Every finding on record at Maple Manor Rehab Center of Novi Inc

Based on observation, interview and record review the facility failed to implement an effective water management program, appropriately initiate Enhanced Barrier Precautions and provide infection control practices with medication administration, this had the ability to affect all the resident's residing in the facility including six [R27, R85, R86, R87, R88 and R89] residents identified. Findings include, On 04/27/2026 at 10:15 AM, during a building tour with Maintenance Technician (MT) S and Director of Maintenance (DM) F observed four hot water tanks with setting at 130 degrees F. At this time DM F indicated that mixing valves are on resident point-of-use fixtures and monitored and logged. MT S and DM F indicated flushing protocols for unoccupied rooms but do not document this and have not identified other potential areas of stagnation for flushing. When asked about any additional control measures DM F said that legionella testing is done annually. On 04/27/2026 a Record Review of Maple Manor Rehab and Neuro Center Water Management Program policy dated January 2026 and supplement Water Management Program: Water Management Team (no date) found the following: Facility policy states Water Management Team (WMT) shall include: building owner, administrator, Maintenance, Chief Nursing Officer, Infection Control Designee A risk assessment will be conducted by the water management team annually. No risk assessment was in the program documentation at time of review. Based on the risk assessment, control points will be identified and Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. The measures shall be specified in the water management program action plan. No control points have been identified, and no action plan was documented. When control limits are not maintained, corrective actions will be taken and documented accordingly. On 04/27/2026 a Record Review of Legionella Surveillance policy dated January 2024 found that facility Primary prevention strategies include: d. Temperature Controls: ii: Hot water shall be stored above 140 degrees F and circulated at a minimum return temperature of 124 degrees F. Included in the WMP documentation were annual legionella test results from the vendor laboratory, including the most recent results date reported 7/30/25 which included several sampled areas testing positive for Legionella pneumophila Group. On 04/27/2026 at 1:30 PM an interview with the Nursing Home Administrator Assistant (NHA-A) and DM F regarding the WMP and legionella testing results took place. When asked about WMT meetings, NHA-A said that DM F reports any water related concerns at Quality Assurance and Process Improvement (QAPI) meetings. DM F indicated he thought the last sampling results were acceptable based on the cover sheet from the vendor laboratory. NHA-A indicated that they thought if there was a problem, the health department would contact the facility. At this time, both confirmed that there is currently no action plan in the WMP and no response was taken after receiving the last annual test results. On 04/27/2026 at 2:00 PM an interview continued with NHA-A, DM F and MT S regarding the WMP. NHA-A provided a completed Risk Assessment checklist dated April 2026 at this time. DM F and MT S confirmed that the only monitoring currently documented is water temperatures. When asked about WMP training, DM F and MT S indicated they have not completed any specific training on the CDC WMP guidance. On 4/27/26 at 3:11 PM, Infection Preventionist [IFP] B was interviewed and asked if she was aware the facility had tested positive for Legionella. IFP B explained she was not aware, the Maintenance Director had reported to her and the DON that there were no issues and everything was fine. IFP B was asked if she attended the water management meetings. IFP B explained she did not. On 4/27/26 at 3:42 PM, the DON was interviewed and asked if she had attended the water management meetings. The DON explained they did not have water management meetings, that the Maintenance Director would just report to them that there were no issues. Review of the infection control line listings revealed: R86 had facility acquired pneumonia with an onset date of 6/30/25. R87 had facility acquired pneumonia with an onset date of 7/23/25. R88 had facility acquired pneumonia with an onset date of 8/22/25. R89 had facility acquired pneumonia with an onset date of 2/14/26. On 4/28/26 at 2:46 PM, IFP B was asked if R86, R87, R88 and R89 had acquired pneumonia while residing at the facility. IFP B confirmed all were facility acquired pneumonia. IFP B was asked if R86, R87, R88 or R89 had been tested for Legionella. IFP B explained they had not tested anyone for Legionella as they were unaware of the facility testing positive. When asked if these residents should have been tested, IFP B agreed they should have been tested. Review of a Quality, Safety and Oversight Group [QSO] memorandum QSO-17-30 revised 7/6/18 by Centers for Medicare & Medicaid Services [CMS] read in part, .Facilities must. Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Medication Administration Observation On 4/28/26 at 9:07 AM, Licensed Practical Nurse (LPN) A was observed preparing the morning medications for R85. After prepping multiple tablets in to the medication cup, LPN A was observed to have spilled all of the tablets on to the medication cart and multiple paper documents on top of the cart. LPN A was observed to have don on a glove and returned all the dropped tablets back into the medication cup. At 9:17 AM, LPN A administered the medications to R85. A review of the facility policy titled Medication Administration revised January 2026, documented in part . If a medication is dropped onto a clean, disinfected medication cart or tray during preparation or administration, it shall not be considered contaminated, provided the surface has been sanitized and the medication remains intact/dry and free from visible contamination. All medications designated for disposal such as dropped medication. must be placed in the approved drug buster waste container. On 4/28/26 at 11:46 AM, the Director of Nursing (DON) was interviewed regarding the spilled medications by LPN A. The DON confirmed that LPN A should have properly disposed of the medications and prepared new medications for the resident. Enhanced Barrier Precaution/EBP: R27 On 4/27/26 at 10:24 AM, R27 was observed seated in a wheelchair beside their bed, getting dressed. R27 reported they had a wound vac for a pressure ulcer on their bottom (sacrum) and when asked about treatments, reported they went to an outside wound clinic but if the wound vac needed to be resealed, the facility staff were able to reapply. There were no infection control precautions (such as EBP) implemented for R27. On 4/28/26 at 9:33 AM, R27 was still observed to have no EBP implemented. Review of the clinical record revealed R27 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: infection of amputation stump, right lower extremity, pressure ulcer of sacral region, stage 4 (full-thickness skin and tissue loss), paraplegia, acquired absence of right leg below knee, personal history of traumatic brain injury, and other motorcycle injured in unspecified nontraffic accident. Review of the resident's physician orders included: Start Date 4/15/26, monitor wound vac (Peel and Place) in place. Keep area clean and dry. Do not apply direct pressure to wound vac. Cannot be off more >2 hrs. call wound clinic for any issues with wound vac. patient must stay off sacrum/wound vac and switch positions q (every) 2 hrs (hours).Wound vac should be in place until follow up with (wound specialist) Every Shift Day Shift 07:00 - 19:00, Night Shift 19:00 - 07:00. Start Date 4/8/26, Monitor wound vac daily. Do not turn off or remove. If leakage occurs, reinforce dressing with clear tegaderm only. Every Shift Day Shift 07:00 - 19:00, Night Shift 19:00 - 07:00. There were no current orders for EBP. Review of the discontinued orders revealed EBP had been in place from 11/5/25 - 12/17/25. Further review of the clinical record revealed R27 had recently had a debridement and graft application to the sacral wound on 4/6/26 and following this had the current wound vac implemented. On 4/28/26 at 11:05 AM, an interview was conducted with the Infection Preventionist (IP 'B') and the Wound Care Nurse (Nurse 'C'). When asked about the facility's practices regarding implementation of EBP, IP 'B' reported EBP should be implemented for residents that had pressure ulcers, including those that used medical devices. When asked if a wound vac should've been considered as a medical device, IP 'B' reported it should have. Nurse 'C' reported the resident's EBP orders were discontinued a while back due to the wound was dry with no drainage. When asked why the facility had not re-implemented the EBP upon R27's wound changes and implementation of the wound vac on 4/6/26, IP 'B' and Nurse 'C' offered no further explanation. According to the facility's policy titled, Enhanced Barrier Precautions dated January 2026: .An order for enhanced barrier precautions will be obtained for residents with any of the following: e. Wounds (e.g., chronic wounds such as pressure ulcers .unhealed surgical wounds .

This citation pertains to intake# 2788480 Based on observation, interview and record review, the facility failed to maintain a clean and homelike environment for two residents (R57 and R65) of five residents reviewed for environmental concerns, as well as the residents that utilized the central shower room, resulting in unclean floors and shower/resident rooms in disrepair. Findings include: On 04/27/2026 at approximately 10:33 a.m., R57 was observed in their room, laying in the bed. R57's floor was observed to have old food debris covering it. R57 was queried regarding their floor, and they reported that housekeeping was not doing a good job of moping the floor. At that time, R57's Baseboard by their hand sink was observed to be peeling away from the wall along with the corner drywall strips. On 04/27/2026 at approximately 11:08 a.m., R65 was observed in their room, up in their wheelchair. R65's floor was observed to be sticky with darkened dirt spots covering it. On 4/29/2026 at approximately 10:40 a.m., R57 was observed in their room, laying in their bed. R57's baseboard was still observed to be peeling away from the drywall. R57's drywall was reviewed with the Maintenance Director F (MD F). MD F indicated they were unaware of the need to repair R57's walls and that they would have to start on the repair. On 04/27/2026 at 10:25 AM on a building tour with Director of Maintenance (DM) F and Maintenance Technician (MT) S the following was observed in the central spa areas: blue shower mats worn/cracked and no longer smooth and cleanable in the 2nd floor north and 1st floor north shower rooms light bulb burned out in the 1st floor north showering area at the showering area perimeter at the floor/wall juncture caulk is missing and this area is soiled with black mold-like substance in the 2nd floor north and 1st floor north shower rooms a disinfectant unit/cart containing bleach product was stored next to the sink in the 2nd floor south shower room several bottles of personal care items (soaps and shampoos) stored on the sinks in all spa rooms At this time, these observations were also noted by DM F and MT S, and they indicated these items would be addressed. The disinfectant unit was relocated, and they would let an administrator know about shower mats needing replaced. A record review of Routine Cleaning and Disinfection policy dated January 2026 found that these guidelines do not address cleaning and disinfection of the central spa areas. A record review of Safe and Homelike Environment policy dated January 2026 found the following compliance guidelines:Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.The facility will provide and maintain adequate and comfortable lighting levels in all areas.Report any furniture in disrepair to maintenance promptly.

Based on observation, interview and record reviews the facility failed to ensure preventive interventions were implemented as noted in the plan of care, for two residents at risk for development of pressure injuries (R's 3 & 65) of five residents reviewed for pressure injury. Findings include:R65 On 04/27/2026 at approximately 11:08 a.m., R65 was observed in their room, up in their wheelchair. R65 was observed to have their feet with bilateral ace bandages on. No PRAFO boots (boots used to relieve pressure and prevent contractions) were observed applied to their legs/feet. R65's heels were observed to be touching the pedals of the wheelchair. On 4/27/26 at approximately 3:31 p.m., R65 was observed in their room, laying in their bed. R65 was observed with their heels flushed to the mattress, without any protective boots providing relief from pressure. On 4/28/26 at approximately 11:32 a.m., R65 was observed in their room, sitting in their wheelchair. R65 was observed to be without any pressure relieving boots applied and their heel were flushed with the wheelchair pedals. On 4/28/26 at approximately 12:45 p.m., was observed in their room, still up in their wheelchair. R65's heels were observed to be flushed to the wheelchair pedals without any pressure reduction boots being applied. On 4/28/26 at approximately 1:42 p.m., R65 was observed in their room, lying in bed with Nurse L. R65 was observed to have their heels flushed to mattress without any pressure reduction boots applied. Nurse L was queried regarding R65's soft boots and their PRAFO boots not being applied when sitting in their wheelchair or in lying in their bed and they indicated they would get a CNA (Certified Nursing Assistant) to put them on. Nurse L was queried if R65 should have their boots applied per the orders and they reported they should. On 4/27/26 the medical record for R65 was reviewed and revealed the following: R65 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and [NAME] insufficiency. A review of R65's MDS (minimum data set) with an ARD (assessment reference date) of 2/11/26 revealed R65 needed assistance from facility staff with all of their activities of daily living. R65's BIMS score (brief interview for mental status) was zero indicating severely impaired cognition. A Physician's order dated 3/6/25 revealed the following: Bilateral soft heel protectors on at all times when in bed. A second Physician's order dated 3/6/25 revealed the following: SPLINTING: Apply [ brand of pressure/contracture reduction boots] to bilateral ankles when up in the wheelchair. A Nurse Practitioner evaluation dated 4/22/26 revealed the following: .Impression/Plan: Skin Management-Continue air loss mattress and [brand of specialized cushion], Continue frequent turns Q2H (every two hours) per nursing protocol. Continue bilateral [pressure reduction boots] heel protectors in bed. Wound team . A review of R65's care plan revealed the following: Pressure Ulcer/Injury Resident is at risk for skin breakdown due to pressure ulcer hx (history) of coccygeal/ sacral area wound and impaired mobility .Approach-Keep resident clean, dry and off affected areas as possible . On 2/28/26 at approximately 3:00 p.m., during a conversation with the Director of Nursing (DON), the DON was informed of the observations of R65's heels being flushed to the pedals and the mattress and the indicated that the staff should be following the orders and the care plan regarding the application of the boots to reduce pressure points. On 4/27/26 at 10:11 AM, two aides were observed providing care to R3 in their room. R3 was observed in their wheelchair getting their hair braided by one of the aides. Two inflated green boots were observed in the chair by the window. R3 was observed with no socks on and their feet touching the footboards of their wheelchair. The aides were asked about the inflated green boots and responded that the resident wears the boots when they are in bed. A review of the medical record revealed R3 was admitted to the facility on [DATE] with a readmission date of 1/26/26 and diagnoses that included: quadriplegia and dependence on ventilator. R3 was dependent on staff for all Activities of Daily Living (ADLs). A review of a care plan titled . I am at risk of contracture, discomfort and skin breakdown necessitating splint or brace use. I wear (name of inflated boots) on both my feet when I'm up in my wheelchair. The goal of the care plan was documented as . Maintain or improve functional abilities, prevent contractures, enhance comfort and promote skin integrity. On 4/28/26 at 12:02 PM, the Director of Nursing (DON) was interviewed and asked about the observation with R3 and the two aides. The DON replied the aide assigned to that unit is normally assigned to another unit and may not be familiar with R3's plan of care. The DON said they would follow up and educate the aides.

Based on observation, interview and record review the facility failed to ensure professional standards of practice for medication administration for one resident (R83) of three residents reviewed for medication administration. Findings include:On 4/28/26 at 8:43 AM, Licensed Practical Nurse (LPN A) was observed preparing the morning medications for a resident. When asked the resident's name, LPN A replied with the resident's room number and bed. When asked for the resident's name that resided in that room number and bed, LPN A replied with the resident's first name and stated they were not sure of the last name. At 8:52 AM, LPN A was observed to have handed R83 their medications to consume. The nurse failed to properly identify the resident.A review of the facility policy titled Medication Administration revised January 2026, documented in part . Ensure that the six right of medication administration are followed. Right resident. with MAR (Medication Administration Record) to verify resident name.At 8:58 AM, LPN A asked R83 why they were not wearing their oxygen. R83 explained they had been off of the oxygen all day the day before and no longer needed the oxygen per the Physician. LPN A told R83 they would look into it.A review of the Medication and Treatment Administration Record for April 2026 revealed LPN A had already signed the oxygen order as administered for their shift without verifying the administration of the oxygen therapy.A review of the facility policy titled Oxygen Administration revised January 2026, documented in part . Oxygen is administered to residents who need it, consistent with professional standards of practice. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen.On 4/28/26 at 11:46 AM, the Director of Nursing (DON) was interviewed and asked about the professional standards, protocols and practices for the nursing staff when administering medications and oxygen to the residents. The DON acknowledged the resident should have been verified properly before medication administration and the oxygen administration should have been signed after assessing the resident and ensuring oxygen was administered. The DON said they would follow up and provide LPN A with additional education.

This citation pertains to intake # 2714575Based on observation, interview, and record review, the facility failed to implement proper safety interventions to prevent falls for one resident (R501) of three residents reviewed for falls, resulting in a fall with injuries requiring a transfer to the hospital for skin tears and sutures to R501's forehead. Findings include:On 1/20/26 at 11:05 AM, a review of R501's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: a fall with femur fracture, diabetes, chronic obstructive pulmonary disease, urinary tract infection, urinary retention, and adjustment disorder. R501's fall risk assessment calculated on 12/9/25 scored them as an 18, with anything greater than 13 equating a high fall risk.A review of R501's progress notes was conducted and revealed a note entered into the record by Nurse 'D' on 1/7/26 at that read, At around 1:15 am, NOD (nurse on duty) heard a loud sound from (R501's room #). NOD found patients [sic] siting [sic] on floor with her back on the wall, walker in between her legs. Forehead was bleeding, rt. (right) arm skin tear, bilateral legs skin tear. Removed the walker, cleanse [sic] the wound on her forehead and pressure applied. called [sic] 911 .911 came at around 1:30 am and left at 1:45 am.A nursing progress note dated 1/7/26 at 11:20 PM entered into the record by Nurse 'J' was reviewed and read, Post fall Day 1. Night shift nurse reports resident had a fall at around 1:15am and was sent out to (Hospital Name).resident returned to the facility around 8:00am.Resident returned with Sutures [sic] in place to forehead.bruising to left temporal area, Xeroform (wound care treatment) wrapped with kerlix (bulky dressing) to Left lower arm skin tear, steri [sic] strips in place to BLE (bilateral lower extremities).Review of a note entered into the record by Dr. 'I' on 1/9/26 at 4:37 PM was conducted and read, .patient reports mechanical fall approximately four days ago with scalp laceration requiring sutures.A review of a RESIDENT ASSISTANCE FORM completed by R501's family member on 1/14/26 was reviewed and read, WHAT is your complaint about? This fall was preventable if proper safety protocol was followed. A handwritten attachment accompanying the form read, On January 7 2026, at approximately 1:00 AM my.mother, who uses a walker and is recovering from a surgical repair of a broken femur.was being assisted to the bathroom by a facility aide.upon exiting the bathroom and walking toward her bed my mother fell.The aide did not physically support my mother. My mother lost her balance and fell striking her head. She sustained a deep laceration to her.forehead requiring 13 stitches, multiple skin tears.this fall was totally preventable if the aide used the proper safety protocols.A review of a facility provided investigation file regarding R501's fall where R501 alleged CNA (Certified Nurse Aide) 'B' pushed them causing the fall was conducted and contained a typed document that read, .The patient is alert and oriented x2 (person/place) with intermittent confusion. During multiple interviews, the patient provided inconsistent statements regarding the incident.When interviewed with (CNA 'B'), the CNA involved, she denied pushing the resident and stated she did not have her hands on the resident at any point.An interview with (CNA 'C').revealed that the patient expressed she wished (CNA 'C') had been working that night and stated she would not have fallen if he had been present. When (CNA 'C') further inquired about the incident and he asked about (CNA 'B's) positioning, both the patient and the patient's daughter responded that the aide was not close enough to prevent the fall. Further review of the file contained staff education and a document titled, Therapy Terms that read, .CGA=Contact Guard Assist. Needs someone standing keeping their hand on them for safety. Likely using a gait belt. The patient is not safe to walk yet.On 1/20/26 at 12:55 PM, a telephone interview was conducted with CNA 'B' regarding R501's fall. They were asked to describe how they remembered the incident and said they went in to answer R501's call light and assisted them to the bathroom. They said after they were done in the bathroom, R501 ambulated back to their bed with their walker. They said R501 was positioned with their back to the bed and their walker to the side. They explained that when R501 took a step back to get into bed they lost their balance, became tangled in the walker and fell to the floor. CNA 'B' said they were not close enough to get a hand on the resident to prevent the fall. CNA 'B' further volunteered they knew R501 had a red tag on their walker, and that meant they were supposed to provide contact guard (hands on assist) and use a gait belt when ambulating with the resident and they did not provide contact guard assist or use a gait belt when R501 sustained the fall.On 1/20/26 at 1:25 PM, an interview was conducted with the facility's Rehabilitation Director. They indicated R501 required contact guard assist. They were asked what that meant and said someone should be, right there in case something happens. They further explained CNA 'B' should have had a hand on R501 and likely should have used a gait belt.On 1/20/26 at 1:40 PM, R501 was observed in their room in a wheelchair. A scar was observed on their forehead and yellowing of a healing bruise was observed over their left eye. At that time, an interview was conducted with R501 regarding the fall. R501 said, Everything seems so blurry. They further said they sustained a fall and had to go to the hospital for 13 stitches to their forehead. They were asked if the staff member used a gait belt and said they did not, but they should have. After the interview, R501's walker was observed with a red tag attached that read, CGA (contact guard assist)-Amb (ambulate) with walker.On 1/20/26 at 2:36 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R501's fall. They indicated R501 was a contact guard assist as indicated by a red tag on their walker. They continued to say staff should have had a hand on R501 or at least near enough to attempt to prevent the fall. They further indicated they encourage the use of gait belts especially if preferred by the resident and/or family.A review of a facility provided policy titled, Fall Prevention Program revised 1/2026 was conducted and read, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.A review of a second facility provided policy titled, Use of Gait Belt revised 1/2026 was also conducted and read, Policy: It is the policy of this facility to use gait belts with resident that cannot independently ambulate or transfer for the purpose of safety.

Based on observation, interview, and record reviews the facility failed to ensure infection control standards and practices were consistently implemented by the facility staff and failed to implement an effective infection control surveillance program for 47 or 47 (including Resident R14, R19, R5, R35, R2,R342 ad R24) residents residing at the facility during the time of the survey. Findings include: On 3/4/25 at approximately 8:35 AM, upon entrance into the facility. The receptionist informed the survey team that the facility was currently experiencing an Influenza outbreak and a surgical mask would have to be worn by all surveyors. On 3/4/25 at 9:18 AM, upon entry onto the second floor, a contained unit was observed. Two doors interlocked to the unit. Observed on the door was a signage informing all of Droplet Precautions. The signage informed staff and providers to wear a surgical mask and eye protection. The signage also noted for all visitors to speak with a nurse. On 3/4/25 at 9:20 AM, Licensed Practical Nurse (LPN) C was observed at a medication cart. LPN C was asked what information or required Personal Protective Equipment (PPE) was required for the facility visitors. LPN C replied visitors must wear the surgical mask and they recommend hand hygiene. On 3/4/25 at 9:22 AM, upon entry into R14's room, the same Droplet Signage observed on the unit double doors was observed on R14's room. Observations were made of R14 and their environment. On 3/4/25 at 9:30 AM, upon entry into R19's room, a sign for Enhance Barrier Precautions was observed by the door. Observed outside of the room was a PPE cart that contained gowns, gloves and hand sanitizer. The signage documented for all providers and staff to complete hand hygiene and to wear gloves and a gown for high contact resident care activities. The Signage noted for everyone to clean their hands before entering and when leaving the room. Upon entrance in the room, Certified Nursing Assistant (CNA) I was observed providing care and dressing the resident. CNA I was observed with gloves on but no gown. After exiting R19's room, LPN C stated they forgot to mention that visitors should wear a shield when entering into Droplet Precaution rooms. LPN C was asked what the staff and providers were expected to wear when going into Droplet Precaution rooms and LPN C stated the surgical mask and shield as well. A walk through observation was conducted and multiple rooms had the Droplet signage observed posted outside of their rooms, with multiple residents heard coughing from the hallway. On 3/4/25 at 9:54 AM, observed on R5's door was a Droplet Precaution sign. R5 was observed in bed. A brief interview was conducted at that time. A review of R5's medical record revealed R5 had recently been diagnosed with Influenza A. A Physician's order documented the following: Droplet Precautions Indication: For infections transmitted through respiratory droplets from coughing, sneezing, or talking. Precaution of Diagnosis: Specify: flu . Special Instructions: Hand Hygiene: Perform before and after patient contact and after removing PPE. Patient Placement: Private room; door can remain open. PPE: Surgical mask, gloves, gown, eye protection. On 3/4/25 at 9:38 AM, an interview was conducted with the facility's Infection Control Preventionist (ICP) B to inquire about the correct PPE usage for the facility's droplet rooms for staff and visitors. Initially, ICP B stated that visitors had to complete hand hygiene, wear a surgical mask and shield, but then ICP B stated the staff had to complete hand hygiene, surgical mask, shield and a gown. ICP B was shown the multiple staff members in the contained hallway that was observed entering into the Droplet Precaution rooms with no gown. ICP B then stated that the Medical Director stated the gowns were not needed, however they (ICP B) recommended it to their staff. ICP B was shown their signage of Droplet Precautions that does not guide the facility staff to don on gowns and ICP B stated they were in talks with the medical director regarding the correct protocol moving forward. A review of the facility policy titled . Transmission-Based (Isolation) Precautions revised January 2025, documented in part . It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission . 'Droplet precautions' refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions . Healthcare personnel will wear a facemask for close contact with an infectious resident . if there is a risk of exposure of mucous membranes or substantial spraying of respiratory sections is anticipated, gloves and gown as well as goggles (or face shield) should be worn . Droplet- Gloves, Gown- As per standard precautions. Mask- [NAME] a mask upon entry into the patient room or cubicle . The facility staff failed to consistently follow the physician order for Droplet Precautions and failed to follow the facility's policy. Infection Surveillance Program Review of the facility's infection control surveillance program revealed no documentation for the facility's February 2025 infection surveillance and No mapping of the facility's infections from May 2024 to current (March 2025). On 3/5/25 at 2:17 PM, the facility's Infection Control Preventionist (ICP) B was interviewed and asked about the missing documents and stated they had them. When asked why it was not provided when the Infection Control Surveillance Program was requested, ICP B stated they take it home to work on it because they cover two buildings. At 2:22 PM, ICP B provided the missing documents. Review of Infection Surveillance Program revealed the following: March 2025 - No data, despite the facility having a current outbreak. February 2025 surveillance- No mapping completed and the line listing of infections were incomplete. The line list for Outbreaks revealed a staff member was identified to be positive for the Flu on 2/21/25. The first resident identified to be positive with the Flu was noted to be transferred to the hospital on 2/21/25 for a fever and reported to be positive for the Flu on 2/22/25. The line listing revealed two more residents became positive with the Flu before ICP B contacted the local health department on 2/25/25. Further review of the outbreak line listing revealed 10 additional residents and five additional staff members were diagnosed to be positive for Influenza A and/or symptomatic in the month of February 2025. Review of the Local health department Recommendation For Prevention And Control Of Influenza Outbreaks In Long Term Care Facilities documented in part, . Early recognition and testing of suspected influenza cases . Long term care facilities are required to report all suspected and confirmed outbreaks to local public health per Michigan Public Health Code . LTCF's (Long Term Care Facilities) are required to report the following . A sudden increase in acute febrile respiratory illness over the normal background rate . two (2) or more cases of acute respiratory illness occurring within 72hours of each other . Any resident who tests positive for influenza . Acute febrile respiratory illness is defined as fever > 100 F AND one or more respiratory symptoms (runny nose, sore throat, laryngitis, or cough). However please note that elderly patients with influenza may not develop a fever. Testing for influenza should occur when any resident has signs and symptoms that could be due to influenza . Review of the facility transfers to the hospital identified R35 who exhibited signs and symptoms that could have been due to influenza and not identified on the facility's line listing. Review of R35's progress notes revealed the following: On 2/25/25 at 6:25 PM, . had a fever of 100.1 . has a cough . On 2/25/25 at 11:43 PM, . patient has been coughing constantly. She is wheezing . short of breath . patient is very anxious, coughing and wheezing . On 3/6/25 at 11:02 AM, a meeting was held with ICP B to review the facility's Infection Control Surveillance Program. February surveillance was reviewed and the concern of February mapping not being completed, the infection surveillance line listing to not be fully completed and the failure to implement a system to timely identify, report, investigate, intervene and control the facility's outbreak. ICP B stated they had gotten really busy and had a lot going on and was unable to complete February's surveillance in real time. ICP B stated normally they would review the Infection Control data weekly and complete the line listing and report at the end of the month. ICP B was informed of the concern of their review of the infection control data to not be in real time (daily) especially considering the facility currently being in the middle of an Influenza outbreak. ICP B was asked why they delayed in reporting to their local health department the facility's outbreak, considering the first resident was identified positive with Influenza A on 2/22/25, the second resident confirmed positive on 2/24/25 and the third resident on 2/25/25. ICP B stated they did not consider to count the first resident who was sent out to the hospital for being symptomatic on 2/21/25 and diagnosed positive on 2/22/25, which was then reported to the facility. ICP B was then asked about R35 and why the facility did not test the resident for Influenza and ICP B stated the facility stopped testing residents since one resident was confirmed positive and told to consider everyone that was symptomatic positive. The guidance provided by the health department was reviewed with ICP B that noted to continue testing for resident with signs and symptoms of Influenza. The observations made of the facility staff not following proper infection standards and protocols was reviewed with ICP B as well and ICP B stated the facility had just in-serviced all staff on the infection protocols. No further explanation or documentation was provided by the end of the survey. Review of a facility policy titled . Infection Prevention and Control Program revised February 2024, documented in part . the designated Infection Preventionist is responsible for oversight of the program and serves . infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases . responsible for . A system of surveillance . utilized for prevention, identifying, reporting, investigation, and controlling infections and communicable diseases . All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE . 30675 R342 On 3/4/25 at 12:03 PM, R342's room was observed to have signage on the door that read, CONTACT PRECAUTIONS .EVERYONE Clean hands prior to entering .NECESSARY PPE (Personal Protective Equipment) Gown and gloves . At that time, Certified Nursing Assistant (CNA 'E') was observed retrieving a lunch meal tray from a cart in the hallway and entered into R342's room without cleaning hands, or donning any personal protective equipment. While in the room, CNA 'E' was observed leaning on the resident's walker next to their bed, touching their face mask, and moving items around the bed. On 3/4/25 at 12:10 PM, CNA 'E' was observed to have their face mask down around their chin and then proceeded to touch their face mask several times, while holding several drink cups and enter into room [ROOM NUMBER]. They immediately exited the room and was not observed using any hand hygiene. Review of the clinical record revealed R342 was admitted into the facility on [DATE] with diagnoses that included: shingles (as of 2/26/25). Review of the care plans included: Start Date: 3/3/25 I need to be in isolation related to herpes zoster. Interventions included: Follow facility's Infection Control policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen, disinfecting equipment, etc. Use principles of infection control and universal/standard precautions. Review of the physician orders included: Contact Precautions Indication: To prevent the spread of infections transmitted through direct contact with patient skin, bodily fluids, or contaminated surfaces/equipment. Precaution/Route of Diagnosis: Specify: shingles .Special Instructions: Hand Hygiene: Wash hands with soap and water before and after patient contact. PPE: Gloves and gown required. This order started on 2/26/25. On 3/4/25 12:15 PM, an interview was conducted with CNA 'E'. They reported they worked for a staffing agency and this was their second time at the facility. When asked if they were aware R342's room had contact precautions and to explain what they should do, CNA 'E' reported that resident had the flu (which was not correct) and they didn't come into contact with the resident. They were asked to clarify if they were sure the resident was on those precautions for flu and not something else, CNA 'E' reported they were told by another CNA it was the flu. When informed of the observations of them touching the resident's environment and signage that indicated they were to don/doff PPE and clean hands prior to entering the room, CNA 'E' offered no further response. When asked about the observations of them pulling their face mask down and touching their face mask several times, CNA 'E' reported they had really bad sinus issues and didn't know the remedy to that with also having to wear a mask. CNA 'E' further reported if they touched their mask, they should be sanitizing their hands after and acknowledged they did not. R24 On 3/4/25 at 9:23 AM, observation of R24's room revealed there was a PPE cart in the hallway just outside their room. Signage on the door documented STOP Droplet Precautions VISITORS: Please speak with nurse prior to entering room. PROVIDERS & STAFF Clean hands Prior To Entering And Upon Leaving; PROVIDERS & STAFF Wear A Surgical Mask; PROVIDERS & STAFF Wear Eye Protection; PROVIDERS & STAFF Use Dedicated or Disposable Equipment. The door to the room was closed. Review of the clinical record revealed R24 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: influenza due to unidentified influenza virus with other respiratory manifestations (as of 2/28/25). On 3/4/25 at 9:30 AM, CNA 'F' was asked about why R24 was on droplet precautions and they reported they thought it was for the flu. On 3/4/25 at 9:31 AM, the Infection Preventionist (IP 'B') was asked about the reason for R24 being on droplet precautions and they reported the resident was on droplet precautions for influenza A and further reported the staff only had to wear surgical mask, face shield, and gown. When asked why the signage only indicated staff were to don/doff face shield and surgical mask, they reported if they wanted to they could wear a gown. On 3/4/25 at 9:53 AM, Physical Therapy Assistant (PTA 'J') was observed donning a gown, gloves, surgical mask, was already wearing glasses and entered the room. At 10:05 AM, PTA 'J' was observed exiting the room and while doing so, brought a blood pressure/vital machine on wheels out of the room and down to the center alcove in the hallway to plug into an outlet. PTA 'J' was not observed cleaning the machine. On 3/4/25 at 10:08 AM, an interview was conducted with PTA 'J'. When asked about the observation of them bringing the vital sign machine out of R24's room, PTA 'J' reported they needed to check their vitals as the resident had a change while participating in a bedside therapy session. When asked about the cleaning of the vital sign machine, PTA 'J' reported they used the can (sanitizer wipes) to wipe down the finger area of the machine which they did in the room. When asked to confirm if the rest of the unit was sanitized, they reported only the finger area. When asked about the signage that indicated staff were to use dedicated equipment, PTA 'J' reported there was no dedicated equipment for the vital signs for this side of the building and they made sure to clean it as best they could. When asked what they had been educated on about donning/doffing PPE for residents on droplet precautions, PTA 'J' reported they were told it's just glasses, mask and gloves. At first we were told to wear gowns, but that was dropped. R2 On 3/4/25 at 10:18 AM, an interview was conducted with CNA 'K'. When asked about what PPE should be don/doffed for residents on droplet precautions, which included R2, CNA 'K' reported you don't need to wear gowns, only face mask and eye protection. When asked where you would clean the face mask off, CNA 'K' pointed to the table in the hallway and stated use the purple sani-wipes. When asked to clarify if that should be done in the room or in the hallway, CNA 'K' reported not in the rooms, in the hallway. On 3/4/25 at 10:26 AM, an interview was conducted with IP 'B'. When asked to confirm the process to don/doff PPE for residents on droplet precautions, IP 'B' reported it was recommended to wear a gown if providing care, but just out of an abundance of caution. When asked about the cleaning of the face shields, IP 'B' reported that should be done in the resident rooms prior to going into the hallway. On 3/4/25 at 10:32 AM, the resident's room door was closed, with signage on the door indicating they were on droplet precautions. An interview was conducted with the resident at that time. When asked about their current isolation status, R2 reported they had been sick with the flu since last Tuesday (2/25/25) and they never felt so sick on their life. Review of the clinical record revealed R2 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: radiculopathy lumbar region, chronic pain due to trauma, fusion of spine thoracolumbar region, influenza due to other identified influenza virus with other respiratory manifestations, type 2 diabetes mellitus with unspecified complications, and acquired absence of right leg below knee.

Based on observation, interview, and record review, the facility failed to ensure the facility's 'wireless' call light communication system was fully operational and had adequate alternate interventions for residents to summons help. This deficient practice has the potential to effect all residents, including R142, R144, R143, R344, and one anonymous resident (AR). Findings include: R142 On [DATE] at 9:55 AM, the door to the room was closed. There were no audible or visual signals that any call lights were activated. Upon entry into the room, R142 was observed seated upright in bed, wearing a cervical collar. The resident reported they were extremely upset and had been waiting for their medication now for over an hour and was in pain. When asked about their pain level on a scale of ,d+[DATE] with 10 being the worst, R142 reported their current pain level was a 5. When asked if they pressed the call light for help, they reported their roommate did (for them). Review of the clinical record revealed R142 was admitted into the facility on [DATE] with diagnoses that included: nondisplaced posterior arch fracture of first cervical vertebra, Huntington's disease, unspecified injury of head, contusion of right hand, and unspecified displaced fracture of second cervical vertebra. According to the Minimum Data Set (MDS) assessment dated [DATE], R142 had intact cognition and was dependent on staff for most activities of daily living (ADLs). R144 On [DATE] at 10:09 AM, R144 (roommate of R142) was observed laying in bed with an ice pack to their left hip area. When asked about whether they had any concerns, R144 reported their only concern was the call lights were not working. They further reported they were given a bell and pointed to the bell on their bedside table. The bell was observed to be a small (hotel-style) bell in which the top was pressed and made a [NAME]-like noise. R144 also reported they were worried that with their doors having to be shut because of the flu outbreak, the staff weren't able to hear the bell. When asked if they experienced anything like that since they were given the bell to use, R144 reported yesterday they had to wait a long time (over a half hour) and frequently used the bell for their roommate's need for help as well. At that time, R144 was requested to activate both the call light and the bell to see about staff's response. No staff responded after about five minutes. The resident further stated they had already done that for their roommate before this surveyor entered the room and they were still waiting without any response from facility staff. Review of the clinical record revealed R144 was admitted into the facility on [DATE] with diagnoses that included: fracture of unspecified part of neck of left femur. According to the MDS assessment dated [DATE], R144 had intact cognition and required partial/moderate assistance with most ADLs. R143 On [DATE] at 9:54 AM, observation of R143's room revealed they were in a room that was at the end of the hallway. There was a sign on the door that requested staff left the door open. During this time, the wifi connection on this surveyor's laptop computer stopped functioning a few doors away from R143's room. The connection didn't resume until this surveyor returned to the nursing station (closer to the center of the second floor). On [DATE] at 12:15 PM, the door to R143's room was observed closed. At that time, an interview was conducted with R143. When asked about the sign on the door requesting to keep it open, R143 reported that was because their call lights on the bed don't work. I'm at the end of the hall and if the door is closed, you can't hear the bell. R143 was observed with a hotel-like bell on their bedside table. The resident further reported Maintenance had been in several times to check but the call light still doesn't work. They further reported the other day, they had been ringing their bell off and on and staff did not respond. Review of the clinical record revealed R143 was admitted into the facility on [DATE] with diagnoses that included: acute respiratory failure with hypoxia, obstructive sleep apnea, chronic kidney disease stage 3b, and influenza due to other identified influenza virus with other respiratory manifestations. According to the MDS assessment dated [DATE], R143 had intact cognition and required assistance with most activities of daily living. R344 During an observation completed on [DATE] at approximately 11:10 AM, R344 was observed sitting in their wheelchair. R344 was wearing a sling on their right arm. R344 had a hotel-like bell on their table. R344 was queried about the stay at the facility and staff assistance. R344 reported that they had to wait longer for staff assistance when they called for help. When queried about the call light in the room and bathroom. R344 reported that they were not sure if the lights worked properly outside and/or if the staff were not checking. They added that the call bell on the table was not loud enough and while they were in the bathroom they were asking the staff members to leave the bathroom door open so they could yell for help. When queried if there were any pattern with the long wait times such as certain days, times etc., R344 added that it was throughout the day, they felt it was more during the shift change. Anonymous Resident (AR) During an observation completed for AR on [DATE] at approximately 9:05 AM. AR was observed in their bed and they had a tracheostomy (an opening surgically created through the neck into the trachea/windpipe to allow air to fill the lungs). AR also had a hotel-like call bell on their table. AR was communicating by typing their responses on their cell phone. When queried about their care at the facility and staff assistance, AR reported that they had to wait longer when they called for assistance. They reported that with their condition (with tracheostomy) it was important they received timely assistance. On [DATE] at 12:15 PM, an interview was conducted with Certified Nursing Assistant (CNA 'E'). When asked about their assignment, they reported they were working with CNA 'F' on the second-floor north unit and further reported they were from an agency. When asked about the call light system and how they were notified of a resident needing help, CNA 'E' reported there was a sound on the page monitor (box at second floor nursing alcove). When asked if they utilized a pager, they reported when they were here the last time, they got one then, but they did not today. They further reported this was only their second time working at the facility and the last time they worked, they were on the first floor. On [DATE] at 12:23 PM, an interview was conducted with CNA 'F'. When asked about the facility's call light system and how they became aware of a resident needing assistance, CNA 'F' reported there was a musical alert and pointed to a small black box at the nursing alcove. CNA 'F' then pressed a button to show the most recent alert showed room [ROOM NUMBER] alerted at 2:48 AM and the current time showed as 2:49 AM and a date of [DATE]. When asked if they were to also utilize a pager, CNA 'F' reported they were, but confirmed they were not. CNA 'F' then opened a drawer at the nursing alcove and retrieved a pager but reported it didn't work. When asked about the wrong date/time on the call light response box, CNA 'F' reported if you set it to the correct time/date, it will revert back the next day. When asked how they were able to know if someone else turned the light off, or how long it took to respond, CNA 'F' reported they were not sure. When asked about the use of the hotel-like bells, CNA 'F' reported those were difficult to hear when the doors were closed. They further reported the call light system does not work consistently and frequently looses wifi signal. On [DATE] at 8:50 AM, an interview was conducted with the Director of Nursing (DON) and the Assistant Administrator (AA 'A'). When asked about the facility's call light system, both AA 'A' and the DON reported they were aware the system didn't function at times and if the button wasn't held down long enough it might not activate and reported the facility had bids on a new system. The DON confirmed residents were given an additional metal bell to ring. When informed of the concerns identified with residents and observations from [DATE] of the metal bell not being audible when doors to the rooms were closed due to the current flu outbreak, concerns from residents, and interviews with staff not having all components of a fully functioning call light system, the DON confirmed the pagers were to be utilized as part of that system and was not aware the call alert box on the nursing alcove had any concerns with incorrect dates/times. On [DATE] at 1:17 PM, AA 'A' reported they recently signed a contract to install a new call light system and the target date to finish the installation was at the end of this month on the 31st. Review of the documentation provided directed the facility To place an order, sign quote and return with payment information . This quote was signed by facility staff and dated [DATE]. On [DATE] at 1:45 PM, AA 'A' was asked if the facility had any documentation of discussion or quotes obtained prior to [DATE] (after the survey team identified a concern). On [DATE] at 2:24 PM, AA 'A' reported they had been in discussion about the call light system verbally and also had emails of quotes from other vendors. On [DATE] at 2:31 PM, review of the additional documentation provided by AA 'A' revealed one quote from [DATE]. On [DATE] at 9:15 AM, an interview was conducted with the Maintenance Director (Staff 'H'). When asked about how the facility monitored their call light system to ensure it was functioning properly, Staff 'H' stated when there was a complaint with call lights not working they would then check the batteries which were in the box where the call light went into the wall in the resident rooms. Staff 'H' reported there was no light in the hallway, or in the rooms and bathrooms. Staff 'H' further reported their system was not hard-wired, but was wireless and dependent upon the wifi signal. They reported the transmitter was located on the first-floor top of the ceiling and at times the wifi signal would cut out (not function) due to signal loss and sometimes was interfered. Staff 'H' reported at times, when the wifi signal cut out, it would start again in a few minutes. When asked to confirm if they did any room audits to ensure the call lights were functional, Staff 'H' reported they did not, they waited for complaints. Staff 'H' further reported the system was set up to show an alert on the monitor at the nursing desk if there was a low battery or the system wasn't working. When asked if the staff should be using pagers as part of the call light system, Staff 'H' reported they should and there was also a small junction box at the nursing desk in the hallway that looked like a radio that staff could see which rooms were going off. When asked about the incorrect dates/times visible on the small junction box, Staff 'H' reported they were not aware of any concerns like that but would check it out and follow-up. There was no additional follow-up by the end of the survey. Review of the specific call light system documentation provided by the facility dated [DATE] documented, in part: .Testing Personal Help Buttons (PHBs) is an important part of ensuring that residents are completely protected. Not only does it guarantee button operation, but, more important, it reminds the resident of the crucial and convenient part of the CarePoint safety system. NOTE: [Specific Name of System] recommends that communities test PHBs monthly and supplement these tests with a program to ensure that residents remember them and know how to use them .System Setup .SmartCare makes a sound at every new alert .If a Network Monitoring Station is disconnected from the network for any period of time, it may be necessary to re-sync the display .SmartCare stores information in Microsoft Access database files . This documentation further identified the system was complete when pagers were utilized. According to the facility's policy titled, Call Lights: Accessibility and Timely Response dated [DATE]: .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response .All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied .Ensure the call system alerts staff members directly or goes to a centralized staff work area .All staff members who see or hear an activated call light are responsible for responding .

Based on interview and record review, the facility failed to ensure that there was a stop/end date for PRN (as needed) psychotropic medication and failed to ensure that resident specific non-pharmacologic interventions were attempted prior to the administration of PRN psychotropic medication (anxiolytic) for two (R5 and R12) of five residents reviewed for unnecessary medications with potential for adverse side effects and decreased quality of life. Findings inlude: R12 R12 was admitted to facility on 2/5/25 after hospitalization. R12's admitting diagnoses included: stroke, diabetic neuropathy, history of falls, heart failure, kidney failure, generalized anxiety disorder, restlessness and agitation. Based on the Minimum Data Set (MDS) assessment dated [DATE], R12 had Brief Interview for Mental Status (BIMS) score of 13/15, indicative of intact cognition. Review of R12's physician orders revealed an order for alprazolam (anti-anxiety medication). The order read alprazolam - schedule IV tablet 0.5 milligram oral twice a day PRN (as needed) started in 2/5/25 with no end date. Review of R12's Medication Administration Record (MAR) from 2/5/25 through 3/5/25 revealed R12 received the PRN alprazolam on the following dates: 2/5/25 (1 dose); 2/6/25 (2- doses); 2/7/25 (1 dose); 2/9/25 (2-doses); 2/10/25 (1-dose); 2/11/25 (2-doses); 2/12/25 (2-doses); 2/13/25 (1-dose); 2/19/25 (1-dose); 2/21/25 (2-doses); 2/23/25 (1-dose); 2/28/25 (1-dose); 3/4/25 (1-dose), and 3/5/25 (1 -dose). PRN medication administration reasons under MAR included: Behavior issues, other and pain. Review of R12's nursing progress notes revealed multiple notes that revealed yelling for assistance and staff were redirecting R12 to use call light for assistance. There was non evidence on R12's EMR about R12's target behaviors monitoring and use of resident specific non-pharmacological interventions prior to administration of PRN psychotropic medication. Review of R12's Electronic Medical Record (EMR) revealed a care plan for mood state dated 2/7/25. The care plan read, I have signs and symptoms of mood distress, related to diagnoses of generalized anxiety disorder, delirium, insomnia, restlessness and agitation . One of the approaches read offer non-pharmacological interventions to improve mood and lessen anxiety depending on patient's preference like attending social activities, deep breathing exercises, massage, listening to music. An interview with Director of Nursing (DON) was completed on 3/6/25 at approximately9:45 AM. DON was queried about the R12's order for PRN psychotropic medication with no end date and the facility process on non-pharmacological interventions prior to administering PRN psychotropic medication. DON reviewed the EMR and reported that they would contact the physician regarding the end date. They also added that staff should administer non-pharmacological interventions prior to administration of PRN medication and should document in progress notes. They were notified of the concerns and they reported that they understood the concern. Review of facility provided document titled Use of Psychotropic Medications with a revision date of January 2025 read in part, It is the intent of this policy to ensure that residents only receive psychotropic medications when other non-pharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 2. Psychotropic medications are to be used only when a practitioner determines that the medication is appropriate to treat residents specific diagnosed and documented condition and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. 3. Other medications not classified as antipsychotic, antidepressant, anti-anxiety are hypnotic medications but can affect brain activity should not be used as a substitution for another psychotropic medication unless prescribed with the documented clinical indication for use consistent with accepted clinical standards of practice. 4. When a medication is used that can affect brain activity example antihistamines anticholinergic medications and central nervous system agents for use in conditions such as seizures, mood disorders, pseudobulbar effect and muscle spasms are stiffness and the documented use appears to be a substitution for another psychotropic medication rather than the original or approved indication, then the medication is subject to the requirements pertaining to psychotropic medications. 5. The indications for initiating, maintaining, or discontinuing medications as well as the use of non-pharmacological approaches, will be determined by evaluating the residence physical, behavioral, mental, and psychological science and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and preferences and goals for treatment. 6. Nonpharmacological approaches must be attempted unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. 7. The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication, specifically an anti-psychotic medication to another category psychotropic medication 16. Psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the use of for the PRN OK use documented in the residence medical record and is subject to the limitations as noted: a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond 14 days. The medical record should include documentation from the physician our prescriber for the rationale for the extended time period and indicate a specific duration. b. PRN antipsychotic medication only, shall be limited to 14 days with no exceptions. If the attending physician or the prescribing practitioner believes it is appropriate to write a new order for the PPRN antipsychotic, they must first evaluate the resident to determine if the new order for the PCR and antipsychotic is appropriate . R5 On 3/4/25 at 9:55 AM, R5 was observed lying back in their bed. Oxygen was observed being administered via nasal cannula and an interview was conducted with the resident at that time. A review of the medical record revealed R5 was readmitted to the facility on [DATE] with diagnoses that included: fracture of lower end of the left femur. A review of the physician orders revealed the following: Start date: 2/15/25- Xanax 1 mg twice a day PRN (as needed). The End Date was noted as Open Ended. The order did not have a stop date. A review of a facility policy titled Use of Psychotropic Medication(s) revised January 2025, documented in part . PRN orders for psychotropic medications . shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescribing for the rationale for the extended time period and indicate a specific duration . Further review of the medical record contained no documentation by the prescribing practitioner on why the Xanax order was extended beyond the 14 days. A review of the March 2025 Medication Administration Record (MAR) documented the Xanax as administered on the following dates: 1st at 8:51 AM and 9:12 PM. 3rd at 8:45 PM. Further review of the medical record revealed no documentation of non-pharmacological interventions utilized before the administration of the Xanax PRN medication. On 3/5/25 at 10:58 AM, the Director of Nursing (DON) was interviewed and asked about R5's Xanax order extending beyond 14 days and asked about the requirements of utilizing and documenting non-pharmacological interventions prior to the administration of the PRN psychotropic medication and the DON acknowledged the order should have a stop date and staff should be documenting interventions prior to administration. No further explanation or documentation was provided by the end of the survey.

Based on interview and record review the facility failed to consistently maintain a system that monitored antibiotic use, this had the ability to affect any resident prescribed an antibiotic in the facility of the 47 residents that resided in the facility at the time of the survey. Findings include: Review of the facility's February 2025 Infection Control Form line listings revealed 5 pages of documented infections in the facility. None of the identified infections were identified to have met or not meet the criteria for infection. The area was left blank on all five pages. None of the infections were identified as resolved or ongoing. None of the infections were identified as Nosocomial (in house acquired) or Community acquired. The area was left blank. Most of the identified infections failed to note signs and symptoms of the infection. Further review of the documentation revealed additional blank sections revealing the surveillance log to be incomplete. On 3/6/25 at approximately 11:10 AM, the facility's Infection Control Preventionist (ICP) B was interviewed and asked about the incomplete antibiotic review for February 2025. ICP B stated they had been very busy lately and was unable to maintain the data. ICP B was asked how they ensured that all resident listed on the five pages met criteria for an infection if the data is incomplete. ICP B stated they hung the McGeer checklist at each nurses station for the nurses to follow. No further explanation was provided. A review of a facility policy titled . Antibiotic Stewardship Program revised January 2025, documented in part . It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program . The facility uses the . updated McGeer criteria . to define infections .

Based on observation, interview, and record reviews the facility failed to ensure physician ordered medications had an indication for use and failed to transcribe physician orders per the facility policy for two (R's 5 and 7) of two residents reviewed for unnecessary medications. Findings include: R5 On 3/4/25 at 9:55 AM, R5 was observed lying back in their bed. Oxygen was observed being administered via nasal cannula and an interview was conducted with the resident at that time. A review of the medical record revealed R5 was readmitted to the facility on [DATE] with diagnoses that included: fracture of lower end of the left femur. Review of the Physician orders revealed the following: Bupropion sustained release 150 mg (milligram) twice a day. For the diagnosis section on the order, staff documented N/A (not applicable). Trazodone 150 mg once daily. For the diagnosis section on the order, staff documented N/A. Xanax 1 mg twice a day PRN (as needed). For the diagnosis section on the order, staff documented N/A. A review of a facility policy titled . Medication Orders revised January 2025, documented in part . This facility shall use uniform guidelines for the ordering of medication . Elements of the Medication Order . Diagnosis or indication for use . The facility staff failed to document the indication for use for each medication as required by the facility policy. R7 On 3/4/25 at 12:54 PM, R7 was observed in their room. A brief interview was conducted with the resident at that time. A review of the medical record revealed R7 was readmitted to the facility on [DATE] with diagnoses that included atrial flutter and heart failure. Review of the Physician orders revealed the following: Eliquis 5 mg every 12 hours. For the diagnosis section on the order, staff documented N/A. Hydrocodone-acetaminophen 5-325 mg every four hours PRN. For the diagnosis section on the order, staff documented N/A. On 3/5/25 at 10:58 AM, the Director of Nursing (DON) was interviewed and asked why R' 5 & 7 had no indication documented for the medications prescribed to them and the DON stated the indications are usually put in by the Physician and are usually in the Physician's progress notes. The DON was asked why the indications were not documented when the medication orders are transcribed and the DON stated they will try to implement a process moving forward so the indication section is completed. No further explanation or documentation was provided by the end of the survey.

Based on observation, interview and record reviews the facility failed to ensure oxygen therapy was consistently administered as ordered by the Physician for one (R14) of two residents reviewed for respiratory care. Findings include: On 2/4/25 at 9:22 AM, R14 was observed lying on their back in bed. Oxygen tubing was observed on the bed, disconnected from the oxygen concentrator. At this time Licensed Practical Nurse (LPN) C asked to reconnect and apply R14's oxygen. LPN C stated R14 always takes out their oxygen tubing on their own. LPN C proceeded to reconnect the tubing to the concentrator and apply the nasal cannula to R14. A review of the medical record revealed R14 was admitted to the facility on [DATE] with diagnoses that included: sepsis and delirium. R14 required assistance from staff for all Activities of Daily Living (ADLs). Review of a Physician order documented the following: Oxygen via nasal cannula at 2 LPM (Liters Per Minute) Maintain SPO2 (oxygen saturation) = (equal) or > (greater than) 90%. Review of the care plans revealed no care plan implemented for non-compliance regarding their oxygen therapy. Further review of the medical record revealed no interventions implemented regarding noncompliance of oxygen therapy. On 3/5/25 at 11:07 AM, R14 was observed sleeping in their bed, with the oxygen nasal cannula observed on the top of their upper lip. At this time Registered Nurse (RN) D was informed of R14's nasal cannula placement. RN D entered the room and woke R14 up from their sleep and informed them that they had to keep their oxygen on. RN D was observed reapplying the oxygen cannula. A review of a facility policy titled . Oxygen Administration revised January 2025, documented in part . Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . Oxygen is administered under orders of a physician . The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment . Monitoring for complications associated with the use of oxygen . Staff shall notify the physician of any changed in the resident's condition . or evidence of complications associated with the use of oxygen . On 3/6/25 at 9:05 AM, the Director of Nursing (DON) was interviewed and informed of the observed incidents with R14's oxygen administration and the DON stated they were not aware of R14 being noncompliant with their oxygen therapy. The DON stated that R14's non compliance could have started over the weekend, however had they known they could have implemented interventions for the concern. No further explanation or documentation was provided by the end of the survey.

Based on observations, interviews, and record review, the facility failed to ensure a positioning device (hand splints) were implemented for one (R16) of one resident reviewed for positioning and range of motion services resulting in the potential for contracture progression (hardening of the muscles, tendons, and other soft tissues) with further decline in range of motion and compromise with skin integrity. Findings include: R16 R16 was a long-term resident originally admitted to the facility on [DATE]. R16's admitting diagnoses included traumatic brain injury from motor vehicle accident, quadriplegia (paralysis of both arms and both legs) and seizures. R16 had a tracheostomy (An opening surgically created through the neck into the trachea/windpipe to allow air to fill the lungs) and they were breathing with the assistance of a ventilator (breathing machine). R16 was non-verbal and were totally dependent on staff assistance with all their needs. An initial observation was completed on 3/4/25 at approximately 9:35 AM. R16 was observed laying on their bed and a staff member was in the room. R16 had bilateral hand contractures, the fingers in both of their hands were bent in a clawed position. Some fingertips were close to the palm of hands. R16 did not have any type of splint/device on their hands. Two follow up observations were completed later that day at approximately 11:30 AM and 1:20 PM. R16's hands were observed in the same position. There were no hands splints or braces in R16's room. On 3/5/25 at approximately 10:15 AM, a follow up observation was completed the next day. R16 was observed in their bed. R16's hands were in the clawed position as yesterday. R16 did not have splints/devices on their hands. Review of R16's Electronic Medical Record (EMR) revealed a care plan that I require splint on bilateral hands at night . that was initiated on 9/25/20 and goal for 4/19/25 read Resident's bilateral hands will be free from injury, skin break down, edema, atrophy and contractures. An interview with Licensed Practical Nurse (LPN) L who was assigned to care for R16 was completed on 3/5/25 at approximately 10:35 AM. LPN L reported that they had been working at the facility for about 3 years and they regularly worked the unit where R16 was residing and they were very familiar with them. They were queried about R16's hand contractures and if any interventions were in place. LPN L reported that some staff members used rolled washcloths but they were not sure why it was not on. When queried further about R16's hand splints LPN L reported that they had never seen any splints for the resident and they confirmed that R16 did not have any hand splints in their room. An interview with Certified Nursing Assistant (CNA) N who was assigned to care for R16 was completed on 3/5/24 at approximately 11:45 AM. CNA N reported that they had been at the facility for about 8 years and they had regularly worked the unit where R16 was residing. CNA N was queried how they had obtained their information to care for their residents and they reported that they obtained information from the CNA care card that was kept in the resident's room, from the computer and also from their charge nurses. CNA N brought the document from R16's room was titled Resident Care Guide. CNA N brought 3 different sheets. They were no dates on the documents and they were not able to identify the most current document. The document did not specify use of any splints. CNA N logged on to the computer and showed the CNA care plan for R16 upon request. One care plan read I require splint on bilateral hands . When queried if R16 was using any splints, CNA N reported that R16 did not have any splints. They added that some staff members used rolled wash cloths and added that it was not consistent and was dependent on the staff member who were assigned to work with the resident. An interview with the Director of Rehab (DOR) M was completed on 3/5/25 at approximately 10:45 AM. They were queried about R16's hand contractures and if they had any splints in place as stated on their care plan. DOR M reported that they were not aware if R16 had any splints but they remembered R16 having some type of device such as a carrot and they would look into it. When queried further they reported that staff might have missed the splints after R16's readmission from the hospital; they would look into system to ensure that orders were reinstated and would initiate some audit. When queried about R16's contractures and their high-risk for worsening contractures, DOR M reported that they understood and agreed the rationale for the concern and they would follow up with their team. An interview with the Director of Nursing (DON) was completed on 3/5/25 at approximately 12:40 PM. The DON was queried about R16's splint and how the CNAs documented and who was providing oversight to ensure that CNAs were following the plan of care. The DON reported that CNAs were supposed to follow the plan of care and document; and nurses were providing the oversight. They were notified on the concern regarding R16's contracture and their risk with no plan in place to maintain their range of motion. They reported that they understood the concern and they would follow up with their team. A facility provided document titled Prevention of Decline in Range of Motion with a revision date of January 2025, read in part, Resident who enter facility without a range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Policy Explanation and compliance guidelines: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical slash occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment appropriate care planning and preventive care. 2. Assessment for range of motion: a. The facility will assess the residence range of motion (such as current extent of movement of his slash her joints and identification of limitations) on admission readmission, regularly and upon significant change period the facility will communicate with therapy regarding any range of motion limitations noted, as necessary. b. Nursing assistants will report any significant changes in range of motion, as noted during daily care activities, to the resident's nurse when any change is noted. c. The assessment should include identified risks which could impact residents' range of motion including but not limited to: i. Immobilization ii. neurological conditions causing functional limitations iii. any condition where movement may result in pain, spasms, or loss of movement iv. clinical conditions such as immobilized limbs or digits because of injury, fractures or surgical procedures including amputations 3. Appropriate care planning: a. Based on the comprehensive assessment, the facility will provide interventions, exercises and or therapy to maintain or improve range of motion. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes but not limited to: i. Appropriate services (specialized rehabilitation, restorative, maintenance). ii. Appropriate Equipment (braces or splints). iii. Assistance as needed (active assisted, passive, supervision) .

Based on observation, interview, and record review, the facility failed to ensure appropriate assessments and physician orders with medical symptoms were completed for audible position change alarms for two (R6 and R342) of two Residents reviewed for restraints resulting in the potential to restrict body movements due to the fear of sounding the alarm with physical discomfort and psychological distress utilizing a reasonable person concept. Findings include: R6 Record review revealed R6 was recently admitted to the facility on [DATE]. R6's admission diagnoses included urinary tract infection, peripheral vascular disease, heart disease, diabetes and Alzheimer's disease. Based on the nursing admission assessment dated [DATE], R6 was able to make their needs known and they were living at home with their wife prior to this admission. An initial observation was completed on 3/4/25 at approximately 10:45 AM. R6 was observed sitting in their wheelchair (WC) with a position change alarm box in their wheelchair. When queried what it was they were not sure what it was for. When queried what did they do when they needed to get assistance from staff they reported that they would call for help. R6 was able to move around in their wheelchair. A sensor pad for position change alarm for their bed was also observed in R6's bed. A follow up observation was completed later that day at approximately 2 PM. R6 was sitting up in their WC. R6 had position change alarm pad and box in their bed. Review of R6's Electronic Medical Record (EMR) revealed that an order dated 2/27/25 that read, Chair alarm monitoring protocol: check placement and function: once per shift. Placement: ensure the chair alarm is properly attached and positioned on the chair. Test the alarm functionality to ensure it is working correctly . The order did not indicate the medical symptom and or the diagnosis that warranted the use of chair. There was no order to use an alarm in bed and R6 had an alarm unit on their bed. Nursing progress notes dated 3/1/25, 3/2/25, 3/3/25 and 3/4/25 revealed the use of alarms in bed and in wheelchair. However, the progress notes did not reveal any rationale why a position change alarm was used in the wheelchair and bed. There was no evidence of any documentation in R6's EMR that the facility had attempted any least restrictive approaches prior to use of a position change alarm. There was no documentation that indicated that medical symptom that warranted the use of a position change alarm. Review of R6's assessments did not reveal any nursing and or interdisciplinary assessments that recommended the use of a position change alarm. Review of R6's care plan revealed a care plan for physical restraints dated 2/14/24. The care plan did not reveal use of any position change alarms. Review of R6's fall care plan did not reveal the use of any position change alarms. R342 R342 was admitted to the facility on [DATE] after hospitalization . R342's admitting diagnoses included orthostatic hypotension and muscle weakness. R342 was living at home with their family prior to hospitalization and they were admitted to the facility for short-term skilled nursing and rehabilitation care. Review of R342's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a score of 15/15, indicative of intact cognition. Review of the nursing admission assessment dated [DATE] revealed that R342 was aware of their limitations and able to use to call light and ask for assistance. An initial observation was completed on 3/4/25 at approximately 10:30 AM from the hallway. R342 had a sign on the door that read that they were on contact precautions. A staff member was in R342's room. R342 was observed sitting on their edge of their bed and they had a position change alarm box attached to the side of their bed. During a follow-up observation completed on 3/5/25 at approximately 12:15 PM, R342 was observed sitting in the edge of the bed eating lunch. This Surveyor heard the alarm in the hallway. R342 was trying to reposition themselves in the bed to make the alarm noise stop. The alarm stopped for a few seconds and started to go off again and R342 was trying to readjust themselves in bed trying to stop the alarm and a staff member went in to assist the resident. Later that afternoon at approximately an hour after the observation an interview was completed with the resident. R342 was still sitting on their edge of their bed and the position change alarm box was attached to the side. They were queried about the alarm and they thought they needed the alarm because they might fall. They also added that they knew how to use their call light and ask for assistance. Review of R342's Electronic Medical Record (EMR) did not reveal any order for the use of any position change alarm. Review of progress notes revealed a physician progress note dated 2/18/25 that revealed that R342 had a history of near falls or near misses at home due to their orthostatic hypotension (a condition where blood pressure drops when a person stands up from a sitting or lying position). Further review of R342's nursing progress revealed since admission to the facility multiple notes that read R342 was alert and oriented to and able to make their needs known. A progress note dated 2/21/25 read in part, received patient alert, lying in bed and oriented x 3 .needs 1 person assist ADL's (Activities of Daily Living) and toileting bed alarm in place working . Further review of R342's EMR did not reveal any nursing or interdisciplinary assessments that recommended the use of alarms. There were no orders with any medical symptoms that warranted the use of position change alarms. There was no evidence of any documentation that other least restrictive measures were attempted prior to use of position change alarms. R342's care plan did not reveal the use of any position change alarms. Review of a Minimum Data Set (MDS) assessment dated [DATE] did not reveal use of any position change alarm. An interview Certified Nursing Assistant (CNA) O was completed on 3/5/25 at approximately 12 PM. They were working on the unit where R342 and R6 were residing. CNA F was queried about the use of position change alarms and why they were used. They reported that they were used to let the staff know when residents attempted to get out of bed/wheelchair. They added they used alarm for residents if they were a fall risk. When queried if R342's was able to ask for staff assistance they reported that they were able to ask for assistance. When queried further about the process and who made the determination they reported that they were not sure. An interview with CNA F was completed on 3/5/25 at approximately 12:15 PM. CNA F' was also assigned on the unit where R6, and R342 were residing. CNA F reported that they had been at facility for approximately 5 years and they had regularly worked that unit. They were queried about the use of position change alarms. CNA F reported that the facility used alarms for residents if they were a fall risk. They added alarms were used to alert the staff members if residents attempted to stand or transfer on their own. When they queried about the process and who made the determination, CNA F reported that usually nurses made the decision, sometimes therapy staff. They added that at times if the CNAs felt that residents were at risk for fall they would let the nurses know and put an alarm for the resident. When queried what other interventions they would attempt before attaching an alarm they were not sure. An initial interview with Director of Nursing (DON) was completed on 3/5/25 at approximately 12:30 PM. They were queried about the facility process for use of position change alarms. The DON reported that the facility completed a nursing and or interdisciplinary assessment upon admission and throughout the resident stay as needed if resident's condition warranted use of any such devices. When queried further about the process, they added if residents had a fall or if they had history of falls then interdisciplinary team recommended the use of alarms. They were queried about the interdisciplinary assessments and other interventions attempted etc. for R6 and R342. They were queried about if the expect their staff to have assessments, orders and care plan etc. for the use of position change alarms including other measures that were attempted prior to use of alarms and they reported yes. The DON reviewed the EMR and reported that there was no documentation in the EMR for R6 and R342 and reported that they understood the concern. They added they would check for any internal documents they might have and would report back. A follow up interview was completed with the DON on 3/6/24 at approximately 10 AM. The DON reported that they did not have any additional documents and they understood the concerns for use of position change alarms for R6 and R342. They added both residents were at risk and they had added orders and care plans. When queried about the assessment they added that they would follow up. A facility provided document titled Resident Alarms with a revision date of 01/25 read in part, It is the policy of the facility to use 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. Definition: An 'alarm' is any physical or electronic device that monitors resident movement when alerts the staff, by either audible or inaudible means, when movement is detected. Policy Explanation and Compliance Guidelines: 1. The use of alarms does not eliminate the need for adequate supervision of threshold. Types of alarms include: a. Bed alarms . b. Chair alarms . c. Floor mat alarms . d. Motion sensor alarms . e. Wander/elopement alarms . f. Other . 2. Identification of risk a. Each resident shall be assessed for fall and elopement risk upon admission and periodically thereafter as part of the comprehensive assessment process. b. Medical symptoms shall be identified and documented in the medical record. This information may come from the resident's medical history, physical exam, or individual observation. 3. Evaluation and analysis of risk a. The interdisciplinary team shall analyze each resident's unique risks and medical symptoms to determine the root cause of each risk. b. The interdisciplinary team shall consider the severity of risks slash symptoms, the immediacy of risks, and trends such as time of the day, location, or stated reasons for the behavior/ fall. 4. Implementation of interventions a. Resident directed approaches shall be implemented in accordance with the resident's needs, goals, and preferences. b. Alarms shall be initiated only to address a specific medical symptom or unique risk, when the benefit of the alarm outweighs the risk associated with its use. c. Interventions shall be communicated to all relevant staff, including frequency/timeframes and responsibility .

Based on observation, interviews, and record reviews the facility failed to ensure consistent dialysis communication documentation and assessments were maintained in the clinical record for one (R40) of one resident reviewed for dialysis. Findings include: On 4/22/24 at 1:41 PM, R40 was observed in bed. When asked, R40 stated they receive dialysis care five days a week for two and a half hours each day. R40 explained the dialysis entity comes to the facility and provide their dialysis treatment at the bedside. Review of the medical record revealed R40 was readmitted to the facility on [DATE], with a diagnosis that included end stage renal disease. Review of the medical record on 4/22/24, revealed the last dialysis communication/assessment documentation in the medical record was dated 5/8/23. On 4/23/24 at 10:36 AM, the Director of Nursing (DON) was interviewed and asked where the documentation for R40's dialysis treatments/communication/assessments are kept, and the DON stated the entity emails them to the facility. The DON was then asked why the communication/assessments had not been uploaded to the R40's medical record since May 2023 and the DON stated they would look into it further and follow back up. At 1:59 PM, the DON stated they had gotten in touch with the dialysis center and received all of the communication/assessments from dialysis since May 2023 to current and it's now uploaded in the resident's record. No further explanation or documentation was provided by the end of the survey.

Based on interview and record review, the facility failed to ensure three (R46, R48, and R108) of four residents reviewed for advance directives had their code status/treatment preferences clearly documented in their clinical record. Findings include: R46 A review of R46's clinical record revealed R46 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: spinal stenosis, anemia, hypertension, and diabetes. A review of R46's Minimum Data Set (MDS) assessment dated [DATE] revealed R46 had intact cognition. On [DATE] at 1:55 PM, a review of R46's full electronic medical record (EMR) was conducted. A review of a form titled, (Facility Name) Advance Directives revealed R46's wife signed the form and indicated R46 did not want Cardio-Pulmonary Resuscitation (CPR) in the event where my heart stops beating, or my respirations cease. The form was signed on [DATE]. A review of a progress note for R46 dated [DATE], revealed, .Resident would like to be DNR (Do-Not-Resuscitate) . On [DATE] at 10:41 AM, an interview was conducted with the Director of Nursing (DON). When queried about where the nurses looked to confirm a resident's code status, the DON reported it would be flagged on the home page in the EMR whether the resident was DNR or Full Code. When queried about why R46 had a progress note that noted he wanted to be a DNR and a signed Advance Directives form that indicated DNR, but there was nothing flagged in the EMR to notify nursing of R46's wishes, the DON reported she would look into it. On [DATE] at 2:06 PM, the DON followed up and reported there was a new Advance Directives form put into R46's EMR that was found in a hard chart that was kept on the unit. The DON reported nurses could access the hard chart or EMR to confirm a resident's code status, but that both charts should match. The DON reported the Social Worker had to ensure everything was in place prior to the code status being flagged in the EMR. On [DATE] at 2:55 PM, an interview was conducted with the Social Worker. When queried about the facility's process for obtaining residents' advance directives and ensuring their treatment wishes were readily available for staff to review in the case of an emergency, the Social Worker reported the nurse reviewed advance directives with the residents upon admission, the social services reviews them during the Social Services Assessment. Residents' preferred code status was reported to the nurse or the DON and was placed into the physician's mailbox for a signature. The Social Worker further reported there was a binder on the units that included the residents' advance directives forms in addition to being flagged in the EMR. According to the Social Worker, nursing was responsible for ensuring residents' code status was updated in the EMR. When queried about R46 and why there was no code status flagged in the EMR, a DNR form in the EMR, and a full code form in the binder, the Social Worker reported it was also documented in her assessment. The Social Worker reported R46 changed his code status to full code upon readmission to the facility on [DATE]. A review of a Social Services assessment dated [DATE] revealed R46's Advance Directive was Do Not Resuscitate (DNR) and the request was In MD (physician's) box for signature. A review of a Social Services assessment dated [DATE] revealed R46's Advance Directive was full code (all life saving measures should be attempted in the event the resident stops breathing, including CPR). It should be noted that the signed Advance Directive in the EMR on [DATE] was for DNR and did not match what was in the binder on the unit, which was Full Code as of [DATE]. R48 On [DATE] at 12:17 PM, a review of R48's clinical record revealed no code status flagged in the EMR and no advance directive form was found in the EMR. Further review of R48's clinical record revealed R48 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: cerebral infarction, hypertension, and hemiplegia. A review of a MDS assessment dated [DATE] revealed R48 had severely impaired cognition. A review of R48's progress notes revealed a Social Services note dated [DATE] that noted, .Advanced directive completed with nursing and son, SW (social work) reviewed with patient . A review of R48's Social Services assessment dated [DATE] revealed R48's advance directive was a Full Code. There was no indication in R48's EMR that she was a full code. On [DATE], the facility uploaded an Advance Directives form that indicated R48 wanted CPR, tube feeding, hospitalization , and intravenous (IV) fluids. The form was signed on [DATE]. On [DATE] at 2:06 PM, the DON reported the form was in the binder on the unit, but not in the EMR prior to questioning. R108 On [DATE] at 2:15 PM, a review of R108's clinical record revealed no code status flagged in the EMR and no advance directives form to indicate R108's treatment wishes. Further review of R108's clinical record revealed R108 was admitted into the facility on [DATE] with diagnoses that included: atrial fibrillation, diabetes, and urinary tract infection. On [DATE] at 10:46 AM, R108's code status and advance directives were requested from the DON. On [DATE] at approximately 2:06 AM, it was discovered that the facility uploaded an Advance Directives form for R108 into the EMR that indicated she wished to be a full code, but did not want to donate organs. The form was signed on [DATE]. The DON reported the form was in the binder on the unit, but not in the EMR. A review of R108's Social Services assessment dated [DATE] revealed R108's advance directive was full code. A review of a facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, revised ,d+[DATE], revealed, in part, the following, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .Upon admission, the resident or an appropriate legal representative will be asked to complete and sign an advance directive for the facility .Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care .

Based on observation, interview, and record review, the facility failed to provide a privacy cover over an indwelling catheter bag for one Resident (R2) of two residents reviewed for catheters. Findings include: On 4/22/24 at 9:31 AM, R2 was observed resting in bed. An observation that was made on R2's catheter bag revealed no dignity privacy bag covering the catheter bag. On 4/23/24 at 8:43 AM, R2 was observed watching TV in bed. R2's catheter bag revealed no dignity privacy bag covering the catheter bag. On 4/24/24 at 1:09 PM, the DON was interviewed regarding the lack of a dignity privacy bag for R2. The DON said that R2 should have had a dignity privacy bag for his catheter bag. The DON it was explained that the nursing staff are to check that residents with catheter bags have dignity privacy bags in place. A review of R2's Electronic Medical Record (EMR) revealed R2 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. R2 had the following medical diagnoses: Neuromuscular Dysfunction of the Bladder, Multiple Sclerosis, and Paraplegia. A review of R2 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed R2 had a Brief Interview of Mental Status score of 13/15 (cognitively intact). According to the MDS, R2 required maximal assistance with bed mobility, toileting hygiene, and transfers. The MDS included that R2 had an external catheter. A review of the facility policy titled, Promoting/Maintaining Resident Dignity, with a revised date of 11/2023, revealed, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .Maintain resident privacy.

Based on observation, interview, and record review, the facility failed to thoroughly assess and document a pressure ulcer for one (R30) of two residents reviewed for pressure ulcers. Findings include: On 4/22/24 at 9:50 AM, R30 was observed seated in a wheelchair with a splint applied to his right arm. When asked questions, R30 replied, Okay to each question. A review of R30's clinical record revealed R30 was admitted into the facility on [DATE] with diagnoses that included: traumatic brain injury. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R30 had severely impaired cognition and was dependent on staff assistance for all activities of daily living, bed mobility, and transfers. A review of R30's Physician's Orders revealed an active order with a start date of 1/18/24 for Venelex ([NAME]-[NAME] oil) ointment applied to the coccyx and covered with an ABD (abdominal) pad every day shift and night shift and as needed. A review of an Entrance Conference Worksheet Electronic Health Record (EHR) Information form completed by the facility revealed documentation regarding pressure ulcers was located in the EHR under Wound Care Progress Note/Flowsheet. A review of the Wound Care Progress Note/Flowsheet documentation for R30 revealed no documentation since 2020. A review of R30's Medication Administration Records (MAR) from February 2024 through April 2024 revealed orders for Skin Assessment/Shower Schedule .Write Progress Notes: Must do skin assessment after each shower or if resident declined shower . The following was documented: 2/16/24 - redness on coccyx 2/20/24 - old redness on coccyx 2/27/24 - open skin on coccyx 3/5/24 - old open skin on coccyx 3/12/24 - old open skin on coccyx 3/22/24 - old open skin on coccyx 3/26/24 - open skin on coccyx 4/1/24 - old open skin on coccyx 4/9/24 - old open skin on coccyx 4/16/24 - open skin on buttocks A review of the Certified Nursing Assistant (CNA) documentation to indicate any skin problem for the resident (R30) revealed open area was documented on the following dates: 4/8/24, 4/10/24, 4/13/24, 4/16/24, 4/17/24, 4/19/24, 4/21/24, 4/22/24, Further review of R30's clinical record revealed no documentation of the measurements and characteristics of the open skin on R30's coccyx and buttocks as documented on the MAR. On 4/24/24 at 9:24 AM, an interview was conducted with the wound care coordinator, Licensed Practical Nurse (LPN) 'C'. When queried about where weekly skin assessments were documented, LPN 'C' reported they were completed on shower days and results were documented on the MAR. When queried about any wounds that R30 had currently, LPN 'C' reported he did not have any wounds and all treatment was being done as a preventative intervention. LPN 'C' explained Physician 'EE' evaluated all wounds and documented his evaluations in the clinical record (progress notes). LPN 'C' further explained that Physician 'EE' was not currently following R30 because he did not have any pressure ulcers. At that time, LPN 'C' was asked if there was any documentation of R30's skin as a result of the CNA and nurse documentation that mentioned open area to the coccyx. LPN 'C' reported she did not see anything in the record and would look into it. LPN 'C' further reported that she was notified last week that R30 had an open area to his coccyx, but it had not yet been assessed. On 4/24/24 at 9:47 AM, an interview with the Director of Nursing (DON) was conducted. The DON explained that weekly skin assessments were documented on the MAR and if a resident had a wound, Physician 'EE' evaluated the resident and documented in a progress note. At that time, the DON was asked where any assessment of R30's open areas to the coccyx were documented. The DON reviewed the EHR and confirmed there was no documented assessment of R30's wound. The DON reported she did not know if R30 had any open areas. On 4/24/24 at 9:58 AM, an observation of R30's skin was conducted with LPN 'C'. When R30's brief was removed, no treatment was observed on R30's coccyx, bloody drainage was observed in the brief and a large area of scar tissue with scattered areas of what appeared to be moisture damaged skin and partial thickness skin loss. On 4/24/24 at 11:30 AM, the Administrator and Nurse Practitioner (NP) 'D' followed up regarding R30 and reported that NP 'D' had been evaluating R30's wounds. NP 'D' reported she started working at the facility in October 2023 and R30 had always had issues with the skin on his coccyx. NP 'D' reported she never saw the coccyx open up completely. When queried about where were evaluation/assessment of R30's coccyx would be documented, NP 'D' reported it would be in the progress notes. A review of R30's Physician progress notes revealed the following documentation written by NP 'D': On 1/5/24, 1/19/24, 1/23/24, 2/6/24, NP 'D' documented, .Stage IV (full thickness skin and tissue loss) sacral and ischial ulcer with ulceration and minor bleeding of surrounding area .Plan: Continue with Venelex ointment and cover with ABD pad . The next time NP 'D' evaluated R30 was on 3/15/24 and the following was documented, .Stage IV sacral and ischial ulcer with ulceration and minor bleeding of surrounding area .Plan: Continue with Venelex ointment and cover with ABD pad . The same thing was documented on 3/19/24. On 4/9/24, NP 'D' documented, .Stage IV sacral and ischial ulcer .Hx (history) of Stage IV sacral and ischial ulcer. Resolved but high risk for breakdown . The same was documented by NP 'D' on 4/16/24. There was no documentation to describe the measurements and characteristics of R30's coccyx. It was documented by NP 'D' that the wound was resolved. However, based on the observation made on 4/24/24, there was open areas and bloody drainage. A review of a facility policy titled, Skin Assessment, revised 1/2024, revealed, in part, the following: .Documentation of skin assessment: .Document type of wound .Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) .

Based on interview and record review, the facility failed to develop and implement a care plan for hearing loss for one Resident (R19) hearing loss or one resident reviewed for hearing loss/communication. Findings include: A review of R19's Electronic Medical Record (EMR) revealed R19 was admitted to the facility on [DATE] with the pertinent medical diagnosis of hearing loss of the right ear. A review of R19's annual Minimum Data Set (MDS) dated [DATE] revealed R19 had a Brief Interview for Mental Status score of 3/15 (severely cognitively impaired). According to the MDS, R19 had hearing aids. A review of R19's comprehensive care plan, with no date, revealed R19 did not have a care plan regarding hearing concerns and the use of hearing aids. On 4/14/24 at 1:41 PM the MDS Coordinator F was interviewed regarding a hearing care plan. MDS Coordinator F said the care plan for R19's hearing concerns was missed. MDS Coordinator F said the hearing care plan was placed in the EMR the night of 4/23/24 because it was overheard that R19 did not have a care plan for hearing aids. On 4/24/24 at 1:14 PM the Director of Nursing (DON) was interviewed regarding the lack of a hearing care plan in the EMR. The DON said R19 should have had a hearing care plan related to the hearing aids. The DON said it is expected that it is the duty of the MDS Coordinator to make care plans for the residents.

Based on interview and record review, the facility failed to document urinary output consistently for one Resident (R2) of two residents reviewed for catheters. Findings include: A review of R2's Electronic Medical Record (EMR) revealed R2 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. R2 had the following medical diagnoses: Neuromuscular Dysfunction of the Bladder, Multiple Sclerosis, and Paraplegia. A review of R2 's quarterly Minimum Data Set (MDS) dated [DATE] revealed R2 had a Brief Interview for Mental Status score of 13/15 (cognitively intact). According to the MDS, R2 required maximal assistance with bed mobility, toileting hygiene, and transfers. The MDS included that R2 had an external catheter. A review of R2's catheter care plan dated 4/22/24 revealed Monitor/document (urine) odor, color, amount, and sediment Q (every) shift. A review of the Treatment Administration Record (TAR) for the month of January 2024 revealed the following undocumented outputs for the day shift: 1/14, 1/15, 1/18, and 1/23. A review of the Treatment Administration Record (TAR) for the month of January 2024 revealed the following undocumented outputs for the night shift: 1/12, 1/13, 1/14, 1/15, and 1/16 A review of the Treatment Administration Record (TAR) for the month of February 2024 revealed the following undocumented outputs for the day shift: 2/5, 2/8, 2/9, 2/10, 2/11, 2/13, 2/14, 2/15, 2/16, 2/20, 2/22, 2/25, and 2/26 A review of the Treatment Administration Record (TAR) for the month of February 2024 revealed the following undocumented outputs for the night shift: 2/4, 2/6, 2/7, 2/8, 2/9, 2/10, 2/11, 2/12, 2/13, 2/14, 2/15, 2/17, 2/18, 2/19, 2/20, 2/25, and 2/29 A review of the Treatment Administration Record (TAR) for the month of March 2024 revealed the following undocumented outputs for the day shift: 3/5, 3/7, 3/8, and 3/19 On 4/24/24 at 1:13 PM the Director of Nursing (DON) was interviewed regarding the undocumented urinary outputs. The DON said the nursing staff have to record the output when the foley catheter has been emptied. Upon departure from the facility there was no facility policy given that addressed the documentation of urinary catheter output.

Based on interview and record review the facility failed to implement an effective antibiotic stewardship program that included consistent implementation of protocols for appropriate antibiotic use for two (R's 159& 160), this deficient practice had the ability to affect multiple residents who were prescribed antibiotics during their inpatient care at the facility. Findings include: According to the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 2015: .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year .studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic- resistant organisms .Infection prevention coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections .Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use . The Core Elements of Antibiotic Stewardship for Nursing Homes (cdc.gov) Review of the facility's Infection Surveillance program from June 2023 through April 2024 documented multiple N/A documentation under criteria met for McGeer's for residents admitted from the hospital on an antibiotic. R159 Review of the facility's Infection Control Form for January 2024, documented the following in part, . (R159's name) Date of onset 01/08/2024 . Type of Infection- COVID-19 . Symptoms- productive cough . Amoxicillin 875-125 MG (milligram) BID (twice a day) x 7 days . McGeer criteria- Y (Yes) . [R159's name] Date of onset 01/08/2024 . Type of Infection- COVID-19 . Symptoms- productive cough . Doxycycline 100 MG BID X7Days . McGeer criteria- Y (Yes) . Review of R159's progress notes documented the following: On 1/4/24 at 7:30 AM, a nurse's note documented in part . alert, verbal able to communicate needs, received awake in bed . no resp. (respiratory) distress noted. No c/o (complaints of) pain, scheduled medications given . swabbed for covid last night, tested positive . ordered to quarantine patient . On 1/8/24 at 10:12 PM, a nurse's note documented in part . Resident in bed . able to make needs known verbally . BP (blood pressure) 136/81, PR (pulse rate) 61, RR (respiration rate) 18, temp (temperature) 97.5 . 02 sat (oxygen saturation) 93% on RA (room air). Denied SOB (shortness of breath) or respiratory distress. No chest pain, nausea and vomiting . new order given for oral antibiotics . Further review of the medical record revealed no additional signs or symptoms documented or justification for the prescribed antibiotics. Review of January 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the administration of the doxycycline hyclate 100 mg and amoxicillin-pot clavulanate 875-125 mg medications administered twice a day from 1/8/24 until 1/15/24. R160 Review of the facility's Infection Control Form for February 2024, documented the following in part, . (R160's name) . Type of Infection- UTI (urinary tract infection) . Symptoms- nausea, vomiting, poor appetite, abdominal pain, + dipstick, leukocyte . Cultures 1/29- no growth . Cipro 250 MG BID x3 days . McGeer criteria Y (yes) . Review of a physician note dated 1/29/24 at 5:05 PM, documented in part . she had some nausea/vomiting earlier today-she says it is more gagging rather than vomiting, but still poor appetite . no chills, no runny nose, no sore throat, no body aches, no dysuria (pain with urination), UA (urinalysis) dip stick done today is positive for LE (leukocyte esterase), will give cipro 250 mg bid x 3 days-urine sent for UA/culture, she is awake and alert and visiting with family members. She apparently was having this nausea at the hospital . Review of the UA culture collected 1/29/24, documented the following results in part . Mixed genital flora isolated. These superficial bacteria are not indicative of a urinary tract infection. No further organism identification is warranted on this specimen . This did not meet the criteria of an UTI infection. On 4/23/24 at 3:23 PM, an interview was conducted with the facility's Infection Control Preventionist (ICP) B. ICP B confirmed the facility utilized McGeers criteria and was asked about the review of residents who admit to the facility from the hospital prescribed an antibiotic and why they were all documented as N/A in on the surveillance record, ICP B explained they don't review the resident prescribed antibiotics at the hospital because they usually come to the facility and finish the antibiotic in a few days and that is why N/A is documented. On 4/24/24 at 10:24 AM, a second interview was conducted with ICP B, and they were asked why R159 was prescribed Amoxicillin-pot clavulanate 875-125 mg (milligram) and Doxycycline 100 mg on January 8th, 2024, until 1/15/24? And why R160 was started on Cipro 250 mg, twice a day for three days for a urinary tract infection prophylactically when neither resident met criteria and the ICP B stated they would follow up on it. At 2:47 PM, the ICP B returned and stated they could not provide and explanation or documentation for R159's antibiotic administration, however provided the physician's note from 1/29/24, UA and culture results for R160. No further explanation or documentation was provided before the end of the survey.

This citation pertains to Intake Number MI 759. Based on observation, interview, and record review, the facility failed to prevent an unsupervised exit from the facility by one (R#801) of one resident reviewed for elopement who exhibited known wandering and exit seeking behaviors, had severely impaired cognition for decision making, a [MEDICAL CONDITION] (TBI), and was at risk for falls. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when R#801 exited the building through a door on the second floor, went down two flights of stairs, and walked approximately a half mile away from the facility. R#801 was found 45 minutes to an hour later lying on the ground near a busy road with unrestricted access to a frozen lake located across the street, in 25 degree Fahrenheit (F) weather, without a coat or hat. This placed the resident at risk of serious injury, serious harm, and/or death. Findings include: The IJ began on 12/16/20. The IJ was identified on 1/12/21. The Administrator was notified on 1/12/21 at 1:40 PM and a plan to remove the immediacy was requested. The immediacy was removed on 12/16/20 based on the facility's implementation of an acceptable plan of removal verified on-site by the surveyor on 1/13/21. Although the IJ was removed on 12/16/20, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy. A Facility Reported Incident (FRI) submitted to the State Agency documented R#801 eloped from the facility on 12/16/20. On 1/12/21 at approximately 10:30 AM, R#801 was observed in their room with a one-on-one sitter present. R#801 was observed standing from the chair and walking throughout the room. R#801 was moving a chair and table into a position to be interviewed. R#801 reported they did leave the facility to go for a stroll and stated, I went into the wrong dorm and couldn't get back. When asked for clarification, R#801 was unable to clearly express what he was trying to say. A review of R#801's clinical record was conducted and revealed the following: R#801 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#801 had a Brief Interview of Mental Status (BIMS) score of zero, which indicated they had severely impaired cognition. The MDS documented R#801 did not exhibit any behaviors including wandering and required limited physical assistance with ambulation. An investigation conducted by the facility was reviewed and revealed the following: An investigation summary documented, On 12/16/20 at 7:30am received a call from charge nurse that resident (R#801) was not in his room. Facility search was initiated. Staff also started a sweep of the facility grounds, parking lots, dumpsters, stores across the street, and apartment complexes. The administrator was notified, (city name redacted) police were notified. At around 8:03am staff member (initials of Nurse D) called and informed that resident was noted lying down on the ground, alert and oriented to his name .Police and ambulance personnel arrived on scene. The resident was taken to (hospital name redacted) Hospital for further evaluation .Staff interview and Missing resident investigation initiated. Per CNA (Certified Nursing Assistant) assigned, resident was first noted in his room at around 6:15 am as he was busy going through his belongings. Around 6:30am the resident was observed walking up and down the hallway, and he redirected to his room several times with some encouragement. He was last seen at around 7am. At around 7:20-7:30am breakfast tray was delivered to his room and the resident was not there. No alarms were triggered during this time period. At around 7:30am nurses were at the nursing station doing change of shift report/endorsement, they were informed by the CNA that resident was not in his room. The whole unit was searched and other staff in the building were notified of the missing resident (code orange was called). The searched <sic> was extended to the surrounding premises as noted above. During the interview with the resident after coming back from the ER, he verbalized that he did enter a code on the key pad, the light had turn <sic> green and he pushed the door open. He reports that he wanted to go out for a walk . Written statements from staff that were part of the facility's investigation were reviewed and revealed the following: A signed statement (undated) by Registered Nurse (RN) A documented, While giving report to incoming nurse around 0730 (7:30AM) at the nursing station, the Nursing assistant came into the nursing station and reported that she could not find the patient in (room number redacted) (R#801). The incoming Nurse and writer immediately rushed out of the nursing station and started searching for the patient in the unit including other patient's rooms without success. Staff from other units were notified and all staff joined in the search. The whole units and rooms in the facility were searched. The search extended to outdoor. The entire premises of the facility and surroundings were searched without success. DON (Director of Nursing) notified. At 0753 (7:53 AM) writer called 911 and reported the incidence. Around 0803 (8:03 AM) patient was noted outside of the facility. Thereafter pt was taken to hospital for evaluation . A signed statement dated 12/16/20 by CNA C documented, First time I saw him about 6:15 (AM), at that time he was busy with his clothes in his room. Around 6:30 (AM) I saw him walking up and down in the hallway. I redirected him to the room. He didn't want to come with me at that time so I said let's go to your room and talk to your son. Then he came. Then I gave some papers to him and asked him to find out his sons telephone number. Then he <sic> to go over that papers. The <sic> I lef <sic> his room and started to take BP (blood pressure) on resident when I was in (room number redacted), he came to that room, then I came back with him outside of the room and he directed him to his room and said 'wait over their <sic> till <sic> I come to help you to call your son' and started to take othe <sic> BP. It was around 7:00 am when I redirected him to his room. I had to pass breackfirst <sic> and I went to his room with his food around 7:20-7:30 (AM) he wasn't there. Then I cheked <sic> him other rooms and I couldn't <sic> find him. So I informed to my nurses. A signed statement dated 12/16/20 from Licensed Practical Nurse (LPN) D documented, After a couple minutes of receiving report from the midnight nurse, the CNA stated that (R#801) was not in his room. The midnight nurse and I jumped up and began to search the patient's room. When we realized he was not in his room and not in his bathroom, we began to search the other patients' rooms. As we searched the rooms other nurses from other units began to assist in the search. Once I realized the patient was not in the building, I began to search the outdoor grounds of the facility. I noticed someone looking as if they had found something seen (R#801) laying on the grass a few feet from the street. I called DON and informed her. The police officer placed an emergency rescue blanket on (R#801) and waited for EMS and the fire department to arrive before moving him. A signed statement (undated) from Sitter E documented, I am (R#801's) sitter and before (R#801) got out of (facility name) we would go for walks to the end of the hallway and then we would sit and chat. I notice then when people were punching the code in the key pad that (R#801) would watch. I am pretty sure that is how he got the code to get downstairs and out the emergency exit. On 1/12/21 at 11:05 AM, the DON was interviewed. When queried about which door R#801 exited the building through, the DON reported the resident exited through the second floor (2 South) stairwell doorway. An observation was made with the DON at that time. A fire door that required a code to be entered in order to open without an alarm sounding was observed at the end of the 2 South hallway. When queried about whether or not the alarm sounded when R#801 exited through that door, the DON reported the resident said he put the code in and left through that door and therefore the alarm would not have sounded. When queried about how the R#801 knew the code to the door, the DON reported that when she interviewed one of the resident's sitters (Sitter E) she said the resident would often sit at the end of the hallway and watch people go in and out of the door and probably memorized the code that way. The DON reported R#801 repeated the code verbally to her and it was correct. When queried about whether or not Sitter E notified anyone about R#801's fixation of people going in and out of the exit door, the DON reported that she did not think Sitter E identified it at an issue prior to R#801's elopement from the facility. On 1/12/21 at 11:15 AM, any camera footage from the 2 South unit from 12/16/20 was requested from the Assistant Administrator. On 1/12/21 at 11:33 AM, the Assistant Administrator reported there was no camera footage from the actual hallway and the stairwell camera footage was no longer available. The Assistant Administrator provided a picture of the camera video footage which is time stamped 12/16/20 at 7:13 AM. There is a man observed at the door that led to the outside of the facility who was identified by the Assistant Administrator as R#801. On 1/12/21 at 12:12 PM, an attempt to interview RN A via the telephone was made. RN A was not available for an interview prior to the end of the survey. On 1/12/21 at 12:18, an attempt to interview CNA B via the telephone was made. CNA B was not available for an interview prior to the end of the survey. On 1/12/21 at 12:48 PM, the DON was further interviewed regarding interventions that were in place for R#801 prior to the elopement and additional details of the facility's investigation. The DON reported R#801 had a one-to-one sitter from 8:00 AM until 8:00 PM prior to the elopement incident on 12/16/20. When queried about why R#801 had a sitter, the DON reported it was because he was a fall risk and stood up all the time unassisted. The DON was asked what interventions were in place when a sitter was not present and to address R#801's wandering, the DON stated, Keep an eye on him. When queried about who was assigned to R#801 on 12/16/20, the DON reported CNA C was the assigned aide and the nurses were giving report during shift change when the event occurred. The DON reported CNA C had noticed R#801 going through his belongings in his room and then R#801 was walking up and down the hall and showed up in another resident's room after CNA C brought R#801 back to his room. When queried about what CNA C should have done when R#801 required repeated redirection for wandering out of his room and to other resident's rooms, the DON reported the CNA should have notified the nurse or another staff member to watch R#801 if he was repeatedly wandering. When queried about what should have been done if R#801 made any statements or gestures that indicated he may be at risk for exiting the facility, the DON reported she should have been made aware and interventions should have been put in place. The DON was queried about the investigation conducted by the facility. When queried about who found R#801 outside of the building, the DON reported it was LPN D. When queried about the location where R#801 was found, the DON stated, It was less than a mile away on the street past the apartment complex located behind the facility. On 1/12/21 at 1:02 PM, an interview with CNA C was conducted via the telephone. When queried about what occurred with R#801 on 12/16/20, CNA C stated, He usually has a one to one (sitter) from an agency but didn't have one that day, so I had to watch him and also take care of other residents. He was up and down the hall repeatedly. He was going through his belongings in his room. I like him to try to stay in his room so I can take care of other residents, but he didn't want to stay in his room. He came to another resident's room, so I took him back to his room and gave him some papers to go through. When queried about whether anyone else working that shift was made aware of R#801's wandering behaviors that morning, CNA C stated, I think the nurses knew. CNA C reported she did not inform anyone prior to providing care to other residents. On 1/12/21 at 1:06 PM, LPN D was interviewed via the telephone. LPN D was queried about what occurred with R#801 on 12/16/20. LPN D reported that a CNA reported R#801 was missing during shift change. LPN D reported it was somewhere between 7:15 AM and 7:30 AM because she had arrived late to work that day. LPN D further reported they looked outside of the building for R#801 and went down the street. LPN D stated, I saw someone standing over something, looking down. It was a someone on a bike. I went down there, and it was (R#801) lying on the ground. When queried about where R#801 was located when he was found on the ground, LPN D reported the resident was at the corner of the street that ran east and west along the north side of the facility and the street that ran north and south parallel to the facility lying close to the road. It was reported R#801 was not wearing a coat or hat. When queried about any behaviors exhibited by R#801, LPN D reported R#801 wandered non-stop up and down the hallway and into other resident's rooms. LPN D stated, He sometimes stops at the end of the hallway and sits down to take a break. On 1/13/21 at approximately 8:00 AM, an observation was made of the location where R#801 was found on 12/16/20 as described by LPN D. The aforementioned corner was approximately one-half mile from the facility along two main roads (one going east and west and the other running north and south) and directly across the street was a frozen lake with unrestricted access (no barrier to prevent access to the lake). Further review of R#801's clinical record was conducted and revealed the following: A physician progress notes [REDACTED].Per nursing, the patient was up all night. He was walking up and down hall and has tried to enter other patient's rooms. At times he is difficult to redirect and becomes aggressive . A Nursing progress note dated 11/2/20 documented, .constantly getting out of chair, walking hallways and trying to enter other residents rooms . A Physician note dated 11/3/20 documented, .Per nursing, the patient was up at 2AM walking in the hall . Multiple progress notes from November 2020 document R#801 had a sitter. A progress note dated 12/2/20 documented R#801 was ambulating in the hallway multiple times. A progress note dated 12/5/20, written by RN F documented, Received sitting in chair. Alert oriented x1. confused and unaware of safety needs. attempts to stand and walk outside of his room. Able to redirect back to room. Requires frequent rounds .3:30 am noted patient up walking in the hallway. he states he wanted to go outside. Was only able to redirect back to the room upon after 2 walks around the hallway. And upon explaining that its 3 am and everything is closed at the moment. When back in the room, patient was not able to redirect back to sit in chair or lay back in bed .1:1 supervision given until patient was convinced to go back to sleep. frequent rounds will monitor . Care Plans for R#801 were reviewed and revealed the following: An ADL Functional/Rehabilitation care plan initiated on 10/25/20 documented, Resident has history of wandering r/t (related to) TBI due to motor vehicle accident. Interventions initiated on 11/15/20 (prior to the day R#801 eloped from the facility on 12/16/20) documented the following, .use verbal cues and gentle touch to redirect my exit-seeking behaviors .Allow me to call close family/ friends for reassurance when exit-seeking behaviors are occurring . A Wandering assessment dated [DATE] (admitted ) documented R#801 was disoriented, combative, and had a recent change of roommate. It was documented that R#801 was non-ambulatory but is able to wheel self around in wheelchair. No wandering was identified at that time. The assessment was not signed or dated when completed. A Wandering assessment dated [DATE] documented R#801 was oriented (Note: An MDS assessment on 11/2/20 documented R#801 had severely impaired cognition), does not understand surroundings, Does not understand what is being said, Ambulates with one assist, and Known wanderer/hx (history) of wandering. It was not checked that R#801 wandered aimlessly on the unit and there was no check mark next to the question that asked, Was a family member asked whether the resident has a hx of elopement or leaving without notice? A Psychiatric Consult dated 12/17/20 documented, .Per report (R#801) left the building secretly yesterday .He seemed to memorize the password of the exit door although he changed his elopement story .He seemed to look for exit . A Social Services progress note dated 12/16/20 documented, SW (social worker) spoke with the patient in his room upon his return from the hospital. Patient has 1:1. The patient stated he didn't know why he left the building this morning, he did not state a purpose for his departure. SW asked the patient if he would attempt to exit the building again and he stated, 'I might'. An ED (Emergency Department) Report dated 12/16/20 documented, .He was last seen by staff this morning at 7 AM. He was then found a half mile from (facility name redacted) .He was out in the cold therefore he was brought in to the ER for evaluation . A handwritten physicians order dated 11/5/20 was scanned into the electronic medical record for R#801 that documented, Sitter. 1:1 supervision for 12 hours per day. Dx (diagnosis): [MEDICAL CONDITION]. Incident reports for R#801 were reviewed and revealed R#801 had a fall in his room on 11/6/20. A review of weather history for the early morning of 12/16/20 in the city where the facility was located was conducted. It was noted that the temperature at that time was 25 degrees F. A facility policy titled, Elopements and Wandering Residents (Revised January 2021) was reviewed and documented, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .The facility is equipped with door locks/alarms to help avoid elopements .Adequate supervision will be provided to help prevent accidents or elopements .

Based on observation, interview, and record review, the facility failed to ensure licensed and/or registered nurses conducted assessments, administered medications (orally, intravenously, sucutaneously, and via PEG tube (Percutaneous Endoscopic Gastrostomy, a tube surgically inserted into the stomach to provide nutrition), administered wound treatments, provided PICC line (Peripheral Inserted Central Catheter, a tube inserted directly into a vein) care, and/or provided trachesostomy a surgical opening to provide direct airway through the windpipe) care and ventilator (a machine that helps a person breathe when they cannot breathe on their own) care for 19 (R#'s 10, 396, 398, 45, 23, 97, 397, 34, 20, 43, 5, 15, 44, 96, 14, 16, 19, 39, and 49) of 43 residents reviewed for staff qualifications, resulting in an Immediate Jeopardy (IJ) and the likelihood of serious injury, serious harm, and/or death due to the risk of worsening pressure ulcers, the development of new pressure ulcers, the development of wound infections, complications from [DEVICE], PEG tube complications, malfunction and/or dislodgement, PICC line complications and/or infection, and respiratory complications. Findings include: The IJ started on 4/27/19. The IJ was identified on 6/26/19 at 10:30 AM. The facility Administrator was notified of the IJ on 6/26/19 at 3:45 P.M. and a plan to remove the immediacy was requested. On 6/24/19 at approximately 10:00 A.M., during an initial screening of residents who resided in the facility, it was discovered R#10 did not reside in the room that was documented on the census provided by the facility or the room documented in the electronic medical record (EMR). Certified Nursing Assistant (CNA) Z reported that R#10 was moved to another room on the neuro unit (a unit that was not certified for long term care (LTC) residents). When queried about why R#10 was moved, CNA Z stated, He was moved after he came back from the hospital at the end of May. There is no alarm system for the ventilator on this side (long term care). The Director of Nursing (DON) was interviewed at approximately 11:00 A.M. on 6/24/19 and reported she had been the DON for about six weeks. When queried about R#10's room change, the DON reported he was moved because he was on a ventilator. When asked why a different room number was documented on the resident census and in the EMR, the DON did not offer an explanation. On 6/24/19 at 12:15 PM, R#10's room was observed to have signage that indicated R#10 was on contact isolation precautions. At that time, R#10 was observed in bed with family at the bedside. R#10 appeared to be in a vegetative state and was not responsive to verbal communication and only slightly tracked movement with his eyes. R#10 was observed to have a PICC line, [MEDICAL CONDITION], and was on mechanical ventilation . A tube feeding pump and pole were observed at the bedside and R#10 was observed to have a urinary catheter. A functioning [DEVICE] system was observed at the bedside with the drainage tubing observed to run from the pump and was attached to R#10's body. At that time, R#10's family was queried about the [DEVICE] system and they explained that R#10 had a pressure wound on his buttocks and that was why the [DEVICE] system was in place. On 6/24/19, an interview was conducted with CNA AA (a CNA assigned to the neuro unit). CNA AA reported the nurse assigned to R#10 was Nurse Tech A (A Nurse Technician is not a licensed or registered nurse in the State of Michigan. The facility referred to the Nurse Technicians as Nurse Techs. Hereinafter, Nurse Techs will be referred to as Unlicensed Personnel - ULP). On 6/24/19 at approximately 1:45 PM, an interview with ULP 'A' was conducted regarding her role in R#10's care. ULP 'A' explained that she assisted with R#10 and stated, I just help with repositioning him, changing him, and with other ADL's (activities of daily living). A review of R#10's clinical record revealed documentation from ULP A that indicated they had provided skilled nursing care to the resident. On 6/25/19 at 4:06 PM, a follow-up interview with ULP 'A' was conducted regarding their duties as a Nurse Tech. ULP 'A' stated, Since I passed my competencies I can take care of him (R#10) by myself. A list of all staff currently employed by the facility was reviewed and revealed five staff members who had titles of Nurse Technicians (ULP A, ULP B, ULP C, ULP D, and ULP E). Further review of R#10's clinical record revealed documentation from ULP B, and [NAME] that indicated they had provided skilled nursing care to the resident. Personnel files for ULPs A, B, C, D, and [NAME] were requested from the Director of Human Resources (DHR). At that time, the DHR was queried about the role of the Nurse Techs. The DHR reported they were currently enrolled in LPN (Licensed Practical Nurse) classes, but were not currently licensed nurses. The DHR reported there were competency evaluations that were completed for each Nurse Tech/ULP which according to the facility's policy allowed them to provide some nursing care under the supervision of a licensed nurse. Personnel files of ULPs A, B, C, D, and [NAME] were reviewed. The following was revealed: ULP A's personnel file revealed a Human Resources Employee File Checklist that documented the Position as Nurse Technician/ULP. The date hired section was left blank. An Application for Employment revealed no date or specific position applied for and was signed on 2/26/19 by ULP A. A resume documented ULP A had a Bachelors of Science in Nursing degree from a foreign country. There was no documented evidence of a nursing degree or license from the State of Michigan. A CNA certification dated 3/2/19 was present in the file. ULP A was not licensed to work as a nurse in the State of Michigan. ULP B was hired as a housekeeper on 9/24/14 and was hired as a CNA after completing the nurse aide course on 8/5/15. There was no evidence of a license to practice nursing in the State of Michigan (LPN or Registered Nurse - RN) for ULP B. ULP C was hired as a CNA in (YEAR). ULP C had a current CNA certification, but there was no evidence of a license to practice nursing in the State of Michigan. ULP D was hired as a CNA in (MONTH) (YEAR). ULP D was certified as a CNA on 5/15/15, but there was no evidence of a license to practice nursing in the State of Michigan. ULP [NAME] applied for an administrative assistant any clerical job position with the facility on 12/23/13. ULP E's application and resume listed past employment as a business partner for a clothing company and food cart business. Past employment did not document any nursing or health care positions. A degree in nursing from a foreign country was present in the file. However, there was no evidence of a license to practice nursing in the State of Michigan. On 6/25/19 at 3:35 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding the facility's utilization of Nurse Techs/ULPs. The DON reported the facility did not utilize Nurse Techs/ULP for LTC residents (on the SNF - Skilled Nursing Facility units) and was unaware that they were providing care on the SNF unit, as well as unaware the the ULPs had access to document in the Medication Administration Records (MARs), Treatment Administration Records (TARs), and progress notes in the electronic medical record (EMR). When queried about how it would be documented, if a licensed and/or registered nurse directly supervised a ULP who provided care or administered medications, the DON stated, There is no place in (EMR software name) for them to sign-off that they provided oversight. The DON was then queried about whose license the ULPs were [MEDICATION NAME] under and the DON explained that the ULP's work under the supervision of the nurse on the floor. The DON was then asked if the nurses remained with the ULP while they performed nursing duties such as wound care, feeding tube care, PICC line care, [MEDICAL CONDITION] care, ventilator care, and medication administration and stated, They don't stay with them for every task. When asked if the supervising nurse should remain with the ULP when they performed wound care treatments or assessed pressure ulcers and [DEVICE] (a type of therapy to help wounds heal with the use of a pump that decreases air pressure on the wounds and a tube for wound drainage), the DON had no response. On 6/25/19 at 4:12 PM, an interview with the facility's Administrator was conducted regarding the role of the Nurse Techs/ULP and their training. The Administrator explained that the facility employed five Nurse Techs/ULP, and of the five, one had graduated from a nursing program and was scheduled to take their licensure examination (ULP C) , two were still in a nursing program and had not graduated (ULP B and ULP D), and two ULPs (ULP 'A' and ULP E) had graduated from a nursing program in a foreign country, but were not licensed or registered to practice in the State of Michigan. When queried about the role of the ULPs, the Administrator stated, During their (one month) orientation they (ULPs) are directly supervised (by a licensed nurse) until they pass their competencies. Then, they can do things on their own and the nurse is more of a resource person they can go to for questions. The Techs (ULPs) are competent, but not licensed. The Administrator reported that ULPs only required direct supervision by a licensed nurse during the one month orientation period and after the month of direct supervision, they could work alone on things they were allowed to do with a small number of residents. The Administrator reported ULPs administered medications, conducted assessments, obtained vitals, and did simple wound care dressings. When queried about who performed PEG tube assessments, care of the PEG tube site, PEG tube placement verification, and medication administration through a PEG tube, the Administrator stated, We have the nurses do the PEG tubes. It was further explained by the Administrator that ULPs could not do anything with PEG tubes, PICC line care, or hanging IVs and that respiratory therapists (RTs) provided [MEDICAL CONDITION] and ventilator care. When queried about general assessment of residents, the Administrator reported ULPs could report any change in condition to the nurse and the nurse would document in the clinical record and notify the physician. When asked how the facility audited and ensured the nurses provided supervision to the ULPs, the Administrator stated, The charge nurses review the MARs and the orders to ensure they are being carried out properly. The Administrator reported the licensed and/or registered nurses should sign off on the MAR and/or TAR when care was provided and that the signature on the MAR and/or TAR represented the person who actually provided the care. Any evidence of a licensed or registered nurses's direct oversight of the ULPs was requested at that time and nothing was provided by the end of the survey. On 6/26/19 at approximately 9:00 A.M., the Administrator was further interviewed. The Administrator stated, I read the Michigan Public Health Code last night. I should have read it before. I made a mistake putting them (ULPs) on if it's going to jeopardize my survey. The only reason I did it was because the CNAs were begging me to work here. R#10 Further review of R#10's clinical record was conducted and revealed an initial admission date of [DATE], a transfer to the Emergency Department on 5/11/19, and a re-admission date of [DATE]. R#10's [DIAGNOSES REDACTED]. A review of R#10's most recent Minimum Data Set (MDS) assessment dated [DATE] was conducted and revealed #10 had severe cognitive impairment. R#10 was non-ambulatory and required extensive to total assistance with bed mobility, transferring, wheelchair mobility, dressing, eating, toilet use, personal hygiene, and bathing. R#10's MDS assessment also indicated R#10 had bilateral upper and lower extremity impairments and had the presence of a urinary catheter. A progress note written on 6/24/19 at 6:38 P.M. documented, .At around 1740 writer was informed by respiratory therapist that resident is experiencing jerking/facial twitching. Vitals stable, resident switched back to AC mode on vent, MD informed, assessed at bedside, [MEDICATION NAME] 2mg given at 1822, later order received to transfer resident to hospital for [MEDICAL CONDITION], 911 called, resident left facility around 1930 with respiratory therapist and MMRC vent machine, MD called ER for the report . It should be noted that R#10 did not return to the facility during the survey and therefore was unavailable for any further observations. Continued review of R#10's clinical record revealed that on 6/16/19, R#10's Braden Score (an assessment performed to measure a residents risk for developing pressure ulcers) was assessed by ULP 'E'. A review of R#10's physician's orders [REDACTED].#10's coccyx pressure ulcer every shift with special instructions that read, CLEANSE WITH NS (normal saline) MOISTEN ROLL GAUZE WITH DAKIN'S SOLUTION 0.25% WRING EXCESS FLUID PACK WOUND THEN COVER WITH DRY DRESSING THEN ABD (abdominal) PAD SECURE WITH TAPE . R#10's TAR's were reviewed and the following was discovered: On 4/27/19, 4/28/19, 5/5/19, 5/6/19, and 5/8/19 ULP 'E' signed off on the TAR that she had completed the coccyx treatment on the day shift and created a progress note that read, .Coccyx dressing with Dakin's solution done and spent 20 mins . On 5/10/19, ULP 'E' signed off on the TAR that she had completed the above coccyx treatment on the day shift. Further record review for R#10 was conducted and revealed that upon R#10's re-admission to the facility on [DATE] a [DEVICE] had been placed to his coccyx. A review of physician's treatment orders was conducted and revealed an order written [REDACTED].FEET/HEEL: Assess feet/heel IF ANY CHANGES WITH WOUND APPEARANCE (DTI)(deep tissue injury, A pressure-related injury to subcutaneous tissues under intact skin) OR OPEN AREA TO Notify physician of abnormal findings. (Document on the chart) . The assessment was noted to be signed off in the record by ULP 'A', ULP 'B', and ULP 'E' on the following days: 6/3/19 Day shift signed out by ULP 'E' 6/5/19 Day shift signed out by ULP 'A' 6/6/19 Day shift signed out by ULP 'A' 6/7/19 Day shift signed out by ULP 'E' 6/8/19 Day shift signed out by ULP 'E' 6/9/19 Day shift signed out by ULP 'B' 6/9/19 Night shift signed out by ULP 'E' 6/10/19 Day shift signed out by ULP 'A' 6/11/19 Night shift signed out by ULP 'B' 6/11/19 Day shift signed out by ULP 'A' 6/13/19 Day shift signed out by ULP 'E' 6/14/19 Day shift signed out by ULP 'A' 6/14/19 Night shift signed out by ULP 'E' 6/15/16 Day shift signed out by ULP 'B' 6/15/16 Night shift signed out by ULP 'E' 6/16/19 Day shift signed out by ULP 'B' 6/16/19 Night shift signed out by ULP 'E' 6/17/19 Day shift signed out by ULP 'A' 6/18/19 Day shift signed out by ULP 'A' 6/19/19 Day shift signed out by ULP 'E' 6/20/19 Day shift signed out by ULP 'A' 6/20/19 Night shift signed out by ULP 'B' 6/22/19 Day shift signed out by ULP 'E' 6/23/19 Day shift signed out by ULP 'B' A review of R#10's progress notes for (MONTH) 2019 was conducted and revealed the following: 6/5/19-A progress note by ULP 'A' that read, .Wound vac dressing still on and no issues noted . 6/6/19-A progress note by ULP 'A' that read, .Wound vac dressing still on and no issues noted . 6/10/19-A progress note by ULP 'A' that read, .Wound vac dressing still on and no issues noted . 6/11/19-A progress note by ULP 'B' that read, .wound vac: maintained cleanliness around site, trimmed soiled [MEDICATION NAME], (occlusive dressing) reapplied, and reinforced. Maintained vacuum seal and no leaks noted. Skin integrity around wound kept dry and skin intact . 6/15/19-A progress note by ULP 'B' that read, .Due medications administered and treatments/dressings completed .Maintained skin integrity. Wound vac intact . 6/16/19-A progress note by ULP 'B' that read, .Patient is on Ventilator .wound vac on coccyx area .Due medications administered and treatments/dressings completed . 6/21/19-A progress note by ULP 'B' that read, .treatments completed .Wound dressing/Vac intact in the buttocks/sacral region .noticed skin breakdown on right side of neck . 6/23/19-A progress note by ULP 'B' that read, .Treatments completed. Wound vac intact and functional. Trimmed soiled [MEDICATION NAME] around perimeter of wound, cleansed, applied new [MEDICATION NAME] and re-enforced . Continued review of R#10's clinical record was conducted and revealed that on 5/1/19, 5/5/19, 5/6/19, 5/8/19, and 5/10/19, ULP 'E' signed off in the TAR that they checked the placement of the PEG tube by aspirating stomach contents and flushed the PEG tube. On 5/1/19, 5/2/19, 5/5/19, and 5/8/19, ULP [NAME] started R#10's tube feeding. Further review of the record revealed a progress note written by ULP 'E' on 5/10/19 at 4:43 PM that documented, Patient has been having oxygen desaturation episodes early in the morning with observed distended abdomen. Stat lab results reveal abnormal labs . MD/NP (Nurse Practitioner) notified and ordered to send out to hospital. A review of R#10's History and Physical dated 5/11/19 from the Hospital physician documented the following, .Assessment/Plan .4. Malposition of PEG tube .GI: tube to be removed and [MEDICAL CONDITION] resolves will replace .Physical exam .Abdomen: .PEG tube site inspected, does not freely rotate .Diagnostic Results .Impression: .3. Gastrostomy tube with it's balloon and tip in the the left rectus muscle (abdominal muscle). Left rectus muscle is enlarged in this region . R#10 was readmitted into the facility on [DATE]. Further review of R#10's clinical record was conducted and included a review of R#10's physicians orders. The following was revealed: A tube feeding order for tube feeding formula to be started at 9:30 PM and finished at 2:30 AM. A review of the MAR documenting the 9:30 PM start of the tube feeding was conducted and revealed the tube feeding was started by ULP 'E' on 6/1/19, 6/8/19, 6/13/19, 6/14/19, 6/15/19 and 6/16/19. Continued review of the MAR showed that on 6/10/19 ULP 'B' started the feeding and on 6/20/19, ULP 'A' started the feeding. A tube feeding order dated 5/29/19 for tube feeding formula to be started three times a day scheduled for 8 AM, 2 PM, and 6 PM and a change to the order on 6/14/19 that indicated the formula was to be started 4 times a day, at 6 AM, 10 AM, 2 PM, and 6 PM. A review of the MAR documenting the start times of the tube feeding was conducted and revealed the following: 6/2/19 Formula started by ULP 'B' for all three administration times. 6/3/19 Formula started by ULP 'E' at 8 AM and 2 PM. 6/5/19 Formula started by ULP 'A' for all three administration times. 6/6/19 Formula started by ULP 'A' for all three administration times. 6/7/19 Formula started by ULP 'E' for all three administration times. 6/8/18 Formula started by ULP 'E' for all three administration times. 6/9/19 Formula started by ULP 'B' for all three administration times. 6/10/19 Formula started by ULP 'A' at 8 AM and 2 PM. 6/11/19 Formula started by ULP 'A' for all three administration times. 6/13/19 Formula started by ULP 'A' for all three administration times. 6/14/19 Formula started by ULP 'A' for all three administration times. 6/15/19 Formula started by ULP 'E' at 6 AM. 6/15/19 Formula started by ULP 'B' at 10 AM, 2 PM, and 6 PM. 6/16/19 Formula started by ULP 'E' at 6 AM. 6/16/19 Formula started by ULP 'B' at 10 AM, and 2 PM. 6/17/19 Formula started by ULP 'E' at 6 AM. 6/17/19 Formula started by ULP 'A' at 10 AM, 2 PM, and 6 PM. 6/18/19 Formula started by ULP 'A' at 10 AM, 2 PM, and 6 PM. 6/19/19 Formula started by ULP 'E' at 10 AM, 2 PM, and 6 PM. 6/20/19 Formula started by ULP 'A' at 10 AM, 2 PM, and 6 PM. 6/21/19 Formula started by ULP 'B' at 6 AM. 6/21/19 Formula started by ULP 'E' at 10 AM, 2 PM, and 6 PM. 6/22/19 Formula started by ULP 'E' at 10 AM, 2 PM, and 6 PM. 6/23/19 Formula started by ULP 'B' at 10 AM, 2 PM, and 6 PM. Continued review of R#10's physician's orders [REDACTED]. and an order that read, Enteral: PEG site care: Cleanse with NS (normal saline) pat dry, apply split sponge and secure with tape change daily. A review of R#10's TARs for the three orders was conducted and revealed the following: 6/3/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/5/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/6/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/7/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/8/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/9/11 Placement, monitoring, and site care documented as completed by ULP 'B' 6/10/11 Placement, monitoring, and site care documented as completed by ULP 'A' 6/11/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/13/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/14/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/15/19 Placement, monitoring, and site care documented as completed by ULP 'B' 6/16/19 Placement, monitoring, and site care documented as completed by ULP 'B' 6/17/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/18/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/19/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/20/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/21/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/22/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/23/19 Placement, monitoring, and site care documented as completed by ULP 'B' A physician's orders [REDACTED]. A review of R#10's TAR for (MONTH) 2019 was reviewed and it was noted that ULP 'E' signed out on the TAR that she had discontinued (removed) the PICC line. A review of R#10's progress notes was conducted and did not include any notes regarding the removal of the PICC line. Upon re-admission to the facility on [DATE], a physician's orders [REDACTED].#10's PICC line dressing was to be changed weekly. A review of the TAR for (MONTH) 2019 was conducted and it was discovered that the PICC line dressing change was performed by ULP 'E' on 6/9/19 and 6/16/19. A physician's orders [REDACTED].Flush PICC/IV Line with 10 ml (milliliters) NS (normal saline) before and after each medication administration and Q (every) shift then Apply Swab cap (Sterile cap) after each IV access . A review of R#10's TAR's was conducted and revealed the following: ULP 'E' documented on the TAR for PICC line care for 5/29/19 day shift, 6/1/19 night shift, 6/3/19 day shift, 6/7/19 day shift, 6/8/19 day shift, 6/8/19 night shift, 6/9/19 night shift, 6/13/19 night shift, 6/14/19 night shift, 6/15/19 night shift, 6/19/19 day shift, 6/21/19 day shift, and 6/22/19 day shift. ULP 'A' documented on the TAR for PICC line care for 6/5/19 days shift, 6/10/19 day shift, 6/11/19 day shift, 6/13/19 day shift, 6/14/19 day shift, 6/17/19 day shift, 6/18/19 day shift, and 6/20/19 day shift. ULP 'B' documented on the TAR for PICC line care for 6/9/19 day shift, 6/15/19 day shift, 6/16/19 day shift, 6/20/19 night shift, and 6/23/19 night shift. On 7/1/19 at 12:21 PM, an interview with the facility's Director of Nursing (DON) and Administrator was conducted regarding who could remove a PICC line. It was reported that only a Physician or an Advanced Practice Nurse such as a NP could remove a PICC line. When queried if it would be within the scope of practice for a ULP to remove a PICC line., The Administrator reported that ULPs should not remove PICC lines. When queried if there should have been a progress note in the record regarding a PICC removal, the Administrator indicated that if a Doctor or Advanced Practice Nurse removed the PICC line, they should have put a progress note in the record. The Administrator and DON were then queried if the facility's ULPs should be performing assessments and care of PICC lines and it was reported that either the licensed or registered nurses should have performed assessment and maintenance of the PICC line and signed it off on the TAR. A review of R#10's (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 MARs was conducted and revealed ULP 'E' signed off as having administered physician ordered medications for R#10 (including medications through a PEG tube, intravenous medications, eye drops, and inhaled medications through the [MEDICAL CONDITION]) on: 4/27/19, 4/28/19, 5/1/19, 5/5/19, 5/6/19, 5/8/19, 5/10/19, 5/31/19, 6/1/19, 6/3/19, 6/7/19, 6/8/19, 6/9/19, 6/13/19, 6/14/19, 6/15/19, 6/16/19, 6/19/19, 6/21/19 and 6/22/19. Continued review of R#10's MARs revealed ULP 'B' signed off as having administered medications to R#10 on: 6/2/19, 6/9/19, 6/10/19, 6/15/19, 6/16/19, and 6/23/19. Further review of R#10's MAR's documented that ULP 'A' signed off as having administered R#10's medications on: 6/5/19, 6/6/19, 6/10/19, 6/11/19, 6/13/19, 6/14/19, 6/17/19, 6/18/19, and 6/20/19. There was no documentation in R#10's clinical record that a licensed or registered nurse provided direct oversight for any of the above documented care and treatment. No documentation showing direct supervision or oversight by a licensed and/or registered nurse was provided prior to the end of the survey. Resident #396 On 6/25/19 at 1:53 PM, a review of R#396's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#396's MAR's for (MONTH) 2019 was reviewed and revealed R#396 ULP 'D' signed off as having administered R#396's medications on 6/22/19 and ULP 'B' signed off as having administered the medications on 6/25/19. Resident #398 On 6/25/19 at approximately 2:00 PM, a review of R#398's clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#398's MAR's for (MONTH) 2019 was conducted and revealed R#398 was administered physician ordered medications including an intravenous antibiotic and a narcotic pain medication signed off as given by ULP 'D' on 6/9/19 and 6/22/19. Continued review of R#398's MAR's revealed R#398 was administered physician ordered medications signed off as given by ULP 'B' on 6/25/19. Resident #45 On 7/1/19 at approximately 10:00 AM, a review of R#45's clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#45's MAR for (MONTH) 2019 and (MONTH) 2019 was conducted and revealed that R#45 received physician ordered medications signed off as given by ULP 'D' on 5/25/19 and 6/15/19, and received physician ordered medications signed off as given from ULP 'E' on 5/26/19. Resident #23 On 7/1/19 at approximately 10:10 AM, a review of R#23's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#23's MAR for (MONTH) 2019 and (MONTH) 2019 was conducted and revealed that ULP 'C' signed off the physician ordered medications as given on 5/22/19, 5/23/19 and 6/13/19. Further review revealed R#23 received physician ordered medications signed off as given from ULP 'D' on 5/29/19. Resident #97 On 7/1/19 at approximately 9:50 AM, a review of R#97's clinical record was conducted and revealed and admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#97's MAR for (MONTH) 2019 was conducted and revealed that ULP 'B' signed off the MAR as having administered R#97's medications (including a narcotic pain reliever and a controlled substance anti-anxiety medication) on 6/24/19 and 6/25/19. Further review of the MAR revealed that ULP 'D' signed off as having administered R#97's medications on 6/22/19. R#397 On 7/1/19 at approximately 11:00 AM, a review of R#397's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#397's MAR for (MONTH) 2019 was conducted and revealed that ULP 'D' signed out as having administered R#397's medications (including subcutaneous - into the skin) injections, controlled substances, and narcotic pain medications) on 6/22/19. Resident #34 On 7/1/19 the medical record for R#34 was reviewed and revealed the following: R#34 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#34's (MONTH) 2019 MAR revealed R#34 was administered Physician ordered medication by ULP B on 5/24/19, 5/30/19 and 5/31/19, and ULP D on 5/25/19. Review of R#34's (MONTH) 2019 MAR revealed R#34 was administered medication by ULP D on 6/15/19. Resident #20 On 7/1/19 the medical record for R#20 was reviewed and revealed the following: R#20 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#20's (MONTH) 2019 MAR revealed R#20 was administered Physician ordered medication by ULP C on 5/23/19 and 5/30/19 and had medication administered by ULP D on 5/29/19. Resident #43 On 7/1/19 the medical record for R#43 was reviewed and revealed the following: R#43 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#43's (MONTH) 2019 MAR revealed R#43 was administered Physician ordered medication by ULP C on 6/12/19 and 6/13/19, ULP B on 6/8/19 and ULP D on 6/9/19. Resident #5 On 7/1/19 the medical record for R#5 was reviewed and revealed R#5 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#5's (MONTH) 2019 MAR revealed R#5 was administered Physician ordered medications including a [MEDICATION NAME] injection (blood thinning medication) was documented as being administered (TRUNCATED)

Based on interview and record review, the facility failed to utilize its resources in an effective and efficient manner to ensure skilled nursing care was provided by licensed or registered nurses, resulting in an immediate jeopardy (IJ) when the facility administration hired and utilized unlicensed personnel to provide services of a licensed or registered nurse, including assessment of residents, wound care, PEG tube (Percutaneous Endoscopic Gastrostomy, a tube surgically inserted into the stomach to provide nutrition) care, medication administration, PICC line (Peripheral Inserted Central Catheter, a tube inserted directly into a vein) care, [MEDICAL CONDITION] (a surgical opening to provide direct airway through the windpipe) care, and ventilator (a machine that helps a person breathe when they cannot breathe on their own) care to 19 (R#'s 10, 396, 398, 45, 23, 97, 397, 34, 20, 43, 5, 15, 44, 96, 14, 16, 19, 39, and 49) of 43 residents reviewed for Administration. This had the likelihood to put all 19 residents at risk of serious injury, serious harm, and/or death. Findings include: The IJ started on 4/27/19. The IJ was identified on 6/26/19 at 10:30 AM. The facility Administrator was notified of the IJ on 6/26/19 at 3:45 P.M. and a plan to remove the immediacy was requested. During the annual survey, it was discovered that the facility utilized unlicensed personnel to provide services of a licensed or registered nurse and referred to those personnel as Nurse Techs (A Nurse Technician is not a licensed or registered nurse in the State of Michigan. Hereinafter, Nurse Techs will be referred to as Unlicensed Personnel - ULP). A list of all staff currently employed by the facility was reviewed and revealed five staff members who had titles of Nurse Technicians (ULP A, ULP B, ULP C, ULP D, and ULP E). Personnel files for ULPs A, B, C, D, and [NAME] were requested from the Director of Human Resources (DHR). At that time, the DHR was queried about the role of the Nurse Techs. The DHR reported they were currently enrolled in LPN (Licensed Practical Nurse) classes, but were not currently licensed nurses. The DHR reported there were competency evaluations that were completed for each Nurse Tech/ULP which according to the facility's policy allowed them to provide some nursing care under the supervision of a licensed nurse. Personnel files ULPs A, B, C, D, and [NAME] were reviewed. The following was revealed: ULP A's personnel file revealed a Human Resources Employee File Checklist that documented the Position as Nurse Technician. The date hired section was left blank. An Application for Employment revealed no date or specific position applied for and was signed on 2/26/19 by ULP A. A resume documented ULP A had a Bachelors of Science in Nursing degree from a foreign country. There was no documented evidence of a nursing degree or license from the State of Michigan. A CNA certification dated 3/2/19 was present in the file. ULP A was not licensed to work as a nurse in the State of Michigan. ULP B was hired as a housekeeper on 9/24/14 and was hired as a CNA after completing the nurse aide course on 8/5/15. There was no evidence of a license to practice nursing in the State of Michigan (LPN or Registered Nurse - RN) for ULP B. ULP C was hired as a CNA in (YEAR). ULP C had a current CNA certification, but there was no evidence of a license to practice nursing in the State of Michigan. ULP D was hired as a CNA in (MONTH) (YEAR). ULP D was certified as a CNA on 5/15/15, but there was no evidence of a license to practice nursing in the State of Michigan. ULP [NAME] applied for an administrative assistant any clerical job position with the facility on 12/23/13. ULP E's application and resume listed past employment as a business partner for a clothing company and food cart business. Past employment did not document any nursing or health care positions. A degree in nursing from a foreign country was present in the file. However, there was no evidence of a license to practice nursing in the State of Michigan. On 6/27/19 at 9:35 AM, the Director of Human Resources (DHR) was interviewed regarding the above Nurse Tech/ULP positions. The DHR reported that ULP D was hired on 6/29/15 as a CNA and was currently enrolled in LPN (Licensed Practical Nurse) classes. ULP B was hired as a housekeeper in (YEAR) and switched to a CNA position. When queried about when ULP B was transferred to the Nurse Tech (ULP) position, the DHR stated, It was a verbal transition and reported there was no documentation on file of the position transfer. The DHR reported ULP A was hired as a Nurse Tech (ULP) on 2/27/19, and an application was pending to take the National Council Licensure Examination (NCLEX - an examination taken after completing nursing school that is required to be licensed as a nurse, LPN or RN - Registered Nurse) and she was not currently licensed to practice as a nurse in the State of Michigan. (ULP E) was hired as an administrative assistant on 12/22/13 and transitioned to a Nurse Tech (ULP) position on 1/16/19 because she has a Bachelors in Nursing from (name of foreign country) and is working on an application for NCLEX. The DHR further stated that ULP [NAME] was not a CNA, but was a patient sitter because of her background. The DHR reported ULP C was hired on 9/13/17 as a CNA and was currently enrolled in LPN classes, but not currently licensed as a nurse. A review of the clinical records of all 43 residents who resided in the facility was conducted and revealed a total of 19 residents who received care from ULPs under the scope of practice of a licensed and/or registered nurse. R#s 10, 396, 398, 45, 23, 97, 397, 34, 20, 43, 5, 15, 44, 96, 14, 16, 19, 39, and 49 received physician ordered medications from ULPs A, B, C, D, and/or [NAME] between the dates of 4/27/2019 and 6/26/19 and one resident (R#10) received medications through a PEG tube, received PEG tube care, tube feeding administration, wound care (including a pressure ulcer with a [DEVICE] and a treatment requiring packing of the wound), PICC line care (including removal of the PICC line), [MEDICAL CONDITION] care, and ventilator care from ULP A, B, and E. A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for R#s 10, 396, 398, 45, 23, 97, 397, 34, 20, 43, 5, 15, 44, 96, 14, 16, 19, 39, and 49 between (MONTH) 2019 and (MONTH) 2019 was conducted and included initials from ULP A, ULP B, ULP C, ULP D, and ULP E. (Initials on the MAR or TAR indicated that person administered the medication, treatment, or care). On the last page of the MARs and TARs there was a key that matched the initials documented to the actual names of ULP A, B, C, D, and E. MARs, TARs and progress notes were reviewed from (MONTH) 2019 through (MONTH) 2019 and revealed medications were administered by ULPs for 19 residents. Five residents (R#s 5, 34, 97, 397, and 398) received controlled substances (including narcotic pain medications and anti-anxiety medications) from ULPs. Two residents (R#s 5 and 397) received subcutaneous (into the skin) injections administered by ULPs. Three residents (R#s 5, 15, and 44) received anticoagulant (blood thinners) injections by ULPs. One resident (R#10) received medications via a PEG tube, IV medications, eye drops, and inhaled medications via a [MEDICAL CONDITION], all signed off as administered by ULPs A, B, and E. In addition to medication administration, it was documented (either by initials on the MAR and/or TAR or a progress note signed by the respective ULP) that R#10 received the following care and/or treatment from ULPs: - Ventilator weaning trials (a process of decreasing the amount of support a patient receives from a mechanical ventilator, so the patient assumes a greater proportion of the ventilatory effort) provided by ULP A, B, and E. - [MEDICAL CONDITION] hygiene (a set of methods used to clear mucus and secretions from the airway), cough assistance, and suctioning provided by ULP A, B, and E. - Mechanical ventilation settings that included the lung volume, the respiratory rate, the ventilator mode, and the oxygen level was completed by ULP A, B, and E. - Braden Score (an assessment performed to measure a residents risk for developing pressure ulcers) was assessed by ULP 'E'. - Wound care, including wound packing of a coccyx wound was provided by ULP E. - Assessment of wounds were completed by ULP A, B, and E. - Care of a wound with a wound vac was provided by ULP B. - Tube feeding formula administration (including starting the tube feeding pump and hooking up to the PEG tube) was provided by ULP A, B, and E. - Placement, monitoring, and care of the PEG tube site was provided by ULP A, B, and E. - Discontinuation (removal) of a PICC line was completed by ULP E. - PICC line care (including flushing and dressing changes) were provided by ULP A, B, and E. On 6/26/19 at 10:59 AM, an interview with ULP 'A' was conducted. At that time, ULP 'A' was asked to confirm if the initials (ULP 'A's initials redacted) on the TAR were hers and she stated, Yes, those are my initials. On 6/25/19 at 3:35 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding the facility's utilization of Nurse Techs/ULP. The DON reported the facility did not utilize Nurse Techs/ULP for LTC residents (on the SNF - Skilled Nursing Facility units) and was unaware that they were, as well as unaware the the ULPs had access to document in the MARs, TARs, and progress notes in the electronic medical record (EMR). When queried about how it would be documented, if a licensed or registered nurse directly supervised a ULP who provided care or administered medications, the DON stated, There is no place in (EMR software name) for them to sign-off that they provided oversight. The DON was then queried about whose license the ULPs were [MEDICATION NAME] under and the DON explained that the ULPs work under the supervision of the nurse on the floor. The DON was then asked if the nurses remained with the ULP while they performed nursing duties such as wound care, feeding tube care, PICC line care, [MEDICAL CONDITION] care, ventilator care, and medication administration and stated, They don't stay with them for every task. When asked if the supervising nurse should remain with the ULP when they performed wound care treatments or assessed pressure ulcers and [DEVICE], the DON had no response. On 6/25/19 at 4:06 PM, a follow-up interview with ULP 'A' was conducted regarding their duties as a ULP. ULP 'A' was asked if they had a nurse supervising them when they provided care. ULP 'A' explained that while she was training to be a Nurse Tech, a nurse did follow her. ULP 'A' stated, Since I passed my competencies I can take care of him (R#10) by myself. On 6/25/19 at 4:12 PM, an interview with the facility's Administrator was conducted regarding the role of the Nurse Techs/ULP and their training. The Administrator explained that the facility employed five Nurse Techs/ULP, and of the five, one had graduated from a nursing program and was scheduled to take their licensure examination (ULP C) , two were still in a nursing program and had not graduated (ULP B and ULP D), and two ULPs (ULP 'A' and ULP E) had graduated from a nursing program in a foreign country, but were not licensed or registered to practice in the State of Michigan. When queried about the role of the ULPs, the Administrator stated, During their (one month) orientation they (ULPs) are directly supervised (by a licensed nurse) until they pass their competencies. Then, they can do things on their own and the nurse is more of a resource person they can go to for questions. The Techs (ULPs) are competent but not licensed. The Administrator reported that ULPs only required direct supervision by a licensed nurse during the one month orientation period and after the month of direct supervision, they could work alone on things they were allowed to do with a small number of residents. The Administrator reported ULPs administered medications, conducted assessments, obtained vitals, and did simple wound care dressings. When queried about who performed PEG tube assessments, care of the PEG tube site, PEG tube placement verification, and medication administration through a PEG tube, the Administrator stated, We have the nurses do the PEG tubes. It was further explained by the Administrator that ULPs could not do anything with PEG tubes, PICC line care, or hanging IVs and that respiratory therapists (RTs) provided [MEDICAL CONDITION] and ventilator care. When queried about general assessment of residents, the Administrator reported ULPs could report any change in condition to the nurse and the nurse would document in the clinical record and notify the physician. When asked how the facility audited and ensured the nurses provided supervision to the ULPs, the Administrator stated, The charge nurses review the MARs and the orders to ensure they are being carried out properly. The Administrator reported the licensed and registered nurses should sign off on the MAR and/or TAR when care was provided and that the signature on the MAR and/or TAR represented the person who actually provided the care. Any evidence of a licensed or registered nurses's direct oversight of the ULPs was requested at that time. Any evidence of a licensed or registered nurse directly overseeing the Nurse Techs care and treatment that was signed off as provided at that time. No evidence was received prior to the end of the survey. The Administrator was then queried about how it was decided the facility was going to employ Nurse Techs (ULP) for medication administration to residents who were receiving skilled care, and stated, I did some research online, but I couldn't find the Michigan Public Health Code. On 6/26/19 at approximately 9:00 A.M., the Administrator was further interviewed. The Administrator stated, I read the Michigan Public Health Code last night. I should have read it before. I made a mistake putting them on if it's going to jeopardize my survey. The only reason I did it was because the CNAs were begging me to work here. The State of Michigan website for nursing license verification was checked for ULPs A, B, C, D, and E. The search results revealed none of the five ULPs employed by the facility were licensed nurses in the State of Michigan. The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey. The immediacy was removed on 6/27/19 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the IJ was removed on 6/27/19, the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to all staff not yet being inserviced and sustained compliance has not been verified by the State Agency. The facility submitted the following plan of removal: F 835 Administration Abatement P[NAME] to Remove IJ Element #1: 5 Unlicensed (Nurse Tech/LPN) Nurses have been terminated effective 6/26/19. On 6/26/19 the 5 unlicensed nurses received notification of termination verbally by phone or in person done by the HR Director on 6/26/19 7:00 pm. A follow-up termination letter (written) sent via certified mail to the 5 un-licensed nurse and by email on 6/27/19 at 7:00 pm by the HR Manager. On 6/24/19, R # 10 was evaluated by attending physician around 5:45 pm because of twitching of left side of face, persistent despite [MEDICATION NAME]. He is a [AGE] year old male status [REDACTED]. He was sent to ER for diagnostic and management of twitching. Mother was at bedside during episode and transfer. On 6/26/19 at 5:00 pm, the following residents were seen and assessed namely Residents R#396, R#398, R#14, R#16, R#19, R#5, and R#43. R 396 - Patient with recurrent UTI with chronic foley due to urine retention/[MEDICAL CONDITION]; patient was seen on 6/26/19 was started on IV fluids. No untoward or adverse effects or reactions were observed or noted with regards to IV fluid administration or medication administration. No untoward effects were noted with regards to medication administration and nursing care. Care plan was updated and nursing staff was re-educated on IV fluid management and medication administration. R#398 - [AGE] year old male s/p amputation of left hallux and partial amputation of 2nd left digit toe, with [MEDICAL CONDITION]; on IV medication ( Cefipime). Patient has PICC line. Patient was assessed by NP on 6/24, 6/25. On 6/27 patient's wound was assessed by attending physician; wound was intact, No signs of [DIAGNOSES REDACTED] or dehiscence or infection. PICC line was evaluated, no signs of peri Picc line [DIAGNOSES REDACTED], no exudate nor expressible purulence. Picc working well. Due for dressing change by nurse on 6/27. Seen again on 6/30 by wound doctor; findings same. No untoward reaction or effects. NP assessed patient on 7/1 at 12:00 noon. IV cefipime to continue. PICC line was clean and dry ; no signs of infection; wound unchanged; daily wound care by nurse. Daily monitoring to continue. No untoward effects were noted with regards to medication administration and nursing care. Care plan was updated and nursing staff re-educated on PICC line care, wound care and medication administration. R#14 - She is a [AGE] year old female with [MEDICAL CONDITION] exacerbation due to HCAP, severe [MEDICAL CONDITION] EF of 20%, cardiac [DIAGNOSES REDACTED] and acute UTI. She was assessed by physician on 6/26 at 8:49 am and was started on [MEDICATION NAME] for acute UTI and increased [MEDICATION NAME] due to [MEDICAL CONDITION] exacerbation. She was again assessed on 6/28 at 9:51 am and patient was improving with no increasing [MEDICAL CONDITION] and no adverse effects with nursing care. At 14:58 patient developed chest pain and shortness of breath. Patient was sent out to ER because of chest pain and SOB. No untoward effects were noted with regards to medication administration or nursing care. Care plan was updated. Nursing staff was re-educated on medication administration. R#16 - Patient had sacral pressure ulcer Stage I - II upon readmission from the hospital. Patient was re-assessed on 6/28. And again on 6/30 for sacral pressure ulcer. Pressure sore improving. No untoward effects were noted in nursing care. Care plan was updated. Nursing staff was re-educated on medication administration and pressure ulcer care. R#19 - Patient had sacral pressure ulcer acquired in the hospital, stage 1 - 2. Patient was seen by wound doctor on. Nursing staff did daily wound care. He was discharged on [DATE] with skin in sacrum clean and dry. No untoward effects were noted in nursing care. Care plan was updated. Nursing staff was re-educated on medication administration and pressure ulcer care. R# 5 - Patient is being followed for hemothorax and pleural effusion secondary to MVC. Patient was assessed for any untoward effects of nursing care with medication administration on 6/26 at 13:31 by NP, and on 6/27 by attending physician at 17:33 and on 7/1 by NP at 11:35. No untoward effects were noted. Care plan was updated. Nursing staff was re-educated on medication administration and pressure ulcer care. R#43 - Patient has metabolic [MEDICAL CONDITION] and [DIAGNOSES REDACTED] and AKI secondary to [MEDICAL CONDITION]. Patient was assessed by NP on 6/26 at 13:00 , then by attending physician on 6/27 at 16:00 and on 7/1 at 11:46 by NP. No untoward effects were noted with regards to nursing care or medication administration. Care plan was updated. Nursing staff was re-educated on medication administration and pressure ulcer care. Element#2: On 6/26/19 at 8:00 am, all like residents were assessed by the physician and NP for any untoward or adverse effects or reactions related to the citation with no negative or adverse findings secondary to nursing care. R # (initials redacted) has peg tube, Stage IV pressure ulcer, Stage III ulcer in heel; and PICC line for IV antibiotics. Patient was assessed again on the 28th by NP; PICC line clean and dry; peg tube patent; skin around peg clean and dry. No untoward effects from nursing care were noted. Wound care doctor assessed patient for wounds. Wounds are stable; not acutely infected. On 6/26/19 at 6:00 pm, HR Director reviewed ALL Employee records for licensures. No employees were found without an active current Michigan licensure. Care plan was updated. Nursing staff was re-educated on medication administration, pressure ulcer care, wound care, peg tube care and PICC line care. No untoward effects were noted. Element #3: The facility policy for medication administration, Pe[DEVICE] Care, Ventilator/[MEDICAL CONDITION] and Respiratory Care, PICC Line Care, and Care for patients with wounds and Pressure Sores were reviewed and revised by the DON (Director of Nursing) and Medical Director on 6/26/19 at 7:00 pm. All nursing staff were in-serviced starting on 6/27/19 at 9:00 am to 6/30/19 at 5 pm. HR (Human Resources) Director conducted a full audit of all licensed staff. All licensed nursing staff (17) RNs, (12) LPNs, currently employed have active licensure in the State of Michigan. The Administrator on 6/26/19 at 10:00 pm, reviewed the Michigan Public Health Code and LARA State of Michigan Rules, and the facility policy for hiring licensed personnel. HR Director received a 1:1 re-education on Public Health Code LARA State of Michigan Requirements on 6/27/19 at 12:00 pm. All employee files and licenses were reviewed to ensure that their licenses are current; Nurses were re-educated on medication administration, IV fluid management, peg tube care, [MEDICAL CONDITION] care, suctioning, and wound care. Licenses will be monitored for renewal. Element #4: Starting on 6/27/19, daily audit were conducted by the DON/designee on licensed nurses on duty to ensure appropriate med pass, care and treatments are delivered according to the nursing standards of practice. Results will be reported by the HR Director to the monthly QAPI Committee meeting. The Administrator and DON will be responsible for sustained compliance.

Based on observation, interview, and record review, the facility failed to ensure the administration of medications by licensed personnel for 19 residents (R#'s 10, 396, 398, 45, 23, 97, 397, 34, 20, 43, 5, 15, 44, 96, 14, 16, 19, 39, and 49) of 43 residents reviewed for medication administration, resulting in an immediate jeopardy (IJ) and the likelihood for medication administration complications, serious injury, harm, and/or death. Findings include: The IJ started on 4/27/19. The IJ was identified on 6/26/19 at 10:30 AM. The facility Administrator was notified of the IJ on 6/26/19 at 3:45 P.M. and a plan to remove the immediacy was requested. Resident #10 On 6/24/19 at 12:15 PM, R#10's room was observed to have signage that indicated R#10 was on contact isolation precautions. At that time, R#10 was observed in bed with family at the bedside. R#10 appeared to be in a vegetative state and was not responsive to verbal communication and only slightly tracked movement with his eyes. R#10 was observed to have a PICC line (Peripheral Inserted Central Catheter, a tube inserted directly into a vein), [MEDICAL CONDITION] (a surgical opening to provide direct airway through the windpipe), and was on mechanical ventilation (a machine that helps a person breathe when they cannot breathe on their own). A tube feeding pump and pole were observed at the bedside and R#10 was observed to have a urinary catheter. A functioning [DEVICE] system was observed at the bedside with the drainage tubing observed to run from the pump and be attached to R#10's body. On 6/24/19, an interview was conducted with CNA AA. CNA AA reported the nurse assigned to R#10 was Nurse Tech A (A Nurse Technician is not a licensed or registered nurse in the State of Michigan. The facility referred to the Nurse Technicians as Nurse Techs. Hereinafter, Nurse Techs will be referred to as Unlicensed Personnel - ULP). On 6/24/19 at approximately 1:45 PM, an interview with ULP 'A' was conducted. ULP A reported she had the ability to document in the residents' medical records and could access the Medication Administration Record (MAR) or Treatment Administration Record (TAR). A review of R#10's clinical record was conducted and revealed an initial admission date of [DATE], a transfer to the Emergency Department on 5/11/19, and a re-admission date of [DATE]. R#10's [DIAGNOSES REDACTED]. A review of R#10's most recent Minimum Data Set (MDS) assessment dated [DATE] was conducted and revealed severe cognitive impairment and extensive to total assistance of one to two staff members for all activities of daily living. A review of R#10's (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 MARs was conducted and revealed ULP 'E' signed off as having administered physician ordered medications for R#10 (including medications through a PEG tube, intravenous medications, eye drops, and inhaled medications through the [MEDICAL CONDITION]) on: 4/27/19, 4/28/19, 5/1/19, 5/5/19, 5/6/19, 5/8/19, 5/10/19, 5/31/19, 6/1/19, 6/3/19, 6/7/19, 6/8/19, 6/9/19, 6/13/19, 6/14/19, 6/15/19, 6/16/19, 6/19/19, 6/21/19 and 6/22/19. ULP 'B' signed off as having administered medications to R#10 on: 6/2/19, 6/9/19, 6/10/19, 6/15/19, 6/16/19, and 6/23/19. ULP Tech 'A' signed off as having administered R#10's medications on: 6/5/19, 6/6/19, 6/10/19, 6/11/19, 6/13/19, 6/14/19, 6/17/19, 6/18/19, and 6/20/19. On 6/25/19 at 4:06 PM, a follow-up interview with ULP 'A' was conducted regarding their duties as a Nurse Tech (ULP). ULP 'A' was asked if they had a licensed or registered nurse supervising them when they provided care. ULP 'A' explained that while she was training to be a Nurse Tech (ULP), a nurse did follow her. ULP 'A' stated, Since I passed my competencies I can take care of him (R#10) by myself. On 6/26/19 at 10:59 AM, another follow-up interview with ULP 'A' was conducted. At that time, ULP 'A' was asked to confirm if the initials (ULP 'A's initials redacted) on the MAR were hers and she stated, Yes, those are my initials. On 6/25/19 at 3:35 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding the facility's utilization of Nurse Techs/ULP. The DON reported the facility did not utilize Nurse Techs/ULP for LTC residents (on the SNF - Skilled Nursing Facility units) and was unaware that they were, as well as unaware the the ULPs had access to document in the MARs, TARs, and progress notes in the electronic medical record (EMR). When queried about how it would be documented, if a licensed or registered nurse directly supervised a ULP who administered medications, the DON stated, There is no place in (EMR software name) for them to sign-off that they provided oversight. The DON was then queried about whose license the ULPs were [MEDICATION NAME] under and the DON explained that the ULPs work under the supervision of the nurse on the floor. On 6/25/19 at 4:12 PM, an interview with the facility's Administrator was conducted regarding the role of the Nurse Techs/ULP and their training. The Administrator explained that the facility employed five Nurse Techs/ULP, and of the five, one had graduated from a nursing program and was scheduled to take their licensure examination (ULP C) , two were still in a nursing program and had not graduated (ULP B and ULP D), and two ULPs (ULP 'A' and ULP E) had graduated from a nursing program in a foreign country, but were not licensed or registered to practice in the State of Michigan. When queried about the role of the ULPs, the Administrator stated, During their (one month) orientation they (ULPs) are directly supervised (by a licensed nurse) until they pass their competencies. Then, they can do things on their own and the nurse is more of a resource person they can go to for questions. The Techs (ULPs) are competent but not licensed. The Administrator reported that ULPs only required direct supervision by a licensed nurse during the one month orientation period and after the month of direct supervision, they could work alone on things they were allowed to do with a small number of residents. The Administrator reported ULPs administered medications. When asked how the facility audited and ensured the nurses provided supervision to the ULPs, the Administrator stated, The charge nurses review the MARs and the orders to ensure they are being carried out properly. The Administrator reported the licensed and registered nurses should sign off on the MAR and/or TAR when care was provided and that the signature on the MAR and/or TAR represented the person who actually provided the care. Any evidence of a licensed or registered nurses's direct oversight of the ULPs was requested at that time and was not provided by the end of the survey. The Administrator was then queried about how it was decided the facility was going to employ Nurse Techs (ULP) for medication administration to residents who were receiving skilled care, and stated, I did some research online, but I couldn't find the Michigan Public Health Code. A clinical record review was conducted for all 43 residents who resided in the facility at the time of survey and it revealed that a total of 19 residents (including R#10) were administered medications by a ULP documented, as follows: R#396 On 6/25/19 at 1:53 PM, a review of R#396's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#396's MAR's for (MONTH) 2019 was reviewed and revealed R#396 ULP 'D' signed off as having administered R#396's medications on 6/22/19 and ULP 'B' signed off as having administered the medications on 6/25/19. R#398 On 6/25/19 at approximately 2:00 PM, a review of R#398's clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#398's MAR's for (MONTH) 2019 was conducted and revealed R#398 was administered physician ordered medications including an intravenous antibiotic and a narcotic pain medication signed off as given by ULP 'D' on 6/9/19 and 6/22/19. Continued review of R#398's MAR's revealed R#398 was administered physician ordered medications signed off as given by ULP 'B' on 6/25/19. R#45 On 7/1/19 at approximately 10:00 AM, a review of R#45's clinical record was conducted and revealed an admission date of [DATE] and a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#45's MAR for (MONTH) 2019 and (MONTH) 2019 was conducted and revealed that R#45 received physician ordered medications signed off as given by ULP 'D' on 5/25/19 and 6/15/19, and received physician ordered medications signed off as given from ULP 'E' on 5/26/19. R#23 On 7/1/19 at approximately 10:10 AM, a review of R#23's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#23's MAR for (MONTH) 2019 and (MONTH) 2019 was conducted and revealed that ULP 'C' signed off the physician ordered medications as given on 5/22/19, 5/23/19 and 6/13/19. Further review revealed R#23 received physician ordered medications signed off as given from ULP 'D' on 5/29/19. Resident #97 On 7/1/19 at approximately 9:50 AM, a review of R#97's clinical record was conducted and revealed and admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#97's MAR for (MONTH) 2019 was conducted and revealed that ULP 'B' signed off the MAR as having administered R#97's medications (including a narcotic pain reliever and a controlled substance anti-anxiety medication) on 6/24/19 and 6/25/19. Further review of the MAR revealed that ULP 'D' signed off as having administered R#97's medications on 6/22/19. R#397 On 7/1/19 at approximately 11:00 AM, a review of R#397's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of R#397's MAR for (MONTH) 2019 was conducted and revealed that ULP 'D' signed out as having administered R#397's medications (including subcutaneous - into the skin) injections, controlled substances, and narcotic pain medications) on 6/22/19. R#34 On 7/1/19 the medical record for R#34 was reviewed and revealed the following: R#34 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#34's (MONTH) 2019 MAR revealed R#34 was administered Physician ordered medication by ULP B on 5/24/19, 5/30/19 and 5/31/19, and ULP D on 5/25/19. Review of R#34's (MONTH) 2019 MAR revealed R#34 was administered medication by ULP D on 6/15/19. R#20 On 7/1/19 the medical record for R#20 was reviewed and revealed the following: R#20 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#20's (MONTH) 2019 MAR revealed R#20 was administered Physician ordered medication by ULP C on 5/23/19 and 5/30/19 and had medication administered by ULP D on 5/29/19. R#43 On 7/1/19 the medical record for R#43 was reviewed and revealed the following: R#43 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#43's (MONTH) 2019 MAR revealed R#43 was administered Physician ordered medication by ULP C on 6/12/19 and 6/13/19, ULP B on 6/8/19 and ULP D on 6/9/19. R#5 On 7/1/19 the medical record for R#5 was reviewed and revealed R#5 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#5's (MONTH) 2019 MAR revealed R#5 was administered Physician ordered medications including a [MEDICATION NAME] injection (blood thinning medication) was documented as being administered by ULP 'C', and unlicensed staff person. A Review of R#5's (MONTH) 2019 MAR revealed R#5 was administered physician ordered medications including controlled substances, subcutaneous injections by ULP C on 6/5/19 and 6/6/19. ULP 'D' signed off as having administered R#5's physician ordered medications on 6/9/19. R#15 On 7/1/19 the medical record for R#15 was reviewed and revealed R#15 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#15's (MONTH) 2019 MAR revealed R#15 was administered Physician ordered medications including subcutaneous injections on 5/25/19 and 6/15/19 by an unlicensed personnel, ULP 'D'. On 5/26/19 and 5/30/19. ULP 'B' signed off as having administered R#15's medications including subcutaneous injections, nebulizer treatments on 5/26/19 and 5/30/19. R#44 On 7/1/19 the medical record for R#44 was reviewed and revealed R#44 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#44's (MONTH) 2019 MAR revealed R#44 was administered Physician ordered medications including an anticoagulant (blood thinner) injection by an unlicensed personnel, ULP 'C' on 6/12/19 and 6/20/19. Further review of R#44's (MONTH) 2019 MAR revealed ULP 'B' administered physician ordered medications including and anticoagulant injection on 6/20/19 and 6/22/19. R#96 On 7/1/19 the medical record for R#96 was reviewed and revealed R#96 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#96's (MONTH) 2019 MAR revealed R#96 was administered physician ordered medications by ULP 'D' on 6/22/19 and ULP B on 6/25/19. R#14 On 6/24/19 at 11:45 a.m., the medical record for R#14 was reviewed and revealed the following: R#14 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of R#14's (MONTH) MAR revealed R#14 was administered Physician ordered medication by ULP D on 6/1/19, 6/2/19, 6/8/19, and 6/12/19; ULP C on 6/12/19 and 6/21/19; and ULP B on 6/22/19. R#16 On 6/24/19 at 2:35 p.m., the medical record for R#16 was reviewed and revealed the following: R#16 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of R#16's MARs revealed R#16 was administered Physician ordered medications by ULP B on 6/24/19 and 6/25/19. R#19 On 6/25/19 at 3:00 p.m., the medical record for R#19 was reviewed and revealed the following: R#19 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of R#19's MARs revealed Physician ordered medications were administered by ULP C on 5/27/19, 6/11/19, 6/12/19, and 6/21/19; and ULP D on 6/1/19, and 6/8/19. R#39 On 6/24/19 at 10:50 a.m., the medical record for R#39 was reviewed and revealed the following: R#39 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#39's MARs revealed physician ordered medications were administered by ULP D on 6/8/19; ULP C on 6/12/19 and 6/21/19; and ULP B on 6/22/19. R#49 On 6/27/19 at 3:30 p.m., the medical record for R#49 was reviewed and revealed the following: R#49 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#49's MARs revealed physician ordered medications were administered by ULP C on 6/1/19; and ULP B on 6/24/19. A review of a facility provided document titled Nurse Technician Policy with a revision date of (MONTH) (YEAR) was reviewed and read, A nurse technician is a student in a licensed practical nursing program or registered nursing program who has completed the program and is preparing for the licensing examination .Nurse Technician Duties and Responsibilities .Gives direct patient care, such as bathing, dressing, and feeding patients, and assisting in examinations and treatments .Requirements .Must be presently enrolled in an accredited school of nursing program .Have completed or graduating from a Licensed Practical Nursing program and awaiting licensure . A review of a second facility provided policy titled, Medication Administration with a revision date of (MONTH) 2019 was reviewed and read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state (emphasis added) . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey. The immediacy was removed on 6/27/19 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the IJ was removed on 6/27/19, the facility remained out of compliance at a scope of widespread and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to all staff not yet being inserviced and sustained complaiance has not been verified by the State Agency. The facility submitted the following plan of removal: F 755 Medication Administration Unlicensed Nurse Abatement Plan to Remove IJ Element #1: 5 Unlicensed (Nurse Tech/LPN) Nurses have been terminated effective 6/26/19. On 6/26/19 the 5 unlicensed nurses received notification of termination verbally by phone or in person done by the HR Director on 6/26/19 7:00 pm. A follow-up termination letter (written) sent via certified mail to the 5 un-licensed nurse and by email on 6/27/19 at 7:00 pm by the HR Manager. On 6/26/19 at 5:00 pm, Residents R#386, R#14, R#16, R#19, R#5, R#43 and R 398 were examined by the physician for evaluation and no untoward or adverse effects or reactions were observed or noted. R#10 was admitted to the hospital on [DATE] for [DIAGNOSES REDACTED]. Resident will receive physical evaluation upon his return. Element#2: On 6/27/19 at 8:00 am, all like residents were assessed by the licensed nurses for any untoward or adverse effects or reactions related to the citation with no negative findings were found. On 6/26/19 at 6:00 pm, HR Director reviewed ALL Employee records for licensures. No employees were found without an active current Michigan licensure. Element #3: The facility policy for medication administration, Pe[DEVICE] Care, Ventilator/[MEDICAL CONDITION] and Respiratory Care, PICC Line Care, and Care for patients with Pressure Sore was reviewed and revised by the DON (Director of Nursing) and Medical Director on 6/27/19 at 5:00 pm. 14 RN & 12 LPNS (14/14 & 12/12) employees received an in-service started on 6/27/19 at 5:00 pm, and will continue to in-service all licensed nursing staff before returning to work. HR (Human Resources) Director conducted a full audit of all licensed staff. All licensed nursing staff (14) RN, (14) LPN, currently employed have active licensure in the State of Michigan. The Administrator on 6/27/19 at 10:00 pm, reviewed the Michigan Public Health Code and LARA State of Michigan Rules, and the facility policy for hiring licensed personnel. HR Director received a 1:1 re-education on Public Health Code LARA State of Michigan Requirements on 6/27/19 at 12:00 pm. Element #4: Starting on 6/27/19 at 7 :00 am, daily audit were conducted by the DON/designee on licensed nurses on duty to ensure appropriate med pass, care and treatments are delivered according to the nursing standards of practice. Results will be reported by the HR Director to the monthly QAPI Committee meeting. The Administrator and DON will be responsible for sustained compliance.

This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to ensure respiratory treatment and services including, nebulizer treatments, [MEDICAL CONDITION] hygiene, chest physical therapy, cough assistance, [MEDICAL CONDITION] suctioning, ventilator weaning, and assessment of ventilator settings, by licensed personnel for one resident, (R#10) of two residents reviewed for respiratory treatment and services, resulting in an immediate jeopardy (IJ) and the likelihood for respiratory complications, serious injury, harm, and or death. Findings include: The IJ started on 6/1/19. The IJ was identified on 6/26/19 at 10:30 AM. The facility Administrator was notified of the IJ on 6/26/19 at 3:45 P.M. and a plan to remove the immediacy was requested. On 6/24/19 at approximately 10:00 A.M., during an initial screening of residents who resided in the facility, it was discovered R#10 did not reside in the room that was documented on the census provided by the facility or the room documented in the electronic medical record (EMR). Certified Nursing Assistant (CNA) Z reported that R#10 was moved to another room on the neuro unit (a unit that was not certified for long term care - LTC residents). When queried about why R#10 was moved, CNA Z stated, He was moved after he came back from the hospital at the end of May. There is no alarm system for the ventilator on this side (long term care). The Director of Nursing (DON) was interviewed at approximately 11:00 A.M. on 6/24/19 and reported she had been the DON for about six weeks. When queried about R#10's room change, the DON reported he was moved because he was on a ventilator. When asked why a different room number was documented on the resident census and in the EMR, the DON did not offer an explanation. On 6/24/19 at 12:15 PM, R#10's room was observed to have signage that indicated R#10 was on contact isolation precautions. At that time, R#10 was observed in bed with family at the bedside. R#10 appeared to be in a vegetative state and was not responsive to verbal communication and only slightly tracked movement with his eyes. R#10 was observed to have a PICC line, [MEDICAL CONDITION], and was on mechanical ventilation . A tube feeding pump and pole were observed at the bedside and R#10 was observed to have a urinary catheter. A functioning [DEVICE] system was observed at the bedside with the drainage tubing observed to run from the pump and be attached to R#10's body. At that time, R#10's family was queried about the [DEVICE] system and they explained that R#10 had a pressure wound on his buttocks and that was why the [DEVICE] system was in place. On 6/24/19, an interview was conducted with CNA AA (a CNA assigned to the neuro unit). CNA AA reported the nurse assigned to R#10 was Nurse Tech A (A Nurse Technician is not a licensed or registered nurse in the State of Michigan. The facility referred to the Nurse Technicians as Nurse Techs. Hereinafter, Nurse Techs will be referred to as Unlicensed Personnel - ULP). On 6/24/19 at approximately 1:45 PM, an interview with ULP 'A' was conducted regarding her role in R#10's care. ULP 'A' explained that she assisted with R#10 and stated, I just help with repositioning him, changing him, and with other ADL's (activities of daily living). A review of R#10's clinical record revealed documentation from ULP A, B, and [NAME] that indicated they had provided skilled nursing care to the resident. On 6/25/19 at 4:06 PM, a follow-up interview with ULP 'A' was conducted regarding their duties as a Nurse Tech. ULP 'A' stated, Since I passed my competencies I can take care of him (R#10) by myself. ULP 'A' reported she had the ability to document in R#10's (and other residents') medical records and could access the Medication Administration Record (MAR) or Treatment Administration Record (TAR). A review of R#10's clinical record was conducted and revealed an initial admission date of [DATE], a transfer to the Emergency Department on 5/11/19, and a re-admission date of [DATE]. R#10's [DIAGNOSES REDACTED]. A review of R#10's most recent Minimum Data Set (MDS) assessment dated [DATE] was conducted and revealed a Brief Interview for Mental Status score of 0/15 indicating severe cognitive impairment. R#10 was non-ambulatory and required extensive to total assistance with bed mobility, transferring, wheelchair mobility, dressing, eating, toilet use, personal hygiene, and bathing. R#10's MDS assessment also indicated R#10 had bilateral upper and lower extremity impairments and had the presence of a urinary catheter. A progress note written on 6/24/19 at 6:38 P.M. documented, .At around 1740 writer was informed by respiratory therapist that resident (R#10) is experiencing jerking/facial twitching. Vitals stable, resident switched back to AC mode on vent, MD informed, assessed at bedside, [MEDICATION NAME] 2mg given at 1822, later order received to transfer resident to hospital for [MEDICAL CONDITION], 911 called, resident left facility around 1930 with respiratory therapist and MMRC vent machine, MD called ER for the report . R#10 did not return to the facility during the survey and therefore was unavailable for any further observations. A review of R#10's physician's orders [REDACTED]. The following was discovered during the review: A physician's orders [REDACTED].#10 was to have ventilator weaning trials (a process of decreasing the amount of support a patient receives from a mechanical ventilator, so the patient assumes a greater proportion of the ventilatory effort) every shift. The (MONTH) 2019 administration records revealed that the weaning was documented as being completed by ULP 'A' on 6/11/19, 6/13/19, 6/14/19, 6/17/19, 6/18/19, and 6/20/19. ULP 'B' signed off as completing the weaning trials on 6/15/19, 6/16/19, and 6/23/19. Further review of the (MONTH) administration record revealed the weaning was signed off as being completed by ULP 'E' on 6/19/19, 6/21/19, and 6/22/19. A physician's orders [REDACTED]. The (MONTH) 2019 administration record for R#10 revealed the [MEDICAL CONDITION] hygiene, cough assistance, suctioning, and nebulized medication administration was documented as being completed by ULP 'A' on 6/5/19, 6/6/19, 6/10/19, 6/11/19, 6/13/19, 6/14/19, 6/17/19, 6/18/19, and 6/20/19. The [MEDICAL CONDITION] hygiene, cough assistance, and suctioning was documented as being completed by ULP 'B' on 6/2/19, 6/9/19, 6/10/19, 6/11/19, 6/15/19, 6/16/19, 6/21/19, and 6/23/19. Further review of the (MONTH) 2019 administration record revealed the [MEDICAL CONDITION] hygiene, cough assistance, suctioning, and nebulized medication administration was documented as being completed by ULP 'E' on 6/1/19, 6/2/19, 6/3/19/ 6/7/19, 6/8/19, 6/9/19, 6/10/19, 6/13/19, 6/14/19, 6/15/19, 6/16/19, 6/17/19, 6/19/19, 6/21/19, and 6/22/19. A physician's orders [REDACTED]. The (MONTH) administration records revealed the ventilator settings were signed off by ULP 'A' on 6/5/19, 6/6/19, 6/10/19, 6/11/19, 6/13/19, 6/14/19, 6/17/19, 6/18/19, and 6/20/19. The ventilator settings were signed off by ULP 'B' on 6/9/19, 6/10/19, 6/15/19, 6/16/19, 6/20/19, and 6/23/19. Further review of the (MONTH) 2019 administration record revealed the ventilator settings were signed off as being completed by ULP 'E' on 6/1/19, 6/3/19/ 6/7/19, 6/8/19, 6/9/19, 6/13/19, 6/14/19, 6/15/19, 6/16/19, 6/19/19, 6/21/19, and 6/22/19. On 6/25/19 at 3:35 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding the facility's utilization of Nurse Techs. When queried if a Licensed or Registered Nurse should be documenting that they were supervising the Nurse Techs with their performance of nursing tasks, the DON stated, There is no place in (EMAR software name) for them to sign-off that they provided oversight. The DON was then queried about whose license the ULPs were [MEDICATION NAME] under and the DON explained that the ULPs work under the supervision of the nurse on the floor. The DON was then asked if the nurses remain with the ULPs while they are performing nursing duties such as checking ventilator settings, suctioning, chest physical therapy, or administration of nebulized medications, and the DON stated, They don't stay with them for every task. When queried if the supervising nurse should remain with the ULP when they are performing nursing assessments, treatments, or administration of medications, the DON had no response. On 6/26/19 at 10:59 AM, a follow-up interview with ULP 'A' was conducted. At that time, ULP 'A' was asked to confirm if the initials (ULP 'A's initials redacted) on the MAR and TAR were hers and she stated, Yes, those are my initials. On 6/25/19 at 4:12 PM, an interview with the facility's Administrator was conducted regarding the role of the Nurse Techs and their training. The Administrator explained that the facility employed five Nurse Techs, and of the five, one had graduated from a nursing program and was scheduled to take their licensure, two were still in a nursing program and had not graduated, and another Nurse Tech (Nurse Tech 'A') had graduated from a nursing program in a foreign country but was not licensed or registered to practice in the country or state. When queried about the supervision the licensed and registered nurses provided, the Administrator stated, During their orientation they are directly supervised until they pass their competencies then they can do things on their own, then the nurse is more of a resource person they can go to for questions. The Techs are competent but not licensed. The Administrator was then queried about the assignments for the Nurse Techs and explained that a Nurse Tech is paired with a nurse and takes four to six of the nurses assigned residents and the nurse takes the rest of the residents. When asked how the facility audits and ensures the nurses are providing the supervision to the Nurse Techs the Administrator stated, The charge nurses review the MAR's (medication administration records) and the orders to ensure they are being carried out properly. On 6/25/19 at 4:12 PM, an interview with the facility's Administrator was conducted regarding the role of the Nurse Techs/ULP and their training. The Administrator explained that the facility employed five Nurse Techs/ULP, and of the five, one had graduated from a nursing program and was scheduled to take their licensure examination (ULP C) , two were still in a nursing program and had not graduated (ULP B and ULP D), and two ULPs (ULP 'A' and ULP E) had graduated from a nursing program in a foreign country, but were not licensed or registered to practice in the State of Michigan. When queried about the role of the ULPs, the Administrator stated, During their (one month) orientation they (ULPs) are directly supervised (by a licensed nurse) until they pass their competencies. Then, they can do things on their own and the nurse is more of a resource person they can go to for questions. The Techs (ULPs) are competent but not licensed. The Administrator reported that ULPs only required direct supervision by a licensed nurse during the one month orientation period and after the month of direct supervision, they could work alone on things they were allowed to do with a small number of residents. The Administrator reported ULPs administered medications, conducted assessments, obtained vitals, and did simple wound care dressings. When queried about who performed PEG tube assessments, care of the PEG tube site, PEG tube placement verification, and medication administration through a PEG tube, the Administrator stated, We have the nurses do the PEG tubes. It was further explained by the Administrator that ULPs could not do anything with PEG tubes, PICC line care, or hanging IVs and that respiratory therapists (RTs) provided [MEDICAL CONDITION] and ventilator care. When queried about general assessment of residents, the Administrator reported ULPs could report any change in condition to the nurse and the nurse would document in the clinical record and notify the physician. When asked how the facility audited and ensured the nurses provided supervision to the ULPs, the Administrator stated, The charge nurses review the MARs and the orders to ensure they are being carried out properly. The Administrator reported the licensed and registered nurses should sign off on the MAR and/or TAR when care was provided and that the signature on the MAR and/or TAR represented the person who actually provided the care. Any evidence of a licensed or registered nurses' direct oversight of the ULPs was requested at that time and was not received by the end of the survey. The State of Michigan website for nursing license verification was checked for ULPs A, B, C, D, and E. The search results revealed none of the five ULPs employed by the facility were licensed nurses in the State of Michigan. A review of a facility provided document titled Nurse Technician Policy with a revision date of (MONTH) (YEAR) was reviewed and read, A nurse technician is a student in a licensed practical nursing program or registered nursing program who has completed the program and is preparing for the licensing examination .Nurse Technician Duties and Responsibilities .Gives direct patient care, such as bathing, dressing, and feeding patients, and assisting in examinations and treatments .Requirements .Must be presently enrolled in an accredited school of nursing program .Have completed or graduating from a Licensed Practical Nursing program and awaiting licensure . It was noted the Nurse Technician policy did not address whether a Nurse Technician was able to perform assessments. A review of a second facility provided policy titled, Adult Ventilator Protocols dated 1/2018 was reviewed and read, Policy: The MD and/or RCP (Respiratory Care Practitioner) shall determine ventilator settings .Due to their intimate role with the patient, RN (Registered Nurse) and LPN's (Licensed Practical Nurse) shall be relied upon to provide clinical and observational data upon which such changes might be determined .Scope: These mechanical ventilation policies and procedures transcend the solely physician driven approach to include the entire critical care team: incorporating, to some degree, all members: physicians(MD), Respiratory care practitioners (RCP) and registered Nurse or LPN (Licensed Practical Nurse) . A review of a third facility provided, untitled policy, with an effective date of 11/2018 was reviewed and read, I. SUBJECT: Weaning from Mechanical Ventilation. II. PURPOSE: To assure consistent and safe weaning of ventilator-dependent patients. III. SKILL LEVEL: Respiratory Care Specialist . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey. The immediacy was removed on 6/27/19 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the IJ was removed on 6/27/19, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to all staff not yet being in-serviced and sustained compliance has not been verified by the State Agency. The facility submitted the following plan of removal: F 695 Vent/Trache Respiratory Care Abatement Plan to Remove IJ Element #1: R#10 was admitted to the hospital on [DATE] for [DIAGNOSES REDACTED]. 5 Unlicensed (Nurse Tech/LPN) Nurses have been terminated effective 6/26/19. On 6/26/19 the 5 unlicensed nurses received notification of termination verbally by phone or in person on 6/26/19 7:00 pm. A follow-up termination letter (written) sent via certified mail to the 5 un-licensed nurse and by phone on 6/27/19 at 7:00 pm. Element#2: On 6/26/19 at 6:00 pm, there are no other resident identified requiring ventilator and [MEDICAL CONDITION] assessment and care. Resident #10 will receive physical evaluation from the attending physician upon his return. HR Director reviewed ALL Employee records for licensures. As of 6/26/19 at 7:00 pm, all employees requiring licensure were found with an active licensure from the State of Michigan LARA. Element #3: The facility policy for Medication Administration, Ventilator and [MEDICAL CONDITION] Care and Hiring Licensed Nursing Personnel were reviewed by the DON (Director of Nursing) on 6/27/19 at 12:00 noon. HR (Human Resources) Director and was deemed appropriate. ALL licensed nursing staff must have active licensure in the State of Michigan. The Administrator reviewed facility policy for hiring licensed personnel. All employees requiring licensure received an inservice 6/27/2019 - 5pm (14) RN, (12) LPN and will continue to in-service all licensed staff before returning to work. Element #4: Starting 6/27/17 at 8:00 am, a daily audit will be conducted by the DON on licensed nurses on duty to ensure appropriate med pass, Ventilator and [MEDICAL CONDITION] care, and respiratory treatments are delivered. HR Director reviewed all Employee records for licensures. Results will be reported by the HR Director monthly to the QAPI Committee meeting. The Administrator and DON will be responsible for sustained compliance. Deficient Practice #2 Based on observation, interview and record review, the facility failed to clean and maintain exterior filters on the oxygen concentrator, for one (R#14) of two residents reviewed for respiratory therapy, resulting in the potential of improper air flow and respiratory distress. Findings Include: On 6/24/19 at 10:02 a.m., R#14 was observed in bed resting watching television. There was an oxygen concentrator turned on at 2 lpm (liters per minute). The filter in the back of the concentrator was dusty on both sides with lint, and there was no date on any parts (nasal tubing or humidifier water bottle) of the concentrator to determine when the filter had last been cleaned. The medical record was reviewed and revealed R#14 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the Minimum Data Set ((MDS) dated [DATE] revealed R#14's Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating intact cognition and required extensive assistance with one to two-person physical assist for ADL care. The MDS indicated R#14 received oxygen therapy while a resident at the facility. A physician's orders [REDACTED]. On O2 (oxygen) @ (at) 2L/m via (passing through) nc (nasal cannula) prn (as needed) for sob (shortness of breath)/desat (desaturation) Once A Day PRN . On 6/25/19 at 8:50 a.m., R#14 was sitting in a wheelchair with oxygen turned on at 2 lpm. The filter in the concentrator was still dusty with lint. On 6/25/19 at 9:18 a.m., during an interview, when asked who was responsible for the maintenance of R#14's oxygen concentrator, Certified Nurse Assistant (CNA) 'V' stated, Respiratory Therapy. On 6/25/19 at 4:35p.m., an interview was conducted with Respiratory Therapist (RT) 'W' and RT 'X'. When queried who was responsible for maintenance of the oxygen concentrators, RT 'X' stated, We all are responsible and share the duties of maintenance. At that same time, RT 'W' stated, If it's broken, we tell maintenance and they do the repairs. We change the tubing every week (on Saturday or Sunday). It depends on if we are busy on Saturday, then we do it Sunday. When asked who is responsible for ensuring the filters on the concentrators are cleaned, RT 'W' stated, We do those too. If they are dirty, we wash them or replace them. When asked about the nasal tubing and humidifier water bottles, RT 'W' stated, We don't date them (tubing). We were dating them, but they (Director of Nursing - DON) told us not to date them, since we change them every week . At that same time, when queried which respiratory therapist was responsible for cleaning the filters on R#14's oxygen concentrator, both RTs 'W' and 'X' did not know if either had clean/change the filters on R#14's oxygen concentrator. On 6/25/19 at 5:08 p.m., during an interview, when asked about the responsibilities of the respiratory therapists for the facility's oxygen concentrators, the DON stated, They are here 24 hours and they are supposed to do all the respiratory stuff. A review of the facility's policy titled Oxygen Concentrator revised (MONTH) 2019 documented the following: Policy: To administer oxygen for the treatment of [REDACTED]. Policy Explanation and Compliance Guideline: The maintenance department, or oxygen concentrator supplier, assists with the maintenance of oxygen concentrators as needed . 1. Care of the Resident- a. Obtain physician's orders [REDACTED].) . j. Cannulas and masks should be changed weekly or as necessary . 2. Care of the Concentrator - Document in the resident's clinical record. a. Wash filters weekly and as needed. b. Change tubing weekly. c. Change humidifier bottle every seventy-two hours or as recommended by maker .

Based on observation, interview, and record review, the facility failed to ensure licensed personnel provided PICC (peripherally inserted central catheter-a type of intravenous access that is inserted in a smaller vein in the upper arm and terminates in a larger vein in the chest near the heart) line assessment, care, dressing changes, and removal for one resident, (R#10) of one resident reviewed for PICC lines, resulting in the likelihood for PICC line complications, serious harm, injury and or death. Findings include: The IJ started on 4/27/19. The IJ was identified on 6/26/19 at 10:30 AM. The facility Administrator was notified of the IJ on 6/26/19 at 3:45 P.M. and a plan to remove the immediacy was requested. On 6/24/19 at approximately 10:00 AM, during an initial screening of residents who resided in the facility, it was discovered R#10 did not reside in the room that was documented on the census provided by the facility or the room documented in the electronic medical record (EMR). Certified Nursing Assistant (CNA) Z reported that R#10 was moved to another room on the neuro unit (a unit that was not certified for long term care (LTC) residents). On 6/24/19 at 12:15 PM, R#10's room was observed to have signage that indicated R#10 was on contact isolation precautions. At that time, R#10 was observed in bed with family at the bedside. R#10 appeared to be in a vegetative state and was not responsive to verbal communication and only slightly tracked movement with his eyes. R#10 was observed to have a low air loss mattress in place and bilateral soft heel pressure reducing boots on his feet. R#10 was observed to have a PICC (peripherally inserted central catheter intravenous access) in their left arm, [MEDICAL CONDITION], and was on mechanical ventilation. A tube feeding pump and pole were observed at the bedside and R#10 was observed to have a urinary catheter. On 6/24/19, an interview was conducted with CNA AA. CNA AA reported the nurse assigned to R#10 was Nurse Tech A (A Nurse Technician is not a licensed or registered nurse in the State of Michigan. The facility referred to the Nurse Technicians as Nurse Techs. Hereinafter, Nurse Techs will be referred to as Unlicensed Personnel - ULP). A list of all staff currently employed by the facility was reviewed and revealed five staff members who had titles of Nurse Technicians (ULP A, ULP B, ULP C, ULP D, and ULP E). A review of R#10's clinical record was conducted and revealed an initial admission date of [DATE], a transfer to the Emergency Department on 5/11/19, and a re-admission date of [DATE]. R#10's [DIAGNOSES REDACTED]. A review of R#10's most recent Minimum Data Set (MDS) assessment dated [DATE] was conducted and revealed a Brief Interview for Mental Status score of 0/15 that indicated severe cognitive impairment. R#10 was non-ambulatory and required extensive to total assistance with bed mobility, transferring, wheelchair mobility, dressing, eating, toilet use, personal hygiene, and bathing. R#10's MDS assessment also indicated R#10 had bilateral upper and lower extremity impairments and had the presence of a urinary catheter. A review of R#10's physician's orders [REDACTED]. A review of R#10's Treatment Administration Record (TAR) for (MONTH) 2019 was reviewed and it was noted that ULP 'E' signed out on the TAR that she had discontinued (removed) the PICC line. A review of R#10's progress notes was conducted and did not include any notes regarding the removal of the PICC line. Further review of R#10's clinical record was conducted and revealed that upon re-admission to the facility on [DATE] a physician's orders [REDACTED].#10's PICC line dressing was to be changed weekly. A review of the TAR for (MONTH) 2019 was conducted and it was discovered that the PICC line dressing change was performed by ULP 'E' on 6/9/19 and 6/16/19. Continued review of R#10's physician's orders [REDACTED].Flush PICC/IV Line with 10 ml (milliliters) NS (normal saline) before and after each medication administration and Q (every) shift then Apply Swab cap (Sterile cap) after each IV access . A review of R#10's TAR's was conducted and revealed the following: ULP 'E' documented on the TAR for PICC line care for 5/29/19 day shift, 6/1/19 night shift, 6/3/19 day shift, 6/7/19 day shift, 6/8/19 day shift, 6/8/19 night shift, 6/9/19 night shift, 6/13/19 night shift, 6/14/19 night shift, 6/15/19 night shift, 6/19/19 day shift, 6/21/19 day shift, and 6/22/19 day shift. ULP 'A' documented on the TAR for PICC line care for 6/5/19 days shift, 6/10/19 day shift, 6/11/19 day shift, 6/13/19 day shift, 6/14/19 day shift, 6/17/19 day shift, 6/18/19 day shift, and 6/20/19 day shift. ULP 'B' documented on the TAR for PICC line care for 6/9/19 day shift, 6/15/19 day shift, 6/16/19 day shift, 6/20/19 night shift, and 6/23/19 night shift. On 6/25/19 at 4:12 PM, an interview with the facility's Administrator was conducted regarding the role of the Nurse Techs/ULP and their training. The Administrator explained that the facility employed five Nurse Techs/ULP, and of the five, one had graduated from a nursing program and was scheduled to take their licensure examination (ULP C), two were still in a nursing program and had not graduated (ULP B and ULP D), and two ULPs (ULP A and ULP E) had graduated from a nursing program in a foreign country, but were not licensed or registered to practice in the State of Michigan. When queried about the role of the ULPs, the Administrator stated, During their (one month) orientation they (ULPs) are directly supervised (by a licensed nurse) until they pass their competencies. Then, they can do things on their own and the nurse is more of a resource person they can go to for questions. The Techs (ULPs) are competent, but not licensed. The Administrator reported that ULPs only required direct supervision by a licensed nurse during the one month orientation period and after the month of direct supervision, they could work alone on things they were allowed to do with a small number of residents. The Administrator reported ULPs administered medications, conducted assessments, obtained vitals, and did simple wound care dressings. When queried about who performed PEG tube assessments, care of the PEG tube site, PEG tube placement verification, and medication administration through a PEG tube, the Administrator stated, We have the nurses do the PEG tubes. It was further explained by the Administrator that ULPs could not do anything with PEG tubes, PICC line care, or hanging IVs and that respiratory therapists (RTs) provided [MEDICAL CONDITION] and ventilator care. When queried about general assessment of residents, the Administrator reported ULPs could report any change in condition to the nurse and the nurse would document in the clinical record and notify the physician. When asked how the facility audited and ensured the nurses provided supervision to the ULPs, the Administrator stated, The charge nurses review the MARs and the orders to ensure they are being carried out properly. The Administrator reported the licensed and/or registered nurses should sign off on the MAR and/or TAR when care was provided and that the signature on the MAR and/or TAR represented the person who actually provided the care. Any evidence of a licensed or registered nurses' direct oversight of the ULPs was requested at that time. The State of Michigan website for nursing license verification was checked for ULPs A, B, C, D, and E. The search results revealed none of the five ULPs employed by the facility were licensed nurses in the State of Michigan. On 7/1/19 at 12:21 PM, an interview with the facility's Director of Nursing (DON) and Administrator was conducted regarding who could remove a PICC line. It was reported that only a Physician or an Advanced Practice Nurse such as a Nurse Practitioner could remove a PICC line. When queried if it would be within the scope of practice for a Staff Nurse or a ULP to remove a PICC line, it was reported that it would not be. When queried if there should have been a progress note in the record regarding a PICC removal, the Administrator indicated that if a Doctor or Advanced Practice Nurse removed the PICC line, they should have put a progress note in the record. The Administrator and DON were then queried if the facility's ULPs should be performing assessments and care of PICC lines and it was reported that either the licensed or registered nurses should be performing assessment and maintenance of the PICC line and signing it off on the TAR. A review of a facility provided document titled, Nurse Technician Policy dated (MONTH) (YEAR) was reviewed. The policy described nurse technician duties and responsibilities and it was noted that policy did not address assessment, care, or maintenance of PICC lines. A review of two additional facility provided policies titled Policy and Procedure for PICC line or Midline Catheter Dressing Change revised 1/2019 and Flushing the PICC Line revised 1/2019 was conducted, however; the policies did not address which staff members were qualified for the assessment, care, maintenance, or removal of a PICC line. The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey. The immediacy was removed on 6/27/19 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the IJ was removed on 6/27/19, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to all staff not yet being inserviced and sustained compliance has not been verified by the State Agency. The facility submitted the following plan of removal: F 694 [MEDICATION NAME] Fluids (PICC) Plan to Remove IJ-Abatement Element #1: R#10 was admitted to the hospital on [DATE] for [DIAGNOSES REDACTED]. R# 398 PICC Line was assessed by a physician 6/27/19 at 3:00 pm and 6/30/19 by wound care,and 7/1/19 examined by NP with no apparent negative findings. Care Plan was reviewed and daily nursing PICC Line assessment and care were documented by a licensed nurse. 5 Unlicensed (Nurse Tech/LPN) Nurses have been terminated effective 6/26/19. On 6/26/19 the 5 unlicensed nurses received notification of termination verbally by phone or in person on 6/26/19 7:00 pm. A follow-up termination letter (written) sent via certified mail to the 5 un-licensed nurse and by phone on 6/27/19 at 7:00 pm. Element#2: R#10 was admitted to the hospital on [DATE] for [DIAGNOSES REDACTED]. There are no residents requiring PICC line other than R#10 and R#398 at this time. Resident #10 will receive PICC line assessment/evaluation by the attending physician, nursing assessment and care plan review upon his return from the hospital. Element #3: The facility policy for PICC Line Care was reviewed and revised by the DON (Director of Nursing) and Medical Director on 6/26/19 at 5:00 pm. HR (Human Resources) Director conducted a full audit of all licensed staff. All licensed nursing staff (14/14) RN, (12/12) LPN, currently employed have active licensure in the State of Michigan. The Administrator on 6/26/19, reviewed the Michigan Public Health Code and LARA State of Michigan Rules, and the facility policy for hiring licensed personnel. HR Director will receive a 1:1 re-education on Public Health Code LARA State of Michigan Requirements. 14/14 RN & 12/12 LPNS (26/26) employees requiring licensure received an in-service and re education started on 6/27/19 9am to 6/30/19 5pm on Medication Administration, PICC line Care, Wound Care, Trache/Vent. Care. Care plan updated Element #4: HR Director reviewed all Employee records for licensures. No other current employees were found without an active current Michigan licensure. Daily Audit will be conducted by the DON on licensed nurses on duty to ensure appropriate care for PICC Line is delivered according to the standards of practice. Results will be reported by the HR Director and DON to the monthly QAPI Committee meeting. The Administrator and DON will be responsible for sustained compliance.

Based on observation, interview, and record review, the facility failed to ensure PEG (percutaneous endoscopic gastrostomy-a tube passed through the abdominal wall and into the stomach and used for nutrition) tube assessment, care, placement confirmation, and enteral feedings were performed by licensed personnel for one resident (R#10) of one resident reviewed for PEG tubes, resulting in an immediate jeopardy (IJ) and the likelihood for PEG tube complications, malfunction, dislodgement, serious injury, harm, and or death. Findings include: The IJ started on 5/1/19. The IJ was identified on 6/26/19 at 10:30 AM. The facility Administrator was notified of the IJ on 6/26/19 at 3:45 P.M. and a plan to remove the immediacy was requested. On 6/24/19 at approximately 10:00 AM, during an initial screening of residents who resided in the facility, it was discovered R#10 did not reside in the room that was documented on the census provided by the facility or the room documented in the electronic medical record (EMR). Certified Nursing Assistant (CNA) Z reported that R#10 was moved to another room on the neuro unit (a unit that was not certified for long term care (LTC) residents). On 6/24/19 at 12:15 PM, R#10's room was observed to have signage that indicated R#10 was on contact isolation precautions. At that time, R#10 was observed in bed with family at the bedside. R#10 appeared to be in a vegetative state and was not responsive to verbal communication and only slightly tracked movement with his eyes. R#10 was observed to have a low air loss mattress in place and bilateral soft heel pressure reducing boots on his feet. R#10 was observed to have a PICC (peripherally inserted central catheter for intravenous infusion) line, PEG tube, indwelling urinary catheter, [DEVICE], [MEDICAL CONDITION], and was on mechanical ventilation. A tube feeding pump and pole were observed at the bedside. On 6/24/19, an interview was conducted with CNA AA. CNA AA reported the nurse assigned to R#10 was Nurse Tech A (A Nurse Technician is not a licensed or registered nurse in the State of Michigan. The facility referred to the Nurse Technicians as Nurse Techs. Hereinafter, Nurse Techs will be referred to as Unlicensed Personnel - ULP). On 6/24/19 at approximately 1:45 PM, an interview with ULP 'A' was conducted regarding her role in R#10's care. ULP 'A' explained that she assisted with R#10 and stated, I just help with repositioning him, changing him, and with other ADL's (activities of daily living). A review of R#10's clinical record revealed documentation from ULP A, B, and [NAME] that indicated they had provided wound care and wound assessment to R#10. On 6/25/19 at 3:35 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding the facility's utilization of Nurse Techs/ULP. The DON reported the facility did not utilize Nurse Techs/ULP for LTC residents (on the SNF - Skilled Nursing Facility units) and was unaware that they were, as well as unaware the the ULPs had access to document in the MARs, TARs, and progress notes in the electronic medical record (EMR). When queried about how care and treatment would be documented, if a licensed or registered nurse directly supervised a ULP, the DON stated, There is no place in (EMR software name) for them to sign-off that they provided oversight. The DON was then queried about whose license the ULPs were [MEDICATION NAME] under and the DON explained that the ULPs work under the supervision of the nurse on the floor. The DON was then asked if the nurses remained with the ULP while they performed nursing duties such as PEG tube care and stated, They don't stay with them for every task. When asked if the supervising nurse should remain with the ULP when they performed PEG tube care, the DON had no response. On 6/25/19 at 4:12 PM, an interview with the facility's Administrator was conducted regarding the role of the Nurse Techs/ULP and their training. The Administrator explained that the facility employed five Nurse Techs/ULP, and of the five, one had graduated from a nursing program and was scheduled to take their licensure examination (ULP C) , two were still in a nursing program and had not graduated (ULP B and ULP D), and two ULPs (ULP 'A' and ULP E) had graduated from a nursing program in a foreign country, but were not licensed or registered to practice in the State of Michigan. When queried about the role of the ULPs, the Administrator stated, During their (one month) orientation they (ULPs) are directly supervised (by a licensed nurse) until they pass their competencies. Then, they can do things on their own and the nurse is more of a resource person they can go to for questions. The Techs (ULPs) are competent but not licensed. The Administrator reported that ULPs only required direct supervision by a licensed nurse during the one month orientation period and after the month of direct supervision, they could work alone on things they were allowed to do with a small number of residents. The Administrator reported ULPs administered medications, conducted assessments, obtained vitals, and did simple wound care dressings. When queried about who performed PEG tube assessments, care of the PEG tube site, PEG tube placement verification, and medication administration through a PEG tube, the Administrator stated, We have the nurses do the PEG tubes. It was further explained by the Administrator that ULPs could not do anything with PEG tubes, PICC line care, or hanging IVs and that respiratory therapists (RTs) provided [MEDICAL CONDITION] and ventilator care. When queried about general assessment of residents, the Administrator reported ULPs could report any change in condition to the nurse and the nurse would document in the clinical record and notify the physician. When asked how the facility audited and ensured the nurses provided supervision to the ULPs, the Administrator stated, The charge nurses review the MARs and the orders to ensure they are being carried out properly. The Administrator reported the licensed and registered nurses should sign off on the MAR and/or TAR when care was provided and that the signature on the MAR and/or TAR represented the person who actually provided the care. Any evidence of a licensed or registered nurses's direct oversight of the ULPs was requested at that time and was not received by the end of the survey. The State of Michigan website for nursing license verification was checked for ULPs A, B, C, D, and E. The search results revealed none of the five ULPs employed by the facility were licensed nurses in the State of Michigan A review of R#10's clinical record was conducted and revealed an initial admission date of [DATE], a transfer to the Emergency Department on 5/11/19, and a re-admission date of [DATE]. R#10's [DIAGNOSES REDACTED]. A review of R#10's most recent Minimum Data Set (MDS) assessment dated [DATE] was conducted and revealed R#10 had severely impaired cognition. R#10 was non-ambulatory and required extensive to total assistance with bed mobility, transferring, wheelchair mobility, dressing, eating, toilet use, personal hygiene, and bathing. R#10's MDS assessment also indicated R#10 had bilateral upper and lower extremity impairments and had the presence of a urinary catheter. Continued review of R#10's clinical record was conducted and revealed that on 5/1/19, 5/5/19, 5/6/19, 5/8/19, and 5/10/19, ULP 'E' signed off in the TAR that they checked the placement of the PEG tube by aspirating stomach contents and flushed the PEG tube. On 5/1/19, 5/2/19, 5/5/19, and 5/8/19, ULP [NAME] started R#10's tube feeding. Further review of the record revealed a progress note written by ULP 'E' on 5/10/19 at 4:43 PM that documented, Patient has been having oxygen desaturation episodes early in the morning with observed distended abdomen. Stat lab results reveal abnormal labs . MD/NP (Nurse Practitioner) notified and ordered to send out to hospital. A review of R#10's History and Physical dated 5/11/19 from the Hospital physician documented the following, .Assessment/Plan .4. Malposition of PEG tube .GI: tube to be removed and [MEDICAL CONDITION] resolves will replace .Physical exam .Abdomen: .PEG tube site inspected, does not freely rotate .Diagnostic Results .Impression: .3. Gastrostomy tube with it's balloon and tip in the the left rectus muscle (abdominal muscle). Left rectus muscle is enlarged in this region . R#10 was readmitted into the facility on [DATE]. Further review of R#10's clinical record was conducted and included a review of R#10's physicians orders. The following was revealed: A tube feeding order for tube feeding formula to be started at 9:30 PM and finished at 2:30 AM. A review of the MAR documenting the 9:30 PM start of the tube feeding was conducted and revealed the tube feeding was started by ULP 'E' on 6/1/19, 6/8/19, 6/13/19, 6/14/19, 6/15/19 and 6/16/19. Continued review of the MAR showed that on 6/10/19 ULP 'B' started the feeding and on 6/20/19, ULP 'A' started the feeding. A tube feeding order dated 5/29/19 for tube feeding formula to be started three times a day scheduled for 8 AM, 2 PM, and 6 PM and a change to the order on 6/14/19 that indicated the formula was to be started 4 times a day, at 6 AM, 10 AM, 2 PM, and 6 PM. A review of the MAR documenting the start times of the tube feeding was conducted and revealed the following: 6/2/19 Formula started by ULP 'B' for all three administration times. 6/3/19 Formula started by ULP 'E' at 8 AM and 2 PM. 6/5/19 Formula started by ULP 'A' for all three administration times. 6/6/19 Formula started by ULP 'A' for all three administration times. 6/7/19 Formula started by ULP 'E' for all three administration times. 6/8/18 Formula started by ULP 'E' for all three administration times. 6/9/19 Formula started by ULP 'B' for all three administration times. 6/10/19 Formula started by ULP 'A' at 8 AM and 2 PM. 6/11/19 Formula started by ULP 'A' for all three administration times. 6/13/19 Formula started by ULP 'A' for all three administration times. 6/14/19 Formula started by ULP 'A' for all three administration times. 6/15/19 Formula started by ULP 'E' at 6 AM. 6/15/19 Formula started by ULP 'B' at 10 AM, 2 PM, and 6 PM. 6/16/19 Formula started by ULP 'E' at 6 AM. 6/16/19 Formula started by ULP 'B' at 10 AM, and 2 PM. 6/17/19 Formula started by ULP 'E' at 6 AM. 6/17/19 Formula started by ULP 'A' at 10 AM, 2 PM, and 6 PM. 6/18/19 Formula started by ULP 'A' at 10 AM, 2 PM, and 6 PM. 6/19/19 Formula started by ULP 'E' at 10 AM, 2 PM, and 6 PM. 6/20/19 Formula started by ULP 'A' at 10 AM, 2 PM, and 6 PM. 6/21/19 Formula started by ULP 'B' at 6 AM. 6/21/19 Formula started by ULP 'E' at 10 AM, 2 PM, and 6 PM. 6/22/19 Formula started by ULP 'E' at 10 AM, 2 PM, and 6 PM. 6/23/19 Formula started by ULP 'B' at 10 AM, 2 PM, and 6 PM. Continued review of R#10's physician's orders [REDACTED]. and an order that read, Enteral: PEG site care: Cleanse with NS (normal saline) pat dry, apply split sponge and secure with tape change daily. A review of R#10's TARs for the three orders was conducted and revealed the following: 6/3/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/5/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/6/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/7/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/8/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/9/11 Placement, monitoring, and site care documented as completed by ULP 'B' 6/10/11 Placement, monitoring, and site care documented as completed by ULP 'A' 6/11/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/13/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/14/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/15/19 Placement, monitoring, and site care documented as completed by ULP 'B' 6/16/19 Placement, monitoring, and site care documented as completed by ULP 'B' 6/17/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/18/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/19/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/20/19 Placement, monitoring, and site care documented as completed by ULP 'A' 6/21/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/22/19 Placement, monitoring, and site care documented as completed by ULP 'E' 6/23/19 Placement, monitoring, and site care documented as completed by ULP 'B' A review of a facility provided document titled, Nurse Technician Policy dated (MONTH) (YEAR) was conducted and read, .Gives direct patient care, such as bathing, dressing, and feeding patients, and assisting in examinations and treatments . It was noted the policy did not indicate whether a Nurse Tech could be providing PEG tube care, assessment, or verification of placement. A review of a second facility provided policy titled, Care and treatment of [REDACTED]. Policy Explanation and Compliance Guidelines: .5. Licensed nurses will explain to the resident any procedures performed with the feeding tube prior to performing the procedure. 6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey. The immediacy was removed on 6/27/19 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the IJ was removed on 6/27/19, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to all staff not yet being inserviced and sustained compliance has not been verified by the State Agency. The following plan of removal was submitted by the facility: F 693 Tube Feed Management/Restore Eating Plan to Remove IJ Element #1: R#10 was admitted to the hospital on [DATE] for Diagnosis: [REDACTED]. 5 Un-licensed (Nurse Tech/LPN) Nurses have been terminated effective 6/26/19. On 6/26/19, 5 un-licensed nurses received notification of termination verbally by phone or in person by the HR Director at 7:00 pm. A follow-up termination letter (written) was sent via certified mail to the 5 un-licensed nurses and by an email notice sent by the HR Director on 6/27/19 at 7:00 pm. Element #2: On 6/26/19 at 5:00 pm, there is one resident identified Resident MT requiring daily tube feeding, assessment and care. Resident MT received a re-assessment/evaluation of peg tube site and feeding by the attending physician's NP on 6/26/19at 613;14:00 pm, 6/28 at 3pm, also seen by PMR's group on 6/26 and 6/28/2019,Also seen by wound care team on 6/30/2019. Pegtube site free of any s/s of infection. No adverse reaction noted related to peg care. Nursing treatments and assessments were documented. Res. MT's care plan was reviewed and revised for appropriateness. Resident #10 will receive physical evaluation, care of peg tube & assessment from the attending physician upon his return from the hospital. Element #3: The facility policy for Tube Feeding and Medication Administration was reviewed and revised by the DON (Director of Nursing) and Medical Director on 6/26/19 at 5:00 pm. employees requiring licensure received an in-service started on 6/26/19, and will continue to in-service all licensed nursing staff before returning to work. HR (Human Resources) Director conducted a full audit of all licensed staff. All licensed nursing staff (14) RN, (12) LPN, currently employed have active licensure in the State of Michigan. License Nurses were re educated on peg tube management, medication administration, PICC line care Vent/Trache Care and wound care on 6/27/19 9am to 6/30/19 5pm.The Administrator on 6/26/19 at 7:00 pm, reviewed the Michigan Public Health Code and LARA State of Michigan Rules, and the facility policy for hiring licensed personnel. HR Director received a 1:1 re-education on Public Health Code LARA State of Michigan Requirements on 6/26/19 at 7pm The HR (Human Resources) Director and the Administrator received inservice education of the facility policy for hiring licensed personnel and Public Health Code. Element #4: HR Director reviewed ALL Employee records for licensures. No other current employees were found without an active current Michigan licensure. Daily Audit will be conducted by the DON on licensed nurses on duty to ensure appropriate Medication Administration, Tube feeding are delivered according to the standard of practice. Results of the audit will be reported by the DON and HR Director to the monthly QAPI Committee meeting. The Administrator and DON will be responsible for sustained compliance.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer assessment, [DEVICE] assessment, and pressure ulcer treatments were performed by licensed personnel for one resident (R#10) of three residents reviewed for pressure ulcers, resulting in an immediate jeopardy (IJ) and the likelihood for the worsening of existing pressure ulcers, the development of new pressure ulcers, the development of wound infections, complications from [DEVICE], serious injury, harm, and/or death. Findings include: The IJ started on 4/27/19. The IJ was identified on 6/26/19 at 10:30 AM. The facility Administrator was notified of the IJ on 6/26/19 at 3:45 P.M. and a plan to remove the immediacy was requested. On 6/24/19 at approximately 10:00 AM, during an initial screening of residents who resided in the facility, it was discovered R#10 did not reside in the room that was documented on the census provided by the facility or the room documented in the electronic medical record (EMR). Certified Nursing Assistant (CNA) Z reported that R#10 was moved to another room on the neuro unit (a unit that was not certified for long term care (LTC) residents). When queried about why R#10 was moved, CNA Z stated, He was moved after he came back from the hospital at the end of May. There is no alarm system for the ventilator on this side (long term care). On 6/24/19 at 12:15 PM, R#10's room was observed to have signage that indicated R#10 was on contact isolation precautions. At that time, R#10 was observed in bed with family at the bedside. R#10 appeared to be in a vegetative state and was not responsive to verbal communication and only slightly tracked movement with his eyes. R#10 was observed to have a low air loss mattress in place and bilateral soft heel pressure reducing boots on his feet. R#10 was observed to have a PICC (peripherally inserted central catheter intravenous access) tracheotomy trachesostomy (a surgical opening to provide direct airway through the windpipe), and was on mechanical ventilation. A tube feeding pump and pole were observed at the bedside and R#10 was observed to have a urinary catheter. A functioning [DEVICE] system (a type of therapy to help wounds heal with the use of a pump that decreases air pressure on the wounds and a tube for wound drainage) was observed at the bedside with the drainage tubing observed to run from the pump and be attached to R#10's body. At that time, R#10's family was queried about the [DEVICE] system and they explained that R#10 had a pressure wound on his buttocks and that was why the [DEVICE] system was in place. On 6/24/19, an interview was conducted with CNA AA. CNA AA reported the nurse assigned to R#10 was Nurse Tech A (A Nurse Technician is not a licensed or registered nurse in the State of Michigan. The facility referred to the Nurse Technicians as Nurse Techs. Hereinafter, Nurse Techs will be referred to as Unlicensed Personnel - ULP). On 6/24/19 at approximately 1:45 PM, an interview with ULP 'A' was conducted regarding her role in R#10's care. ULP 'A' explained that she assisted with R#10 and stated, I just help with repositioning him, changing him, and with other ADL's (activities of daily living). A review of R#10's clinical record revealed documentation from ULP A, B, and [NAME] that indicated they had provided wound care and wound assessment(s) to R#10. On 6/25/19 at 3:35 PM, an interview with the facility's Director of Nursing (DON) was conducted regarding the facility's utilization of Nurse Techs/ULP. The DON reported the facility did not utilize Nurse Techs/ULP for LTC residents (on the SNF - Skilled Nursing Facility units) and was unaware that they were, as well as unaware the the ULPs had access to document in the MARs, TARs, and progress notes in the electronic medical record (EMR). When queried about how wound care treatment and/or assessment of wounds would be documented, if a licensed or registered nurse directly supervised a ULP who provided wound care, the DON stated, There is no place in (EMR software name) for them to sign-off that they provided oversight. The DON was then queried about whose license the ULPs were [MEDICATION NAME] under and the DON explained that the ULPs work under the supervision of the nurse on the floor. The DON was then asked if the nurses remained with the ULP while they performed nursing duties such as wound care and stated, They don't stay with them for every task. When asked if the supervising nurse should remain with the ULP when they performed wound care treatments or assessed pressure ulcers and [DEVICE], the DON had no response. On 6/25/19 at 4:12 PM, an interview with the facility's Administrator was conducted regarding the role of the Nurse Techs/ULP and their training. The Administrator explained that the facility employed five Nurse Techs/ULP, and of the five, one had graduated from a nursing program and was scheduled to take their licensure examination (ULP C) , two were still in a nursing program and had not graduated (ULP B and ULP D), and two ULPs (ULP 'A' and ULP E) had graduated from a nursing program in a foreign country, but were not licensed or registered to practice in the State of Michigan. When queried about the role of the ULPs, the Administrator stated, During their (one month) orientation they (ULPs) are directly supervised (by a licensed nurse) until they pass their competencies. Then, they can do things on their own and the nurse is more of a resource person they can go to for questions. The Techs (ULPs) are competent but not licensed. The Administrator reported that ULPs only required direct supervision by a licensed nurse during the one month orientation period and after the month of direct supervision, they could work alone on things they were allowed to do with a small number of residents. The Administrator reported ULPs administered medications, conducted assessments, obtained vitals, and did simple wound care dressings. The Administrator reported ULPs could report any change in condition to the nurse and the nurse would document in the clinical record and notify the physician. When asked how the facility audited and ensured the nurses provided supervision to the ULPs, the Administrator stated, The charge nurses review the MARs and the orders to ensure they are being carried out properly. The Administrator reported the licensed and registered nurses should sign off on the MAR and/or TAR when care was provided and that the signature on the MAR and/or TAR represented the person who actually provided the care. Any evidence of a licensed or registered nurses's direct oversight of the ULPs was requested at that time and was not provided by the end of the survey. A review of R#10's clinical record was conducted and revealed an initial admission date of [DATE], a transfer to the Emergency Department on 5/11/19, and a re-admission date of [DATE]. R#10's [DIAGNOSES REDACTED]. A review of R#10's most recent Minimum Data Set (MDS) assessment dated [DATE] was conducted and revealed R#10 had severely impaired cognition. R#10 was non-ambulatory and required extensive to total assistance with bed mobility, transferring, wheelchair mobility, dressing, eating, toilet use, personal hygiene, and bathing. R#10's MDS assessment also indicated R#10 had bilateral upper and lower extremity impairments and had the presence of a urinary catheter. Continued review of R#10's clinical record revealed that on 6/16/19, R#10's Braden Score (an assessment performed to measure a residents risk for developing pressure ulcers) was assessed by ULP 'E'. The assessment did not include any evidence that a licensed or registered nurse verified or supervised the assessment performed by the ULP. A review of R#10's physician's orders [REDACTED].#10's coccyx pressure ulcer every shift with special instructions that read, CLEANSE WITH NS (normal saline) MOISTEN ROLL GAUZE WITH DAKIN'S SOLUTION 0.25% WRING EXCESS FLUID PACK WOUND THEN COVER WITH DRY DRESSING THEN ABD (abdominal) PAD SECURE WITH TAPE . R#10's TAR's were reviewed and the following was discovered: On 4/27/19, 4/28/19, 5/5/19, 5/6/19, and 5/8/19 ULP 'E' signed off on the TAR that she had completed the coccyx treatment on the day shift and created a progress note that read, .Coccyx dressing with Dakin's solution done and spent 20 mins . On 5/10/19, ULP 'E' signed off on the TAR that she had completed the above coccyx treatment on the day shift. Further record review for R#10 was conducted and revealed that upon R#10's re-admission to the facility on [DATE] a [DEVICE] had been placed to his coccyx. A review of physician's treatment orders was conducted and revealed an order written [REDACTED].FEET/HEEL: Assess feet/heel IF ANY CHANGES WITH WOUND APPEARANCE (DTI)(deep tissue injury, A pressure-related injury to subcutaneous tissues under intact skin) OR OPEN AREA TO Notify physician of abnormal findings. (Document on the chart) . The assessment was noted to be signed off in the record by ULP 'A', ULP 'B', and ULP 'E' on the following days: 6/3/19 Day shift signed out by ULP 'E' 6/5/19 Day shift signed out by ULP 'A' 6/6/19 Day shift signed out by ULP 'A' 6/7/19 Day shift signed out by ULP 'E' 6/8/19 Day shift signed out by ULP 'E' 6/9/19 Day shift signed out by ULP 'B' 6/9/19 Night shift signed out by ULP 'E' 6/10/19 Day shift signed out by ULP 'A' 6/11/19 Night shift signed out by ULP 'B' 6/11/19 Day shift signed out by ULP 'A' 6/13/19 Day shift signed out by ULP 'E' 6/14/19 Day shift signed out by ULP 'A' 6/14/19 Night shift signed out by ULP 'E' 6/15/16 Day shift signed out by ULP 'B' 6/15/16 Night shift signed out by ULP 'E' 6/16/19 Day shift signed out by ULP 'B' 6/16/19 Night shift signed out by ULP 'E' 6/17/19 Day shift signed out by ULP 'A' 6/18/19 Day shift signed out by ULP 'A' 6/19/19 Day shift signed out by ULP 'E' 6/20/19 Day shift signed out by ULP 'A' 6/20/19 Night shift signed out by ULP 'B' 6/22/19 Day shift signed out by ULP 'E' 6/23/19 Day shift signed out by ULP 'B' A review of R#10's progress notes for (MONTH) 2019 was conducted and revealed the following: 6/5/19-A progress note by ULP 'A' that read, .Wound vac dressing still on and no issues noted . 6/6/19-A progress note by ULP 'A' that read, .Wound vac dressing still on and no issues noted . 6/10/19-A progress note by ULP 'A' that read, .Wound vac dressing still on and no issues noted . 6/11/19-A progress note by ULP 'B' that read, .wound vac: maintained cleanliness around site, trimmed soiled [MEDICATION NAME], (occlusive dressing) reapplied, and reinforced. Maintained vacuum seal and no leaks noted. Skin integrity around wound kept dry and skin intact . 6/15/19-A progress note by ULP 'B' that read, .Due medications administered and treatments/dressings completed .Maintained skin integrity. Wound vac intact . 6/16/19-A progress note by ULP 'B' that read, .Patient is on Ventilator .wound vac on coccyx area .Due medications administered and treatments/dressings completed . 6/21/19-A progress note by ULP 'B' that read, .treatments completed .Wound dressing/Vac intact in the buttocks/sacral region .noticed skin breakdown on right side of neck . 6/23/19-A progress note by ULP 'B' that read, .Treatments completed. Wound vac intact and functional. Trimmed soiled [MEDICATION NAME] around perimeter of wound, cleansed, applied new [MEDICATION NAME] and re-enforced . R#10's clinical record did not include any evidence of supervision by a Licensed or Registered Nurse for the assessment of R#10's deep tissue injuries and/or pressure ulcers or assessment of the [DEVICE] by ULPs 'B', 'A', or 'E'. On the last page of the MARs and TARs there was a key that matched the initials documented to the actual names of ULP A, B, C, D, and E. The State of Michigan website for nursing license verification was checked for ULPs A, B, C, D, and E. The search results revealed none of the five ULPs employed by the facility were licensed nurses in the State of Michigan A review of a facility provided document titled Nurse Technician Policy with a revision date of (MONTH) (YEAR) was reviewed and read, A nurse technician is a student in a licensed practical nursing program or registered nursing program who has completed the program and is preparing for the licensing examination .Nurse Technician Duties and Responsibilities .Gives direct patient care, such as bathing, dressing, and feeding patients, and assisting in examinations and treatments .Requirements .Must be presently enrolled in an accredited school of nursing program .Have completed or graduating from a Licensed Practical Nursing program and awaiting licensure . It was noted the Nurse Technician policy did not address whether a Nurse Technician was able to perform assessments. A review of an undated facility provided policy titled Wound Packing was conducted and read, Policy: wound packing promotes wound healing. A licensed nurse or therapist performs packing according to the physician's orders [REDACTED]. A review of a second undated facility provided policy titled, Wet-To-Dry Dressing was conducted and read, Purpose: A licensed nurse or therapist applies a wet to dry dressing . The facility was asked if they had any additional information to provide regarding the concern; none was received by the end of the survey. The immediacy was removed on 6/27/19 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the IJ was removed on 6/27/19, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to all staff not yet being inserviced and sustained compliance has not been verified by the State Agency. The facility submitted the following plan of removal: F 686 PRESSURE SORE Plan to Remove IJ-Abatement Element #1: R#10 was admitted to the hospital on [DATE] for [DIAGNOSES REDACTED]. 5 Un-licensed (Nurse Tech/LPN) Nurses have been terminated effective 6/26/19. On 6/26/19, 5 un-licensed nurses received notification of termination verbally by phone or in person by the HR Director at 7:00 pm. A follow-up termination letter (written) was sent via certified mail to the 5 un-licensed nurses and by an email notice sent by the HR Director on 6/27/19 at 7:00 pm. Element#2: R#10 was admitted to the hospital on [DATE] for [DIAGNOSES REDACTED]. Upon his return from the hospital, Res. #10 will be assessed and evaluated by the attending physician/wound specialist, nursing assessment and treatment will be performed and care plan will be revised. There are 5 residents identified requiring pressure sore care at this time. Each 5 residents: (initials redacted) received a re-assessment/evaluation of pressure sore wounds by the attending physician on 6/28/19, nursing treatments and assessments were documented. All 5 resident's care plan were reviewed and revised for appropriateness. Element #3: The facility policy Care for Patients with Pressure Sore was reviewed and revised by the DON (Director of Nursing) and Medical Director on 6/26/19 at 5:00 pm. 14RN & 12 LPNS employees requiring licensure received an in-service started on 6/27/19, and will continue to in-service all licensed nursing staff before returning to work. HR (Human Resources) Director conducted a full audit of all licensed staff. All licensed nursing staff (12) RN, (12) LPN, currently employed have active licensure in the State of Michigan. The Administrator on 6/26/19 at 10:00 pm, reviewed the Michigan Public Health Code and LARA State of Michigan Rules, and the facility policy for hiring licensed personnel. HR Director received a 1:1 re-education on Public Health Code LARA State of Michigan Requirements on 6/27/19 at 12:00 pm. Element #4: The DON /designee will monitor the resident's treatment orders and monitor wound pressure sore status weekly. No other current employees were found without an active current Michigan licensure. Daily Audit will be conducted by the DON on licensed nurses on duty to ensure appropriate care for Pressure Sore is delivered according to the standards of practice. HR Director reviewed all Employee records for nursing licensure's. Results of the audit will be reported by the DON & HR Director to the monthly QAPI Committee meeting. The Administrator and DON will be responsible for sustained compliance.

Based on observation, interview and record review, the facility failed to monitor one resident (#506) out of 7 residents who has had a history of [REDACTED]. On 4/5/17 at 10:00 a.m., resident #506 was observed self-propelling herself in a wheelchair in the facility's parking lot near the main street in front of the facility without knowledge of the facility staff. This resulted in an immediate jeopardy that had the potential for serious harm and or injury and required immediate corrective action. The Administrator was notified of the Immediate Jeopardy on 4/5/17. A plan to remove the immediacy was requested. The immediacy was removed on 4/6/17 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: On 4/4/17 at 11:45 a.m., Resident #506 was observed sitting in a wheelchair inside the resident's room. Someone inside Resident #506's room stated that she was from a local medical staffing agency and a sitter for Resident #506. On 4/4/17 at approximately 12:30 p.m. and 3:45 p.m., Resident #506 was observed outside of the facility being pushed in a wheelchair by Staff Member 'A' from a local contract sitter (Medical Staffing Agency) while going down the sidewalk near the facility's parking lot. On 4/5/17 at 10:00 a.m., Resident #506 was observed self-propelling herself in a wheelchair in the facility's parking lot near the main street in front of the facility without knowledge of the facility staff. At that time, Registered Nurse (RN) 'B' was asked if Resident #506 should be outside without a sitter. RN 'B' stated, No and preceded to Resident #506's room. RN 'B' observed that Resident #506 was not in the room, and headed to the front entrance of the facility while notifying other staff members to look for the resident. At that time, Resident #506 was observed at the end of the sidewalk near the facility's parking lot that was near the main street. Staff Member 'Y' was asked to bring Resident #506 back inside the facility. RN 'B' stated, Resident #506 goes outside sometimes to smoke. On 4/5/17 at 10:00 a.m., when queried if the resident was observed going outside of the facility through the main lobby door, Administrative Assistant 'C' stated, I saw her (Resident #506) over there (in the lobby) on the phone, I thought she was going back to her room. Administrative Assistant 'D' stated, I left (the front desk) to go to the back . Receptionists 'C' and 'D' both admitted that they did not see Resident #506 leave out the lobby entrance door. On 4/5/17 at 10:55 a.m., during an interview, Certified Nursing Assistant (CNA) 'E' stated, I was in another room getting a resident ready for therapy. I had left (resident name) in her room. CNA 'E' further stated, Last Friday (4/1/17), I saw (resident's name) smoking. She already had the cigarettes, I reported it to the nurse. On 4/5/17 at 11:00 a.m., contract sitter, Medical Staff Member 'F' stated, Today, I was 10 minutes late. I was supposed to be here (facility) at 10:00 a.m., she (Resident #506) was already outside smoking when I arrived. A review of the facility's Investigation Procedure Summary dated 3/28/17 at 3:18 a.m., revealed patient (Resident #506) was seen by RN 'G' going out from the main door. RN 'G' assisted her back in the . Further review of the Investigation Procedure Summary's Brief description of plan to avoid this situation in the future (if applicable) revealed Main doors shall be closed after 8PM. Patient shall be monitored regularly. In-serviced/Re-educated patient not to go out the building alone. Further review of an Investigation Procedure Summary dated 4/5/17 at 2:00 a.m., revealed resident eloped to the front of the building to smoke cigarette . The Investigation Procedure Summary's Brief description of conclusion: The resident claimed that she just want to smoke and it is her right . Brief description of plan to avoid this situation in the future (if applicable) revealed Monitor resident's whereabouts as she is going out to smoke by herself. During the entrance conference on 4/4/17, the Director of Nursing (DON) stated the facility was a Smoke Free Facility, and provided an undated policy that revealed the facility was a Non-Smoking Campus . Accordingly, smoking on (facility name) property is strictly prohibited by all staff, patients and guests. Further review of the facility's undated Non-Smoking Policy revealed The facility is also informing the resident/caregiver/responsible party/legal guardian that (Facility Name) is a Smoke-Free Environment. This means that residents are not permitted to smoke in the building, or on the facility grounds. The DON also provide a list with zero (0) residents who smoke. A review of the clinical record revealed Resident #506 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the admission Minimum Data Set ((MDS) dated [DATE], indicated Resident #506 received antipsychotic and anti-anxiety medication for seven days during the assessment. A review of an unsigned physician's orders [REDACTED]. Communication Method: Phone Order Summary: 1:1 (one-to-one) 8 hours sitter at bedside (day time) Confirmed By: (name) Charge Nurse On 4/5/17 at 11:30 a.m., an interview was conducted with the Administrator and DON. When queried about Resident #506 leaving (elopement) out of the facility without knowledge of the staff, and smoking on the facility premises, the Administrator stated, I don't know. That shouldn't happened. We try to be smoke free. She (Resident #506) is probably the only person in the building who smokes . When asked who is responsible for monitoring the resident when the sitter is late or not at the facility, the Administrator stated, Typically, we make sure the sitters are on time. They (residents) should be monitored if it's a doctor's order. That's what we should do. On 4/5/17 at 3:12 p.m., a called was placed to Resident#506's Guardian 'J'. On 4/6/17 at 9:13 a.m., Guardian 'J' returned the call. When queried why Resident #506 needed a sitter? Guardian 'J' stated, Resident #506 is very anxious, has bipolar, gets really upset for no reason, and makes up a lot stuff in her head. When asked where Resident #506 gets her cigarettes and lighter, Guardian 'J' stated, I don't know. She has been a smoker for a very long time, but I have just spoke with the local Medical Staffing Agency, and informed them that they are not to provide the resident with cigarettes. When queried if Resident #506 is allowed outside of the building alone, Guardian 'J' stated, That is unacceptable. Staff need to be with her at all times, especially when she goes outside. On 4/6/17 at 11:50 a.m., when asked about the facility's policy and procedure for residents that leave outside of the building Administrative Assistant 'C' stated, Usually, residents sign out with their nurse or aide if they are just stepping out. At that time, a request was made to review the residents' sign out/sign in logs. The residents' Sign Out/Sign In Sheet had signature entries that started on 8/21/16 through 11/23/16. There were no other entries in the binder. When asked why there were no other entries after 11/23/16, Administrative Assistant 'C' did not have an explanation, and stated, We were in-serviced this morning. On 4/6/17 at 12:15 p.m., the Administrator and DON were queried about the facility's Sign Out/Sign In Sheet, and were unaware of the blank entries after 11/23/16. A review of the facility's policy titled Elopement Policy revised April 1, 2014 revealed the following: Procedure 1. Assess the potential for elopement with each new admission and quarterly thereafter and as needed. 2. All care plans are to reflect the potential for elopement of the resident and will be reviewed, revised, and updated as needed by the interdisciplinary team. 3. All plans of care for residents at risk for elopement will be reviewed by the Behavior Management Committee at minimum quarterly with any revisions made as appropriate. 4. Educate all staff upon hire and at minimum quarterly thereafter of their roles in providing care to these residents and the monitoring of these residents to ensure their safety . 6. In the event of a suspected elopement the following will occur: a. Check the sign-out form in the resident's chart to see if the resident left without notifying the staff or left with family. b. Charge nurse will notify the outer unit(s) of missing resident, all staff will thoroughly search the building immediately room by room. c. Make an immediate check of the area outside of the building. Check outside of the doors, immediate grounds, parking areas, streets, and sidewalks that the resident may use to walk away from the facility. Check areas 10 (ten) blocks in each direction . f. Charge Nurse will notify the police department, DON, Administrator, attending physician, and the family/guardian/responsible party of the resident's elopement. g. The Administrator and the DON will report to the building and notify family as well as direct staff in continuation of the search in cooperation with the police department . h. Charge Nurse will complete an incident/Accident Report . 7. When the resident is returned to the facility, a complete assessment will be done to identify any problems needing to be addressed for the care and treatment of [REDACTED]. 8. Charge Nurse will complete all appropriate documentation in the Nursing Notes . The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 4/6 /17: Element #1: Resident 506 was identified for this citation. On April 5, 2017, the Guardian of Resident 506 requested that Resident 506 be discharged from the facility to the Assisted Living of (Name of facility) immediately so that Resident 506 will have more independence and freedom to walk around the facility and outside on the common grounds since Resident 506 is high functioning. Accordingly, Resident 506 was discharged on [DATE] and the immediate jeopardy and the resident at risk was removed. Element #2: Resident 506 was affected by this citation. Resident 506 has been discharged and thus, the resident at risk has been removed. All residents' whereabouts have been accounted for and a proper head count of all residents in the building was conducted. Element #3: To ensure that this alleged deficient practice does not reoccur again, various precautionary measures have been immediately taken: Resident Monitoring Log has been immediately initiated to monitor the whereabouts of all residents every 4 hours. All CNA's and Nurses have been In-Serviced on the Resident Monitoring Log. If a CNA discovers a patient is missing or unaccounted for, the CNA must immediately notify the attending Nurse to begin a search by notifying all nurse stations. If the patient cannot be found, the Nurses shall notify the Director of Nursing. Director of Nursing shall proceed to use Elopement Procedures. All Front Desk staff were In-Serviced on Sign-In and Sign-Out and all residents must sign in and out when they come in and out of the facility, and reason and location is indicated. Front Desk should not be left unattended. This will ensure that staff have knowledge of the whereabouts of all patients at all times, including when patients go outside to enjoy the outdoors. All facility staff were In-Serviced on Front Door Policy. The Main Front door will be manually locked at night starting at 8pm to prevent any patients leaving or eloping from the building after hours, when the Front Desk is not attended. The Main Door is re-opened at 8am when the Front Desk attended and monitoring the Main Entrance. It is emphasized that the whereabouts of all residents should be known at all times. The CNA's, Nurses and Front Desk will strictly monitor this on an ongoing basis to prevent re-occurrence. If a resident deemed missing, they must notify the Director of Nursing, who will proceed to use Elopement Procedures. Element #4: The Administrator shall ensure ongoing compliance of the Resident Monitoring Log, Sign In-Out sheets, and the Front Door closure on a daily basis and in Quality Assurance Meetings on a quarterly basis.