Every finding on record at Marywood Nursing Care Center

This citation refers in part to intake 3072219. Based on observation, interview, and record review, the facility failed to ensure the care plan was revised to reflect the current needs of the resident for three residents (R154, R35, R147) of five reviewed for individualized care plans. Findings include: R154 On 08/25/2026 at 10:35 AM, R154 was observed dressed and seated in a wheelchair on the door side of the bed. R154 had a hinged support brace on the right leg which extended from the thigh to the calf. the hinge of the brace was below the level of the knee joint. The resident was asked about the position of the leg brace and commented the hinge should be at the knee joint, R154 attempted to pull the brace up. The position of the brace did not change. A review of the active care plan and tasks revealed no intervention or task to indicate a brace was in use. On 08/25/2026 at 4:20 PM and 5:20 PM, R154 was seated in their wheelchair on the door side of their bed. The leg brace was further down leg, with the hinge at level of the calf and the top of the brace just above the top of the knee. On 08/26/2026 at 9:25 AM, R154 was dressed and seated in a wheelchair at the door side of the bed. The leg brace was observed to be loosely placed on the left leg. On 08/26/2026 at 10:56 AM, Physical Therapist Assistant (PTA) was observed to return R154 to their room and reported brace was to be on the right leg and did not have to be worn while in bed. PTA D suggested if the brace was on the left leg the resident may have put it on. On 08/27/2026 at 8:53 AM, R154's Certified Nursing Assistant (CNA) C was asked about the leg brace for the resident and reported they did not know R154 had a brace and they were trained to apply leg braces. On 08/27/2026 at 2:34 PM, R154 was reviewed with the Assistant Director of Nursing (ADON) reported all CNAs are trained by the therapy department to properly apply braces. A review of the care plan from 08/25/26 revealed no reference to or an intervention for the leg brace. It was reported the care plan should reference use of the leg brace. A review of the electronic medical record revealed R154 was admitted into the facility on [DATE] with diagnoses that included Fracture of Upper End of Right Tibia (lower leg bone), Restless Legs Syndrome and Difficulty Walking. The active care plan I am at risk for falls (related to) r/t Gait/balance problems .Initiated: 08/18/2026 Created on: 08/18/2026 . did not reference the leg brace. The care plan I have an (Activities of Daily) ADL Self Care Performance Deficit r/t Impaired balance Date Initiated: 08/18/2026Created on: 08/18/2026 documented R154 required .limited assist x 1 staff participation with transfers. The care plan did not include interventions related to the leg brace. R35 A review of the electronic medical record revealed R 35 was admitted into the facility on [DATE] with diagnoses that included Difficulty Walking, Muscle Weakness, Anxiety and Speech and Language deficits. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition, the need for partial/moderate assistance for eating, and substantial/maximal assistance from staff for going from sitting to standing, transfers and walking. A review of the fall report for 08/22/26 documented a fall in the resident's room around 3:30 PM it was unwitnessed, the resident had no injury, and an assessment was completed. Details included, Patient was found on the floor alert and oriented x2. No injuries observed. (R35) was helped back to the wheelchair by the staff, existing bruise and blister documented, no treatment required.On 08/25/2026 at 9:37 AM, R35 was dressed and seated in a wheelchair in the common area. A family member reported R35 had a fall on Saturday 08/22/26. It was noted during the initial care conference R35 was reported as a high fall risk on admission related to impulsiveness and confusion. A review of a Nurse Practitioners (NP) note dated 08/25/25 at 0800 revealed no reference to the fall from 08/22. On 08/25/2026 at 4:09 PM, R35 was seated in their wheelchair at the table in the common area of their assigned unit. A review of physical and occupational therapy notes dated 08/24/26 and 08/25/26 revealed no reference to the fall on 08/22/26. The notes documented poor safety awareness with the need for constant cues for safety and the need for substantial/maximal staff assistance for walking and transfers. A 08/24/26 Speech Therapy note documented, .addressing higher level language and cognition. Pt (Patient) continues to present at a max level of impairment/max level of cueing required in the areas of language cognition including orientation, recent recall and reasoning, judgement and safety. Pt continues to require consistent supervision to ensure safety during daily tasks and routines . A review of the active care plan revealed, .I am at risk for falls r/t Gait/balance; Anticipate and meet my needs. Date Initiated: 08/12/2026. Staff to offer to lay resident down after lunch for a nap. Date Initiated: 08/24/2026 . Communication problem: Bed in lowest position and wheels locked, Avoid isolation. Date Initiated: 08/18/2026 . I have an (activities of daily) ADL self-care performance deficit: I am an early riser, I do not take naps, and bedtime routine is late night, Date Initiated: 08/12/2026 . Mobility: Wheelchair .Transfer: I require one-person extensive assist . The intervention added after the 08/22/26 fall was to offer a nap with the care plan which indicated the resident does not take naps. On 08/26/2026 at 4:13 AM and 4:40 AM, R35 was in bed, the lights in the room on, and was actively moving their legs. The bed was up from the lowest position. On 08/27/2026 at 8:30 AM, R35 was in bed eating breakfast. At 8:40 staff went in to ask if done eating at brought tray out with items partially eaten. At 9:18 AM R35 continued in bed with the bed up from the lowest position. The Malnourished care plan initiated 08/12/26 and last revised 08/12/26 documented 1:1 assistance with meals and impaired swallowing. A review of the progress notes revealed, 08/26/2026, Post Fall Evaluation, Fall Details: Date / Time of Fall: 08/26/2026 4:29 PM, Fall was not witnessed. Fall occurred elsewhere. Other fall location: Dayroom Activity at the time of fall: Ambulating attempting to turn the TV off .Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization: Yes. ER Visit/Hospitalization Details: Resident Hit (their) head during fall, Per MD (medical doctor) orders to send out for CT scan (imaging test), Provider: On call MD Time notified: 08/26/2026 Notified of: Fall Resident's responsible party notified: Yes. Person contacted: (Name) Details of notification: Notified of fall and transfer to the hospital Date of Resident's responsible party notification: 08/26/2026 5:15 PM. On 08/27/2026 at 9:16 AM, Licensed Practical Nurse (LPN) E reported they were aware of the fall, and the resident was on neuro checks (neurological assessment) with no other care plan changes given. On 08/27/2026 at 9:23 AM, the Director of Rehab (Staff J) acknowledged R35's poor safety awareness and the need for max staff assist for safety. On 08/27/2026 at 11:14 AM, R35 was in the day room area with their responsible party (RP)who expressed concern regarding staff supervision of R35. At 2:45 PM, the Assistant Director of Nursing (ADON) reported all falls, and the care plans are reviewed with the interdisciplinary team for appropriate interventions and revised as needed. R147A review of a complaint intake revealed, .there have been 5 occurrences where (R147's) Parkinson's medication was given late. In some cases, up to 2 hours late causing withdrawal . instructions were left with the facility that the Levodopa inhaler (to treat Parkinsons symptoms) should be given 30 minutes before the carbidopa/levodopa tablet (also to treat Parkinson's symptoms) but on several occasions, it was given at the same time which is doubling up the dose. Effects from medication being given late includes extreme confusion, shakiness, weakness and shortness of breath . have spoken with many nurses, including the nurse manager, Director of Nursing (DON), Director of Patient Services. I have explained to them (facility staff) multiple times that the one hour before and one hour after protocol cannot be used for (R147) . a letter from the Neurologist was provided which indicated the importance of adhering closely to the medication schedule . Documentation gathered: 06/18/26 11am Sinemet wasn't given until 12; 5:45 PM, Inhaler was given at the same time as tablet at 6:30. Inhaler is supposed to be given at 5:45 and tablet at 6:15 PM; 6/21/26 7 AM tablet was received at 7:30 AM and was struggling; 06/29/26 received both inhaler and tablet at 8pm. 6/30/26 didn't feel good all day today; 07/01/26 at 6:30 pm hadn't received the inhaler or tablet. Both given at same time. 07/03/26 received inhaler at 6:35 PM and the tablet at 6:50 PM.A review of the electronic medical record revealed R147 was admitted into the facility on [DATE] with diagnoses that included, Parkinson's, Muscle Weakness and Falls. R147 was discharged home on [DATE]. The Minimum Data Set (MDS) assessment dated , 07/01/26 documented intact cognition with 14/15 Brief Interview for Mental Status (BIMs) score and independence in eating, personal hygiene and upper body dressing. Assistance was required for all other activities of daily living.On O8/27/2026 at 12:57 PM, Nurse Practitioner (NP) L reported the facility would have tried to follow home regimen for R147, Parkinson's medication and recalled hearing family speaking with Unit Manager K about the home regimen. The NP further noted R147 as a frail neurology patient and that neurologists try to do different things for people to meet their specific needs and technically the medications should be given as able according to the home regimen. On 08/27/2026 at 2:02 PM, the Assistant Director of Nursing (ADON) reported Parkinson's medication usually come up as a resident concern and the facility can adjust the time code in the order to suit the resident.A review of the care plan I am on Antiparkinsonian Therapy initiated 06/22/26, documented to administer the medications as ordered. No other interventions were documented. Nothing was documented about the need to be exact about the timing for administration. The actual administration times for the Parkinson's medication were requested but not provided prior to survey exit.A review of the nursing progress notes and electronic medication administration notes did not indicate the exact time medications the inhaler and tablets were administered.A review of the physician orders revealed for the Carbidopa/Levodopa 25/100 milligram tablet unsupervised self-administration was ordered/allowed. This was not documented for the inhaler. The care plan did not document any self-administration of medications.

This citation pertains to Intake 2706540Based on observation, interview, and record review the facility failed to serve hot liquids in a safe manner for one resident (R700) out of three reviewed for accidents, resulting in a second-degree burn blister. Findings include:A review of an incident investigation dated noted the following, IDT (Interdisciplinary Team) incident investigation. On 12/15/2025 resident spilled hot soup onto [their] lap. Nursing assessment was completed including skin assessment and pain assessment. No pain or injury at the time of the incident. Resident alert and orientated and continued to deny pain. Nursing assessment completed every shift with no redness or pain noted. On 12/18/2025, blister developed to the right medial thigh and new order received for triad daily and PRN (As needed) until resolved. Nursing assessment completed every shift with continued denial of pain, redness, etc .Further review of the progress notes revealed the following, 12/15/2025 11:50 am, Nursing Progress Note.: Residential had a witnessed injury on 12/15/2025 at around 11:30 this morning. Resident asked for hot soup from kitchen. Nurse aide brought soup and witnessed resident tip soup bowl over, accidentally causing the soup to spill into resident's lap. Redness observed on resident's anterior thighs bilaterally. Cleansed thighs and applied silicone cream, per resident's wishes. 12/23/2025 10:44 am, Wound Care note.Desiccated (dried out) blister to [their] right medial thigh from 2nd degree burn . Continue Rx (prescription) with thin layer of Triad daily and PRN until resolved.A review of the medical record revealed R700 was admitted into the facility on [DATE] with the following medical diagnoses, Muscle Weakness and Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non dominant side. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) of 14/15 indicating an intact cognition. R700 also required staff assistance with bed mobility and transfers.On 1/8/2026 at 12:44PM an interview was conducted with Certified Nursing Assistant (CNA) B. CNA B reported R700 did not eat much, and their daughter would bring in soup packets to heat up for R700 to eat. CNA B reported they had been working with R700 for the past three days, and they usually drink the soup with a straw out of a personal coffee cup. CNA B reported they could not find R700's cup, so they warmed the soup up in a white foam cup for approximately 45 seconds. CNA B reported they gave the cup to R700 with a straw, but they wanted some crackers and a spoon. CNA B reported they left to go to the kitchen, so they could obtain a different style of cup for R700's soup to make it safer to eat with a spoon and when they returned to the room, R700 had spilled the soup on themselves, and on the floor. CNA B confirmed they did not use the thermometer to get a temperature reading on the soup before giving it to R700. On 1/8/2025 at 1:32 PM, a phone interview was conducted with Family Member (FM) C. FM C reported R700 was at home now and the blister has turned into a scab and is being treated daily by the home care nurse, as well as themselves. FM C reports R700 did not have a great appetite, so they would bring the soup packets and a handled cup you just add water to. FM C reported R700 still complains about pain in the burn area.On 1/18/2025 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON reported there is a thermometer, as well as a sign saying what the temperature of hot liquids should be by every microwave in the nourishment rooms. The DON reported their expectation is staff obtain the temperature of hot liquids prior to serving them to residents.A review of a facility policy titled, Hot Liquid Safety Policy and Procedure noted the following, .Policy: Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. Staff are to be cautious when handling hot liquids.

This citation pertains to Intake #2680166.Based on interview and record review the facility failed to ensure after visit care was provided for two residents (R900, R903) of three residents reviewed for continuity of care. Findings include:R900On 12/4/24, R900 was admitted to the facility the following diagnoses: fracture right femoral neck and fracture of right greater trochanter requiring surgical intervention, and severe osteopenia. R900's Brief Interview for Mental Status dated 12/8/24 revealed intact cognition.On 12/2/25, a review of the After Visit Summary (AVS) from the hospital transfer revealed resident instructions included under the heading, Activity: Do not sit for longer than 30-45 minutes, use chair with arms, and don't sit in low chairs. Sleep on back, legs slightly apart on your side with a pillow between legs for about 6 weeks.do not sleep on your stomach or affected hip. Further review under the heading, Ice and Elevation, put ice or a cold pack on the area for 10 to 20 minutes every 1 to 2 hours for the next 3 days while awake. The AVS further revealed that R900 should prop up your ankle when you ice, sit or lie down. Try to keep above the heart. The instructions further revealed to wear compression stockings.for 4 to 6 weeks after surgery. On 12/2/25 a review of the physician orders for R900 did not reveal any orders regarding sleeping precautions, ice, or elevation. There were no interventions on the care plan for sleeping precautions, ice, or elevation. R902On 11/11/2025 R902 was admitted to the facility with the following diagnoses: Intertrochanteric fracture of the left femur with a Left Total Hip Arthroplasty. R902 Brief Interview for Mental Status revealed intact cognition.On 12/2/25, a review of the AVS for R902 from the hospital transfer revealed resident instructions as follows: Activity: Do not sit for longer than 30-45 minutes, use chair with arms, and don't sit in low chairs. Sleep on back, legs slightly apart on your side with a pillow between legs for about 6 weeks.do not sleep on your stomach or affected hip. Further review under the heading, Ice and Elevation, put ice or a cold pack on the area for 10 to 20 minutes every 1 to 2 hours for the next 3 days while awake. The AVS further revealed that R900 should prop up your ankle when you ice, sit or lie down. Try to keep above the heart. The instructions further revealed to wear compression stockings.for 4 to 6 weeks after surgery. On 12/2/25 a review of the physician orders for R900 did not reveal any orders regarding sleeping precautions, ice, or elevation. There were no interventions on the care plan for sleeping precautions, ice, or elevation. On 12/2/25 at 1:40 PM, an interview with R902 revealed that they have requested ice only a few times. They further reported they were not aware that the affected leg should be elevated whenever possible. On 12/2/25 at 1:00 PM an interview with Licensed Practical Nurse (LPN) A revealed any precautions or treatments would be found in physician orders, on the care plan or in both places. LPN A further revealed when a physician order is written for things like ice or elevation, it would appear on the Treatment Administration Record (TAR). LPN A further revealed that the admitting nurse, an RN or LPN, would add these items to the Care Plan and that most information regarding specific aftercare treatment would be put in by the admitting nurse. Any nurse may add to the Care Plan when necessary. LPN A further revealed that only ice can be applied by the nurse without a physician On 12/2/25 at 1:50 PM, LPN B revealed all physician orders appear on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). If an order from the AVS does not appear on the MAR or TAR, the RN or LPN would call the physician to obtain the order. Once the order is entered, the nurse for that resident would communicate the additional information to the Certified Nursing Assistant (CNA). LPN B further revealed the admitting nurse creates the initial care plan and any nurse can add to it. If the admitting nurse does not finish any part of the admission process, the nurse will endorse to the next shift for completion. LPN B also indicated that if ice were give per resident request, there would be documentation in the progress notes indicating ice was applied, the reason, and its effectiveness. On 12/2/25 at 2:30 PM, an interview with Nurse Practitioner (NP) C revealed they see the resident about two weeks after the initial physician visit unless requested by nursing. She does take a quick look at the AVS and reviews the orders, but relies on the many professionals before them to have the initial orders in. On 12/2/25 at 3:01 PM, an interview with Physician D revealed if ice/elevation were on the AVS, they would put an order in for the same. On 12/2/24 at 3:15 PM, an interview with the Director of Nursing (DON) revealed that orders from the AVS should be put into place by the physician per order, and on the Care Plan by the admitting nurse or nurse who reviews the orders. The policy titled Comprehensive Care Plans, updated May, 2025 revealed A comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. and Resident specific interventions that reflect the resident's needs and preferences and align wit the resident's cultural identity as indicated.

Based on observation, interview, and record review, the facility failed to ensure resident requests were honored timely or in a dignified manner for one resident (R135) of two residents reviewed for resident rights. Findings include:On 09/09/2025 at 12:35 PM, R135 was observed to be dressed and seated in their wheelchair in the hallway outside their room. R135 self-propelled their wheelchair with their arms and feet into the common area between the nurse station and the doorway to the cafe. R135 asked how to get up to the front door of the building as they wanted to go outside. R135 then reported to an unidentified female staff wearing blue scrubs that they would like to go outside. The staff member promptly said the resident could not go outside and indicated the nurses needed to know where R135 was and R135 would have to notify the nurse or get activities to help them. R135 continued up the hallway toward the doorway. Staff E then walked toward R135 from the main hall and R135 asked them about going outside. Staff E told R135 they could not go outside and offered to take them back to their room. R135 was quiet, shook their head slightly and turned around and headed back toward their room. R135 appeared frustrated by the replies of the staff members. At 12:37 PM, R135 was through the doorway when the nurse for R135, Licensed Practical Nurse (LPN) D walked by R135 and R135 asked the nurse to go outside and the nurse replied to R135 that they could not go outside and R135 asked, What is this a prison and the nurse who kept walking, turned slightly and said almost. None of the staff members offered to take R135 outside. R135 had been observed on 09/08/25 to wheel themselves around the facility onto different units. On 09/09/2025 at 12:55 PM, R135 was observed to be seated in a wheelchair in their room with they're TV on. R135 had a window to an interior courtyard, and it was a sunny day. At 1:12 PM, R135 was observed in the hallway outside the therapy entrance and was asked about going outside and reported some frustration and reported staff must think they were going to go five miles away or something. At 2:08 R135 was in bed resting. At 2:47 PM, R135 was observed to be in the therapy room seated in their wheelchair for a physical therapy session. On 09/10/2025 at 8:04 AM, R135 was out of bed seated in wheelchair watching tv back to door, R135 was asked again about the observation and with a smile reported they had been taken outside by a staff member later in the afternoon. On 09/10/2025 at 10:02 AM, Staff E reported residents were not allowed to go out front alone but could go into the courtyard in the summer months. Staff E further noted it was usually activities that took the residents out but was later able to sit with R135 during their lunch. On 09/10/2025 at 10:10 AM and 11:26 AM, concerns were reviewed with the Director of Nursing (DON). The DON reported the expectation was that staff would assist the resident with their request or arrange a time to go outside. A review of the record for R135 revealed R135 was admitted into the facility on [DATE]. Diagnoses included heart disease and Traumatic Brain Injury. The active care plan initiated 09/04/25 documented moderate cognitive impairment with a Brief Interview for Mental Status score of 11/15 and a self-care performance deficit for which R59 required limited assistance with toileting, transfer and bathing. Mobility was documented as wheelchair. A review of the facility policy titled, Resident Rights updated 06/2021, documented, Employees will treat all residents with kindness, respect and dignity .These rights include the resident's right to .self-determination .

Based on observation, interview, and record review, the facility failed to secure confidential medical records for one resident (R139) out of one reviewed for confidential information. Findings include: On 9/8/2025 at 8:30 AM, the laptop located on the B300 hallway cart was observed to be open and visible with patient Medication Administration Record (MAR) displayed. The nurse was not observed to be in the hallway or near the cart. On 9/9/2025 at 8:58 AM, the laptop located on the B300 hallway portable cart was observed to be open with patient Medication Administration Record (MAR) information visible. Registered Nurse (RN) A was not observed to be in the hallway or near the cart. On 9/9/2025 at 11:15 AM, the laptop located on the B300 hallway portable cart was observed to be open with patient MAR information visible. RN A was noted to be in a patient's room. RN A acknowledged the screen was unlocked and stated they would close it when they walked away. On 9/9/2025 at 1:27 PM, the laptop located on the B300 hallway cart was observed to be open with R139's MAR information visible. RN A was noted to be in a patient's room. On 9/10/2025 at 10:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they recognized the problem with screens being open and implemented the screen protectors and medical record timing out quicker (Medical record will go in sleep mode after a few minutes with inactivity). The DON reported their expectation is for screens to be closed and secured when the nurse walks away from them. On 09/10/2025 at 7:50 AM, the P wing resident report sheet (a sheet in which resident confidential information is recorded) was observed to be left face up, exposing confidential resident information to visitors, staff, and passersby on the portable computer station outside room P213. Licensed Practical Nurse (LPN) H was observed at the opposite end of the hall exiting a resident room. On 09/10/25 at 11:40 AM, LPN H noted it had been a busy morning and confirmed the report sheet should not have been left face up. A review of a facility policy titled, Confidentiality of Information and Personal Privacy noted the following, .1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was completed during medication administration for three residents (R134, R84 and R30) of five residents observed during the medication pass. Findings include: On 09/09/2025 at 9:20 AM, Licensed Practical Nurse (LPN) J was observed to check the vital signs of R134 and then return to the medication cart and prepare medications for the resident. LPN J then placed on gloves and brought the medications into the room and started to administer them to R134. R134 needed additional water to take their milk of magnesia and LPNJ went to the medication cart, doffed their gloves, poured water from a pitcher into a cup, donned a pair of gloves and re-entered the room and administered the medication. No hand hygiene was completed. R134 required additional water so LPN J returned to the medication cart, removed their gloves, poured a cup of water from the pitcher and donned a pair of gloves and re-entered the room of R134. No hand hygiene was completed. LPN J completed the medication pass and upon exit dispensed some hand sanitizer but did not rub it on all surfaces of the hands. LPN J acknowledged the need for sanitizer between glove changes. On 09/10/2025 at 8:54 AM, LPN I was observed to prepare medications for R84. The medications included pills and an inhaler. The pills were administered to R84 with a spoon. R84 began to cough after administration of the pills and LPN I exited the room and retrieved the pulse oximeter to check the oxygen of R84 and returned to the room. Hand hygiene was not observed upon exit nor re-entry. R84 was then administered the inhaler and was provided a cup of water to rinse their mouth. LPN I then exited the room. No hand hygiene was observed to be performed on exit. LPN I confirmed the need for hand hygiene after patient care. On 09/10/2025 at 9:30 AM, Registered Nurse (RN) A was observed to prepare medications for R30. Medications included pills and an inhaler. RN A entered the room and provided the pills and inhaler for R30. R30 self-administered the inhaler and RN A provided a cup of water to R30 to rinse their mouth. R30 swished and set the empty cup on the sink. RN A picked it up to throw it away and R30 asked to keep it, so the cup was returned to R30. RN A took the inhaler back to the cart. Hand hygiene was not completed on the way out of the room. RN A set the inhaler on top of the cart and signed off the medications on the computer.On 09/10/2025 at 10:00 AM, Infection Control Preventionist (ICP) B was informed that hand hygiene with residents during med pass was not being completed. ICP B stated Hand hygiene should be completed when entering the patient's room, leaving the patients room and before moving on to another patient.On 09/10/2025 at 10:10 AM, the Director of Nursing (DON) indicated the expectation was that hand hygiene be completed.A review of a facility policy titled, Hand Washing/Hand Hygiene noted the following.1.All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.

This citation pertains to Intake M100152463: Based on interview and record review, the facility failed to maintain a complete medical record for one (R901) of three residents reviewed for medical records. Findings Include: Review of Intake called into the State Agency revealed an allegation that R901 had been discharged from the facility on 04/21/25 and upon review of the home health care admission assessment on 04/22/25, R901 was found to have an intravenous line (IV) remaining in their arm. The report indicated the home care nurse reviewed the facility discharge record which indicated the IV had been physician ordered to be removed on 04/09/25. Review of the facility record for R901 revealed an admission date of 04/08/25 with diagnoses including Right Knee Effusion and Syncope and Collapse. R901's Physician orders included an order dated 04/08/25 stating Discontinue IV in right arm. On 06/04/25 at 9:59 AM, the complainant was interviewed via phone call and confirmed they were contacted by the home care admission nurse who reported the presence of the IV in R901's arm. The complainant reported the home care nurse was instructed by the primary care provider to remove the IV. On 06/04/25 at 10:27 AM, R901 was interviewed via phone call and reported they did recall their home care nurse pointing out they still had an IV in their arm. R901 reported their concern was the IV was supposed to be removed before they were discharged and it was not. On 06/04/25 at 10:55 AM, the Clinical Director of the home care agency, Registered Nurse (RN) B, was interviewed via phone and reported they did recall the reported situation and indicated the admission nurse notified them that R901 had an IV in their arm. RN B reported they reviewed the discharge information from the nursing facility which indicated that the IV was placed 04/08/25 for blood draws and was ordered to be removed 04/09/25. RN B reported R901 was admitted to their home care service on 04/22/25 following discharge from the nursing facility. On 06/04/25 at 1:45 PM, record review revealed a progress noted dated 04/08/25 authored by LPN D indicating R901 refused IV removal three times during the shift. A Skin Assessment note dated 04/15/25, also authored by LPN D, stating IV has been removed. On 06/04/25 at 2:15 PM, the facility Director of Nursing (DON) was interviewed and reported they were not previously aware of the alleged situation of R901's IV not being removed. R901's progress notes were reviewed and the DON acknowledged there was no other documentation pertaining to the IV or its removal other than the previously referenced note authored by LPN D. The DON was asked the expectation regarding documentation of an IV removal and they reported their should be documentation specific to the date, time, and details of the IV removal procedure and acknowledged that this was not present. Review of the facility policy Removal of a Peripheral IV Catheter dated 06/2021, revealed the following instructions under the heading Documentation: 1. The following should be documented in the resident's medical recor .a. Date, time of procedure, and resident tolerance. 2. Location of catheter that was removed. 3. Reason for removal of catheter. 4. Any complications and interventions taken. 5. Any communication with physician or oncoming shift .

This citation is related to Intake MI00147487 Based on interview and record review, the facility failed to report an injury of unknown origin for one resident (R700) of three residents reviewed from abuse. Findings include: On 10/15/24 at 5:05 PM, R700 was interviewed via phone and explained on 9/20/24 two Certified Nurse Assistants (CNAs) were transferring R700 from their wheelchair to their bed and injured R700's toes. A review of R700's medical record revealed they were admitted to the facility on [DATE] with a diagnosis of Spinal Stenosis. A review of R700's Brief Interview for Mental Status (BIMS) revealed a score of 15 indicating intact cognition. Further review of R700s record revealed the following nursing progress note dated 9/20/24: Resident complained of hitting (their) right foot toe against the wheelchair when being transfer to bed. Writer and Nurse assistance transferred resident from the wheelchair to bed but did not observe resident hitting (their) toe. Writer assessed resident's foot for any swelling or bruising and none noted. Writer massaged resident's foot and toe for a relief. A review of a nursing progress note dated 9/23/24 16:52 by DON (Director of Nursing) revealed the following: Injury of unknown origin. Writer in to discuss resident's x ray of the right foot with resident. Resident reports during staff assisted transfer from the wheelchair to the bed on Friday afternoon, 'I heard a pop and pain in my right foot.' Writer question if right foot had bump against any objects or got caught on wheelchair or bed frame. Resident states, no that's what I do not understand. Resident reports while assisted were assisting her in pivoting to the bed (they) felt a pop. X rays were ordered and show: There are minimally displaced acute or recent appearing fractures of the fourth and fifth metatarsal necks. Likely old well healed fracture of the first proximal phalanx. Podiatry appointment has been ordered by NP (Nurse Practitioner) and is scheduled for Wednesday 9/25/2024. A review of the Incident and Accident (I&A) report revealed the following: Incident description: Resident reports that during staff assisted transfer from the wheelchair to the bed on 9/20/24 afternoon I heard a pop and I yelled out in pain. Resident reports the pain is in the right foot. Resident describes hearing pop in the foot during a transfer and experiencing pain. Resident reports (their) foot did not hit against anything and did not get caught on wheelchair or bed frame when writer asked these questions. Notes: Xray shows there are minimally displaced acute or recent appearing fractures of the fourth and fifth metatarsal necks. Statements: no statements found. Agencies/people notified: no notifications found. Notes: On 9/20/24 resident verbalized pain to the right foot. Pain medication adjusted per new order to alleviate pain and xrays ordered per new order. On 9/16/24 at 1:13 PM, during an interview, the Assistant Director of Nursing (ADON) was asked to describe the incident involving R700s injury. The ADON said they believed that during a staff assisted transfer R700 bumped (their) toes and that R700 reported it and that xrays were then taken. The ADON then read the I&A report and stated, It was not bumped that was my mistake so I'm not sure what happened to (their) foot. The ADON was then reviewed resident 700's Electronic Medical record and stated I'm looking for an injury or something. I don't see any lower body scans. I don't see any falls or anything. I don't know. The ADON confirmed there were no statements included from witnesses in the I&A report. The ADON explained when a resident has a new complaint of pain, it should be thoroughly investigated, a clinical work up should be done, and a thorough investigation into how it happened should be done. The ADON confirmed the incident was not reported to the state agency and stated, It was not reported because it was a known injury but it actually wasn't because (they) said (they) didn't bump it on anything so we don't actually know what happened to it. On 10/16/24 at 2:14 PM, during an interview, the Nursing Home Administrator (NHA) stated, Initially it seemed to be an injury of unknown origin. They were pivoting (R700) from wheelchair to bed. During the interviews with the resident, (they) had no explanation for it. No one, even the resident, could explain what happened. Bones break for no reason. The NHA confirms they would normally include interviews and statements from the involved staff in the investigation report and confirms that there are no staff interviews or statements included in the I&A report. The NHA confirmed the incident was not reported to the state agency.

This citation is related to Intake MI00147487. Based on interview and record review, the facility failed to investigate an injury of unknown origin for one resident (R700) of three residents reviewed from abuse. Findings include: On 10/15/24 at 5:05 PM, R700 was interviewed via phone and explained on 9/20/24 two Certified Nurse Assistants (CNAs) were transferring R700 from their wheelchair to their bed and injured R700's toes. A review of R700's medical record revealed they were admitted to the facility on [DATE] with a diagnosis of Spinal Stenosis. A review of R700's Brief Interview for Mental Status (BIMS) revealed a score of 15 indicating intact cognition. Further review of R700s record revealed the following nursing progress note dated 9/20/24: Resident complained of hitting (their) right foot toe against the wheelchair when being transfer to bed. Writer and Nurse assistance transferred resident from the wheelchair to bed but did not observe resident hitting (their) toe. Writer assessed resident's foot for any swelling or bruising and none noted. Writer massaged resident's foot and toe for a relief. A review of a nursing progress note dated 9/23/24 16:52, by the Director of Nursing (DON) revealed the following: Injury of unknown origin. Writer in to discuss resident's x ray of the right foot with resident. Resident reports during staff assisted transfer from the wheelchair to the bed on Friday afternoon, 'I heard a pop and pain in my right foot.' Writer question if right foot had bump against any objects or got caught on wheelchair or bed frame. Resident states, no that's what I do not understand. Resident reports while assisted were assisting her in pivoting to the bed (they) felt a pop. X rays were ordered and show: There are minimally displaced acute or recent appearing fractures of the fourth and fifth metatarsal necks. Likely old well healed fracture of the first proximal phalanx. Podiatry appointment has been ordered by NP (Nurse Practitioner) and is scheduled for Wednesday 9/25/2024. A review of the Incident and Accident (I&A) report revealed the following: Incident description: Resident reports that during staff assisted transfer from the wheelchair to the bed on 9/20/24 afternoon I heard a pop and I yelled out in pain. Resident reports the pain is in the right foot. Resident describes hearing pop in the foot during a transfer and experiencing pain. Resident reports (their) foot did not hit against anything and did not get caught on wheelchair or bed frame when writer asked these questions. Notes: Xray shows there are minimally displaced acute or recent appearing fractures of the fourth and fifth metatarsal necks. Statements: no statements found. Agencies/people notified: no notifications found. Notes: On 9/20/24 resident verbalized pain to the right foot. Pain medication adjusted per new order to alleviate pain and xrays ordered per new order. On 9/16/24 at 1:13 PM, during an interview, the Assistant Director of Nursing (ADON) was asked to describe the incident involving R700s injury. The ADON said they believed that during a staff assisted transfer R700 bumped (their) toes and that R700 reported it and that xrays were then taken. The ADON then read the I&A report and stated, It was not bumped that was my mistake so I'm not sure what happened to (their) foot. The ADON was then reviewed resident 700's Electronic Medical record and stated I'm looking for an injury or something. I don't see any lower body scans. I don't see any falls or anything. I don't know. The ADON confirmed there were no statements included from witnesses in the I&A report. The ADON explained when a resident has a new complaint of pain, it should be thoroughly investigated, a clinical work up should be done, and a thorough investigation into how it happened should be done. The ADON confirmed the incident was not reported to the state agency and stated, It was not reported because it was a known injury but it actually wasn't because (they) said (they) didn't bump it on anything so we don't actually know what happened to it. On 10/16/24 at 2:14 PM, during an interview, the Nursing Home Administrator (NHA) stated, Initially it seemed to be an injury of unknown origin. They were pivoting (R700) from wheelchair to bed. During the interviews with the resident, (they) had no explanation for it. No one, even the resident, could explain what happened. Bones break for no reason. The NHA confirms they would normally include interviews and statements from the involved staff in the investigation report and confirms that there are no staff interviews or statements included in the I&A report. The NHA confirmed the incident was not reported to the state agency.

This citation pertains to Intake MI00146357. Based on interview and record review, the facility failed to ensure call lights were answered timely for two sampled residents (R321 and R403) and five anonymous residents from a total sample of 20. Findings include: On 08/28/24 at 1:47 PM, during a group meeting, anonymous resident (AR) G reported they felt there were not enough aides most of the time and they were not answering call lights timely. AR H reported (certified nursing assistants) CNA's on the afternoon and night shifts were taking too long to answer call lights. AR I agreed and said some staff are on their phones talking instead of caring for residents. AR I also added weekends are a concern for call lights not answered timely. AR J commented staffing seemed worse than the last time they were at the facility. The residents reported call lights were not answered in a timely fashion, saying 10 minutes as reasonable. They indicated the wait time for answering call lights was getting longer. Another resident agreed stating, there are not as much staff as there was the last time I was here. Four of five residents attending agreed the afternoons and midnight shifts were the slowest to respond to call lights. A review of the call log for the room of ARJ for 08/24/24-08/27/24 documented: on 08/24/24 at 2:03 PM the call light was activated for 25 minutes and 54 seconds; On 08/25/24 at 11:18 AM the bed and bath call lights were activated for 15 minutes; At 7:18 PM the call light was activated for 16 minutes; On 08/27/24 at 3:04 PM the bed and bath call lights were activated for 10 minutes; and at 10 PM the call light was activated for 11 minutes. A review of the call log requested for room S308 from 08/01/24 - 08/23/24 documented: On 08/21/24 at 6:51 AM the call light was activated for 25 minutes; On 08/22/24 at 11:20 AM the call light was activated for 41 minutes; On 08/23/24 at 6:48 AM, the call light was activated for 28 minutes. 25 or more call light activations lasted longer than ten minutes. The facility provided the call light logs for R321 from 08/19/24 at 17:44:33 thru 08/27/24 at 22:00:39 which documented the call light was activated in room S308 166 times. Of 166 times, the call light was activated 18 time for greater than 10 minutes, and greater than 15 minutes 13 times. A review of the call logs for room C101 for June 2024 documented 50 or more call light activation times which lasted longer than ten minutes. Greater than ten call light activations lasted longer than 20 minutes. A review of the record for AR J revealed AR J was admitted into the facility 08/11/24. Diagnoses included Diabetes and Heart Disease. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and the need for substantial/maximal assistance for toileting hygiene, bathing and dressing and partial/moderate assistance for chair to bed transfer. A review of the record for AR H revealed AR H was admitted into the facility on [DATE]. Diagnoses included Heart Failure and Kidney Disease. The MDS date 08/16/24 indicated cognition, range of motion impairment to both upper extremities and the need for supervision/touching assistance for most activities of daily living (ADLs). A review of a complaint Intake for R403 documented, .(R403) pushed the button to be changed at 2:15 PM on 08/03/24 and waited an hour and a half in wet pants until 3:45 PM to be changed. A review of the facility call light log for that day documented (R403) activated the call light at 14:19 (2:19 PM) and was on for 12 minutes. Then at 15:07 (3:07 PM) for 10 minutes and at 21:17 (9:17 PM) for 17 minutes and 54 seconds. A review of the record for R403 revealed R403 was admitted into the facility on [DATE] and discharged [DATE]. Diagnoses included Malnutrition and Joint Disease. The Minimum Data Set (MDS) assessment dated [DATE] indicated moderately impaired cognition, frequent incontinence and dependent for toileting hygiene, chair to bed transfer, bathing and lower body dressing. On 08/29/24 around 11:00 AM, an interview with the Director of Nursing (DON) revealed that her expectation is that call lights will be answered within five minutes after the light is activated. The DON further revealed the activation does not distinguish between right or left beds in the room. The call light logs indicate whether the light was activated from a bed or bath. The DON further revealed if the call light was answered and the employee left the room after taking care of the residents needs, and the light is reactivated it may take longer because the employee is taking care of another resident. A review of the facility policy titled, Assessing Falls and their Causes updated May 2023 revealed, .Falls are a leading cause of morbidity and mortality among the elderly in nursing homes .Evaluate chains of events or circumstances preceding a recent fall, including .whether the resident was trying to get to the toilet . A review of the facility policy titled, Quality of Life-Accommodation of needs updated June 2021, revealed, .In order to accommodate individual needs and preferences staff attitudes and behaviors must be directed towards assisting residents in maintaining independence, dignity and well being to the extent possible and in accordance with the resident's wishes .

This citation pertains to Intake: MI00146299. Based on interview and record review, the facility failed to identify and address a significant weight loss for one resident (R309) of one reviewed for nutrition. Findings include: A review of R309's medical record revealed they were admitted into the facility on [DATE], and discharged on [DATE] with diagnoses of Vascular Dementia, Unspecified Severe Protein Calorie Malnutrition, and Heart Failure. Further review revealed that the resident was severely cognitively impaired, and required extensive assistance for bathing and bed mobility. R309 was independent with eating. Further review of R309's medical record revealed the following dietary progress notes: 7/1/2024 16:20 (4:20pm) Dietary Progress Note Admission: Resident is [identifying information] . Current diet is cardiac 2GM (gram) w/ HS (nighttime) snack offered. Resident has natural teeth in fair repair. Denies problems chewing, swallowing, or pocketing with meals but has a history of dysphagia & most recent hx (history) of weakness. Will add cut-up meats for ease Resident reports appetite is 'actually good.' Daughter in room reports resident received 8 oz (ounce) Ensure TID (three times a day) and would like to continue order. Will honor request. Resident's CBW (current body weight) is pending. Hospital weight was 104# (pounds). At a height of 64 (inches) BMI (body mass index) is 18.0, underweight. Resident's daughter reports resident's UBW (usual body weight) was 130# a year ago . hospital weight was 114#. An 8.7% loss in 2 weeks. Severe PCM (protein calorie malnutrition) related to CHF (congestive heart failure) as evidenced by a weight loss of 8.7% in 2 weeks, edema, PO (oral) intakes <75%. Food and beverage preferences obtained and documented. Menus were provided and explained. Dining room encouraged. Will monitor PO intake, tolerance to diet, labs, weight, skin, and adjust plan of care as needed. 7/9/2024 10:36 (10:36am) Dietary Progress Note: S: Resident observed resting. Family was able to provide information. Reports appetite fluctuates r/t (related to) food preferences and texture, tolerating Ensure TID. Discussed texture modification to promote ease of intake, declined at this time .A: CBW (current body weight) is 116.6# (lbs.) Severe PCM applicable. Hx of CHF and pulmonary edema, will increase weighing frequency to daily weights for close monitoring. Diet is non-therapeutic, cut meats thin liquids w (with)/ 8oz Ensure Plus TID with meals and HS snack offered. PO intake fluctuates 0 -100%, mostly 26-75% per record. P: Will monitor for changes and adjust plan of care PRN (as needed). Further review revealed the following care plan for R309, Focus: I have nutritional problem or potential nutritional problem (specify) r/t (related to) the need for a therapeutic diet. Date initiated: 07/01/2024 .Interventions .RD (registered dietician) to evaluate and make diet change recommendations PRN (as needed). Date Initiated: 07/01/2024 . A review of R309's weights revealed the resident did not get weighed daily as indicated by the dietician's progress note dated 7/9/24, and further revealed the following 15.09% weight loss in less than 30 days: 7/8/24-116.6 lbs 7/11/24-116.7 lbs 7/12/24-116.7 lbs 7/13/24-116.5 lbs 7/14/24-114.4 lbs 7/15/24-114.5 lbs 7/18/24 114.6 lbs 7/20/24-114.6 lbs 7/21/24-115 lbs 7/24/24-115.2 lbs 7/25/24-115.8 lbs 7/26/24-103 lbs 7/28/24-103 lbs 7/29/24-104.2 lbs 7/30/24-100.2 lbs 8/2/24-99 lbs On 8/29/24 at 11:43 AM, an interview was completed with Dietician C regarding R309's weight loss, and it not being addressed after a 15.09% weight loss. Dietician C reviewed the resident's medical record and acknowledged the resident's progress notes indicate the edema had resolved, and the resident was no longer on diuretics. She further explained the resident did have a history of edema, and because the resident's intake was good, the issue of weight loss didn't get brought o her attention. No further explanation was provided. On 8/29/24 at 2:02 PM, the Director of Nursing (DON) was asked about R309's weight loss not being addressed, and admitted she couldn't recall the resident being brought up in the IDT (interdisciplinary) meeting. Regarding the relaying of communication when weight loss is triggered, the DON explained an alert in red shows up on the electronic medical record, and this is when it is typically addressed. A review of the facility's Weight Monitoring policy revealed the following, .A weight monitoring scheduled will be developed upon admission for all residents based on individual needs. Updated as clinically indicated. 6. Weight analysis: A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days). b. 7.5.% change in weight in 3 months (90 days). c. 10% change in weight in 6 months (180 days) .

This citation has two deficient practices. Deficient practice number one: Based on observation, interview and record review, the facility failed to ensure opened biologicals, inhalers and or eyedroppers were labeled with the date opened and or a resident identifier in four of four medications carts reviewed. Findings include: On 08/28/24 at 8:55 AM, the C100 wing medication cart was reviewed with Licensed Practical Nurse (LPN) A. A Trelegy Inhaler was not dated with the opened date nor a resident identifier. On 08/28/24 at 9:52 AM, the B100 medication cart was reviewed with LPN D. A Trelegy inhaler was not labeled on the actual inhaler with the date opened nor a resident identifier. The box was also not dated with the date opened. On 08/28/24 at 9:45 AM, the S300 Hall medication cart was reviewed with Registered Nurse (RN) F. Medications identified without open dates were: Two eyedroppers of Latanoprost; One eyedropper bottle of artificial tears; One eyedropper bottle of Moxicillin and one Advair inhaler. RN F reported the expectation is that the open dates should be on all of the listed medication. On 08/28/24 at 11:48 AM, the B300 wing medication cart was reviewed with LPN E. A Trelegy inhaler was not dated when opened on the actual inhaler. A second Trelegy inhaler was not dated when opened and was not labeled with a resident identifier on the actual inhaler. LPN E reported that the protocol is to label and date the actual inhaler. On 08/29/2024 around 11:00 AM, the Director of Nursing (DON) reported eyedropper bottles, insulins (pens or vials), and respiratory medication devices should be labeled with the date opened. A review of the facility's Storage of Medications policy, updated February, 2023 revealed, Policy Statement. The facility stores all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner . A review of the information at Drugs.com revealed: for the Trelegy, Trelegy Ellipta should be discarded in the trash 6 weeks after first use OR when the counter reads 0 which means you are out of medicine, whichever occurs first; and for the Lantanoprost, Once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 weeks. 40384 Deficient practice number two: Based on observation, interview, and record review, the facility failed to ensure resident medications were not left at the bedside for two residents (R2 and R317) of three residents reviewed for medication storage. Findings include: R2 On 8/27/24 at 9:41 AM, R2 was observed lying in bed in their private room. A medication cup containing a white pill was observed on their overbed table. R2 was asked about the medication cup and explained that they had been in therapy, and the medication must have been left for them upon their return. At this time, R2 immediately took the medication cup and swallowed the medication. R2 was again asked if they knew what was in the cup and stated, No, but I guess it's for me since it was left there. On 8/27/24 at 9:55 AM, Licensed Practical Nurse, (LPN) A was asked about the medication left at the bedside and explained that she did not leave any medications at the beside. Surveyor and LPN A entered R2's room at which time, LPN A questioned the resident about the medication. R2 confirmed they had received medications prior to therapy however, upon returning to their room, the medication was sitting on their bedside table, and consumed it. At this time, an unidentified peach colored pill was located on the floor of R2's room. LPN A and R2 denied knowing who the pill belonged to or where it came from. A review of R2's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that include Hypokalemia, Diabetes, and Muscle Weakness. Further review revealed that the resident was cognitively intact however, there was not a self-administration assessment completed for the resident. 49699 R317 On 8/26/2024 at 10:28 AM, two bottles of Flonase were observed on the bedside table of R317. R317 was asked where the medication came from, the response indicated that R317 was admitted the night before between 6:00 PM and 7:00 PM and the Flonase bottles were left there. A review of the facility record revealed R317 was admitted into the facility on [DATE]. R317's diagnoses included: Morbid Obesity, Toxic Encephalopathy, Diabetes Mellitus-Type 2, Major Depressive Disorder, Fibromyalgia, Hypertension, Urinary Retention, History of Malignant Neoplasm of Breast, History of Left Artificial Knee Joint, Obstructive Sleep Apnea, Rhabdomyolysis, Low Back Pain, and Muscle Weakness. On 8/29/24 at 2:27 PM, the Director of Nursing (DON) was interviewed regarding the observation of medications being left at the bedside. The DON explained that medications are not supposed to be left at the bedside. A review of the facility's Storage of Medications policy was reviewed and revealed the following, Policy Statement. The facility stores all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner .

This citation pertains to Intake: MI00146299. Based on observation, interview and record review, the facility failed to ensure proper donning of Personal Protective Equipment (PPE) for droplet precautions for one sampled resident (R261) of one resident reviewed for infection control practices, resulting in the potential for the spread of infection. Findings include: On 8/27/24 at 1:15 PM, Staff M was observed entering R261's room without donning Personal Protective Equipment (PPE) to remove R261's lunch tray. The room of R261 had a sign on the door for Droplet Transmission Based Precautions and a hanging drawer with necessary equipment and supplies to don. R261 was admitted on [DATE] with the diagnoses of Covid -19, Acute Kidney Failure, and Congestive Heart Failure. A review of the medical record noted R261 was on droplet contact precautions for diagnosis of Covid-19. Further review of R261's medical record revealed a physician order dated 8/25/24 stated Resident is to remain in the room. Full droplet and contact precautions every shift for Covid positive. On 8/29/24 at 10:00 AM, an interview occurred with the Infection Control Nurse (Nurse L). Nurse L was asked about staff donning PPE when entering a resident's room on droplet precautions. Nurse L stated, Full Personal Protection Equipment should be worn when entering the resident's room when signage indicates the same. A review of the facility policy titled, Transmission Based Precautions Policy and Procedure updated 7/22 revealed, Transmission Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection, arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that are generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning .Masks will be worn in the room when entering the room. Gloves, gown, and goggles should be worn when entering the room.

This citation pertains to Intake MI00140765. Based on interview and record review, the facility failed to ensure labs were reviewed and available in the record timely for one resident (R901) of three resident reviewed for labs, resulting in a delay in treatment and hospitalization . Findings include A review of an Intake for R901 revealed, R901 looked awful and we wanted (R901) transferred to the hospital. The emergency room physician at the hospital reported (R901) was dehydrated (the place should have known that) and their blood sugar was so high they put (R901) on insulin and (R901) stayed in the hospital for 3 days to bring it down. The Intake further noted R901 had been incontinent of urine and stool and had not been changed timely. A review of the record for R901 revealed: R901 was admitted into the facility 08/30/23. Diagnoses included Dementia, Diabetes, Right Hip Fracture and Weakness. R901 was discharged to the hospital on 09/15/23. A review of the lab result dated 09/01/23 (white blood cell count (WBC) - leucocytes) was 18.7 (normal range 3.4 to 9.6). A review of the lab was not documented until the Nurse Practioner (NP) note dated 09/08/23 at 7:24 AM. A review of the lab result dated 09/08/23 documented the WBC was 20.8. The blood sugar was 235 (normal range 80 to 140). A review of the lab result was not documented as reviewed until 09/14/23. The NP note dated 09/14/23 at 8:19 AM documented the repeat lab 09/08 pending. The note further documented resident family concern for R901 and symptoms of a urinary tract infection. A review of the 23 documented blood sugar checks listed, four were less than 200, seven were greater than 250 and four of those were greater than 300. On 09/15/23 at 9:30 AM the blood sugar was documented at 276. A review of the physician orders and medication administration record revealed R901 was not on insulin. The care plan initiated 08/31/23 documented, I have a risk of dehydration .I have a nutritional or potential nutritional problem related to malnutrition .I have a communication problem related to my ability to understand and be understood .I have an ADL (activities of daily living) self care deficit related to limited mobility . The physician order for the antibiotic Ceftriaxone prescribed for the leucocytosis (high white blood cell count indicative of infection) was ordered 09/14/23. On 03/07/24 at 3:55 PM, Unit Manager D reported there was a time when labs were delayed and recalled the September 2023 time frame. On 03/07/24 at 4:43 PM, the Director of Nursing (DON) was asked about the identified labs and reported that the facility had changed labs it was noticed that it took an extensive amount of time for the lab results to be received. A review of the facility policy titled, Lab and Diagnostic Test Results update June 2021, revealed, .Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results .whether the result should be conveyed to a physician regardless of other circumstances, that is the abnormal result is problematic regardless of any other factors .

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 88 residents who receive meal services. Findings include: On 9/19/2023 at 10:51 AM, the surveyor inquired with Registered Dietitian, staff G, if they could test the sanitizing solution of a wiping cloth bucket to verify its concentration to which they replied, yes. On 9/19/2023 at 10:52 AM, testing of the quaternary ammonium sanitizer concentration at the cooking station by staff G via a test strip revealed a concentration of zero. Upon observation staff G stated, that's strange. Let me check the 3-comparment sink. On 9/19/2023 at 10:54 AM, testing of the quaternary ammonium sanitizer concentration in the 3-comparment sink by staff G via a test strip revealed a concentration of zero. Upon observation Executive Chef, staff I, stated, I'll make new sanitizer from our dispenser. On 9/19/2023 at 10:56 AM, testing of the newly dispensed quaternary ammonium sanitizer concentration by staff I via a test strip revealed a concentration of zero to which they stated, I'll call my chemical company right now to fix this. At this time the surveyor inquired with both staff G and staff I on if they kept logs to monitor and verify the sanitizer's proper concentration to which they both replied, not for this, just the dish machine. At this time staff I stated, We will mix the solution by hand and re-test it. On 9/19/2023 at 11:08 AM, Staff I showed the surveyor a test strip revealing a concentration of 200-300 parts per million of quaternary ammonium for the sanitizing solution taken from the 3- compartment sink. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization Temperature, pH, Concentration, and Hardness directs that: A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under S7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), (2) Have a concentration as specified under S 7-204.11 and as indicated by the manufacturer's use directions included in the labeling, P

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 88 residents. Findings include: On 9/19/23 between 9:30 AM and 1:00 PM, numerous live flies were observed in the kitchen's dishwashing area, around the serving line, janitor's closet, dry storage room, food preparation tables, and in the clean equipment storage areas. On 9/19/23 at 9:43 AM, the surveyor inquired with Registered Dietitian, staff G, on the current state of the insects in the kitchen to which they replied, the flies are coming from our drains. We have a company that comes and treats the building for them, but they keep coming back. At this time the surveyor requested the facility's pest control policy to review. On 9/19/23 at 2:09 PM, record review of the most recent pest service inspection report dated 8/22/23, revealed that multiple areas of the facility are currently being treated for insects and rodents. On 9/19/23 at 2:19 PM, upon interview with Maintenance Director, staff H, the surveyor inquired who is responsible for monitoring and informing the Maintenance staff of pest concerns throughout the facility so they may contact the pest control company to schedule a treatment, to which they replied, everyone. Review of 2017 U.S. Public Health Service Food Code, Chapter 6-501.111 Controlling Pests, directs that: The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (B)Routinely inspecting the PREMISES for evidence of pests; (C)Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS 7-202.12,7-206.12, and 7-206.13; Pf

This citation pertains to intake MI00137274 Based on observation, interview, and record review the facility failed to ensure that activities of daily living care (ADLs) was provided for dependent residents (R160, R164, R165, R459, R460, and three confidential group residents), of eight residents reviewed for ADLs, resulting in dissatisfaction with care and services. Findings include: R160 On 9/18/23 at 9:32 AM, during an initial tour of the facility R160 was interviewed about the care they received at the facility and indicated that staff frequently fail to assist them with toileting in a timely manner. R160 stated, They turn my call light off and tell me that they have other things to do. On 9/20/23 at 9:00 AM, a review of R160's electronic medical record (EMR) revealed that R160 was admitted to the facility on [DATE] with diagnoses that included Hypertension and Hyperlipidemia (elevated level of fats, cholesterol, or triglycerides). R160's most recent minimum data set assessment (MDS) dated [DATE], revealed that R160 had an intact cognition and required two person extensive assistance for toileting. R164 On 9/18/23 at 10:31 AM, during an initial tour of the facility R164 was interviewed about the care they received at the facility and indicated that they frequently have to wait up to an hour for staff to assist them with toileting. On 9/20/23 at 9:12 AM, a review of R164's EMR revealed that R164 was admitted to the facility on [DATE] with diagnoses that included Arthrodesis (joint fusion) and Depressive disorder. R164's most recent MDS dated [DATE] revealed that R164 had an intact cognition and required two person extensive assistance for toileting. R165 On 9/18/23 at 10:46 AM, during an initial tour of the facility R165 was interviewed about the care they received at the facility and indicated that they frequently have to wait up to forty five minutes for toileting assistance. On 9/20/23 at 9:20 AM, a review of R165's EMR revealed that R165 was admitted to the facility on [DATE] with diagnoses that included Depressive disorder and Hypertension. R165's most recent MDS dated [DATE] revealed that R165 had an intact cognition and required two person extensive assistance for toileting. On 9/18/23 at 3:34 PM, resident council meeting notes were reviewed for the months of April 2023-August 2023 and revealed the following, Resident Council Meeting .May 2023; Name of Resident(s) Reporting Concern: [Four group residents]; Written Description of Concern: Sometimes CNAs (certified nursing assistants) come turn off call-light and say they will be back, they come back but not for 30 min (minutes). Resident Council Meeting .August 30th; Name of Resident(s) Reporting Concern: all residents in meeting; Written Description of Concern: Please have the staff that bring food trays to resident's rooms set-up tray; open condiment packets, make sure the resident's food is correct and see if the resident needs anything before leaving the room. On 9/19/23 at 1:35 PM, a confidential group meeting was conducted with seven confidential group residents. The group was asked about care at the facility and three of the group members indicated that they wait up to two hours for a brief change. They also indicated that the CNAs frequently turn off their call light, leave their room, and do not return to assist them. All group members indicated that meal set up was not provided by the CNAs. One group member stated, They drop the tray off and leave. On 9/20/23 at 9:20 AM, CNA K was interviewed about their ability to be able to provide ADL care for their assigned residents. CNA K indicated that they frequently had to work late to Get my assignments done for my residents. On 9/20/23 at 1:34 PM, aOn 9/20/23 at 9:20 AM, CNA K was interviewed about their ability to be able to provide ADL care for their assigned residents. CNA K indicated that they frequently had to work late to Get my assignments done. 44750 R460 On 9/18/2023 at 9:29 AM, R460 was observed in their bed with their call light activated. R460 was heard telling staff that they wanted to get out of bed and brush their teeth and wash their face. R460 call light was deactivated and they were told to give them one minute. On 9/18/2023 at 10:59 AM, R460's call light was observed activated. R460 was observed dressed in bed. On 9/18/2023 at 12:34 PM, an interview was conducted with Family Member (FM) M. FM M: stated that R460 was waiting to be picked up by transportation for an appointment. FM M stated that R460 wanted to get up in their chair prior to their appointment but was told that they did not have anyone to help them get up at the time. FM M stated that R460 was unable to go to therapy prior to their appointment because they were not up in the wheelchair. On 9/18/2023 at 3:18 PM, R460's call light was observed activated. Certified Nursing Assistant (CNA) F was observed talking to FM M regarding their call light. CNA F was observed telling FM M that R460's call light was activated prior to them starting their shift. CNA F stated that they were going to finish getting vital signs on other residents and then come back and render care to R460. On 9/18/2023 at 3:21 PM, an interview was conducted with FM M and asked how long they had been waiting for R460 to be changed. FM M stated that they had been waiting almost 40 minutes for R460 to be changed after having a bowel movement. On 9/18/2023 at 3:30 PM, Licensed Practical Nurse (LPN) D was observed coming in with CNA F to change R460. On 9/20/2023 at 10:54 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they had spoken to the staff regarding not changing R460 immediately and that the nurse did correct the situation and speak with the CNA as well. The DON stated that that should not have been said to R460. On 9/20/2023 during Quality Assurance Performance Improvement meeting with the Assistance Director of Nursing (ADON). The ADON stated that they have a call light Performance Improvement Plan (PIP) in place for call lights. The ADON stated that the expectation is that the call light is not turned off until the care is provided. R459 On 9/19/2023 at 11:22 AM, R459 was observed in their chair dressed. R450 stated that they had a hard time getting help this morning and receiving help. R459 stated that they asked if they were getting a shower before getting dressed and was told that it would be after lunch maybe, but they had to get dressed first so they could go to therapy. R459 stated that their Certified Nursing Assistant (CNA) was the one to tell them this. On 9/19/2023 at 2:31 PM, R459 stated that they still had not received their shower and they wanted one so they could get their leg rewrapped and their bandages changed. On 9/20/2023 at 8:12 AM, R459 was asked if they received their shower the day prior. R459 stated that they never received a shower and was never told why. A review of the medical record revealed that R459 admitted into the facility on [DATE] with the following diagnoses, Chronic Obstructive Pulmonary Disease, Difficulty in Walking, and Muscle Weakness. A review of the Minimum Data Set Assessment revealed a Brief Interview for Mental Status Score of 15/15 indicating an intact cognition. R459 also required extensive one person assistance with bed mobility and transfers. Further review of the master shower schedule revealed that R459 shower days were Tuesday and Friday mornings. Further review of the shower documentation task revealed Not Applicable for 9/19/2023. A review of the progress notes revealed the following, 9/20/2023 10:22. Nursing Progress Note: Note Text: This writer spoke with assigned cena (Certified Nursing Assistant) for 9/19-day shift. Resident would not allow cena to speak to [them] regarding shower and daily adls (Activities of Daily Living). Res (Resident) told cena to leave that [they] didn't like [their] attitude and didn't want [them] in [their] room. On 9/20/2024 at 10:54 AM, an interview was conducted with the Director of Nursing (DON) regarding showers. The DON stated that R459 should have received their shower. The DON stated that the nurses usually do a note when there is a behavior and usually if a resident has a problem with a certified nursing assistant, then the patient will switch out with another staff member. On 9/20/2023 during Quality Assurance Performance Improvement meeting with the Assistance Director of Nursing (ADON). The ADON stated they the facility has a shower team that covers the entire building. The ADON stated that the general expectation is that residents receive a shower twice a week and adjusted per resident preference. A review of a facility policy titled Activities of Daily Living (ADLs) Supporting Updated June, 2021 was reviewed and stated the following, Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition .and personal hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: c. Elimination (toileting); d. Dining (meals .);

Based up interview and record review, the facility failed to ensure timely completion of the annual Preadmission Screening/Annual Resident (PASARR) Mental Illness/Intellectual Disability/Related Conditions identification forms DCH-3877 and/or DCH-3878 documents for submission to the local state agency for evaluation of mental illness and/or intellectual development disability needs for one (R54) of six residents reviewed for PASARR completion, resulting in the potential for unmet mental health care needs. Findings include: Review of the facility record for R54 revealed an admitted [DATE] with diagnoses that included Neurocognitive Disorder, Anxiety Disorder, Major Depressive Disorder, Mood Disorder and Psychotic Disorder with Hallucinations. The Minimum Data Set (MDS) assessment dated [DATE] indicated R54 required primarily Maximum/Total assistance with activities of daily living (ADLs). The Brief Interview for Mental Status (BIMS) assessment score of 4/15 indicated severe cognitive impairment. On 09/19/23 at 9:40 AM, review of R54's facility record revealed PASSAR documentation completed in January 2022 near the time of admission and no further PASSAR documents were identified since admission. On 09/20/23 at 10:20 AM, the facility Social Services Department was notified of the issue and any additional PASSAR documentation for R54 was requested. On 09/20/23 at 10:51 AM, the facility Social Services Director J reported that they reviewed R54's record and there was not an updated PASSAR completed. Social Services Director J reported that their expectation for PASSAR completion is that it be completed at admission, annually thereafter, and following any return from hospitalization /discharge or significant change in status. Social Services Director J acknowledged that the annual PASSAR had not been completed for R54. Review of the facility policy titled Behavioral Health Services dated 10/22 includes the following description under Policy Explanation and Compliance Guidelines: 6. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. This process includes, but is not limited to: a. PASARR screening. Review of the Michigan Department of Health and Human Services PASSAR document DCH-3877 Level 1 Screening (Revised 3/22) includes the following statement: Annual Resident Review or Change in Condition: This form must be completed by the nursing facility.

Based on observation, interview, and record review, the facility failed to develop a care plan for an indwelling catheter for one resident (R460) out of two reviewed for care plans resulting in the potential for unmet care needs. Findings Include: On 9/18/2023 at 9:10 AM, R460 was observed in bed with an indwelling catheter hooked on the side of the bed. R460 was asked how long they had the indwelling catheter, but they were unable to recall. On 9/18/2023 at 12:30 PM, an interview was conducted with Family Member (FM) M. FM M was asked how long R460 had the indwelling catheter. FM M stated that R460 had the catheter placed while they were in the hospital because they were retaining urine. FM M stated that R460 had not seen a urologist and that they had been inquiring about if it could be removed. FM M stated that there has been blood observed in the catheter on numerous occasions and the facility has had to replace it. A review of the medical record revealed that R460 admitted into the facility on [DATE] with the following diagnoses, Urinary Tract Infection, Pressure Ulcer of Sacral Region, Unstageable, and Retention of Urine. A review of the most recent Minimum Data Set revealed a Brief Interview of Mental Status score of 7/15 indicating an impaired cognition. R460 also required extensive two person assist with bed mobility and transfers. On 9/5/2023, a review of the care plan did not reveal a care plan with interventions for the indwelling catheter. On /20/2023 at 10:54 AM, an interview was conducted with the Director of Nursing (DON) regarding R460 not having a care plan for their indwelling catheter. The DON stated that Unit Manager (UM) M was developing one now. The DON stated that their expectation is that a care plan had been developed for their indwelling catheter. A review of a facility policy titled, Care Plans, Comprehensive Person-Centered revealed the following, Policy Interpretation and Implementation .1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Based on observation, interview, and record review, the facility failed to implement a care plan intervention of applying a hip abductor for one resident (R461) out of two reviewed for care plans, resulting in improper positioning and discomfort. Findings Include: A review of the medical record revealed that R461 admitted into the facility on [DATE] with the following diagnoses, Presence of Left Artificial Hip Joint, and History of Falling. A review of the most recent Minimum Data Set revealed a Brief Interview for Mental Status score of 5/15 indicating an impaired cognition. R461 also required extensive two person assist with bed mobility and transfers. Further review of the medical record revealed the following care plan initiated on 9/15/2023, Focus: I have an ADL (Activities of Daily Living) Self Care Performance Deficit r/t (related to) Limited Mobility. Goal: I will maintain/improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene through the review date. Intervention .L THA (Left Hip Abductor), WBAT (Weight Bearing as Tolerated), ABD(Abdominal) Cushion when in bed. Further review of the physician orders revealed the following, Ordered 9/18/2023 .L THA, WBAT, abduction cushion when in bed. Status: Active. On 9/18/2023 at 9:30 AM, R461 was observed in their bed. No hip abductor observed in place. On 9/19/2023 at 8:46 AM, R461 was observed in their bed. R461 was saying that they were uncomfortable. A blue cushion was observed sitting on the floor by the window. On 9/19/2023 at 9:41 AM, R461 was observed in their bed. The blue cushion was still observed on the floor by the window. On 9/19/2023 at 11:54 AM, R461 was observed returning from therapy. Physical Therapist Assistant (PTA) A was asked if the blue cushion sitting by the window was the hip abductor. PTA A stated that it was. On 9/19/2023 at 2:34 PM, R461 was still observed up in their chair. R461 stated that they were comfortable at the time. On 9/19/2023 at 4:08 PM, R461 was observed in the bed. The hip abductor was not in place and observed in R461's closet. On 9/20/2023 at 8:11 AM, R461 was observed in the bed. The hip abductor was not in place and observed in the closet. R461 stated that they were uncomfortable. On 9/20/2023 at 8:27 AM, an interview was conducted with Occupational Therapist (OT) B. OT B stated that staff on the floor are responsible for placing the hip abductor. OT B stated that therapy completes the care plan. On 9/20/2023 at 10:54 AM, an interview was conducted with the Director of Nursing (DON) regarding the application of the hip abductor while in bed. The DON stated that floor staff is responsible for putting the hip abductor in place when they lay her down. The DON stated that it is also in the task for the Certified Nursing Assistants (CNA) to document on as being completed. A review of a facility policy titled, Care Plans, Comprehensive Person-Centered revealed the following, Policy Interpretation and Implementation .2. The care plan interventions are derived from a through analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 (a severe and highly contagious respiratory infection) by allowing a staff member who screened positive for COVID-19 symptoms on 12/29/2020 (cough, shortness of breath, sore throat, headache) to work and provide direct patient care for a full shift on the B-Wing. The employee subsequently tested positive for COVID-19 on 12/30/2020. The facility has had 26 residents (#'s 500, 501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522, 523, 524, 525) test positive for COVID-19 since 12/28/20. Additionally, the facility failed to ensure full personal protective equipment (PPE) (masks, gowns, gloves, face shields/goggles) was utilized by staff for new admissions into the facility per Centers for Disease Control and Prevention (CDC) guidance. This deficient practice resulted in sustained spread of COVID-19 and the likelihood for continued transmission of COVID-19 to all facility residents and staff, decline in overall health, serious illness, and/or death. The Immediate Jeopardy (IJ) started on 12/29/2020 and was identified on 1/25/2021. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 1/25/2021 and was asked for a plan to remove the immediacy. The IJ was removed on 1/25/2021, based on the facility's implementation of the removal plan as verified onsite on 1/26/2021. Although the immediacy was removed, the facility's deficient practice remained as a pattern, actual harm that is not immediate jeopardy. Findings include: On 1/25/21 at 9:49 AM, during the initial tour, the Director of Nursing (DON) explained that the most recent COVID-19 outbreak in the facility started with a staff member and five residents who tested positive for [MEDICAL CONDITION] starting on 12/28/20. The DON indicated that the facility had traced and figured to the best of their ability that the outbreak started around the time when Certified Nursing Assistant (CNA) G, who worked in the B-Wing, tested positive for COVID-19. The DON indicated that as of today (1/25/21) there were 11 residents in the facility's designated COVID-positive unit and that there have been five resident deaths (who were COVID positive) since the outbreak. On 1/25/21 at 10:10 AM, a tour of the S-Wing was conducted. The DON indicated that the S-Wing is the facility's transition unit, holding residents who have completed their 14-day quarantine after admission as well as newly admitted residents under quarantine. Upon touring the three S-Wing hallways, it was noted that gowns were not being utilized by staff when entering patient rooms. Multiple staff were observed wearing KN95 masks with goggles or face shields. There was no signage present indicating which rooms housed newly admitted residents under the 14-day quarantine period and those who were no longer under 14-day observation. CNA H was interviewed and queried regarding PPE utilized in rooms for newly admitted residents. CNA H indicated the staff wear goggles/face shields, masks, gloves if needed, but not gowns. On 1/25/21 at 10:20 AM, Physical Therapy Assistant (PTA) I was queried regarding PPE utilized for the S-Wing. PTA I stated, Masks and goggles or shield. Gloves for skin contact or toileting. When queried regarding residents wearing a mask in their room, PTA I stated, They don't need a mask in the room. We can bring them out with a mask on for therapy only, and they can use the (exercise) bike by the nurses' station with a mask on. On 1/25/21 at 10:22 AM, an unidentified housekeeper was observed cleaning room S304 with no gown on. The S-Wing rooms were noted to not be marked individually regarding quarantine status. On 1/25/21 at 10:57 AM, CNA G was interviewed via phone regarding testing positive for COVID-19. CNA G indicated that the DON had gotten the message that they were COVID-19 positive on 12/30/20 and they were sent home. When queried regarding any COVID-19 symptoms, CNA G stated, Primarily upper respiratory, the doctor thought it was an upper respiratory infection. I was having trouble breathing and nasal congestion and sore throat .(Started) right around the 29th (December) or so. When queried if they informed the facility about their symptoms and put it on their screening form, CNA G stated, Yes. I'm prone to sinus infections so I didn't think anything of it, I wasn't running a temperature. CNA G was then queried about how the facility responded to their screening form having positive COVID-19 symptoms noted. CNA G indicated they did not remember who screened them and believed that the screener contacted someone about the symptoms. When queried if they had told anyone else about their symptoms, such as a nurse or manager, CNA G stated, No. Well, I told them I had a cough and that. They told me to make sure I was wearing my mask and wash my hands and proper infection control. CNA G indicated they worked on the B-Wing on 12/29/20 for a full shift. CNA G indicated they had worn a KN95 mask with goggles over their glasses. CNA G was asked if any residents they worked with ended up testing positive for COVID-19 and responded, I heard residents on my set became positive but don't know which ones. When queried if the residents on the B-Wing wore masks when receiving care, CNA G stated, For the most part they didn't wear them because it's a behavioral unit (long-term care/dementia residents), and it's hard to get them to wear (masks) but we try to encourage it. One or two (wandered) around the unit. On 1/25/21 at 11:42 AM, the DON, who had been overseeing the infection control program, and newly hired Infection Preventionist (IP) were interviewed. The DON again explained the belief that the ongoing COVID-19 outbreak in the facility could be traced back to CNA G, as that staff member had tested positive for COVID-19 on 12/30/20 and had worked on the B-Wing, where the first COVID-19 positive residents started appearing. The DON was queried which days CNA G worked in December 2020 around the start of the outbreak. The DON checked OnShift (scheduling program) and explained that on 12/23/20 and 12/28/20, CNA G had tested negative for COVID-19 during routine testing. The DON stated that according to the schedule, CNA G worked 12/26, 12/27, was off on 12/28 but came in for testing, worked 12/29, and came in for work on 12/30. The DON further explained that CNA G clocked in at 2:40 PM on 12/30 and was sent home at 4:00 PM after the positive COVID test result. The DON stated that CNA G did not work on the floor with residents on 12/30. When asked if CNA G reported any signs/symptoms consistent with COVID-19 prior to the positive test, the DON stated, (They) did not. Verbally (they) complained of sinus congestion when I told (them) about the positive test. The DON and IP were then asked to see CNA G's entrance screening forms from 12/28/20, 12/29/20, and 12/30/20, which were provided. Upon review, the following was noted: 12/28/20: CNA G marked Yes, to the questions, In the past 14 days, have you had any contact with someone with/under investigation for COVID-19, or are ill with respiratory illness? and Do you have a cough? The answer No, was checked off, dated 12/28/20, and signed by the screener (Staff J) to the question, Visitation denied/work restricted. 12/29/20: CNA G marked Yes, to the questions, In the past 14 days, have you had any contact with someone with/under investigation for COVID-19, or are ill with respiratory illness?, Do you have a cough?, Are you experiencing shortness of breath, Do you have a sore throat?, and Do you have a headache? CNA G wrote, Recently, to the question, Onset and duration of symptoms. The answer No, was checked off, dated 12/29/20, and initialed by the screener (Staff L) to the question, Visitation denied/work restricted. 12/30/20: CNA G marked Yes, to the questions, In the past 14 days, have you had any contact with someone with/under investigation for COVID-19, or are ill with respiratory illness?, Do you have a cough?, Are you experiencing shortness of breath, Do you have a sore throat?, and Do you have a headache? CNA G wrote, Recent sinus infection, to the question, Onset and duration of symptoms. The answer No, was checked off, dated 12/30/20, and signed by the screener (Staff J) to the question, Visitation denied/work restricted. CNA G's COVID-19 test result was reviewed from 12/30/20 and was noted to be positive. A review of the facility's log of COVID-19 positive staff, CNA G was noted on the log to have a positive test result on 12/30/20 with, Cough, sinus pressure. Eight staff were noted to have tested positive for COVID-19 after 12/30/20, including B-Wing staff CNA O testing positive on 1/11/21, and Unit Manager N testing positive on 1/18/21. The DON was then asked to review CNA G's screening form dated 12/28/20. The DON indicated she did not know a cough was marked down as a symptom that day and stated that CNA G tested negative for COVID-19 on 12/28/20. The DON then reviewed CNA G's screening form dated 12/29/20. The DON acknowledged the symptoms marked and indicated she had not been aware CNA G was experiencing those symptoms. The DON was asked if CNA G should have been allowed to work that day and stated, No. We would have done another rapid test. On 1/25/21 at 12:15 PM, the DON and IP continued to be interviewed. When queried regarding the most recent positive COVID-19 cases in the building, the DON stated, We had positives last week on B-Wing. When queried when the last admissions to the facility were, the DON indicated the facility admitted three residents on 1/22/21 and two residents on 1/21/21 to the S-Wing. The DON was queried regarding PPE use for new admissions into the facility and stated, KN95 (masks) and goggles, (with the new residents) in private rooms. Every resident is screened for COVID-19 (symptoms) twice a day. When queried regarding using full PPE including gowns when caring for newly admitted residents, the DON stated, We are not using gowns for new admits, I didn't know they were supposed to be using those. The DON was asked if any residents on the S-Wing were recently found to be COVID-19 positive and stated, No. Well one of the positives (resident) was on S-Wing at the time (of the positive test). (They were) tested because (they) went out for an appointment but was originally on the B-Wing (Resident #517). Everyone else (who has tested positive for COVID-19) since 12/28 had been on B-Wing. Upon review of the facility's COVID-19 policy/procedure, it was noted to have information regarding admitting residents into the facility, testing, and to monitor for COVID-19 symptoms, but did not include what PPE to wear. The DON confirmed there was no PPE information specific to new admissions in the policy and stated, We do have KN95s and goggles on everyone in the building. The DON indicated that on 12/31/20, the residents on the B-Wing were rapid tested for COVID-19 but no positive results or symptoms consistent with COVID-19 were found, and the entire B-Wing was placed under droplet transmission-based precautions on 1/7/21. A review was conducted of the list provided by the DON of residents who recently tested positive for COVID-19. The following B-Wing residents tested positive on the following dates per the facility-provided log: 500: 12/28/20 501: 12/28/20 (per DON, 12/28 is the wrong date, the resident rapid tested positive on 12/31) 502: 12/28/20 503: 12/28/20 504: 12/28/20 505: 1/5/21 506: 1/6/21 507: 1/6/21 508: 1/6/21 509: 1/6/21 510: 1/8/21 511: 1/8/21 512: 1/12/21 513: 1/12/21 514: 1/13/21 515: 1/13/21 516: 1/12/21 517: 1/13/21 518: 1/13/21 519: 1/12/21 520: 1/13/21 521: 1/14/21 522: 1/18/21 523: 1/18/21 524: 1/18/21 525: 1/18/21 On 1/25/2021 at 12:43 PM, the screener who initialed CNA G's screening form on 12/29/20, Staff L, was interviewed. Staff L was asked to review CNA G's screening form and was asked if they knew why they had permitted CNA G to work on 12/29/20 despite indicating symptoms consistent with COVID-19 on the form. Staff L stated, I do not (know why). I probably did not check it. I would have notified (the DON) and had (CNA G) get a rapid test. But it looks like I probably didn't check it. The DON indicated that on 12/29/20, she would have expected both CNA G and Staff L to have called her and informed her about CNA G's symptoms, and that they would not have been permitted to work. When queried further regarding the COVID-19 outbreak on the B-Wing, the DON stated, There's a good possibility the staff member (CNA G) interacted with multiple residents on the unit. That was previously our 'clean' (COVID-free) unit. Residents were able to wander more around in the hallway with a mask on. But staff have two-person assist residents, there's passing of meal trays. Staff all help each other so we feel that all of the B-Wing outbreak is related to (CNA G). There are only seven residents left on B-Wing who haven't tested positive. The DON indicated that testing of residents was occurring today (1/25/21) but was not alerted to any positive results thus far. On 1/25/2021 at 12:55 PM, Licensed Practical Nurse (LPN) K was observed to exit a room on the S-Wing wearing a KN95 mask with no goggles/face shield. When queried regarding PPE used for residents on the S-Wing and newly admitted residents, LPN K stated, Face shield and gloves and mask. LPN K pointed to their face shield on their computer cart in the hallway and stated, It's over there, I'm sorry. Upon further review of the S-Wing, a face shield was noted to be hanging on the hallway handrail. CNA M was queried about the face shield and stated, Oh that's (staff name). Let me go give that to her. CNA M was observed to have their mask on with no goggles/face shield. CNA M's goggles were observed to be hanging on the front of their scrub top. On 1/25/2021 at 1:10 PM, the NHA was interviewed and queried regarding what guidance is followed for handling new admissions in to the facility. The NHA stated that the facility puts newly admitted residents onto the Quarantine unit, under isolation, and are tested upon admission. If they do not convert COVID positive, under normal circumstances we would move them off the quarantine unit. With the recent outbreak, bed capacity is incredibly limited. We cannot move them to the B unit. When queried regarding PPE worn on the quarantine unit, the NHA stated, We have KN95s issued on a daily basis, goggles or face shields assigned. We always have gowns available. When queried regarding use of gowns on the quarantine unit, the NHA stated, Unless they're under droplet precautions our current policy doesn't require gowns for new admissions. All residents are required to stay in their rooms (on the S-Wing). When queried regarding expectation of staff upon positive COVID-19 symptoms noted during entrance screening, the NHA stated, The expectation would be to contact the DON immediately. The employee would not go to the floor and just begin working. We have the ability to perform a rapid test very quickly. The best that we can surmise is that (CNA G) is linked to the outbreak on B-Wing. I would believe it was a breakdown by the screener, they should have contacted (the DON) immediately. On 12/30 if I recall correctly, (CNA G) was intercepted after screening and was with the Assistant DON while waiting for the test, and was sent home around 4 o'clock. My understanding is that they never did make it to the floor. I believe (CNA G) worked their full shift on 12/29. A review of the facility's policy/procedure titled, Coronavirus (COVID-19) Policy and Procedure, updated May 2020, revealed, Staff will 'Think COVID-19' when a resident or employee exhibits the following clinical features and epidemiologic risk: fever or cough/shortness of breath and has had close contact with laboratory-confirmed COVID-19 patient within 14 days of symptom onset, fever and cough/shortness of breath requiring hospitalization and a history of travel from affected geographic areas, within 14 days of symptom onset .Two of the following: chills, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste and smell and no identified source of exposure .Interventions to prevent the introduction of respiratory germs into the facility: .Enforce sick leave policies that allow employees to stay home if they have symptoms of respiratory infection. Follow facility policy regarding work restriction when an employee has an infectious disease .If HCP develop even mild symptoms consistent with COVID-19, they must cease patient care activities and notify their supervisor or occupational health services prior to leaving work. These individuals should be prioritized for testing . A review of CDC guidance titled, Preparing for COVID-19 in Nursing Homes, updated 11/20/20, revealed, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. IJ Removal Plan On December 28, 2020, the staff member in question was screened and reported a possible symptom of COVID-19. A rapid [MEDICATION NAME] test was performed and the result was negative. On December 29, 2020, this staff member reported for the afternoon shift. The staff member was screened and reported possible COVID-19 symptoms. When the staff member reported for the afternoon shift on December 30th, the DoN was alerted and the staff member was kept in isolation. The DoN administered a rapid [MEDICATION NAME] test. The test was positive and the staff member was sent home. The staff member did not work on December 30th. Per facility policy, the employee was removed from the schedule and the staff member did not return to work for 10 days. On December 28, 2020, all residents were tested using PCR during routine weekly testing. The test results were received on December 31, 2020 and 4 residents tested positive, all on B wing. On December 31, 2020, the 4 residents were moved to the facility's CRF unit with dedicated staff. On December 31, 2020 all residents on B wing were tested with rapid [MEDICATION NAME] testing and 2 residents were positive. These residents were moved to the facility's CRF unit. On January 5, 2021, 1 resident was symptomatic and rapid [MEDICATION NAME] test was performed and the result was positive. This resident was moved to the CRF unit. The CRF unit was expanded to an 11-bed unit. On January 6, 2021, all residents were tested using PCR. Residents on B wing were tested using both PCR and Rapid [MEDICATION NAME]. 4 residents tested positive via rapid and were moved to the CRF unit. On January 7, 2021, B wing staff were provided gowns for use with all residents and all residents were placed on full PPE usage. The results of the PCR were received on January 8, 2021 and 1 resident was positive. The CRF unit was expanded to include 2 hallways and 24 beds. This resident was moved to the CRF unit and her roommate was tested with rapid [MEDICATION NAME] testing and tested positive. Resident was moved to the CRF unit. On January 11, 2020, all residents were tested using PCR testing; B wing was tested with PCR and rapids. 4 Residents tested positive via rapid and were moved to the CRF unit.PCR results received on January 12 and 13, with 2 additional positive residents. These 2 were moved to the CRF unit. On January 13, 2021, 3 residents were symptomatic and tested with rapid tests and tested positive. These 3 were moved to the CRF unit. On January 14, 2021, 1 resident was symptomatic and rapid [MEDICATION NAME] performed and positive. Resident was moved to the CRF unit. On January 18, 2021, all residents tested with PCR, residents on B wing tested with rapid and PCR, 3 residents tested positive on rapid results and were moved to the CRF unit. On January 21, 2021, residents received PCR testing and 1 resident tested positive. Resident was moved to the CRF unit. All residents currently get tested weekly with PCR testing, rapids on admission, and rapid if symptomatic. On January 25, 2021, the DoN began periodically observing the screening process at changes of shift. The Employee screening form has been reviewed and updated to include notification of any symptomatic employee to the DoN, ADON, or Infection Preventionist. Gowns have been added to the supply of PPE provided for use on the observation unit. The conditions in this IJ citation were fully resolved on January 25, 2021.

This citation pertains to intake MI . Based on observation, interview and record review, the facility failed to protect Resident R#390 from abuse by their Living Together Partner(LTP) of one reviewed for abuse, resulting in a hit to the face and the potential for additional abuse. Findings include: On 8/30/18 at 11:17AM, a video recording of the abuse incident was reviewed with the The Director of Nursing (DON). The video was dated for 8/20/18 with a time stamp of approximately 14:08. The video showed the parameter of the therapy gym. To the left of the video, R#390 was observed sitting in their wheelchair at the parallel bars. Standing to the right of R#390 was their Living Together Partner (LTP), whom the facility refers to as the resident's caregiver. In front of R#390 was Physical Therapist Assistant (PTA) F, and to the left of the resident assisting was the Certified Occupational Therapy Assistant J. As the video continued, the LTP is leaning into R#390's face, and very quickly, LTP slaps R#390 on her right cheek with the right hand. R#390 then stands up in an attempt to walk. During that time, the DON was asked if the LTP is allowed to visit. The DON indicated that the LTP has been allowed back in the building but cannot be left unsupervised with the resident.On 8/30/18 at 11:27AM, Physical Therapy Assistant F was queried about the abuse incident. They indicated that R#390 has Advanced Dementia, and that the resident had walked that day prior to the incident. They reported that R#390 was being encouraged to walk one more time, and had lost focus, and it was in that moment that the LTP slapped R#390 on her face and told resident to, 'Focus, they're talking to you'. PTA F reported that prior to this incident, they has observed LTP and R#390 bicker a lot, and that it gets pretty aggressive with words. PTA F reports that they have been observed telling one another to shut up, to the point where it gets loud and it becomes, uncomfortable. It was reported that nurses have stopped and inquired if everything was ok. They would respond,yes, this is just how we are. On 8/30/18 at 11:54AM, R#390 and their LTP were observed sitting together at a table amongst themselves in the dining room. The LTP was observed to be consistently rubbing R#390 on her back and arm. There were 11 residents, one family member, and two staff members observed in the dining room at this time. The two staff members were not seen to be observing the interaction between R#390 and her LTP. On 8/30/18 at 12:43PM, Dietary Aide G was asked if they had ever seen R#390 and LTP in the dining room. They indicated that they aren't usually in that dining hall but did see R#390 and her LTP yesterday. They were asked if they had been advised of any incident between the two of them and to watch for inappropriate behavior, and they indicated No. On 8/30/18 at 12:09PM, the Director of Social Services was queried regarding their role in the reported incident. They reported that PTA F reported the incident to them, and they in turn notified the DON and the Director of Rehabilitation. The Director of Social Services and the DON both interviewed R#390 and their LTP separately. It was reported that R#390 didn't understand the questions and was unable to recall the incident however, R#390 was able to indicate that they felt safe with the LTP. When the LTP was questioned regarding the incident, they acknowledged that they did slap R#390 in an effort to motivate them. The LTP reported that they had never done it before and wouldn't do it again. The Director of Social Services reported that they now have restricted alone time, and visits are in the common areas only. When queried if the incident was abusive, the Director of Social Services indicated that they believe that it was abusive as R#390 is a vulnerable adult. She also reported that the incident appeared to be based out of frustration and caregiver burnout. They intend to provide the LTP with support such as social work services, and that the LTP is looking for long-term care for R#390.On 8/30/18 at 1:56PM, an interview was attempted with R#390 in the day room of their hall. The resident could not remember what they ate for lunch that day. They were also asked if their LTP had ever hit them, and R#390 replied No. On 8/30/18 at 2:02PM, Unit Clerk I was asked about being made aware of inappropriate behaviors between R#390 and their LTP. They replied that they had overheard the incident but was not told anything directly. Unit Clerk I was sitting at the desk directly across from the dayroom that R#390 was sitting in, with their LTP.On 8/30/18 at 2:16PM, the DON was queried about the date that they implemented the change in visitation between R#390 and the LTP. They reported that the decision was made within hours of the incident occurring. The DON was also asked how staff were notified of this implementation. They reported that staff was notified in Point Click Care (An electronic health record) and that, Only direct staff involved in care should be aware to prevent gossip. A review of R#390's medical record indicated that that resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident has a Brief Interview of Mental Status (BIMS) of three indicating a severe cognitive impairment. In addition, the medical record indicates that the social work department has been providing resources to the LTP to assist in locating a Long-term care facility for R#390. A review of the facility's policy reviewed and revised 12/20/17, Abuse, Neglect, Mistreatment and Misappropriation indicates the following as a part of their prevention and identification: Ensuring that residents are safe from family members or representatives who visit in accordance with facility visitation process .

This citation pertains to intake # . Based on interview and record review, the facility failed to utilize a two person assist with bed mobility as stated in the plan of care for one (#501) of 3 residents reviewed for falls from a total sample of 3, resulting in the resident falling out of bed and sustaining an injury. Findings include: On [DATE] at 9:00 a.m., the clinical record for (R#501) was reviewed and revealed that the resident was admitted into the facility on [DATE] and expired at the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated [DATE], indicated a severely impaired cognition and that the resident required extensive assistance of two persons for bed mobility. On [DATE] at 9:15 a.m., a review of an incident report, dated [DATE] at 3:19 p.m., indicated the following: CENA assigned came to this writer and stated that she needs my help. This writer followed CENA to room. Resident lying on back on mat on floor, verbal and alert. Immediate Action Taken: Resident v.s.s. taken and stable. Resident lifted off floor and put in bed. Injury Type: No injuries observed post incident. On [DATE] at 9:20 a.m. a written statement by Certified Nursing Assistant (CNA) A titled Fall Investigation Tool regarding the incident which occurred on [DATE], was reviewed and revealed the following: (R#501) was getting her brief changed, I turned (R#501) on their side toward the sink and I reached for the brief behind me and (R#501) fell on the mat. On [DATE] at 9:25 a.m., a document titled, Incident Review involving the incident which occurred involving R#501 on [DATE], indicated the following: Cena turned resident on side-reached back for wipe as resident rolled off bed. Assessed-No apparent injury. On [DATE], at 9:35 a.m., a review of a letter in CNA A's personnel file indicated the following: .received your voice message to the Director of Nursing on (MONTH) 18, (YEAR), indicating that you are resigning your employment due to no call no shows and attendance . On [DATE] at 9:45 a.m., a physician progress notes [REDACTED].#501) suffered a fall on [DATE]. [DATE] c/o right arm pain and foot during transfer, facial grimacing during care, bruise on neck. [DATE] MD visit, good ROM no c/o pain. [DATE] family care conference, no concerns. [DATE] bruise noted on public bone-healing. [DATE] leg pain w/care Tylenol given. [DATE] pain in evening noted new bruising in right groin. [DATE] MD visited ordered X-ray. [DATE] X-ray showed laterally displaced femur fracture. On [DATE] at 9:55 a.m., a review of R#501's care plan indicated the following: Focus: Needs total assist with ADL performance. Date Initiated: [DATE]. Goal: Will have ADL basic needs met on daily basis. Date Initiated: [DATE]. Interventions: Two person assist with bed mobility. Date Initiated: [DATE]. On [DATE] at 10:15 a.m., a review of R#501's kardex, which was not dated, indicated the following: 2 persons with bed mobility at all times. On [DATE] at 10:32 a.m., an interview by phone was attempted with CNA A. No answer, left voicemail message. On [DATE] at 10:41 a.m., a phone interview was conducted with Nurse B regarding the incident which occurred involving R#501 on [DATE]. Nurse B stated the following, The CNA came to me and indicated that she needed my help. I entered the room and (R#501) was on the floor, on her mat, sitting by the end of the bed. On [DATE] at 10:56 a.m., CNA C was queried on the level of assistance required by R#501 when changing her brief. CNA C stated, Two person assistance. On [DATE] at 11:11 a.m., CNA D was queried on the level of assistance required by R#501 when changing her brief. CNA D stated, Two persons. On [DATE] at 11:32 a.m., the facility investigation involving R#501 and the incident which occurred on [DATE], was reviewed with the Director of Nursing (DON). The DON stated, When I interviewed the CNA, she had (R#501) on their side and reached back to get a wipe, and the resident fell off the other side of the bed on to a mat. The resident was not in pain at first, then a few days later, the resident was in pain, an X-ray was done, and revealed a fracture to (R#501's) right hip. The DON was queried on the level of assistance required for R#501 when her brief was being changed. The DON stated, I will have to check on that. On [DATE] at 12:05 p.m., R#501's care plan was reviewed with the DON and the section of the resident's care plan which indicated that R#501 required two person assistance with bed mobility was reviewed with the DON. The DON stated, I agree totally with what is on the care plan. On [DATE] at 12:20 p.m., review of the facility policy titled Activities of Daily Living Revised (MONTH) (YEAR) indicated the following: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the plan of care .