Mental Status (BIMS) assessment, which indicated severe cognitive impairment. Resident #1 had no pain and two falls during the assessment period. Review of Resident #1's Accident and Incident report, dated 04/06/23 at 15:35 p.m. (3:35 p.m.), revealed, [CNA FF] saw [Resident #1's] bathroom call light and went in to check it and noticed [Resident #1] on the floor in front of the chair next to bed. Review of Resident #1's RCA report, provided by the DON, revealed sustained a fall on 04/06/23 in their room and was found next to their recliner chair, with a complaint of rib pain, and was found to have rib fracture. A second fall on 04/08/23 was also noted, found on floor in room, appeared to slip out of recliner without injury. Background information showed Resident #1 had multiple falls from February 2023 (3 falls) and April 2023 (3 falls). The report showed the cause appeared related to, Progression of dementia, sleeping more, less alert at times, less engagement, more assistance [unspecified] needed at times. Discussed that roommate may be contributing to falls by shutting the door, attempting to turn off alarms that bother her, and [Resident #1] has been in increased pain from rib fracture with additional pain meds to control pain, which could contribute to fall risk. VST [motion detector] alert on roommates' side of room. Medications could be contributing with advancement of dementia process and less tolerance for meds . Contributing factors included: Staff concern recliner fit and slippery, ear wax caused dizziness with a prior fall, advancement of dementia and spending more time in her room, roommate shuts door, alarms which irritate both Resident #1 and their roommate, and medications may be contributing. These countermeasures were noted as in process. During an observation on 04/19/23 at approximately 4:00 p.m., Resident #1 was observed in their room in their bed. The bed was in the low position, and a bed alarm was observed, along with the call light in reach. Resident #1 reported she was doing well when asked, happy with their care, and did not mention any pain from rib fracture, and had no obvious bruising. The vinyl covered recliner chair was observed adjacent to Resident #1's bed and had a rocker feature which could be a safety concern during transfers, as it was not a stable transfer surface, and appeared a bit low to the ground. Guardian U reported they were happy with Resident #1's care at the facility and understood and had observed Resident #1 progressively declining in her function due to the dementia process. Review of a post fall documentation report, dated 04/06/23, revealed, Resident [#1] found on bottom next to bed. Incontinent of urine. Why did it happen? Increased confusion and incontinence. Dementia . Interventions to help prevent future falls: 1. Pressure alarm on at all times. 2. One assist for all cares. 3. Do not leave in bathroom alone . Review of RN CC's witness statement, dated 04/06/23, revealed on 04/06/23 they discovered Resident #1 laying on her left side on the floor in front of her recliner, with feces on her hand, bottom, and the recliner arms. They found her with her incontinence brief and pants pulled down to her knees. During an interview on 04/19/23 at 5:03 p.m., CNA B confirmed they were working when Resident #1 fell and sustained the rib fracture. CNA B reported she found Resident #1 on the floor on her left side next to the recliner chair. CNA B reported Resident #1 did not always recall to use the call light, and her pants were down, with stool on the recliner chair. CNA B recalled Resident #1 had her shoes on, to their recollection. CNA B believed Resident #1 was falling frequently as she stood up hurriedly, and sometimes tipped to the side and lost her balance, and also sometimes forgot to use her walker. CNA B clarified Resident #1 had required one-person assistance with transfers and mobility even prior to this fall and had been functionally declining. CNA B reported Resident #1's roommate was in the bathroom, and they did not suspect any abuse as Resident #1's former roommate was kind and nurturing towards Resident #1. When asked about Resident #1's recliner and transfers from the recliner, CNA B reported the recliner seemed a bit low to the ground, and given Resident #1's balance concerns, it did not necessarily seem to be a stable surface for transfers. Review of Resident #1's hospital x-ray report of chest and ribs, dated 04/06/23, revealed left rib pain from a fall, and showed, Acute appearing fracture of the left lateral 5th rib . Review of Resident #1's fall report, dated 02/04/23 at 14:00 (2:00 p.m.), revealed Resident #1 had falls in her bathroom on 02/03/23, and 02/04/23, when she hit her head, without complications. The report showed the interventions were to have grippy socks on in the night and showed Resident #1 demonstrated a functional decline at that time, requiring one-assist with gait belt for ambulation to and from dining room and bathroom. This showed a significant functional decline, as Resident #1 had been independent with ambulation in room and in facility. This report confirmed a total of five falls, all while Resident #1 was attempting transfer and/or ambulation. Review of Resident #1's LTC [Long Term Care] Daily Care Plan, dated 04/04/23, received from the DON, revealed on 04/06/23 Resident #1 required, one assist with all cares and transfers [handwritten] 4/6/23. The statement, Independent per PT during daytime, 1 assist in evening and night due to weakness and confusion and I am able to be independent in my room and facility during the day but need 1 assist with my ADLS and mobility in the evening and night due to my confusion per therapy assessment on 3/07/28, was crossed out. The Care Plan also revealed, Do no leave alone in bathroom [handwritten] 4/6/23. Pressure alarms to recliner and bed at all times [handwritten] 4/6/23. It was unclear why Resident #1's Care Plan was updated on 04/06/23 and 03/07/23, when the February fall report showed Resident #1 required one-person assistance after her falls (in February 2023), and was not updated at that time. Review of Resident #1's fall report, dated 01/27/23, revealed Resident #1 had another fall in their bathroom. Resident #1 reported they were trying to get up and use the bathroom and slipped from their bed. This confirmed Resident #1 had at least five falls during transfers and ambulation. On 04/19/23, therapy notes were requested from the DON since January 2023, due to Resident #1's frequent falls, and staff reporting functional decline over the past few months. Speech therapy notes were provided, dated 04/05/23 for evaluation, and showed they addressed swallowing therapy to prevent aspiration, not any cognitive decline, and there were no physical or occupational therapy evaluations or notes provided. Review of Resident #1's progress notes since 01/01/23 revealed staff had reported a progressive decline in transfers, mobility, and increased falls, and Resident #1 was not on physical or occupational therapy caseload, despite being independent with transfers, bed mobility, and walking prior to the falls beginning in January 2023. During an interview on 04/20/23 at approximately 5:30 p.m. the Rehabilitation Director, PTA Q, was asked if Resident #1 had been referred to Physical Therapy or Occupational Therapy after their recent fall with fracture, or recently given their functional decline. PTA Q reported there had not been any therapy referrals after Resident #1's fall and functional decline, and understood the concern. PTA Q clarified they did not routinely screen residents and their staff would only evaluate a resident per referral from the physician team. Further review of the nursing progress notes revealed Resident #1 had another fall while attempting to get a blanket off their bed on 04/15/23, without injury. During an interview on 04/20/23 at approximately 5:45 p.m., concerns were shared with the DON related to therapy not being referred given Resident #1's progressive functional decline and multiple falls, especially after Resident #1's recent fall with fracture on 04/06/23, and another fall on 04/08/23. The DON reported they understood the concern and planned to follow up.

This citation is pertains to Intake #MI00136159. Based on observation, interview, and record review, the facility failed to ensure one Resident (#18) of two residents reviewed for medication administration received their medications as ordered by the physician. This deficient practice resulted in Resident #18 consuming medications prescribed for another resident, and the potential for medication interactions and adverse outcomes, due to the ingestion of unprescribed medications. Findings include: Review of Resident #18's Minimum Data Set (MDS) assessment, dated 03/21/23, revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including anemia (deficiency of oxygenated red blood cells), hypertension (high blood pressure), kidney disease, lung disease, diabetes, malnutrition, depression, and dementia. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 12/15, which indicated Resident #18 had moderate cognitive impairment. Review of Resident #18's assessment medication categories revealed Resident #18 did not receive a diuretic (a water pill to rid the body of sodium and water). Review of a facility reported incident dated 04/18/23 revealed Resident #18 had consumed nine medications intended for another facility resident, Resident #19 at 8:30 a.m., administered by Registered Nurse (RN) AA. The medication error was discovered at approximately 10:30 a.m. These medications included: Bumex (a diuretic) 5 mg (milligrams), Citalopram (an antidepressant) 10 mg, Losartan (an antihypertensive to decrease blood pressure) 50 mg, Magnesium Oxide (a mineral supplement) 275 mg x 3 pills, Metoprolol (Tartrate - an antihypertensive) 25 mg, Amlodipine (an antihypertensive) 10 mg, Famotidine (medication to treat stomach ulcers and acid) 10 mg, Clopidogrel (medication used to prevent blood clots) 75 mg, and Potassium Chloride extended release (a supplement used to treat low potassium) 10 mg. The only medication Resident #18 was scheduled to receive was Magnesium, however, Resident #18's was scheduled to receive a lower dose morning dose of 250 mg. The report further revealed Resident #18 was scheduled to receive: Effexor (a medication to treat depression), Magnesium, Tylenol (for pain), Vitamin B 12 and Vitamin D, and Zofran (a medication for nausea and vomiting). NACL (sodium chloride), Omeprazole (a stomach acid reduction medication), and MiraLAX (a medication for constipation). The report further identified RN AA stated they became distracted when they were interrupted by an unnamed Certified Nurse Aide (CNA), and did not completely follow all the 10 rights of medication administration (right medication, right patient, right dose, right route, right time, right patient education, right documentation, right to refuse, right assessment, and right evaluation). Facility found no medical or functional decline or any adverse outcomes for Resident #18, and their vital signs remained in the normal range when assessed during the next 24-48 hours. Review of RN AA's investigation witness statement revealed RN AA noticed on 04/18/23 at approximately 10:30 a.m. they still had medications for Resident #18 in their medication packet for their morning mediations. RN AA recalled passing Resident #18 their medications and realized they had accidently given Resident #19's medications to Resident #18. RN AA informed Physician's Assistant (PA) DD, who instructed RN AA to monitor Resident #18's vital signs closely for 24 hours. PA DD also approved for Resident #18 to receive their regularly scheduled morning medications, which RN AA administered to Resident #18, apart from holding Magnesium for the day, to push oral fluids, and for Resident #18 to only ambulate with assistance. RN AA's assessment revealed Resident #18 presented with no dizziness or lightheadedness, their neuro and vital signs were stable, with no change in cognition. RN AA reported they informed Resident #18 as well as their guardian of the medication error and continued to monitor Resident #18 closely including frequent vital sign monitoring and instructed staff to do the same. RN AA confirmed there was no change in Resident #18's status. Review of the Director of Nursing (DON)'s statement of the occurrence revealed, On 04/18/23, [RN AA] reported to me a medication error. When I reviewed the medication dispensed to the resident, I then discussed with [RN AA] the following: [RN AA] oversees the distractions. Our policy is to have the CENA's post a note on the medication cart when the nurse is passing medications. The importance of making sure the correct medication is going to the correct resident. [RN AA] expressed the importance of doing this. Reminded [RN AA] we just had education. Signed by the DON. Review of Resident #19's medication profile, dated 04/18/202 at 1:08 p.m., confirmed Resident #18 received Resident #19's scheduled morning doses of their medications as described in their medication orders. Review of Resident #18's progress note dated 04/18/23 confirmed RN AA administered Resident #18 the wrong medications, notified PA DD, and monitored Resident #18's vitals closely. Vital signs were initially blood pressure 121/61, pulse 50, respirations 16, and a blood oxygen saturation level of 94%, which were within the normal range, as compared to Resident #18's vital signs before the incident. PA DD instructed Resident #18 to initially lie in bed with legs elevated, and to stand with assistance. Vitals signs were monitored every two hours. Review of Resident #18's second progress note dated 04/18/23 by RN AA showed Resident #18's vital signs remained within normal limits, and they initially had a headache, which resolved. Review of Resident #18's third progress note on 04/18/23 by RN D revealed Resident #18 was closely monitored and showed they were at their baseline, tolerated activity and denied pain, nausea, or any vision changes, denied a headache, had clear speech, and vital signs were within normal range. Pupils were assessed with no concerns. Review of Resident #18's progress notes on 04/19/23 continued to show no concerns or changes in status; vital signs remained within the normal range. Review of Resident #18's physician progress note dated 04/28/23 showed no notable change in status, and Resident #18 was medically stable. Review of Resident #18's, Resident Vital Sign report, dated 04/01/23 to 04/28/23, revealed no significant changes in systolic blood pressure, since the time of the occurrence. PA DD confirmed this as well. During an interview on 04/28/23 at 10:30 a.m., PA DD was asked about Resident #18's medication error on 04/18/23. PA DD acknowledged RN AA reported the medication error related to Resident #18 receiving Resident #19's morning medications, for a total of nine medications, with the four blood pressure medications and water pill being of the most concern. PA DD reported it was an accident, and RN AA followed their care directives and closely monitored Resident #18 including vital monitoring, with no ill effects. PA DD shared how they ordered extra fluids to counter any effects of the water pill, and for Resident #18 to lay in bed with her feet elevated and assisted mobility to prevent any low blood pressure. PA DD reported the medication dosages were low doses, the majority had rapid clearance, and these dosages would have no long-term effects, and none were observed or discovered. PA DD reported this would be a significant medication error to them, given four hypertensive medications and a water pill was given to a resident (#18) who did not normally take these medications. PA DD reported RN AA was a particularly good nurse, had no impairments, and was very caring and always went the extra mile. PA DD reported RN AA became distracted and gave the wrong medications, and they managed the situation with RN AA, and the DON was made aware, as well as Resident #18's guardian. PA DD confirmed Resident #18 did not require any emergent care, IV fluids, etc. PA DD reported Resident #18 was not upset to their awareness, had stable systolic blood pressures, and there were no adverse outcomes. During an interview on 04/28/23 at 1:57 p.m., RN AA acknowledged the medication error occurred on 04/18/23 at 8:30 a.m. when they were passing morning medications. RN AA confirmed they discovered the error at approximately 10:30 a.m. when they realized Resident #18's medications were still in the medication cart. RN AA reported they were partially listening to the skilled huddle report from their computer monitor on the medication cart while they were completing the medication pass. RN AA clarified this was how they reported the medical status of any of their residents in rehab on their hallway. RN AA reported Resident #18's room was directly across the hall from Resident #19's room, and their names were similar, so the error occurred in part for these reasons. RN AA stated as soon as they discovered the medication error occurred, they reported this to PA DD, who was in the building. RN AA reported PA DD intervened immediately and educated them how to assess and monitor Resident #18 for any reaction. RN AA confirmed Resident #18 had no ill effects from the medications and participated in their normal routine and activities as the day progressed, and Resident #18 understood the error and had no concerns. Resident #18 clarified they regretted the error occurred, and the facility had made strides to help prevent nurses from being distracted during medication pass. RN AA reported the medications were pre-packaged and labeled with resident's names, and stock medications (such as OTC - over the counter) were available on the cart. RN AA confirmed Resident #18 still received their scheduled medications, as well as Resident #19 after the incident. Resident #18 denied working with any impairment, acknowledged they were distracted, and demonstrated how they also carried phones and pagers, as well as how people who approached the cart could distract them. RN AA added they could put a card up to show they were passing medications as another intervention to decrease distractions and did not listen to skilled report when passing medications since the date of the occurrence. During an observation on 04/28/23 at approximately 3:00 p.m., Surveyor observed RN AA pass medications to Resident #17. RN AA showed Surveyor a small plastic sleeve they pulled from the medication cart, which was labeled with Resident #17's name, and the time of day of the dosage. RN AA demonstrated appropriate medication administration for Resident #17's afternoon medications. During an interview on 04/28/23 at 3:20 p.m., Resident #18 was asked if they received their medications regularly. Resident #18 reported they were treated well, were happy with their care, and had no recollection of any medication concerns including missed medications, receiving wrong medications, and received their medications accurately and timely. During an interview on 04/28/23 at 3:50 p.m., the DON, with the Nursing Home Administrator (NHA) present, reported there was no expectation for RN AA to listen to the skilled care call during medication pass. The DON acknowledged the primary cause of the incident was RN AA became distracted during medication pass, and they had provided a note card above his cart to prevent him from being distracted, and nurses could take their cart anywhere to avoid being distracted. The DON denied any disciplinary action at that time, and had done reeducation with all nursing staff, and brainstorming, including with RN AA to prevent any chance of recurrence. During a phone interview on 04/28/23 at approximately 4:10 p.m., the Pharmacist Consultant, Pharmacist BB, was asked about the nine non-prescribed medications ingested by Resident #18, and if any would be considered a significant medication error. Pharmacist BB reviewed Resident #18's diagnoses and medications including dosages given (one time, one day). Pharmacist BB concluded this would not necessarily be a significant medication error, as there was no outcome, given Resident #18's diagnoses, and their lack of a reaction or adverse outcome to the medications. Pharmacist BB reported their concern was the nurse involved (RN AA) had not followed the 5 (main) rights of medication pass (the primary standardized medication administration guidelines), and if they had, the incident would not have occurred. During a phone interview on 04/28/23 at 4:30 p.m., Resident #18's guardian, Guardian U was asked about the medication error on 04/18/23. Guardian U reported they were impressed how the facility notified them immediately, and how closely they monitored Resident #18. Guardian U reported Resident #18 did not seem to know what was happening and had no ill effects or change in status. Guardian U came into the facility the next day (04/19/23) to check on Resident #18 and saw no concerns or change in status for Resident #18, and none since. Guardian U reported they were happy with the care the facility was providing to Resident #18 and appreciated their prompt follow-up and interventions. During a follow-up interview on 04/28/23 at 4:45 p.m., the DON reported the medication error was avoidable, and RN AA had allowed themselves to be distracted, and could have prevented the distractions, per their choice. The DON reported RN AA should not have been listening to the skilled resident meeting during mediation pass. The DON reported RN AA should have been looking at the labeled medication package and could have moved the cart right outside each residents' room if they chose. The Root Cause Analysis (RCA) identified nurses cannot allow distractions, and one accommodation was labeling the medication cups. The DON reported they understood the concern and had taken action to prevent recurrence via all nursing staff training including with RN AA to prevent distractions and ensure best practice standards during medication pass. Review of the Facility's RCA of the incident, provided by the DON, revealed, Resident [#18] received wrong medications. Flow Diagram: Nurse [RN AA] discovered at 10:30 a.m. that rise [sic] medications for resident [#18] were still in the cart and realized that [RN AA] had provided medications to this resident at 8:30 a.m. Nurse realized that resident's [#19's] medications had been provided to [Resident #18] in error. Resident [#18] was monitored after incident for change in condition for 24 hours post incident. No noted change in condition occurred. [medication rights] Wrong patient, wrong drug, wrong dose, right time, right route, wrong documentation .Practice identified by nurses to ensure right patient: Nurse leaves empty packet with patient identifier on med [medication] cart in case of distractions while preparing or giving meds as a double check to ensure right patient is provided the medications. Nurse writes name of resident on med cup during preparation of meds. Nurse leaves the med admin [administration] [record] open in EMR [Electronic Medical Record] that has patient identifiers including name, room, and photo and does not sign off on medications until provided to resident .Barriers identified that contribute to medication errors: Many medications ordered for residents especially for morning med pass. Med packets provided by pharmacy are not always packaged accurately for correct med time .Distractions by staff, residents, phone, doorbell ., morning skilled meeting held at a time when nurses are in the middle of med pass. Nurse that had med error indicated [RN AA] was distracted by watching the time as he knew he would need to get in to report on residents during [skilled] meeting. Nurses feel they need to rush through med pass .Nurse indicated med cart was not well organized on day med error occurred .pharmacy sends meds in totes that are disorganized .confusion sometimes between brand names and generic names of medications . The report further revealed some best practice standards for medication administration were being put in place and were in progress. Review of RN AA's nursing competency education packet, provided by the DON, and completed 04/04/23, revealed RN AA completed medication error education. This education described a medication error as, .any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer . RN AA scored six of six questions correctly. Review of the policy, Administering Medications, undated, provided by the DON, revealed, Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The facility has sufficient staff to allow administering of medications without unnecessary interruptions. Procedures .Administration: 1. Medications are only administered by licensed nursing .and personnel authorized by state laws and regulations to Administer medications. Medications are administered in accordance with written orders of the attending physician .Medications are administered at the time they are prepared. Medications are administered without unnecessary interruptions .Residents are identified before medication is administered .Methods of identification include a. Checking identification band. b. Checking photograph attached to medical records. c. Calling resident by name. d. If necessary, verifying resident identification with other facility personnel .12. Medications supplied for one resident are never administered to another resident .Documentation: 1. The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record] directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administers the medication report off-duty without first recording the administration of any medications . Review of the policy, Medication Error Reporting, undated, revealed: Policy: Medication errors shall be documented in the resident's clinical record and reported to the resident's attending physician. Procedures: 1. In the event of a medication error, nursing personnel should first take whatever immediate action is necessary to protect the resident's safety and welfare. 2. Notify the attending physician promptly of the error. 3. Implement physicians' orders and monitor the resident closely 24 to 72 hours or as directed. 4. Document the following in the resident's clinical record: a. A description of the error b. Name of physician and time notified. c. Physician's subsequent orders. d. Resident's condition for 24 to 72 hours or as directed. 5. Complete an incident/ medication error report that indicates corrective action for the occurrence .6. Describe the incident on the shift change report .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to dispose of expired foods in the walk in refrigerator. B. Failing to ensure that dish washing operations were properly sanitizing food contact surfaces and corrective action was taken when the monitoring of the dish machine indicated improper final rinse water temperature. C. Failing to conduct proper testing of two three compartment sinks in the Greenhouse locations. D. Failing to restrict animals from the food preparation area in one of the Greenhouse kitchen areas. This deficient practice has the potential to result in food borne illness among any or all of the 79 residents in the facility. Findings include: On [DATE] at approximately 9:45 AM, initial observations of the kitchen were made. The walk in refrigerator was observed to have the following expired foods on the shelves: Four containers of Beef Base with Use By (UB) date [DATE] Three containers of Garlic in Water with UB Date [DATE]. One container of Garlic in water, noted to be opened and labeled with an open date of ,d+[DATE], and an UB Date of [DATE]. At approximately 10:05 AM, an interview was conducted with the Certified Dietary Manager (CDM) A while showing her the expired food. CDM A acknowledged the food should have been discarded by the dates on the containers. On [DATE] at approximately 10:13 AM a large chocolate [NAME] dog was observed walking through the South Greenhouse kitchen area. At 11:26 AM an interview with the Greenhouse Universal Workers (GUW) D and E was conducted at this time, who stated the dog was allowed through the kitchen area when food was not being prepared. When explained that clean dishes were on the counter, the dish drainer on the counter, and the potential for hair from the dog to be blown onto the food preparation areas, GUW D stated Oh. We didn't think of that. GUW D acknowledged there were not any gates or other restrictive devices to restrict the animal from entering the kitchen area. During the [DATE] 11:26 AM interview with GUW D and GUW E in the South Greenhouse, it was learned the three compartment sink was used to wash, rinse and sanitize some of the food contact surfaces used for food preparation. It was further learned that the chemical used for the sanitizing step was a quaternary ammonium (Quat) product. When asked about the testing procedure to ensure that proper concentrations of the Quat were present, both GUW D and E stated they did not routinely test the solution. When asked if the kitchen was provided with test strips, both pointed to a drawer and stated they are in there. Two containers of test strips were located in the drawer and revealed one was for testing Lactic Acid sanitizing solution and the other was for quat. The container with the Lactic Acid strips was pulled out and asked if they were the strips used by staff to test the quat solution. GUW E stated Yes. When the other bottle, containing quat test strips was shown to GUW D, the response was Oh. I'm not sure. When asked how the quat strips were to be used, GUW E stated it was to be dipped in the solution for 10? maybe 30 seconds?. A review of the package revealed the required time the strips were to be held in the solution was 90 seconds. Both stated they had never held them in that long and it was not really feasible to stand there for a minute and a half holding a test strip. When asked why there were strips for Lactic Acid, both replied That's what the kitchen brought to us. Both were not aware of the minimum temperature of a Quat sanitizing solution was to be 75°F. On [DATE] at 11:50 AM, an interview with GUW B and C was conducted in the North Greenhouse. Both were unaware of the requirement for their Quat test strips to be immersed for 90 seconds and confirmed that was never done. Both acknowledged they were unaware of the requirement that a Quat solution must be a minimum of 75°F, stating they thought it had to be between 65°F and 75°F. On [DATE] at 12:35 PM observations of the three compartment sink in the main kitchen were made. CDM A was asked what the chemical used for sanitizing was. CDM A stated We use Quat. When asked to produce the testing strips, CDM A handed a vial containing test strips for Lactic Acid. This discrepancy was shown to CDM A who stated Oh, that's what we got from {vendor's name}. An observation of the bottle of sanitizing chemical, sitting to the right of the three compartment sink was made and was revealed the sanitizing chemical was Lactic Acid. CDM A responded, once shown the bottle I didn't know we switched. On [DATE] at 12:44 PM the dish machine in main kitchen was tested for proper sanitizing with both self adhesive irreversible strips and a DishTemp maximum registering digital thermometer which emulated a plate and reported the temperature at the food contact surface. The strips did not turn to the appropriate black color indicating the food contact surface was not reaching the minimum 160°F, as well as the maximum registering thermometer showing it had only reached 148°F during the cycle. The temperature log for the dish machine, which was hanging on the wall, was reviewed with CDM A, which showed 9 of 24 entries for the current month in which the facility's maximum registering thermometer did not reach the required 160°F and included the following: ,d+[DATE]: 157°F breakfast; 155°F dinner ,d+[DATE]: 156°F dinner ,d+[DATE]: 154°F dinner ,d+[DATE]: 158°F breakfast; 158°F dinner ,d+[DATE]: 156°F breakfast; 158°F dinner ,d+[DATE]: 150°F dinner On [DATE] at 12:50 PM an interview was conducted with CDM A concerning the dish machine. CDM A acknowledged she was not aware the dish machine had not been reaching the appropriate temperature of 160°F and had not reviewed the temperature logs for the machine. CDM A acknowledged that no corrective action had been taken in response to the failing sanitizing temperatures. At 1:00 PM a new set of heat sensitive strips and the maximum registering thermometer were placed into the dish machine. During this cycle the machine demonstrated proper sanitizing. CDM A revealed the manufacturer's representative had been out within the last month making adjustments to the machine and was not sure what had been done. The representative was being contacted by the facility to return and make additional adjustments to ensure continued and reliable results during the cycles. The FDA Food Code 2013 states the following: ,d+[DATE].11 Person in Charge. The PERSON IN CHARGE shall ensure that: (J) EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are reused, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH, temperature, and exposure time for chemical SANITIZING; ,d+[DATE].112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in ¶ (B) of this section, in a mechanical operation, the temperature of the fresh hot [NAME] SANITIZING rinse as it enters the manifold may not be more than 90°C (194°F), or less than: (1) For a stationary rack, single temperature machine, 74°C (165°F); or (2) For all other machines, 82°C (180°F}.

Based on observation, interview, and record review, the facility was found to be in an Immediate Jeopardy (IJ) due to the facility failing to: 1. Identify, track, and test residents and staff for COVID-19 per facility policy and standards of practice to control an outbreak of COVID-19; 2. Ensure that results from COVID-19 were tracked accurately and reported to the Infection Preventionist (IP); 3. Ensure that COVID-19 outbreaks were mapped and root cause outbreak analysis was done to prevent reoccurrence of preventable outbreaks; 4. Ensure that infections were being tracked real-time to allow for immediate interventions to prevent further spread; 5. Ensure that staff who had symptoms and were marked as COVID-19 positive were investigated and prevented from working with vulnerable Residents; 6. Ensure that Personal Protective Equipment (PPE) was worn properly by staff for COVID-19 testing and for visitors entering Transmission Based Precaution (TBP) rooms, to prevent further spread of infection to all 78 Residents residing in the building. This deficient practice resulted in the potential for further outbreaks of COVID-19 and Resident death. Findings include: On 8/9/22 at approximately 9:00 a.m., a notice was on the front door notifying visitors of a positive staff case of COVID-19 dated 8/8/22. On 8/11/22 at 9:58 a.m., the DON notified the survey team that Resident #57 (R57) had just tested positive for COVID-19 and was being moved to the COVID unit. On 8/11/22 at approximately 10:30 a.m., an interview was conducted with IP H who was asked to provide the log of Resident COVID-19 testing. IP H reported that her process was to print a census sheet, test the Residents, document results in each Resident's medical record, and then shred all the paper. IP H reported she did not document the lot number of the test card and had no record except for in each medical record, of when and who she tested daily. When asked why R57 was tested on [DATE], IP H reported it was due to him presenting with symptoms that morning. IP H was asked about the positive staff member that was noted on the door of the facility. IP H reported that Certified Nurse Aide (CNA) K (the staff who tested positive on 8/8/22) had only worked on the greenhouse and main long term care unit, and therefore they were the only units that were being tested in outbreak mode. IC H reported that they only tested on units that the positive staff had worked on in the 48 hours prior to testing positive for 14 days. When asked for the contact tracing for CNA K, IC H reported that it was completed by the hospital employee health nurse (Registered Nurse (RN) S), not her. When asked the frequency of testing during outbreak testing due to a positive staff or resident, IP H reported it was twice per week. A review of R57's records revealed he admitted to the facility on [DATE] with type 1 diabetes, bacteremia, and [CONDITION(S)]. A review of R57's Minimum Data Set (MDS) assessment dated [DATE] revealed he scored 11/15 on the Brief Interview for Mental Status, indicating moderately intact cognition. R57 had been residing on a greenhouse unit until he was moved on 8/10/22 to the main long term care section, and on 8/11/22 he had tested positive for COVID-19 via a rapid test. A stack of facility testing logs (loose sheets of paper) dated 7/9/22 through 8/10/22 revealed the following: Over 72 of the tests logged had no card number logged. Over 65 tests logged were missing information whether there were symptoms or not. Three tests were missing results, on 8/1/22, 8/8/22, and 8/9/22. On 8/11/22 at 10:42 a.m., an interview was conducted with IP H, the DON, and the Administrator. IP H was asked to clarify why there was no record of the testing logs for the Residents (including date of test, result, and name of tester) and IP H reported the facility decided they didn't want to keep so many sheets of paper. IP H only kept a record of the number of tests she gave, but not who she tested . When asked which units were currently being tested in outbreak mode, IP H reported they were testing one of the greenhouse units and the main long term care unit (Legacy), as those were the units that CNA K had worked on. IP H confirmed that those were the only units that were currently testing in outbreak mode. When asked about how they ensured staff were testing appropriately, IP H stated, They (staff) are responsible for knowing when to come in . IP H reported that they compiled an email the following Monday for the staff who had failed to complete their testing the week prior. These emails were requested. When asked about contract tracing for each staff or resident who tested positive, the DON, during the same interview on 8/11/22 at 10:42 a.m., reported that RN S who was the hospital Employee Health nurse did the tracking and told IP H when the staff could return to work. IP H was asked if she did her own investigations and surveillance and reported that she did. This document was requested. IP H was asked about why the staff testing logs were missing key information, like symptoms, the control test, the date, who gave the test, and results. The DON stated it would be a good idea to know who gave the test. IP H reported that she reviewed all of the sheets and then put the results into a spreadsheet log. IP H was asked about CNA I who was marked as being positive on 8/4/22 and 8/7/22 dates. IP H reported she must not have seen those test pages, because any positive results are supposed to be reported to Employee Health RN S. IP H confirmed she was not aware of CNA I's positive tests. IP H then stated that per her log (which was composed of test log data) she had marked CNA I as negative on 8/4/22. On 8/11/22 at 11:58 a.m., IP H reported that she only had two weeks of missed testing emails, as she only started doing checks (for who missed testing) on 7/24/22. IP H reported that all staff were supposed to be testing twice per week on the greenhouse and main long term care units. A review of two emailed logs for the weeks of 7/24/22-7/30/22 and 7/31/22 - 8/6/22 revealed the following: CNA I was on both weeks' of logs for not testing. The following staff were noted to be unvaccinated and marked for not testing per policy on both weeks' logs: CNA EE, RN P, CNA M, CNA L, CNA N, CNA Q, and CNA I. On 8/11/22 at 12:05 p.m., a phone interview was conducted with CNA I who was marked as positive on the testing logs on 8/4/22 and 8/7/22. When asked about the tests, CNA I reported he had just spoken with the DON and that he must have accidentally checked the wrong box on both of the tests, as he had tested himself on those two days. CNA I was asked if he had symptoms on 8/4/22 and responded that he didn't have any symptoms. CNA I confirmed that he had never spoken with IP H or RN S, but that a nurse he did not know the name of had called him to verify that he was not positive on 8/4/22 only. On 8/11/22 at 12:09 p.m., the DON reported that CNA I was not competent to be testing himself and should not be testing himself. A review of IP Hs staff tracking log revealed the following: RN J tested positive on 7/30/22 - .exposure: no . Last worked day wed. + test Saturday (>48 hours no exp). Nurse Aide (NA) BB tested positive on 8/5/22.Exposure: yes. Neighborhood: Legacy (main long term care unit). 1st test legacy res on 8/8 . CNA K tested positive on 8/8/22 Exposure: 8/7/22. Neighborhood: legacy and NGH (north greenhouse) . A review of RN Js timesheet revealed she worked on 7/27, 7/28, and 7/29. However, in the staff COVID-19 tracking log indicated that RN J did not work within 48 hours of testing positive on 7/30/22. On 8/11/22 at 2:55 p.m., the DON was asked about RN J's timeline of events of working after she was having symptoms. The DON reported she was not sure of the accuracy of IP H's surveillance and tracking records. On 8/11/22 at 3:16 p.m., RN S was interviewed about her role in tracking COVID-19 positive staff. RN S stated that once she is informed of a positive staff, she tracks the date and when the symptoms start, so she can calculate the five days that the staff need to be off work. When asked if she did the contract tracing, RN S reported that she did not do contract tracing, but that a mass email was sent out to all staff, since the staff could have come in contact with anyone in the facility. When asked if they tested all employees and residents, the DON reported that they did not. RN S was asked to provide her employee tracking log. A review of RN S's Employee COVID-19 tracking log revealed the following: RN J had an onset of symptoms on 7/27/22, last in the workplace on 8/2/22 and tested positive on 7/29/22. NA BB had symptoms onset on 7/28/22, was last in the workplace on 7/29/22, and tested positive on 7/29/22. CNA I was noted on the log as symptomatic on 8/4/22, and a negative test date of 8/11/22. There were two other staff (LPN CC and CNA DD) noted as working in the long-term care unit on this list noted to be positive on 7/30 and 7/31 respectively, but they were not on IP H's log. On 8/15/22 at 2:44 p.m., the DON was asked about the August 2022 infection surveillance, as it was not found in the surveillance book. The DON reported that the monthly infections were not mapped until the first week of the following month. The DON reported she would have IP H send her current line listings for August 2022 infections. The DON was asked to provide the CDC guidance for when COVID-19 staff could return to work. A review of the August 2022 monthly surveillance sent by IP H revealed four current infections, including R57. R57's surveillance line was missing information, including signs/symptoms, symptom onset, and test date. A review of an email dated 8/12/22 sent from IP H to the local health department revealed, I apologize but my email reporting the first case below was in my draft folder but this is our covid update: Positive staff: (RN J) . was positive on 7/29/22, symptomatic. (NA BB) . positive 8/5/22, unvaccinated, symptomatic. (CNA K) . positive 8/8/22, vaccinated, symptomatic. Positive resident: (Name of R_) . was positive 8/11/22, vaccinated, symptomatic, no current antiviral therapy . This revealed that the health department was not being notified of each new case timely. On 8/16/22 at 11:01 a.m., the DON and IP H were asked about the facility return to work policy for COVID-19 positive staff. When asked how many days staff needed to be off work when COVID-19 positive, the DON reported it was five days. IP H was asked about the missing mapping and outbreak summary for June 2022 and reported that she must have not done them. When asked about the emails and logs of the staff that were not testing per policy, the DON reported that staff were supposed to be given a verbal and then a written warning if they missed their testing and were not supposed to be allowed to work if they did not test first. The DON also reported that there was one additional Resident (R229) and staff (unidentified) positive for COVID-19 on 8/15/22. A review of an email dated 8/15/22 revealed, (Name of RN J) symptom and temperature check and was within the normal limits on her worked days of 6/28/2022, 6/29/2022, 6/30/2022 and 7/1/2022 but did not log the information. There was no documentation for her temperature or symptoms despite this email stating the symptoms and temperatures were within normal limits. On 8/10/22 at 8:58 a.m., Nurse Tech (NT) F entered the room of Resident #7 and Resident #68 and performed a COVID-19 antigen test on Resident #68. NT F then exited the room. On 8/10/22 at 9:00 a.m., NT F was observed coming back in the room of Resident #7 and Resident #68 without changing her isolation gown and obtained a COVID-19 test sample from Resident #7. NT F was observed preparing the sample for development and closed the sample in the testing card. NT F then proceeded to touch all 5 timers located on the cart she was using to prepare the samples with contaminated gloves. NT F also proceeded to handle a paper used for recording the results of multiple tests and an ink pen with the same contaminated gloves. After these actions, NT F removed her gloves and proceeded to perform hand hygiene with a hand sanitizer, but failed to clean any of the reusable equipment she had been handling with the contaminated gloves. NT F then proceeded to handle each of the timers again with newly donned gloves which contaminated the gloves and entered the room of Resident #50 to obtain a COVID-19 testing sample. NT F again prepared the sample in a testing card and began handling the timers with contaminated gloves. NT F stated she was directed to perform testing on all of the residents on the hall which included Resident #57 who tested positive the following day on 8/11/22 after developing symptoms. NT F was observed entering and exiting multiple rooms with the same isolation gown, testing multiple residents on the 100 unit. On 8/11/22 at approximately 9:58 a.m. the DON informed the survey team that Resident #57 had been retested that morning after reporting symptoms consistent with COVID-19 and subsequently tested positive. On 8/10/22 at 9:12 a.m., an observation was made of Resident #229 (R229) in her room with a visitor. Outside of R229's door was a sign that read, Quarantine you must DON (put on) the following PPE (personal protective equipment) in this order before entering the resident's room: Hand hygiene, clean gown, remove and discard Surgical Mask, Hand Hygiene, Put on N95 mask, hand hygiene, Put on new surgical mask over N95 mask, Put on Face Shield/Eye Protection, Hand Hygiene, Gloves, Enter Resident Room. During this observation, R229's visitor was not wearing the correct PPE in order to enter the room and had a single surgical mask on below his nose while socializing with R229. R229 was confirmed to be unvaccinated and in quarantine due to a positive case of COVID-19 at the facility. A review of the facility policy titled, Infection Preventionist Surveillance for Long-Term Care revised 7/12/21 revealed, Purpose: To provide a process for infection prevention surveillance for Long Term Care (LTC) . E. The Infection Prevention coordinator (or designee) will be responsible for surveillance of residents' infections . H. Infections requiring reporting to the Health Department will be reported by the Infection Prevention Coordinator (or designee). I. Employee illness with symptoms will be logged with by each manger/designee for all departments that interact with LTC residents or staff. The Manager/designee will communicate this information to the Infection Prevention coordinator who will keep a facility log of illnesses . A review of the facility policy titled, Work Restrictions Because of Illness or Special Condition revised 5/17/21 revealed, . Coronaviruses . Exclude from duty; . Duration: In accordance with the most recent CDC (centers for disease control) recommendations as indicated by Infectious Disease Physician . A review of the facility policy titled, COVID-19 Exposure Control Plan revised 4/22/22 revealed, .1. Managers within clinical settings that have HCP (health care personnel) with a potential for exposure to COVID-19 are responsible to review the transmission/pathogen-based precautions and PPE necessary . C. Employee Responsibility: 1. Perform self-screening daily as required. 2. Self monitor for symptoms, and report any symptoms to Employee Health and manager as per the management tool kit . 5. Properly use the type of PPE indicated by the Standard and Transmission/Pathogen-Based Precautions (Isolation) policy . 7. Stay home when ill . A review of the facility policy titled, COVID-19 Antigen Testing revised 5/4/21 revealed, . A The facility will conduct testing through the use of rapid point-of-care (POC) diagnostic testing devices as per manufacturer's instructions. B. Antigen testing will be used in the following circumstances: 1. Testing of symptomatic residents and staff. 2. Testing of asymptomatic residents and staff in facilities as part of a a COVID-19 outbreak response . A. Testing of symptomatic residents or staff: . 2. If an antigen test is presumptive negative, perform RT-PCR immediately (e.g., within 2 days) a. Symptomatic residents should be kept on Transmission Based Precautions and Symptomatic staff should be excluded from work until RT-PCR results return . A review of the facility Job Description for Infection Preventionist dated October 2019 revealed, . 1. Develops and implements 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. 2. Serves as a resource for staff members regarding infection prevention and control, including the identification of when a resident needs to be placed on isolation precautions. 3. Establishes LTC systems for the prevention, identification, reporting, investigates and control of infections and communicable diseases of resident, staff, and visitors . A review of the facility policy titled, COVID-19 Resident and Family Testing revised 10/2/2020 revealed, . E. Testing will be completed on all residents or staff members with symptoms or suspected exposure. Staff member will not work until the test results are returned and if found to be positive then staff member will be scheduled off for 10- days following the date the test was obtained . K. Positive COVID-19 test results are reported to the Infection Preventionist, or designee, within one hour of receipt so that reporting may begin . An Immediate Jeopardy began on 8/4/22 when CNA I tested positive for COVID 19 and remained at work and in contact with vulnerable residents. The IJ notification was communicated verbally to the Administrator and DON on 8/11/15 at 4:04 p.m. and was followed with an email copy with request for a removal plan. The removal plan was accepted on 8/12/15. An onsite verification of immediacy removal was made on 8/15/22. Facility Removal Plan IJ Abatement plan 8/11/2022 - All staff member will be educated by the DON and Administrator of who is able to test. 8/11/2022 - DON will ensure staff who are permitted to test are competency evaluated and re-educated on the testing procedure. 8/11/2022 - Any staff who are found to have tested themselves will receive disciplinary action and the test will be invalid. 8/11 - 8/12/2022 - The Covid testing log has been updated to reflect appropriate information. 8/11/2022 - 8/12/2022 - All competency approved staff will be educated by the DON and Administrator on proper completion of the covid testing log and who to turn into for review. 8/11/2022 - If there is a long-term care exposure all facility residents will be tested . 8/11/2022 - All staff will be monitored by the infection prevention nurse or designee to ensure they are testing at the correct frequency based on vaccination status. Staff who do not test will not be permitted to return to work 8/12/2022 - Staff performing testing will be re-educated by the DON and Administrator on donning, doffing PPE and proper hand sanitation between resident testing. 8/12/2022 - Infection control prevention nurse will receive 1:1 training to ensure competency and understanding of accurate testing, completion of the testing logs, tracking of staff testing compliance and follow up on positive test results. This person will be expected to collaborate with employee health for the appropriate return to work date. The logs and tracking will be audited by the DON and Administrator once weekly to ensure completion and understanding until substantial compliance is obtained. The facility will immediately change the following: Immediate Action: As of August 11, 2022, all staff will be educated immediately within 24 hours on who is able to test, and this will be done only by competency evaluated staff, The evaluations will be completed by the DON. No other staff will be permitted to test. Staff will be required to complete competency evaluations to the DON or design prior to performing testing. Staff members who are currently competency tested will be required to be re-evaluated for testing and re-educated on our procedures by DON. Any staff member who has been found to have tested themselves will receive immediate disciplinary action. This is our current process staff will be reeducated. NEW PROCEDURES / FORMs for Covid Testing / Tracking The Covid testing log has been updated to reflect the date of the test, the test result, the name of the staff member performing the test, test number, control results and symptom identification. (See updated form attached). When staff are tested this log will be completed in full. All competency tested employees will be reeducated on this process and completion of this form August 11 & 12, 2022. Once the forms are completed at the end of each testing period the forms will be turned into the DON or designee for review. If any discrepancies are noted the employee and tester in question will be notified and an investigation will be initiated. NOTE * If an employee is found to have a positive result the manager on call will be notified immediately as well as the staff member. The manager on call will ensure the employee health nurse and health department are notified. The staff member will not be permitted to report to work until the employee health nurse has approved their return. This is our current policy we will re-educating staff. 8/11/2022 RESIDENTS -Beginning 8/11/2022 If there is an exposure in long term care, all long-term care residents will be tested within 24 hours, they will then be tested 48 hours after and 2 more times the following week. If there is a positive result found the resident will be relocated to our covid unit. If there is a positive test result the 2-week testing period will restart and continue until there are 2 weeks of negative test results. Staff will be required to test 2 times weekly as well remaining 48 hours between tests for 2 weeks, this applies for both vaccinated and unvaccinated staff. The health department will be notified of the resident's positive test result and the results will be entered into NHSN within 24 hours. We are currently and have been doing this, but we are re-educating all staff. Once the logs have been verified that they are completed correctly the data will be entered by the infection control nurse or designee into NHSN. All staff will be monitored by the infection prevention nurse or designee to ensure they are testing at the correct frequency based on their vaccination status and requirements of the CDC. Staff who fail to comply with these standards will not be permitted to return to work until a negative test result has been obtained. Staff who are not complaint will receive disciplinary action. A new form will be developed within 24 hours to appropriately track positive staff members last day worked, areas of exposure to develop an appropriate testing plan and the employees return date. As of August 12, 2022, Staff who are approved to perform resident testing will be reeducation on donning and doffing PPE between resident testing and proper hand sanitation prior to contact with other testing materials and or residents. Weekly audits will be performed and documented when testing is required to ensure compliance until substantial compliance is obtained. This will be done by DON or Designee. On August 12, 2022, the infection prevention nurse will receive 1:1 training with the DON and NHA) to ensure competency and understanding of accurate testing, completion of the testing logs, tracking of staff testing compliance and follow up for positive test results. This person will be expected to collaborate with employee health for the appropriate return to work date. Her logs and tracking will be audited 1X weekly to ensure completion and understanding until substantial compliance is obtained. Although the immediate jeopardy was removed on 8/12/22, the facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that has the potential to affect a large portion of the facility's residents due to the inability to verify staff education, all policy updates, system changes, and sustained compliance.

Based on observation, interview, and record review the facility failed to test residents and staff per facility policy and standards of practice with the potential to effect all 78 Residents residing in the facility. This deficient practice resulted in the potential for undetected COVID-19 and the spread of COVID-19. Findings include: On 8/9/22 at approximately 9:00 a.m., a notice was observed on the front door notifying any visitors of a positive staff case of COVID-19 beginning on 8/8/22. Administrative staff clarified that Certified Nurse Aide (CNA) K currently had COVID-19. During an observation on 8/10/22 at 8:58 a.m., Nurse Tech (NT) F entered the room of Resident #7 and Resident #68 and performed a COVID-19 antigen test on Resident #68. NT F then exited the room. On 8/10/22 at 9:00 a.m., NT F was observed coming back in the room of Resident #7 and Resident #68 without changing her isolation gown and obtained a COVID-19 test sample from Resident #7. NT F was observed preparing the sample for development and closed the sample in the testing card. NT F then proceeded to touch all five timers located on the cart she was using to prepare the samples with contaminated gloves. NT F proceeded to handle a paper used for recording the results of multiple tests and an ink pen with the same contaminated gloves. After these actions, NT F removed her gloves and proceeded to perform hand hygiene with a hand sanitizer but failed to clean any of the reusable equipment she had been handling with the contaminated gloves. NT F then proceeded to handle each of the timers again with newly donned gloves which contaminated the gloves and entered the room of Resident #50 to obtain a COVID-19 testing sample. NT F again prepared the sample in a testing card and began handling the timers with contaminated gloves. NT F stated she was directed to perform testing on all the residents on the hall which included Resident #57 who tested positive the following day on 8/11/22 after developing symptoms. NT F was observed entering and exiting multiple rooms with the same isolation gown, testing multiple residents on the 100 unit. On 8/11/22 at approximately 9:58 a.m. the DON informed the survey team that Resident #57 had been retested that morning after reporting symptoms consistent with COVID-19 and subsequently tested positive. On 8/11/22 at approximately 10:30 a.m., an interview was conducted with Infection Preventionist (IP) H. IP H was asked to provide the log of Resident COVID-19 testing. IP H reported that her process was to print a census sheet, test the Residents, document results in each Resident's medical record, and then shred all the paper. IP H reported she did not document the lot number of the test card and had no record except for in each medical record, of when and who she tested daily. When asked why R57 was tested on [DATE], IP H reported it was due to him presenting with symptoms that morning. IP H was asked about the positive staff member that was noted on the door of the facility. IP H reported that CNA K had only worked on the greenhouse and main long term care unit, and therefore they were the only units that were being tested in outbreak mode. IC H reported that they only tested on units that the positive staff had worked on in the 48 hours prior to testing positive. A stack of facility testing logs (loose sheets of paper) dated 7/9/22 through 8/10/22 revealed the following: More than 72 of the tests logged had no binax now card number or lot number logged to identify the test. Over 65 tests logged were missing information whether there were symptoms present or not. Three tests, on 8/1/22, 8/8/22, and 8/9/22, were missing the test results. On 8/11/22 at 10:42 a.m., an interview was conducted with IP H, the Director of Nursing (DON), and the Administrator. IP H was asked to clarify why there was no record of the testing logs for the Residents (including date of test, control result, result, and name of tester) and reported they decided they didn't want to keep so many sheets of paper. IP H only kept a record of the number of test she gave, but not who she tested . When asked which units were currently being tested in outbreak mode, IP H reported they were testing one of the greenhouse units and the main long term care unit (Legacy), as those were the units that CNA K had worked on. IP H confirmed that those were the only units that were currently testing in outbreak mode. When asked about how they ensured staff were testing appropriately, IP H stated, They (staff) are responsible for knowing when to come in . and that she also compiled an email the following Monday after each week for the staff who had failed to complete their testing. Evidence of these emails were requested. IP H was asked about why the staff testing logs were missing key information, like symptoms, the control test, the date, who gave the test, and results. The DON stated it would be a good idea to know who gave the test. IP H reported that she reviewed all of the sheets and then put the results into a spreadsheet log. IP H was asked about CNA I who was marked as being positive on 8/4/22 and 8/7/22 dates. IP H reported she must not have seen those test pages, because any positive results are supposed to be reported to Employee Health RN S. IP H confirmed she was not aware of CNA I's positive tests. IP H then stated that per her log (which was composed of test log data) she had marked CNA I as negative on 8/4/22. On 8/11/22 at 11:58 a.m., IP H reported that she only had two weeks of missed testing emails, as she only started doing checks (for who missed testing) beginning on 7/24/22. IP H reported that all staff were supposed to be testing twice per week on the greenhouse and main long term care unit. A review of two emailed logs for the weeks of 7/24/22-7/30/22 and 7/31/22 - 8/6/22 revealed the following: CNA I was noted to be on both weeks of logs for not testing. The following staff were noted to be unvaccinated and marked for not testing per policy (of twice per week during outbreak testing) on both weeks' logs: CNA EE, RN P, CNA M, CNA L. CNA N, CNA Q, and CNA I. On 8/11/22 at 12:05 p.m., a phone interview was conducted with CNA I who was marked as positive on the testing logs on 8/4/22 and 8/7/22. When asked about these test results, CNA I reported he had just spoken with the DON and that he must of accidentally checked the wrong box on both of the tests, as he had tested himself on those two days. CNA I was asked if he had symptoms on 8/4/22 and responded that he didn't have any symptoms. CNA I confirmed that he had never spoken with IP H or Hospital employee RN S, but that a nurse he did not know the name of had called him to verify that he was not positive on 8/4/22. On 8/11/22 at 12:09 p.m., the DON reported that CNA I was not competent to be testing himself and should not be testing himself. A review of the facility policy titled, COVID-19 Exposure Control Plan revised 4/22/22 revealed, .1. Managers within clinical settings that have HCP (health care personnel) with a potential for exposure to COVID-19 are responsible to review the transmission/pathogen-based precautions and PPE necessary . C. Employee Responsibility: 1. Perform self-screening daily as required. 2. Self monitor for symptoms, and report any symptoms to Employee Health and manager as per the management tool kit . 5. Properly use the type of PPE indicated by the Standard and Transmission/Pathogen-Based Precautions (Isolation) policy . 7. Stay home when ill . A review of the facility policy titled, COVID-19 Antigen Testing revised 5/4/21 revealed, . A The facility will conduct testing through the use of rapid point-of-care (POC) diagnostic testing devices as per manufacturers instructions. B. Antigen testing will be used in the following circumstances: 1. Testing of symptomatic residents and staff. 2. Testing of asymptomatic residents and staff in facilities as part of a a COVID-19 outbreak response . A. Testing of symptomatic residents or staff: . 2. If an antigen test is presumptive negative, perform RT-PCR immediately (e.g., within 2 days) a. Symptomatic residents should be kept on Transmission Based Precautions and Symptomatic staff should be excluded from work until RT-PCR results return .

Based on observation, interview and record review, the facility failed to properly store controlled medications in two of two medication storage rooms. This deficient practice led to the potential for unauthorized access of controlled medications and the potential for diversion. Findings include: On 8/10/22 at 1:49 p.m., the main medication room located in the center of the 100, 200 and 300 units was observed with Registered Nurse (RN) V. The medication room had a plastic box of controlled medications located in an unlocked cupboard with red plastic fasteners holding the box closed. The plastic fasteners were designed to be able to snap off the box without the use of a secondary key. The medications were accessible with the use of only one key. All nurses working for the day would have access to the room at any given time. On 8/10/22 at 1:55 p.m., the medication room located in the memory care unit was observed with RN W. The medication room had a plastic box of controlled medications located in an unlocked cupboard with red plastic fasteners holding the box closed. The plastic fasteners were designed to be able to snap off the box without the use of a secondary key. The medications were accessible with the use of only one key. All nurses working for the day would have access to the room at any given time. On 8/10/22 at 2:18 p.m., the Director of Nursing (DON) was shown the concern identified and acknowledged the controlled medications were not behind two keyed locks as required. When asked when medications should be signed out after administration, the DON acknowledged controlled medications should be signed out immediately upon removal of the medication from the medication cards during the medication administration process. The DON was asked for a policy regarding controlled medication storage and administration. On 8/16/22 at 12:19 p.m., a link to the policy resource was sent to this Surveyor, but was inaccessible due to user name and pass code requirements. The DON was asked to provide a PDF printout of the material. On 8/17/22 at 11:25 a.m., the DON replied with a email stating she would provide the requested resource, however the survey team had already exited on 8/16/22. On 8/18/22 at 2:13 p.m., an email from the DON was received which had copied verbiage from the facility policy Narcotic Administration, no date. There was no guidance for how controlled medications should be stored at the facility. A review of the website https://ehs.research.uiowa.edu/dea-controlled-substance-secure-storage-guidelines accessed on 8/17/22 read in part: DEA (Drug Enforcement Agency) Controlled Substance Secure Storage Guidelines General storage rule · All controlled substances must be stored behind at least two differently keyed locks at all times. · For keyed lockboxes -Do not store the keys near the lockbox; and -Do not store the keys together. · For combination lock lockboxes -Only the registrant and as few responsible individuals as possible should know the combination. -Whenever anyone who knows the combination is terminated from employment, the combination(s) must be changed .

Based on interview and record review, the facility failed to report an allegation of physical abuse to the State Agency (SA) for one Resident (R16) of one resident reviewed for abuse reporting. This deficient practice resulted in abuse allegations to go unreported. Findings include: Review of R16's medical record revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's 5/10/22 Minimum Data Set (MDS) assessment revealed a 0/15 on the Brief Interview for Mental Status (BIMS) score indicating she was severely cognitively impaired. Review of R16's progress notes dated 7/17/22 at 10:36 a.m. and written by Registered Nurse (RN) X read, in part, .Mood this morning seemed stable; (Certified Nurse Aide (CNA) Y) took resident into the bathroom because she was incontinent of stool. (CNA Y) got her into the lift and then pulled her pants down, she was ok until the pants were down .she started yelling that she was being molested . An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 8/16/22 at 10:35 a.m. The DON confirmed that they were made aware of what R16 stated but did not report the allegation to the SA. A review of the facility's Abuse Prevention Program policy last revised on 9/2019 read, in part, .each resident has the right to be free from abuse .in response to allegations of abuse .the facility must: ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State law .

Based on observation, interview, and record review, the facility failed to ensure adequate equipment safety and safe functional transfers with a mechanical lift, for two Residents (Resident #1 and #11) of six residents reviewed for falls. This deficient practice resulted in actual harm for Resident #1 (a head injury with laceration and staples), and the potential for injury during unsafe transfers for Resident #11. Findings include: Resident #1 Review of Resident #1's quarterly Minimum Data Set (MDS) assessment, reference date 6/23/2020, revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was on hospice services. Resident #1 was one-person extensive assistance for bed mobility, dressing, and hygiene, and total dependence, one-person assistance, for transfers and toilet use. The Brief Interview for Mental Status (BIMS) revealed a score of 99, which showed Resident #1 was unable to complete the cognitive interview. Review of the facility 5-day investigation report, submitted to the State Agency (S.A.) on 7/02/20, revealed on June 26, 2020, at approximately 10:20 a.m., Certified Nurse Aide (CNA) E was assisting Resident #1 to her Geri chair (a reclining positional facility chair) using a mechanical lift, with a size large green sling. During the transfer to the bed, CNA E noticed the part of the sling under Resident #1's left leg was folded. Resident #1 also was kicking her right leg, which was a known occurrence. When CNA E attempted to unfold the sling, during transport of Resident #1 from the bed to the Geri chair, the sling became unclipped from the lift. Resident #1 slipped out of the sling, falling headfirst onto the floor. Resident #1 developed bleeding on the back of her head, and was transported to the Emergency Department for evaluation. The Care Plan at that time showed Resident #1 was able to be transferred with a full body mechanical lift with one-person assistance, using the large, green sling. The DON reported, This is a very unfortunate accident, and we will make improvements to help prevent this from occurring again. Review of Resident #1's (Facility hospital name) Emergency Department Report, dated 6/26/20, revealed, . (Resident #1) was dropped from (a mechanical lift) approximately three feet, striking the back of her head, resulting in a laceration and bleeding. (PA K) said (Resident #1) is on hospice for severe dementia .ER course: An [AGE] year old was accidentally dropped from the Hoyer lift today, suffering a head injury and [MEDICAL CONDITION] .Dx (diagnosis): 1. Head injury with concussion. Question small intercranial hemorrhage. 2. [MEDICAL CONDITION]. Review of Resident #1's progress note, dated 6/27/20 at 1:03 a.m., by Licensed Practical Nurse (LPN) U, revealed, .Four staples to the right (side) of the head are intact. Order in (Electronic Medical Record-EMR) to be removed within 7 to 10 days . Review of a typed witness statement, dated 6/27/20 at 14:43 (2:43 p.m.), by CNA E revealed, I (CNA E) was in resident room (Resident E's room number), cleaning her up and getting her ready to go into her Geri chair for lunch. I lifted (Resident E) in the air with the lift and walked over to where her chair was, (sic) in the middle of going to the chair I noticed her sling under her thigh wasn't on correctly. When I tried to correct it all of a sudden the clip unclipped itself from the lift and (Resident #1) fell out of the sling, having her head hitting the floor headfirst . During an observation on 7/08/20 at approximately 1:30 p.m., Resident #1 was observed lying in her bed sleeping soundly in her room, on the facility memory care unit. The bed was in the low position. During an interview on 7/08/20 at 2:35 p.m., Resident #1's nurse, Licensed Practical Nurse (LPN) F, recalled Resident #1's fall, and reported she was on shift assigned to Resident #1's care at the time of the fall. LPN F stated, I was in the dining room. (CNA E) called me to (Resident #1's) room immediately, and said, .(Resident #1's) on the floor .(Resident #1) was (observed) in the supine position (lying on her back). I noticed blood around her head. I asked her if she was ok. She shook her head 'yeah'. She was moving her extremities freely. She was conscious. I asked (CNA E) what happened. (CNA E) said she adjusted the sling and (Resident #1) somehow fell headfirst out of the sling . LPN K explained RN B and the DON were also present immediately after the fall, and PA K arrived and did an assessment. LPN F reported Resident #1 did not show signs of pain, and EMS (Emergency services from the attached hospital) arrived and transported Resident #1 to the hospital. LPN F reported Resident #1 came back with four staples in the back of her head. They are not there now. I removed them . LPN F stated the interventions that were added included Resident #1 was changed to a two-person transfer with the full body lift, and not to adjust the sling in the air while the resident is being transported. LPN F was asked how the sling should be adjusted. LPN F explained the process is the caregiver would lay the resident down, readjust the sling, and then put them back in the sling by lifting the sling off the transfer surface, then transferring the resident to their chair (or second surface). LPN F confirmed this was a transfer from the bed to her Geri chair. LPN F was asked how Resident #1's fall could have been prevented, and responded, No adjusting the strap (part of sling) in the air .We also put in place to check the slings monthly. They (nursing management) figured out the sling they used was loose, you could barely tap it and it came off (the mechanical lift) .It was overstretched. It was a green shower sling. From what I understand the shower sling is a full (body) sling . LPN F explained the aides do the (Name of full body mechanical lift) transfers with one person (assistance), unless the facility specifies otherwise. This Surveyor asked if Resident #1 was still using a green sling. LPN F responded, .She is in a yellow full body sling. All I know is that the yellow (sling) is smaller than the green . LPN F explained the restorative CNA decides which sling to use and measures the resident for fit. LPN F added, We just changed the sling out yesterday. I noticed it was a little big. We switched her (Resident #1) to a yellow sling. We noticed her bottom was coming out . LPN F reported no other resident falls from mechanical lifts, no additional falls for Resident #1, and no increased pain or change in function for Resident #1 since this fall. During an interview on 7/09/20 at approximately 8:45 a.m., CNA E concurred the incident occurred on 6/26/20, and stated, It was around 10-10:30 ish (a.m.) (sic). I went in there (Resident #1's room), and I see (sic) that her sling was wet. She was in her bed. The sling was on the side of her bed .I went to our area that has our blankets, slings .I only found a shower sling. It was green .It (the green large sling) was in her Care plan .I put the sling on her. I lifted her up. Her Geri chair was next to her closet. As I was walking and transferring her to her Geri chair, I realized the sling was bunched under her left leg. It wasn't on right. So I went to flatten it, and as that happened very fastly (sic) the clip comes (sic) off .(Resident #1) slid out butt first but I think as her one leg was still on (the lift), she (then) went down headfirst. She was completely out of the lift when she was on the floor. I looked at her; she made eye contact. I said, 'Are you ok?' (Resident #1) shook her head (yes) and she understood .I ran to (LPN F), the nurse, and told her I needed help .(LPN F) came in and assessed the situation. There was blood on the floor on (Resident #1's) head, not gushing . CNA E explained Resident #1's Care Plan showed she was a one-person assisted transfer with the full body mechanical lift. CNA E was next asked if she should have been using the shower sling, and reported she was not aware of a concern as it was a full body sling, per Resident #1's Care Plan. CNA E confirmed she received disciplinary action, and was educated on proper use of the full body mechanical lift and sling, including not adjusting the sling between surfaces. CNA E added she is now getting two-assist (two-person assistance) for Resident #1, per the Care Plan. CNA E explained she also received education on when to use a toileting sling, a shower sling, and a regular sling, and that it wasn't a good idea to use a shower sling (for the bed transfer) because of the different (mesh) fabric. CNA E was asked if she adjusted the shower sling 'in the air' (during the resident's transport between surfaces), instead of on a surface, such as the bed or Geri chair. CNA E reviewed the progress note she wrote. CNA E responded, .Yes, it was (flattened) in the air. Yeah, I should have waited. I feel like I should have put her in her chair and then fixed the sling for her instead of in the air . CNA E was asked about the condition of the sling, and responded, I think it was a little old; the tag was gone. There is a plan in place now to date them. During a phone interview on 7/09/20 at 9:53 a.m., Resident #1's physician assistant, PA K was asked about this incident. PA K recalled the incident, and acknowledged being in the facility at the time of the fall. PA K explained RN B, the DON and the CNA E were present when PA K arrived to assess the resident. PA K described the accident: .(Resident #1) was lying on her back. She looked a little scared; she was not tearful. She was on hospice and had a prior stroke. She was able to nod .She had pain in the back of her head, was bleeding, and had a head injury .A head to toe eval (evaluation) was done. There were no major or significant injuries. Besides the wound on the back of her head, I am not remembering any major lacerations. I was able to see at least a centimeter wound to the back of her head and I thought, 'This is going to require staples.' We were able to get her to ER (the emergency room ) . PA K added she instructed facility staff to remove the mechanical lift from the memory care unit until it could be evaluated.It sounded like the straps where they attach to the lift -one popped off and the resident (Resident #1) slid feet first, butt out, and then the back of her head hit the ground .she (Resident #1) was readmitted to the facility (long term care unit) that day. This Surveyor asked about any equipment (lift/sling) malfunction as a possible cause of the fall. PA K responded, It was an accident and we were at fault . PA K was asked to further elaborate on the extent of Resident #1's injuries and a possible subarachnoid hemorrhage, and responded, (It was) a closed head injury with a hematoma with scalp laceration; all due to a fall from the lift .There were no other injuries . PA K was asked if Resident #1 has experienced a functional decline as a result of these injuries, and conveyed no awareness of a major (functional) change. PA K added, (Resident #1) was eating and drinking about the usual, and there was no change in her cognition or consciousness . During an interview on 7/08/20 at approximately 3:00 p.m., RN B, Nurse Coordinator for the memory care unit, was asked about this incident, and confirmed she was present immediately after the incident occurred. RN B reported Resident #1 came back in the afternoon from the hospital with a laceration and four staples to the back of the scalp .RNB explained Resident #1 was at her baseline upon return from the hospital; she was on hospice prior to this fall and had some confusion. RN B added that Resident #1 had been declining, continued to communicate minimally, remained dependent for care, and continued to sit up in her Geri chair. RN B denied resident having any increased pain. RN B reported the green sling was the correct sling for Resident #1's weight and height at the time of the fall. RN B was asked if Resident #1 had lost any weight recently. RN B denied any recent weight loss. This Surveyor asked for a record of Resident #1's recent weights, and her weight at the time of the fall on 6/26/20. RN B soon after returned with a record of Resident #1's recent weights, which showed Resident #1's last weight was 134#, taken on 6/01/20. During an interview on 7/08/20 at 3:40 a.m., the DON was asked about the root cause of this event, and responded, It (the sling) wasn't secure enough. The weight (of Resident #1) wasn't on it (the sling) enough to hold the clip in there (where the sling clips onto the mechanical full lift). (CNA E) tried to unfold it (the sling) and when she moved it around it became unattached. The DON confirmed the sling should not have been adjusted in the air (during resident transport). The DON added, If a sling needs adjustment, they (the CNA's) would do this on the bed or chair, not in the air. It was an unfortunate accident; it wasn't intentional. (CNA E) followed the Care Plan. The DON confirmed there were no other accidents with the Maxi-move mechanical lifts when asked. During this interview, the DON was asked to provide evidence of CNA E's lift/transfer training, education, and/or any competencies, and any process on fitting slings to residents who use the full mechanical lifts. The DON confirmed Resident #1 had not had any other recent falls. During this same interview, the DON was asked about Resident #1's last recorded weight of 134#, on 6/01/20, and if the green sling was appropriate for Resident #1's weight. The DON reported this was the most recent weight, as weights are not taken as frequently with residents receiving hospice care. The DON directed this Surveyor to follow up with CNA D, the restorative aide, and/or RN G, the restorative nurse. The DON showed this Surveyor a picture of the full mechanical lift used during this incident, which was marked as #7 on the side of the lift. The DON confirmed the facility vendor had inspected the lift after this incident, and it was deemed fully operational. The vendor did reportedly convey the sling had some signs of wear and tear, which the DON disagreed with, and provided this Surveyor a copy of this Inspection Report, dated 6/29/10. The DON also reported and provided evidence the facility lifts were all recently inspected by the Vendor, and reported the facility slings are regularly inspected by the facility restorative and nursing staff. Review of the Vendor, Inspection Report, dated 6/29/20, provided by the DON, referenced there was an attached incident report and pictures; this one page report did not appear to have full investigation conclusions. The DON reported the facility had not received these attachments. The report did reference a fraying/ripping failure of the sling, and the lift was function tested to manufacture's specifications (the lift was operational). This Surveyor asked for Vendor contact information for further clarification, which was provided by the DON. During an observation on 7/08/20 at 3:55 p.m., the DON provided the sling used during the transfer when Resident #1 fell out of the sling. The four clips appeared intact and in good condition, on this blue mesh shower sling with green edges. The DON confirmed this sling was size large. There were signs of slight wear on the sling surface; however, there were no obvious tears or holes on the sling surface, including on the edges. A review of Resident #1's Care Plan at the time of this incident, dated 6/24/20 14:24, (2:24 p.m.) revealed, Transfer Skills: 1 (person) Assist. Total Assist. Total Mech (mechanical) Lift - GREEN sling. Total Mech Lift - Full Body Sling Only. Review of an untitled facility letter, dated June, 2016, provided by the DON as a reference to sling fitting, stated: The following residents were identified as using total mechanical lift and were measured for appropriate sling sizes. Measurements were completed per sling sizing tape provided by (Brand name of facility lift vendor). Weights were taken into account also for sling sizing. Residents who lose 10 pounds or more in one month will be measured and sized by Restorative CENA (CNA) to ensure appropriate sling size beginning June 2016 forward. Sling sizing: Red = Small (77 - 132 pounds), Yellow = Medium (121 - 165 pounds), Green = Large (154 - 264 pounds) . A review of Resident #1's Care Plan after the time of the accident, dated 6/30/20 (handwritten), revealed, Transfer Skills: (handwritten) 2 assist, 6/30/20. Total Assist. Total mech lift. Full Body Sling Only. (handwritten) May leave sling under me D/T (due to) comfort, yellow full sling., with handwritten initials. Review of Resident #1's, Resident Weight Report, provided by RN B, on 7/08/20, including most recent weight, were as follows: - 4/02/20: 149.70 (pounds) - 5/05/20: 135.40 (pounds) - 5/11/20: 137.40 (pounds) - 6/01/20: 134.00 (pounds) This Surveyor noted at the time of Resident #1's accident from the sling, Resident #1's last documented weight was 134 pounds, which would have placed Resident #1 in the yellow sling, according to weight. During an interview on 7/08/20 at approximately 4:00 p.m., Restorative CNA D was asked if the green sling (size large) was appropriate for Resident #1, given Resident #1's weight loss. CNA D showed this Surveyor a (Company/Facility Vendor name) Sling Color/Size Guide, which read, Yellow: 121-165 pounds, and Green: 154 - 264 pounds . CNA D reported the restorative staff use a tape measure to select the sling size as well. CNA D was asked if she or restorative staff kept these measurements, and confirmed the restorative staff did not. CNA D described the process of fitting a resident to the sling. We measure from the coccyx to the top of the residents head. Whatever color it lands on is the indicator of which sling to use. CNA D showed surveyor the measuring tape with colored height areas/indicators, and explained, .The next part of the process is to take the Resident's weight and see where it lands (on the indicator), and what color (sling) is appropriate for the resident. CNA D added if a resident falls between two colors they use other observations to select the proper sling, such as resident girth. CNA D explained 134 pounds would have fallen in the weight range for the yellow (medium) sling, per the Vendor Sling Color/Size Guide for weight reviewed with this Surveyor. During an observation on 7/08/20 at 4:10 p.m., CNA D and CNA C were observed transferring Resident #1 from the bed to her Geri chair, per her typical routine, per LPN F to get Resident #1 up for dinner at this time. Resident #1 nodded approval for the transfer, and for this Surveyor to observe the transfer. A yellow sling (blue full body bed transfer sling with yellow edges and solid fabric), medium size, was placed under Resident #1 in bed, and Resident #1 was then transferred to the Geri chair using a full body mechanical lift. Resident #1 did not show any pain, and she smiled and nodded at staff after the transfer. She demonstrated adequate sitting balance in her Geri chair, and did not vocalize or grimace with any pain during this transfer. During an observation on 7/08/20 at 4:20 p.m., CNA D was asked to show this Surveyor the full mechanical lift, #7, also marked #10, which was used by CNA E when this accident occurred. CNA D confirmed this was the lift used during this transfer, and reported/demonstrated this lift as functional and in current use with residents. During an interview on 7/09/20 at 10:15 a.m. the Restorative Nurse, RN G, RN G confirmed there was no documentation kept of the sling measurements for weight and height for any residents, including Resident #1. This Surveyor was therefore unable to confirm measurements (height and weight) for Resident #1 when the green sling was recommended. RN G did not know who changed Resident #1 to the yellow sling. RN G reported residents are reevaluated for a sling when someone has a weight loss of 10 pounds or more in a month. That is supposed to trigger for you (on a standardized assessment). This Surveyor showed RN G Resident #1's weights, and recent weight loss, including the most recent weight of 134#. RN G was asked if Resident #1 should have been in a yellow sling. RN G responded, It would have been determined by fit and comfort . RN G confirmed the restorative aides fit the slings by resident weight and height. During an observation on 7/09/20 at 10:40 a.m., CNA L measured Resident #1, with her permission, seated upright in the Geri chair, using the color-coded vendor tape measure. Resident #1 measured 31 from the top of her head, to the bottom of her coccyx (tailbone), which was in the mid-range for a yellow sling (size medium). CNA L noted Resident #1 measured for a yellow (medium) sling. Both measurements for weight and height placed Resident #1 in a yellow (medium) sling during this survey. She was in a Green sling at the time of her fall. Review of the document, (Vendor name) Sizing Guide Tape for (vendor name) Slings, revealed, .Measure the resident from the coccyx seated to the top of the head. The yellow range was designated as M (medium). This range was shown to be between 28.8 and 33.7. During an observation on 7/09/20 at 10:35 a.m., CNA E and CNA J were observed transferring Resident #1 from the bed to her Geri chair, with Resident #1 nodding permission and observation. CNA L was also present. Staff used a total body lift, with a yellow medium sling, and transferred Resident #1 safely from her bed to her Geri chair. Resident #1 demonstrated adequate sitting balance to sit upright in Geri chair, and did not show any signs of pain. During a phone interview on 7/09/20 at 11:01 a.m. the (Facility Vendor designee), Quality System Analyst, Vendor I, was asked about the results of the 6/29/2020 representative visit to the facility to inspect the lift the lift and sling, as referenced above. Vendor I read technician notes from the 6/29/20 visit, which indicated, The sling showed signs of wear on the stitchings .Our technician found the lift is operating to the OEM (original equipment manufacturer condition) .and the PM (preventative maintenance) was performed .The cause of the malfunction was the staff member (not specified) felt like when the resident's weight wasn't' on the sling properly the left sling clip dislodged very easily. Vendor I reported the results of this investigation have not yet concluded, and declined to provide this Surveyor with the incident report, the technician notes, or the photographs aforementioned. Review of the document titled, Safety Checklist, dated 9/06/2017 (date near CNA E's hire), with CNA E's name handwritten on it, showed staff signed and initialed CNA E had been instructed on the use of Total mechanical lift transfers and Slings, as well as Positioning and safety equipment. Another document was provided titled, Sling agreement, which included, Mechanical lift slings are to be visually inspected prior to use. If in doubt, do not use and consult your charge nurse. When a resident is in a mechanical lift, please place him or her in bed or in a chair prior to adjusting the sling. This document was signed by CNA E on 7/09/20, and all nursing staff will be educated/sign by July 14, 2020, per the DON and this document. Review of the policy, Safe Patient Handling and Movement Policy, revised 6/11/2016, revealed, .It is a policy of (facility) to ensure that the patients/residents are cared for safely .Training and education for all employees on safe lifting is required .All employees whose job descriptions required the employees to lift patients/residents will: 1. Receive training on body mechanics and proper patient lifting techniques upon hire and semi-annually thereafter .The restorative CNA or CENA (nursing CNA) shall measure each resident for proper sizing of correct sling to be used upon initiation of transfer device. Sling measurement will be documented. If the resident's weight changes by more or less than ten pounds, re-measurement of the resident should be done for possible change in sling size. Dieticians will notify the Restorative nurse of all residents who have gained or lost greater than ten pounds in a month. Review of Attachment A. Patient Lifting and Handling Decision Tree., provided by the DON, revealed, (Resident requires) Extensive Assist: 1 to 2 people .mechanical lift . This attachment clarified the facility policy for full body mechanical lift transfers may be completed with 1 to 2 person assistance. Review of the manufacture's guidelines titled, Instructions for use Passive Clip Slings, dated 8/2019, provided by the DON, revealed on Page 9, .Applying the sling .13. Make sure the sling is centered and flat without creases .sling's pieces are not twisted underneath the patient .14. Make sure the patient's arms are inside the sling. 15. Place the lift next to the patient and apply the brakes. 16. Attach the sling. 17. Adjust the spreader bar to reclined position as needed .18. Slightly lift the patient to create tension in the sling. 19. Make sure that: All clips are securely attached. All straps are straight (not twisted), the patient lays comfortably in the sling. 20. If an adjustment is needed, lower the patient, and make sure that the weight of the patient is taken up by the receiving surface (bed or chair) before removing the clip. 21. Release the brakes on the lift. 22. Transfer, transport, and bathe the patient according to the lift Resident #11 Review of the facility provided document, (Brand Name of Full Body Lift) List, provided by the DON on 7/08/20, revealed Resident #11 required a full body lift during transfers. Review of Resident #11's, Quality Assurance Process Fall Documentation report, revealed: Date of Fall: 4/03/20, Time of Fall: 6:30 (a.m.): Resident Statement of what occurred - Tried to stand and couldn't stand anymore .Page 2: Quality Assurance Process Improvement - 5 Why's Analysis: Define the Problem: Resident had to (be) lowered to the floor. Why is it happening? 1. Staff did not use appropriate lift Why? CENA concerned about Res (resident) safety. Res gets bruises and c/o (complains of) pain with transfers. Res hard to transfer regardless of lift. Res unusual shape . This report indicated there was no injury to Resident #11. It was noted CNA S was one of the CNA's who was working with Resident #11 at the time of her fall. Review of Resident #11's Care Plan, dated 2/20/20, provided by the DON, revealed, Transfer Skills: 1 Assist. 2 Assist. Limited Assist. Extensive Assist. Standing Mechanical Lift. When waking up or sleep/nap use sit to stand lift . It was confirmed by the DON this was Resident #11's Care Plan at the time of the 4/03/20 fall. Review of Resident #11's, Quality Assurance Process Improvement Fall Documentation report, provided by the DON on 7/08/20, revealed: Date of Fall: 2/20/20, Time of Fall: 17:00 (5:00 p.m.). Resident statement of what occurred - (Resident #11) couldn't stand .List of changed or added interventions and fall level to help prevent future falls. - USE LIFT AT ALL X'S (TIMES) . During a phone interview on 7/10/20 at 10:17 a.m., CNA S was asked about Resident #11's fall. CNA S recalled the incident, and explained she was giving Resident #11 a bath, and stood her up at the grab bar in the shower room, with a gait belt .CNA S added, .As I was trying to get the shower chair next to her, I was behind her and the chair was close, and she said, 'I can't stand anymore,' when I pushed it (the chair) over to her. I was behind her and I was able to slide her down my leg. CNA S reported Resident #11 did not sustain any injuries. CNA S reported she did not look at Resident #11's Care Plan, which specified to use the sit to stand lift for transfers. CNA S explained (Resident #11) does have obesity and she did not fit in the lift very well. CNA S was asked if she received any disciplinary action. CNA S responded, I believe I got wrote up for it .I make sure I look at everybody's Care Plan. It was a very big mistake. Review of CNA S's (Facility Name) Disciplinary Notice, dated 4/03/20 at 7:00 (a.m.), provided by the DON, revealed, Not following Care Plan - resident is a sit to stand (lift transfer) or total lift (transfer) - stood resident up at bar in tub room - resident had to (sic) (be) lowered to floor. Action to correct: To follow care plan at all times . signed by CNA S, dated 4/03/20. This same document showed reeducation to CNA S provided by RN H. Review of Resident #11's current care plan, dated 7/10/20, provided by the DON, revealed, Transfer Skills: 1 Assist. 2 Assist. Total Mech (mechanical) lift - BLUE sling. Total Mech Lift - Full Body sling Only. May use (name of a standing lift) with green sling and blue belt. Per PT is able to complete standing lift with cues to stand up with one person assist (assistance) but seems to respond differently to staff and at times may require 2 person assist or total lift if unable to stand safely . It was noted this Care Plan showed multiple ways for Resident #11 to transfer, and it was not clear who makes the decision regarding which type of transfer method to use. During a phone interview with the DON on 7/10/20 at 9:53 a.m., the DON was asked to clarify Resident #11's transfer status. The DON responded, (Resident #1) has numerous ways to transfer. Right now they (staff) are using a (type of standing lift). Sometimes she is a mechanical (full) lift .PT (physical therapy) is able to complete standing with one person or with a lift. She (Resident #11) goes back and forth. The DON was asked if the CNAs make the decisions themselves regarding which type of transfer to complete. No clarification of the transfer decision making process was provided by the end of the survey, on 7/10/20.

This citation refers to intake MI 449: Based on interview and record review, the facility failed to adequately monitor nutritional and hydration status for one Resident (#904) out of four Residents reviewed for Nutrition and Hydration out of a total sample of 5 residents. This deficient practice resulted in signs, symptoms, and [DIAGNOSES REDACTED]. Findings include: A review of the medical record for Resident #904 revealed he had been admitted to the facility on [DATE] and was readmitted after a hospital stay ([DATE]- [DATE]) on [DATE]. Resident #904 expired in the facility on hospice services on [DATE]. Resident #904's [DIAGNOSES REDACTED]. A review of the [DATE] Minimum Data Set (MDS) assessment revealed he had scored ,[DATE] on the Brief Interview of Mental Status (BIMS) assessment, indicating severely impaired cognition. A review of the weight record for Resident #904 revealed only the following weights: [DATE] 135 pounds [DATE] 134.8 pounds [DATE] 135.4 pounds [DATE] 135.2 pounds [DATE] 136.4 pounds [DATE] 128.6 No weights were taken between [DATE] and when he was transferred to the emergency room (ER) on [DATE]. A review of the progress notes revealed the following: [DATE]: . Does not want to be in facility . Nurse offered snack and drink and resident refused . [DATE]: . BIMS score ,[DATE] . (Resident #904) feels 'like nothing' . suicidal ideation several days in the past week. When asked if he would ever act on these thoughts, (#904) replied, 'yes' . Author drew up (anti) suicide contract which (#904) signed . [DATE]: Staff reported resident requiring increased assistance over the last few days/weeks . [DATE]: Per staff, resident has had a recent change in cognition including increased shakiness, unsteadiness, possible increase in dementia due to no longer communicating with staff . PRN (as needed) [MEDICATION NAME] administered at 2113 (9:13 p.m.) for vocalization of headache . Resident #904 was exhibiting signs and symptoms of dehydration including dizziness, change in mentation, shakiness, and complaints of headache. [DATE]: . HR (heart rate) and BP (blood pressure) elevated this morning prior to medications, decreased later in the morning. Flat affect continues . [DATE]: . This nurse (Registered Nurse RN I) went to administer medication at 1625 (4:25 p.m.) and found resident unresponsive to sternal rub, diaphoretic, rapid and shallow respirations. No urine output since noon . VS ,[DATE], R (Respirations) 40 . transferred (to ER) at 1645 (4:45 p.m.). A review of Resident #904's care plan revealed no interventions related to fluid or dehydration prior to or after transfer back from the ER. A review of the [DATE] Nursing Admission Assessment revealed his skin turgor as abnormal yet there was no further documentation of this irregularity. A review of the [DATE] Nutrition Assessment completed by Registered Dietitian (RD) C revealed the following, . Oral intake ,[DATE]% of meals consumed averaging 71%; eating less than normal for him per (#904), and would like to have Ensure (liquid nutritional supplement) at meals .Usually feeds himself. When not feeding himself, staff does attempt to feed him. He usually refuses assistance, but accepts being fed on a rare occasion . Diagnosis: [REDACTED]. Will add 8oz Ensure [MEDICATION NAME] q (each) meal . Monitoring and Evaluation: weight, monthly . po (oral) intake varies and he states he's eating less than normal for him . Care plan initiated regarding inadequate PO intake with interventions of Ensure. Although RD C implemented a nutritional intervention, she did not increase the frequency of Resident #904's weight monitoring, resulting in no further weight monitoring until Resident #904 was hospitalized on [DATE]. On [DATE] at 9:23 a.m., Food Acceptance records were requested for Resident #904 for the week prior to his [DATE] hospitalization . Per RN A, they only do food acceptance records for new admits for the first 14 days or per ordered by the Dietitian. A review of the [DATE] ER report conducted by the ER attached to the facility revealed the following, written by Medical Doctor (MD B), .(Resident #904) had a decrease in mentation and also decreased urinary output with lethargy. His BP was also noted to be elevated . There was some conflicting information that perhaps it was 2 days that he has had some decline in mentation . The patient appears to be quite dehydrated, there is a question [MEDICAL CONDITION] . the patient does appear to be extremely dehydrated. He has tenting of the skin, he is quite thin . Resident #904 was then transported to the regional ER in another town. A review of the [DATE] second ER report revealed, . he (Resident #904) appears clinically volume contracted and he has a sodium of 158 (normal sodium is,[DATE] mEq/L), BUN (blood urea nitrogen) 49, and creatinine 1.3 with normal hemoglobin suggesting significant free water loss and dehydration. His initial lactic acid 6.9 and repeat was 3.6 after 1 liter of normal saline (IV hydration) . Impression: 1. [MEDICAL CONDITION] (high sodium) secondary to dehydration and free water loss . If patients nutritional status is significantly compromised and if he cannot participate in therapy . will certainly consider hospice . A review of a [DATE] progress note by RD J at the ER revealed, . Per documentation pt (patient) has been refusing care at baseline and not eating at ECF (extended care facility). Met with pt who could only state that he has not been eating . On [DATE] at 11:11 a.m., an interview was conducted with RN K (The Manager of the onsite emergency room ). When asked what weight Resident #904 had transferred in with, RN K stated, Our Records show 55 kilograms, 121.4 pounds. This revealed that between [DATE] and [DATE], 3 weeks, Resident #904 lost 15 pounds, which is a 10.9 % weight loss. On [DATE] at 12:37 p.m., an interview was conducted with emergency room Doctor, MD B. When asked about the state of Resident #904 when he was admitted to theER on [DATE] stated, He looked dry, and quite thin. He looked cachectic. When asked how long he felt that he had been showing signs of dehydration, MD B stated, A day or two. He wasn't able to respond at all. On [DATE] at 2:17 p.m., a phone interview was conducted with RN I. When asked about Resident #904s mentation change and the events that led to his discharge, RN I stated, The day I sent him he had a change in condition. Previously, we had a meeting on Thursday (4 days prior to his transfer) and they said he was needing more help with ADLS, more assist with eating. So on Saturday, the next day I was there, I updated his care plan to reflect that he needed more care to ensure that he got the proper assistance. When asked how Resident #904 appeared visually, RN I stated, He appeared the same as usual. Thin. When asked about his skin turgor, RN I stated, He had fragile skin. When asked if Resident #904 had tenting, RN I stated, Some. On [DATE] at 2:50 p.m., and interview was conducted with RD C who when asked about the nutritional monitoring of Resident #904 stated, I assessed him on the 18th. When asked why no weights had been obtained between ,[DATE] and ,[DATE] and why more frequent weight monitoring had occurred, RD C stated, Because when I assessed him on the 18th, with the weights we had he was stable. He was already on supplements and he seemed stable. When asked why Resident #904's intake wasn't being monitored with food acceptance records or with Intakes/Output records, RD C stated, I didn't start anything then because the CNAs didn't really report anything to me that he wasn't eating. When asked if she had visually assessed the Resident, RD C stated, It seems like I remember seeing him in bed. He was thin appearing. When asked if Resident #904 was at risk for dehydration, RD C stated, No because we were supplementing him with Ensure. When asked if she had assessed or visualized the Resident between her assessment on the 18th and his transfer out on the 31st, RD C stated, No. And I didn't get any reports of him not eating good. On [DATE] at 3:31 p.m., an interview was conducted with Physician Assistant (PA) H. When asked about monitoring of Resident #904's hydration and nutrition status, PA H stated, I did see him prior to his transfer (to ER), over a week prior. We went over his [MEDICAL CONDITION] but there was no mention to me that he wasn't eating. Occasionally I would overhear the CNAs saying he wouldn't participate or refused care. When asked whether she was concerned that there wasn't frequent monitoring of Resident #904's weights, food acceptance and input and output, PA H stated, Its not unusual to increase the frequency of these when we are worried about nutritional status, but it was not brought to my attention. When asked if she felt that Resident #904 should have been sent to the ER for evaluation sooner, PA H stated, With the change and altered cognition and altered consciousness, I would be asking for weights and getting vitals. When asked if she had been aware of his discussion with the social worker about having suicidal ideation, PA H stated, No, but I wish I had been. When asked how Resident #904 appeared visually, PA H stated, He looked chronically ill, thin and on the cachectic side, but he didn't look in distress. I went and saw him on ,[DATE] and I started him on [MEDICATION NAME] XL (beta-blocker medication). His labs came back mostly normal. He was alert but didn't really talk to me at all.

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY SUPERVISE ONE (RESIDENT #17) OF FOUR RESIDENTS REVIEWED FOR TOILETING SUPERVISION IN THE TOTAL SAMPLE OF 18 RESIDENTS OUT OF A FACILITY POPULATION OF 83 RESIDENTS. THIS FAILURE RESULTED IN HARM WHEN RESIDENT #17 WAS LEFT ALONE ON THE TOILET, AND fell . THIS WAS HER SECOND FALL FROM THE TOILET WHEN LEFT UNSUPERVISED. SHE WAS hospitalized WITH A FRACTURE OF THE RIGHT FEMUR AND SUBSEQUENTLY EXPIRED IN THE HOSPITAL. FINDINGS INCLUDE: DURING THE STANDARD SURVEY, THE [DATE] FACILITY REPORTED INCIDENT INVESTIGATION FOR RESIDENT #17'S FALL WITH FRACTURE WAS REVIEWED. THE SUMMARY REVEALED ON [DATE] AT 12:10 P.M., REGISTERED NURSE (RN) "J" AND RN "K" HEARD RESIDENT #17 YELLING FOR HELP IN HER ROOM. RESIDENT #17 WAS FOUND LYING ON THE BATHROOM FLOOR ON HER RIGHT SIDE. RESIDENT #17 COMPLAINED OF RIGHT HIP PAIN AND STATED, "...I fell AND LANDED ON MY SIDE". VITAL SIGNS WERE TAKEN AND RESIDENT #17 WAS TRANSFERRED TO THE emergency room FOR THE ASSESSMENT OF HER PAIN. AN X-RAY WAS ORDERED AND PERFORMED. A REVIEW OF RESIDENT #17'S X-RAY REPORT DATED [DATE] REVEALED A "DISPLACED OBLIQUE SUBTROCHANTERIC FRACTURED RIGHT FEMUR". PER THE DIRECTOR OF NURSING (DON) ON [DATE] AT 1:00 P.M., RESIDENT #17 DID NOT RETURN TO THE FACILITY AND EXPIRED IN THE HOSPITAL ON [DATE]. A REVIEW OF RESIDENT #17'S MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #17 WAS AN [AGE] year OLD WOMAN REadmitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MDS ASSESSMENT REVEALED RESIDENT #17 HAD MILD COGNITIVE IMPAIRMENT AND USED A WHEELCHAIR AND A WALKER WITH ASSISTANCE. PRIOR TO THE [DATE] FALL, A FACILITY INCIDENT REPORT TITLED "L DOCUMENTATION-NURSING" DATED [DATE], SHOWED RESIDENT #17 HAD "FALLEN OFF THE TOILET AND ONTO THE BATHROOM FLOOR... CENA (CERTIFIED NURSE AIDE) SAYS HE ATTEMPTED TO CATCH HER, BUT COULDN'T GET TO HER FAST ENOUGH... RESIDENT DENIES PAIN." THE INCIDENT REPORT UNDER 'INTERVENTIONS STARTED/CHANGED TO PREVENT FUTURE FALLS' READS: "CENA TO STAND IN BATHROOM WITH RESIDENT WHILE TOILETING." A REVIEW OF RESIDENT #17'S 'FALL CARE PLAN' INITIATED [DATE], SHOWED THE 'FALL CARE PLAN' WAS REVISED ON [DATE] TO INCLUDE, "DO NOT LEAVE (RESIDENT #17) IN THE BR (BATHROOM) UNATTENDED." PER THE [DATE] FACILITY INVESTIGATION SUMMARY, ON [DATE] AT 12:00 P.M., RESIDENT #17 WAS ASSISTED TO THE TOILET BY CERTIFIED NURSE AIDE (CNA) "I". AFTER CNA "I" ASSISTED RESIDENT #17 FROM HER WHEELCHAIR ONTO THE TOILET, CNA "I" DID NOT CORRECTLY IMPLEMENT RESIDENT #17'S FALL CARE PLAN INTERVENTION DATED [DATE], AND LEFT RESIDENT #17 UNSUPERVISED ON THE TOILET. RESIDENT #17 fell OFF THE TOILET AND SUSTAINED A FRACTURED RIGHT FEMUR. ON [DATE] AT 12:15 P.M., AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) PERTAINING TO RESIDENT #17'S [DATE] FALL. THE DON WENT ON TO SAY, CNA "I" WAS RESIDENT #17'S PRIMARY DAYTIME CAREGIVER FOR BOTH FALLS, AND WAS IN ON THE [DATE] NURSING TEAM "HUDDLE" WHEN THE FALL CARE PLAN WAS CHANGED TO NOT LEAVE RESIDENT #17 ON THE TOILET BY HERSELF. THE DON CONFIRMED CNA "I" FAILED TO SUPERVISE RESIDENT #17 WHILE SHE WAS ON THE TOILET. THE DON CONFIRMED CNA "I"'S FAILURE TO SUPERVISE RESIDENT #17 CONTRIBUTED TO HER FALL AND FRACTURE. ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CARE IN ACCORDANCE TO THE WRITTEN CARE PLAN, TO PREVENT THE DEVELOPMENT OF A PRESSURE ULCER IN ONE (#4) OF TWO RESIDENTS WITH PRESSURE ULCERS, FROM A TOTAL SAMPLE OF 17 RESIDENTS. THIS FAILURE RESULTED IN RESIDENT #4 DEVELOPING A STAGE II PRESSURE ULCER WHICH WAS AN OPENED, RED AREA WITHOUT DRAINAGE OR ODOR, ON A RECURRENT SITE. FINDINGS INCLUDE: THE CLINICAL RECORD REVEALED RESIDENT #4 IS AN [AGE] year OLD WOMAN REadmitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. A REVIEW OF THE 5 DAY MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #4 WAS COGNITIVELY INTACT. FURTHERMORE, THE MDS REVEALED RESIDENT #4 HAD ONE STAGE II PRESSURE ULCER ON ADMISSION AND ACQUIRED ANOTHER STAGE II PRESSURE ULCER WHILE IN THE FACILITY. THE "MULTIDISCIPLINARY PROGRESS NOTES" DATED 3/26/12, READ, "(RESIDENT #4) NOTED TO HAVE A RE-OPENING OF SKIN TO HER (RIGHT) CREASE OF HER LOWER BUTTOCK. THIS AREA HAS RE-OPENED WITH (SINCE) HER LAST ADMISSION TO LTC (LONG TERM CARE) APPROXIMATELY ONE MONTH AGO." THE PROGRESS NOTE INCLUDED A WRITTEN NOTATION ON THE SIDE OF THE DOCUMENTATION, DESCRIBING THE PRESSURE ULCER, WHICH READ: "1 CM (CENTIMETER) X 0.4 CM". THE FACILITY CARE PLAN FOR RESIDENT #4 TITLED "INTERDISCIPLINARY CARE PLAN PROBLEM #5... SKIN BREAKDOWNS COCCYX & HEELS" DATED 3/17/12, READ: "GOAL: I WILL BE FREE FROM SKIN BREAKDOWN/PRESSURE ULCERS... 2. CUE & REMIND ME TO REPOSITION (EVERY) 1 HOUR WHEN IN W/C (WHEELCHAIR) OR CHAIR. - ALL 3. IF I AM UNABLE TO SENSE PRESSURE OR REPOSITION MYSELF STAFF ....TO ASSIST TO REPOSITION. - ALL 4. EDUCATE/REMIND ME WHEN WATCHING TV OR LISTENING TO RADIO & SHIFT MY WEIGHT WHEN COMMERCIAL COMES ON. - ALL ...18. EXPLAIN TO ME AND OR MY GUARDIAN SPECIFIC MEASURES IMPLEMENTED TO HELP MAINTAIN MY SKIN INTEGRITY. - ALL" AN INTERVIEW TOOK PLACE ON 3/27/12 AT 2:00 P.M. WITH CERTIFIED NURSE AIDE (CNA) "K" WHO STATED SHE WAS RESIDENT #4'S AIDE. WHEN THIS SURVEYOR ASKED HER HOW OFTEN SHE REPOSITIONS RESIDENT #4, SHE STATED "I REPOSITION HER (RESIDENT #4) EVERY 2 HOURS (WHETHER SHE IS UP IN HER WHEELCHAIR OR IN BED)." CNA "K" WENT ON TO STATE, "YES, SHE CAN'T REPOSITION BY HERSELF... SHE DEFINITELY NEEDS HELP." CNA "K" STATED SHE HAD NOT INSTRUCTED RESIDENT #4 TO REPOSITION HERSELF (BY SHIFTING HER WEIGHT) DURING COMMERCIALS WHILE WATCHING TV. CNA "M" WAS INTERVIEWED ON 3/27/12 AT 2:25 P.M., AND STATED SHE HAS HAD THE RESPONSIBILITY FOR RESIDENT #4'S CARE SINCE HER READMISSION ON 3/17/12. CNA "M" STATED, "SHE (RESIDENT #4) IS IN THE CHAIR (W/C) MOST OF THE TIME... YES, SHE NEEDS OUR HELP TO REPOSITION." CNA "M" STATED SHE REPOSITIONS RESIDENT #4 "ABOUT EVERY 2 HOURS" WHILE SHE PUTS THE RESIDENT BACK TO BED OR TAKES HER TO THE BATHROOM. CNA "M" STATED THOSE ARE THE TIMES THE RESIDENT GETS REPOSITIONED. FURTHERMORE, CNA "M" STATED SHE HAD NEVER BEEN INSTRUCTED TO REPOSITION RESIDENT #4 MORE OFTEN THEN EVERY 2 HOURS, NOR HAD SHE ASSISTED OR INSTRUCTED RESIDENT #4 TO REPOSITION DURING TV COMMERCIALS. DURING AN INTERVIEW WITH RESIDENT #4 ON 3/27/12 AT 2:50 P.M., SHE STATED, "...SOMETIMES I SIT IN MY CHAIR ALL DAY. THE ONLY ONE THAT COMES IN TO REMIND ME ABOUT REPOSITIONING IS THE THERAPY GIRL... I DON'T REALLY NEED TO GET UP OFTEN FOR THE BATHROOM BECAUSE I HAVE A URINE TUBE (FOLEY CATHETER)... THAT'S BEEN PUT IN TO HELP ME HEAL AND I DON'T HAVE CONTROL OF MY BOWELS, BUT I DON'T GO TO THE BATHROOM A LOT. NO, THE GIRLS (CNAS) ARE NOT COMING IN TO REPOSITION ME OR EVEN REMIND ME TO SHIFT MY WEIGHT AROUND... NO ONE HAS EVER SAID THAT TO ME. NO, THEY HAVEN'T SAID TO MOVE AROUND DURING COMMERCIALS... NO, NO ONE HAS EXPLAINED THE IMPORTANCE OF HAVING ME REPOSITION... NO ONE." OBSERVATION OF PRESSURE ULCER CARE FOR RESIDENT #4 TOOK PLACE ON 3/28/12 AT 8:25 A.M., AND WAS PERFORMED BY THE WOUND CARE REGISTERED NURSE (RN) "L" AND CNA "M." RESIDENT #4 WAS IN HER ROOM (IN BED) AND REPOSITIONED TO THE LEFT SIDE EXPOSING HER BUTTOCK AREA. THE BUTTOCK AREA APPEARED BRIGHT RED AND WAS NOTED BY RN "L" TO HAVE A YEAST INFECTION. HOWEVER, THE ONLY OPEN AREA WAS ON THE RIGHT SIDE OF THE RESIDENT'S LOWER BUTTOCK CHEEK, WHERE THE BUTTOCK MEETS THE LEG AREA. THE OPEN AREA OBSERVED WAS APPROXIMATELY 1 CM ROUND, WITH AN OPEN AREA EXTENDING TO THE RIGHT OF THE CIRCULAR AREA, WHICH HAD AN IRREGULAR SHAPE, MEASURING APPROXIMATELY 0.5 CM. THE AREA WAS DEEP RED AND THE TISSUE AROUND THE OPEN AREA WAS SHINY, LIGHTER WHITISH TISSUE, RESEMBLING SCAR TISSUE. THE AREA WAS CLEANSED AND A ZINC BASED CREAM, "SELAN" WAS APPLIED. THERE WAS NO DRESSING APPLIED, LEAVING THE PRESSURE ULCER OPEN TO AIR. DURING AN INTERVIEW ON 3/28/12 AT 8:40 A.M., RN "L" AND SUPERVISOR RN "H" CONFIRMED THE RESIDENT'S PLAN OF CARE FOR "SKIN BREAKDOWN" DATED 3/17/12, HAD NOT BEEN FOLLOWED BY THE FACILITY. RN "L" CONFIRMED RESIDENT #4 SHOULD BE REPOSITIONED WHILE IN HER WHEELCHAIR EVERY HOUR; FURTHERMORE, RN "H" AGREED THE RESIDENT SHOULD BE ENCOURAGED TO SHIFT HER WEIGHT WHILE IN HER CHAIR, DURING TV COMMERCIALS PER THE WRITTEN CARE PLAN. RN "L" STATED THESE SPECIFIC INTERVENTIONS WERE NOT TRANSCRIBED ONTO THE CNA "DAILY CARE PLAN" AND THEREFORE, HAD NOT BEEN FOLLOWED. FURTHERMORE, RN "L" AND RN "H" STATED THERE WAS NO EVIDENCE HER CARE PLAN HAD BEEN DISCUSSED AT ANY TIME WITH RESIDENT #4, TO EXPLAIN THE INTERVENTIONS FOR PREVENTING SKIN BREAKDOWN. ALTHOUGH CARE PLAN INTERVENTIONS HAD BEEN PUT IN PLACE TO ENABLE RESIDENT #4 TO MAINTAIN SKIN INTEGRITY AND PROMOTE HEALING, THE PLAN OF CARE WAS NOT FOLLOWED. THIS FAILURE RESULTED IN RESIDENT #4 DEVELOPING AN AVOIDABLE STAGE II PRESSURE ULCER ON THE LOWER EDGE OF HER RIGHT BUTTOCK CHEEK. ( ) --

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT POTENTIAL ACCIDENTS FOR ONE RESIDENT (#1) OF TWO SAMPLED RESIDENTS IDENTIFIED WITH DEMENTIA AND EXIT SEEKING BEHAVIOR FROM A TOTAL SAMPLE OF FIVE RESIDENTS. THIS FAILURE RESULTED IN IMMEDIATE JEOPARDY FOR RESIDENT #1 WHEN SHE LEFT THE BUILDING UNSUPERVISED AND WALKED OUT INTO THE COMMUNITY ACROSS A BUSY, HIGH TRAFFIC HIGHWAY. IMMEDIATE JEOPARDY WAS IDENTIFIED ON 10/12/10 AT 11 A.M. THE IMMEDIATE JEOPARDY BEGAN ON 7/16/10 AT APPROXIMATELY 11:30 A.M. WHEN THE FACILITY FAILED TO VERIFY THE LEVEL OF SUPERVISION WAS ADEQUATE FOR ALL EXIT DOORS AFTER RESIDENT #1 HAD SHOWN HER ABILITY TO EXIT THE DEMENTIA UNIT AND ENTER THE MAIN FACILITY. THIS FACILITY FAILURE WAS DEMONSTRATED AGAIN ON 10/10/10 AT APPROXIMATELY 12:45 P.M. WHEN RESIDENT #1, A COGNITIVELY IMPAIRED RESIDENT WITH A HISTORY OF EXIT SEEKING BEHAVIOR, WAS FOUND BY A PASSERBY, APPROXIMATELY ONE HALF MILE FROM THE FACILITY ACTING, "LOST AND CONFUSED". SHE HAD CROSSED THE 'HIGH TRAFFIC VOLUME' HIGHWAY. ACCORDING TO THE FACILITY INVESTIGATION REPORT, RESIDENT #1 WAS IDENTIFIED AS WEARING AN 'ANKLE WANDERGUARD' DEVICE WHICH WOULD TRIGGER AN ALARM UPON EXIT. BUT, RESIDENT #1 HAD LEFT THE FACILITY THROUGH A NUMBERED 'KEY PAD' ALARMED DOOR, WHICH WAS NOT EQUIPPED WITH THE WANDERGUARD ALARM SYSTEM. AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) TOOK PLACE AT 10 A.M. ON 10/12/10. THE DON IDENTIFIED CNA "B" AS ONE OF THE STAFF "GUARDS" POSITIONED TO BE ABLE TO VIEW THE EXIT DOOR 24 HOURS A DAY UNTIL THE DEMENTIA UNIT EXIT DOOR WAS ALARMED FOR RESIDENTS WEARING WANDERGUARDS. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 10/12/10 AT 11:30 A.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 10/12/10 AT 2:40 P.M. AFTER OBSERVATIONS AND INTERVIEW WITH FACILITY STAFF VERIFIED THE FOLLOWING; THE EXIT DOOR OF THE DEMENTIA UNIT WAS BEING GUARDED BY FACILITY STAFF, FACILITY STAFF COULD STATE AN ACCURATE UNDERSTANDING OF THE PURPOSE THE DOOR WAS BEING GUARDED, AND WHAT ACTION TO TAKE IF A RESIDENT FROM THE DEMENTIA UNIT ATTEMPTED TO LEAVE, UNSUPERVISED. ON 10/12/10 AT 3:30 P.M., THE WANDERGUARD ALARM WAS OBSERVED ADDED TO THE DEMENTIA UNIT EXIT DOOR. DURING THIS OBSERVATION, ACCOMPANIED BY THE DON, THE WANDERGUARD BRACELET ON RESIDENT #1 WAS tested AND FOUND TO BE FUNCTIONING. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND CONTINUES AT AN ISOLATED LEVEL, WITH THE POTENTIAL FOR MORE THAN MINIMUM HARM UNTIL THE FACILITY HAS PUT THE FOLLOWING PRACTICES IN PLACE: ENSURE ALL EXIT DOORS ARE EQUIPPED WITH WANDERGUARD ALARMS, IMPLEMENT PREVENTIVE MAINTENANCE CHECKS ON ALL EXIT DOOR ALARMS, PROVIDE INSERVICE TRAINING FOR STAFF ON RESIDENTS WITH EXIT SEEKING BEHAVIORS, REASSESS ALL VULNERABLE RESIDENTS IDENTIFIED FOR ELOPEMENT RISK, AND ENSURE APPROPRIATE INTERVENTIONS ARE IN PLACE TO PREVENT THIS TYPE OF ACCIDENT FROM RE-OCCURRING. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S CLINICAL RECORD REVEALED SHE IS [AGE] years OLD AND HAS RESIDED IN THE FACILITY SINCE 9/08/09. THE RESIDENT FACE SHEET SHOWS HER [DIAGNOSES REDACTED]. THE REVIEW OF RESIDENT #1'S 9/09/10 ANNUAL MINIMUM DATA SET (MDS) REVEALED HER COGNITION IS MODERATELY IMPAIRED. HER MENTAL FUNCTION VARIES THROUGHOUT THE DAY AND SHE GETS CONFUSED. RESIDENT #1 HAS BOTH SHORT AND LONG TERM MEMORY PROBLEMS, BUT USUALLY UNDERSTOOD WHAT WAS SAID TO HER. HER 9/09/10 UPDATED CARE PLAN REVEALED RESIDENT #1 IS USUALLY UNDERSTOOD WHEN SHE SPEAKS. FURTHER REVIEW OF THE ANNUAL MDS AND UPDATED CARE PLAN REVEAL RESIDENT #1 IS INDEPENDENT WITH TRANSFERS AND AMBULATION. THE UPDATED CARE PLAN DOCUMENTS HER EXIT SEEKING BEHAVIOR AS SHE EXPRESSES HER NEED TO GO HOME "TO HER MOTHER" OR TO HER CHILDREN. THE REVIEW OF THE 7/16/10 NURSES NOTES REVEAL A WANDERGUARD BRACELET WAS PUT ON RESIDENT #1'S ANKLE AFTER SHE HAD LEFT THE SECURED DEMENTIA UNIT WITH ANOTHER RESIDENT AND ENTERED THE MAIN FACILITY. AN INTERVIEW WAS CONDUCTED WITH THE DON ON 10/12/10 AT 9 A.M. SHE STATED THE WANDERGUARD WAS PLACED ON RESIDENT #1 AFTER SHE HAD EXITED THE DEMENTIA UNIT INTO THE MAIN FACILITY. THE DON EXPLAINED, IF RESIDENT #1 WERE TO AGAIN GET INTO THE MAIN FACILITY AND GET TO ONE OF THE EXIT DOORS, THE WANDERGUARD DOOR ALARM SYSTEM WOULD ALERT STAFF TO THE ATTEMPTED ELOPEMENT. INTERVIEWS WERE CONDUCTED WITH CNA "A", CNA "B" AND CNA "C" ON 10/12/10 AT 11 A.M., 11:20 A.M., AND 2:40 P.M. RESPECTIVELY. A TELEPHONE INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) "D" ON 10/13/10 AT 8:30 A.M. THE STAFF ALL STATED RESIDENT #1 DID NOT LOOK LIKE AND SOMETIMES DID NOT ACT LIKE, THE OTHER RESIDENTS OF THE FACILITY. CNA "A" STATED, "SOME NEW STAFF AND SOME VISITORS HAVE MISTAKEN HER FOR A VISITOR." THE FOUR STAFF STATED RESIDENT #1 "CONSISTENTLY" DISPLAYS EXIT SEEKING BEHAVIORS. CNA "B" STATED, "IT'S USUALLY IN THE AFTERNOON WHEN SHE REALLY WANTS TO GO HOME (THAT RESIDENT #1 ATTEMPTS TO LEAVE)." CNA "C" STATED, "SHE KNOWS THE EXIT DOORS...SHE DOESN'T WANDER AIMLESSLY, SHE'S ON A MISSION TO LEAVE..." ALL THE STAFF INTERVIEWED STATED THEY EACH HAVE HAD TO RE-DIRECT RESIDENT #1 FROM THE EXIT DOOR LOCATED AT THE EAST END OF THE DEMENTIA UNIT. CNA "A" STATED, "ON MORE THAN ONE OCCASION, I'VE CAUGHT HER (RESIDENT #1) TRYING TO LEAVE WITH A VISITOR." DURING AN ADDITIONAL INTERVIEW WITH THE DON ON 10/12/10 AT 10 A.M., SHE EXPLAINED, ALL EXIT DOORS IN THE MAIN FACILITY ARE EQUIPPED WITH SENSOR DEVICES WHICH ALERT STAFF WHEN ANYONE IS EXITING THE BUILDING. SHE EXPLAINED THE FRONT LOBBY DOORS' SENSOR SYSTEM IS DEACTIVATED DURING BUSINESS HOURS, BUT IT ALSO CONTAINS THE WANDERGUARD ALERT SYSTEM. THE DON STATED THE WANDERGUARD ALERT SYSTEM IS NEVER DEACTIVATED AT ANY WANDERGUARD EQUIPPED EXIT DOOR. THE DON EXPLAINED ON 10/10/10 AT APPROXIMATELY 12:45 P.M., CNA "C" ALERTED LPN "D" THAT RESIDENT #1 WAS MISSING. SHE STATED THEY BEGAN THEIR MISSING PERSONS PROTOCOL INCLUDING ALERTING ALL STAFF IN THE FACILITY AND CALLING 911. THE DON EXPLAINED AS THE 911 CALL WAS BEING PLACED, THEY WERE INFORMED BY THE POLICE DEPARTMENT THEY HAD RECEIVED A CALL FROM A HOMEOWNER THAT HE HAD FOUND AN ELDERLY WOMAN WHO WAS "CONFUSED" AND "LOST". THE DON ACKNOWLEDGED RESIDENT #1 HAD BEEN LOCATED APPROXIMATELY ONE HALF MILE AWAY FROM THE FACILITY ACROSS A HIGH TRAFFIC VOLUME HIGHWAY. THE DON STATED THE POLICE RETURNED RESIDENT #1 AT "AROUND 1 P.M.". THE DON EXPLAINED RESIDENT #1 WAS ASSESSED AND FOUND TO HAVE NO INJURIES AND SHE (RESIDENT #1) STATED SHE WAS FINE BUT TIRED. THE DON ALSO STATED RESIDENT #1'S ANKLE WANDERGUARD WAS CHECKED AND WAS FOUND TO BE IN WORKING ORDER. DURING THE 10 A.M. INTERVIEW WITH THE DON, SHE WAS ASKED IF THE FACILITY HAD DETERMINED HOW RESIDENT #1 WAS ABLE TO EXIT THE FACILITY. SHE STATED IT WAS LUNCH TIME AND VISITORS WERE ENTERING AND EXITING THROUGH THE EAST END KEY PAD ALARMED DOOR. SHE STATED MEAL TIME WAS A BUSY TIME FOR STAFF. THE DON EXPLAINED SHE BELIEVED RESIDENT #1 MAY HAVE FOLLOWED A VISITOR OUT THE DOOR STATING, "SHE CAN BE VERY QUICK AND SHE DOES NOT LOOK LIKE A TYPICAL RESIDENT. SHE IS OFTEN MISTAKEN FOR A VISITOR OR A FAMILY MEMBER." THE DON STATED, "AT THE TIME OF (RESIDENT #1'S) ELOPEMENT, THE EAST SIDE EXIT DOOR OUT OF THE DEMENTIA UNIT, OUT TO THE SIDEWALK HAD THE NUMBERED KEY PAD ALARM SYSTEM, BUT DID NOT HAVE A WANDERGUARD SYSTEM." WHEN ASKED WHY THE DOOR WAS NOT WANDERGUARD ALARMED, SHE STATED, "RESIDENTS HAVE NEVER GOTTEN OUT THAT DOOR BEFORE, WE NEVER THOUGHT ABOUT IT." A REVIEW OF THE FACILITY'S 10/10/10 INCIDENT REPORT, 10/10/10 POLICE REPORT AND 10/12/10 8:30 A.M. OBSERVATIONS OF THE FACILITY'S EXIT DOORS, VERIFIED THE INFORMATION GIVEN BY THE DON. DURING THE INTERVIEWS WITH CNA "C" AND LPN "D", THEY STATED AGREEMENT WITH THE INFORMATION GIVEN BY THE DON. LPN "D" SAID, "SHE (RESIDENT #1) WAS IN THE DINING AREA RIGHT AROUND 12:30 P.M. AND THEN SHE WAS GONE... I DID NOTICE VISITORS LEAVING AROUND THE SAME TIME..." AN INTERVIEW WAS ATTEMPTED WITH RESIDENT #1 ON 10/12/10 AT 3 P.M. SHE WAS OBSERVED WALKING INDEPENDENTLY FROM THE HALL AND PROCEEDED TO SIT DOWN AT A TABLE. SHE SMILED AND SAID, "HELLO." WHEN ASKED IF SHE REMEMBERED LEAVING THE FACILITY "A COUPLE DAYS AGO" AND TAKING A WALK, SHE SAID, "I HAVEN'T LEFT." ADDITIONAL COMMENTS AND QUESTIONS WERE ASKED AND RESIDENT #1 SMILED BUT GAVE NO VERBAL RESPONSES. THE FACILITY FAILED TO PROVIDE THE SUPERVISION TO PREVENT THE ELOPEMENT OF A COGNITIVELY IMPAIRED RESIDENT WITH A HISTORY OF EXIT SEEKING BEHAVIORS. IN ADDITION, THE FACILITY FAILED TO HAVE A COMPLETE SYSTEM IN PLACE TO ALERT STAFF WHEN A RESIDENT EXITS THE FACILITY UNSUPERVISED. ( )