Every finding on record at Medilodge of Monroe

This citation pertains to MI00151320. Based on interview and record review the facility failed to properly assess and ensure pain was effectively managed for one resident (R901) of four residents reviewed for a fall with injury resulting in ongoing pain. Findings include: The survey agency received an allegation that the facility failed to effectively manage and assess pain. On 4/1/25 at 9:05 AM, Family Member (FM) A was interviewed. FM A stated they were contacted on 3/10/25 by the unit manager. FM A said the unit manager asked them had anyone contacted her over the weekend. The FM A said no. FM A said they were told because R901 had to be given Lorazepam (anti-anxiety) medication, and they wanted to start R901 on Buspirone (ant-anxiety). FM A explained to the unit manager (UM) B that she did not want R901 placed on Buspirone. FM A said the next day she spoke with nurse supervisor (NS) C that told her despite her saying she did not want R901 on Buspirone he was given the medication. FM A said the unit manager (UM) B denied that her father was given the Buspirone. Record review noted that R901 was initially admitted on [DATE] with a pertinent diagnosis of Acute Osteomyelitis of the Right knee and foot, Cerebral Infarction (stroke), Muscle Weakness, Lack of Coordination, and Chronic Pain. Record review of R901 noted their Minimum Data Set (MDS) Annual Assessment on 3/14/25 for Brief Interview for Mental Status (BIMS) was moderately cognitively impaired with a score of 12 out of 15. Record review of R901's Incident and Accident (I&A) report dated 3/4/25, documented on 3/4/25 at approximately 3:35 AM, that R901 had an unwitnessed fall. The I&A report noted that R901 was found lying on the floor and R901 was on their left side. Initially, the I&A report documented that R901 did not have any pain. Once assisted back to bed with the Hoyer lift R901 complained of pain. R901 complained of pain to the left ribs, left hip and left arm. R901 was given a dose of Tylenol 500 milligrams (mg) for a pain and an ice pack. The Medication Administration Record (MAR) for March 2025, noted R901 had a stated pain score of six. The I&A report noted that the Medical Director (MD) D was contacted at 3:45 AM and ordered x-rays of the chest, left arm and left hip for R901. Review of facility document Pain Evaluation dated 3/4/25, documented R901 pain score was a four. The location of the pain was to R901's left arm and left hip. The area impacted by the pain was R901's day to day activities. According to [NAME] and [NAME] (2022) descriptive pain levels are as follows: 0-1 no pain 2-3 mild pain 4-5 moderate pain 6-7 severe pain 8-10 unbearable pain Review of R901's care plan titled Care Plan Report initiated on 6/17/24 documented, Focus (R901) has/ is at risk for pain . Review of the care plan revealed the pain interventions were most recently reviewed on 2/28/25. However, R901 fell on [DATE] and sustained an injury. The care plan was not updated/reviewed at the time of the fall with injury. There were no new interventions added. Record review of the facility document titled Skin assessment dated [DATE]/at 3:35 AM, documented that R901 did not have any new abnormal skin areas. Review of document Skin assessment dated [DATE] at 9:06 AM documented R901 did not have any new abnormal skin areas. Record review of document titled Radiology Report dated 3/4/25 noted that the X-rays were taken on 3/4/25 at 9:25 AM. The two view chest X-ray noted, no acute fracture. The X-ray of the hip noted, no fracture or dislocation. The X-ray of the humerus noted, no fracture or dislocation. The x-rays taken on 3/4/25 noted no breaks in bones. The facility Skin Assessments documented no abnormal skin areas. However, R901 complained of pain in these areas from 3/4/25 through 3/16/25 (the day of discharge to the hospital.) Review of the MAR (March 2025) for R901noted the following orders. Tramadol 50 mg 1 tab every 6 hrs. as needed was ordered on 3/4/25. Medication documented as administered on the following dates: On 3/4/25 at 10:30 AM-R901 pain score of 5. Documented as effective. On 3/4/25 at 6:22 PM-R901 pain score of 4. Documented as effective. On 3/5/25 at 4:09 AM- R901pain score of 5. Documented as effective. On 3/5/25 at 10:19 AM-R901 pain score of 6. Documented as effective. On 3/5/25 at 6:41 PM-R901 pain score of 6. Documented as effective. On 3/6/25 at 8:00 AM- R901 pain score of 2. Documented as effective. On 3/6/25 at 3:30 PM- R901pain score of 7. Documented as effective. On 3/6/25 at 9:30 PM- R901 pain score of 8. Documented as effective. On 3/7/25 at 8:45 AM- R901 pain score of 5. Documented as effective. Percocet 5mg-325mg 1 tab every 6 hours as needed was ordered on 3/7/25 at 10:30 AM The medication was administered on the following dates. On 3/7/25 at 11:21 PM- R901 pain score of 7. Documented as effective. On 3/8/25 at 6:23 AM- R901 pain score of 8. Documented as effective. On 3/9/25 at 6:24 AM- R901 pain score of 10. Documented as effective. On 3/9/25 at 2:59 PM-R901 pain score of 2. Documented as effective. On 3/9/25 at 9:17 PM- R901pain score of 5. Documented as effective. On 3/10/25 at 5:58 AM- R901pain score of 5. Documented as effective. On 3/10/25 at 6:00 PM- R901pain score of 8. Documented as effective. On 3/11/25 at 12:00 AM- R901pain score of 8. Documented as effective. On 3/11/25 at 10:47 AM- R901pain score of 7. Documented as effective. On 3/11/25 at 4:49 PM- R901pain score of 8. Documented as effective. On 3/11/25 at 10:50 PM- R901 pain score of 8. Documented as effective. On 3/12/25 at 6:30 AM- R901 pain score of 7. Documented as effective. On 3/12/25 at 3:18 PM- R901 pain score of 8. Documented as effective. On 3/13/25 at 8:27 AM- R901 pain score of 4. Documented as effective. On 3/13/25 at 9:33 PM- R901 pain score of 3. Documented as effective. On 3/14/25 at 9:17 AM- R901 pain score of 6. Documented as effective. On 3/14/25 at 10:32 PM- R901 pain score of 2. Documented as effective. On 3/15/25 at 7:41 AM- R901 pain score of 6. Documented as effective. On 3/15/25 at 1:05 PM- R901 pain score of 8. Documented as effective. On 3/15/25 at 9:10 PM- R901 pain score of 8. Documented as effective. On 3/16/25 at 8:46 AM- R901 pain score of 5. Documented as effective. Review of the MAR documented a pain score as reported by R901 prior to the administration of pain medication. However, there was no documented evidence of R901's stated pain score after the medication was administered and there was no evidence the facility implemented scheduled medication to manage R901's pain. Instead, the facility documented effective and continued to administer medications as PRN (as necessary). Review of Electronic Medical Record (EMR) regarding R901, noted the following nursing notes: On 3/8/25 at 8:11AM, License Practical Nurse (LPN) G documented R901, continues with groaning/calling out frequently. Repositioning, PRN medication, reassurance and redirection continues. Dr. notified with PRN lorazepam ordered q8hours PRN x1 day. 1st dose given at 0922 with positive results. Pt is resting in bed at this time. On 3/9/25 at 8:04 AM UM B documented Nurse Practitoner (NP) G notified increased pain, no repeat xrays needed at this time. On 03/10/2025 at 1:39 AM LPN H documented that R901 Resident yelling out, Resident was repositioned and given a Prn for pain. On 3/14 at 3:05 PM UM B documented Spoke with daughter, related to pain meds and recent orders for antianxiety, stated that writer will have provider review meds on Monday, Related verbalized understanding. On 3/16/25 at 1:53PM, LPN E documented R901, Yelling out randomly. Pain medications effective this shift. Poor appetite. Fluids encouraged and tolerated well. On 3/16/25 LPN E documented R901, Daughter in to see R901t this afternoon. Daughter requesting resident be sent to Hospital regarding persistent pain to left side of body following most recent fall. Pain managed with pain medications and effective per resident. MD I contacted, per MD I offer repeat X rays and send to hospital if refused. Daughter declined x rays to be ordered and requested resident be sent to Hospital for evaluation of pain source. Ambulance transferred via stretcher to Promedica of [NAME] at about 1304. New clinical chart sent with resident handed off to EMS driver. Bed hold signed. SBAR completed. On 3/17/25 LPN I documented, Called hospital for status on R901. R901 admitted to [NAME] hospital. R901 admitted for L femoral neck fracture along with L ribs 3-9 fractured. On 4/1/25 at 12:55 PM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were interviewed. The DON explained that after R901 fell and before being discharged to the hospital there were times when R901 was not in pain. The DON added that they did not think there were any broken bones because there was no bruising or swelling on R901. The DON was queried if the R901 experienced another fall after the fall on 3/4/25. The DON said R901 did not have another fall after 3/4/25. The NHA did not offer any comment regarding R901's pain or concerns regarding hospital findings of R901 having a hip and fractured ribs. Review of Policy titled Pain Management with revised date of 10/26/23 documented. The facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. To help a resident attain or maintain his/her highest practicable level of well-being and to prevent or manage pain, the facility should: Recognize when the resident is experiencing pain and identifies circumstances when the pain is anticipated. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and with change in condition or status (e.g., after a fall, with change in behavior or mental status). Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences.

Based on observation, interview, and record review the facility failed to provide a mattress in a timely manner for one resident (R45) of one resident reviewed for accommodation of needs, resulting in the resident's sleep pattern being disturbed and verbalizing frustration of having back pain caused by an uncomfortable mattress. Findings include: On 12/15/2024 at 11:37 a.m., during an interview R45 pointed at the bed and said the mattress had a big hole in it and it was causing lower back pain. The resident reported the mattress was uncomfortable and having to find a higher part of the mattress to get a good night's sleep. R45 said it was reported to a staff member about three weeks ago or longer but was unsure of the staff member 's name. R45's mattress was observed with an observable indentation on the right side approximate to the middle of the bed. According to the Electronic Health Record (EHR), R45 was admitted into the facility on [DATE] with diagnoses of history of falling, generalized epilepsy, dementia, anxiety disorder, extrapyramidal and movement disorder (involuntary motor activity), and osteoarthritis. R45's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R45 was cognitively intact with a BIMS (brief interview for mental status) score of 15/15. Review of the Activity Daily Living (ADL) care plan with a revision date of 11/22/2024, documented, Resident had an ADL self-care deficit . Interventions: Bed mobility one person assist. On 12/17/2024 at 2:50 p.m. R45's assigned Certified Nursing Aid (CNA) A confirmed during an interview that the staff made R45's bed and if the resident needed a new mattress the nurses and the CNAs should have written the order in TELS (a computer system for documented requests, orders, and repairs for maintenance). On 12/17/2024 at 3:11 p.m., Maintenance staff (MS) B said during an interview that it was reported that the resident needed and was requesting a new mattress. MS B confirmed the mattress did have a dip in it and the resident requested the mattress to be remove because R45 was not sleeping well. MS B was queried regarding the facility's protocol for requesting a new mattress. MS B said the staff should have filled out an order, documented in TELS and the order would have been completed for a new mattress, however there was no order put through for a new mattress until the resident was observed verbalizing frustration to a surveyor on 12/15/2024. On 12/17/2024 at approximately 3:50 pm., the Director of Nursing (DON) confirmed the staff should have documented the resident mattress had a large indentation. The DON said the nurses and the CNAs should have observed the mattress because they would change the bed linen. According to the revised 12/28/2023 Accommodation of Needs policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preference of a resident .

Based on observation, interview and record review, the facility failed to provide nail care for two dependent residents (R5 and R66) of five residents reviewed for activities of daily living (ADLs), resulting in unmet care needs. Findings include: R5 On12/15/24 at 12:18 PM, R5 was observed in bed, on their back, wearing a gown. An interview was completed with R5 at this time. When asked regarding level of assistance required by staff to perform Activities of Daily Living (ADLs), R5 revealed they required extensive assistance due to a diagnosis of Multiple Sclerosis (a disease that causes breakdown of the protective covering of nerves causing numbness, weakness, trouble walking, vision changes and other symptoms). Their nails were observed as long in length, extending past the top of their fingers. R5 said that staff has not cut her nails in a while. R5 said, They keep telling me they will cut them during my shower, but I had my showers already .I have MS (Multiple Sclerosis). On 12/16/24 at 10:18 AM, R5 was observed in bed, wearing a gown, and watching television. R5 was asked if their nails were trimmed and they said, They (staff) gave me a bed bath today, but I still need my nails cut. A review of R5's electronic medical record revealed an admission on 9/22/23 with the diagnosis of Multiple Sclerosis, Functional Quadriplegia, Diabetes, Atrial Fibrillation, Convulsions, Muscle Weakness, and Stiff Joints. A review of R187's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was dependent for personal hygiene care. A review of R5's Care Plan revealed the following: Focus . Resident has an ADL self-care performance deficit .Intervention .Bathing: 2 person assist .Bed Mobility: 2 person assist .Personal Hygiene: 1 person assist .Dated 11/9/23. R66 On 12/15/24 at 12:23 PM, R66 was observed sitting in their wheelchair watching television. An interview was completed with the R66 at this time. R66 said that their nails on her right hand needs to be cut. R66's nails were trimmed on their left hand but not on their right hand. Their right-hand fingernails were observed as long in length, extending past the top of their fingers. R66 said, It's frustrating because I can't cut my own nails. On 12/16/24 at 10:44 AM resident was observed in the hallway in their wheelchair. The resident said that staff had not trimmed the nails on their right hand. A review of R66's electronic medical record revealed an admission on 1/19/23 with the diagnosis of Cerebral Infarction, (an ischemic stroke, that occurs when blood flow to the brain is disrupted, depriving brain cells of oxygen and nutrients), Hemiplegia (one-sided muscle paralysis or weakness), Diabetes, Falls, Muscle Weakness, and Chronic Pain. A review of R66's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required substantial/maximal assistance with personal hygiene care. A review of R66's Care Plan revealed the following: Focus .Resident has an ADL self-care performance deficit related to weakness, impaired mobility .Interventions .Personal Hygiene: 2 person assist .Dated 8/4/23. On 12/17/24 at 01:30 PM, an interviewed was conducted with Certified Nurse Assistance (CNA) C and CNA D regarding residents receiving nail trims. Both CNAs stated that nail trims should occur on their shower days unless the resident ask. On 12/17/24 at 03:18 PM, an interview was conducted with the Director of Nursing (DON) regarding nail care in the facility and R5 and R66 untrimmed nails. The DON said they (staff) should trim residents' nails during shower days. The DON also stated that staff will go to each unit to trim nails as needed.

Based on observation, interview, and record review the facility failed to maintain the dignity of five residents (R3, R7, R37, R54 , and R58,) of six residents reviewed, resulting in the residents verbalizing their preferences to have their own personal clothing and frustration of not being completely dressed for breakfast while seated in the dining room (common area). Findings include: R7 On 2/11/2024 at 8:44 a.m., observed R7 sitting in the dining room in a gown, no socks, no shoes with both bare feet on the floor. R7 Stated, My feet are cold. R7 was observed rubbing both arms stating, My arms are cold. R7 arms were observed with no blanket nor sweater. During an interview, R7 stated, They (4 other residents) was not asked if they wanted to be dressed for breakfast or to eat in our rooms. They were just brought to the dining room and sat at the table for breakfast. I would like to be dressed in the dining room. According to the medical record, R7 was admitted into the facility on [DATE] with diagnoses of Alzheimer's disease, congestive heart failure, anxiety disorder, major depressive disorder, and osteoarthritis. R7's Minimum Data Set (MDS) with a reference date of 1/27/2024 indicated R7 had moderately cognition impairment with a BIMS (brief interview for mental status) score of 07/15. Review of the 2/5/2024 Activity Daily Living (ADL) care plan revealed, Resident has an ADL self-care performance deficit related to weakness, impaired mobility, Alzheimer's disease, chronic obstructive pulmonary disease, diabetes mellitus, history of stroke, congestive heart failure, coronary artery disease, anxiety, depression, osteoarthritis, and dementia. Interventions: Dressing and transfers: one person assist. Allow time or resident to express feelings of frustration regarding the need for assistance in ADL tasks. On 2/11/2024 at 10:23 a.m., Certified Nursing Assistant (CNA) H was interviewed regarding the residents not being properly dressed in the dining room. CNA H said, one of the residents was already up in the dining room from midnight shift. CNA H acknowledged bringing other residents in the dining room not properly dressed. CNA H confirmed the residents should have been fully and appropriately dressed for breakfast in the dining room. R37 On 2/11/2024 at 8:44 a.m., observed R37 sitting in the dining room in a gown, no sweater, no socks, no shoes with both feet on the floor. R37 Stated, I am chilly, especially my arms. R37 was asked during an interview the choice to be dressed in the dining room for breakfast. R37 stated, I want to be dressed in the dining room. According to the medical record, R37 was admitted into the facility on [DATE] with diagnoses of muscle weakness (generalized), major depressive disorder, anxiety disorder, and Alzheimer's disease. R37's quarterly Minimum Data Set (MDS) with a reference date of 9/15/2023 indicated R37 had severe cognition impairment with a BIMS (brief interview for mental status) score of 03/15. Review of the 12/6/2023 Activity Daily Living (ADL) care plan revealed, Resident has an ADL self-care performance deficit related to weakness, impaired mobility, history of stroke, history of falls, chronic pain, seizures, dysphagia, anxiety, and Alzheimer's disease. Interventions: Allow resident to make choices/decisions about their preferred activity pursuits. Allow sufficient time for dressing and undressing. Assist resident with choosing minimally restrictive clothing to increase independence with dressing. Transfers and dressing one person assist. R58 On 2/11/2024 at 8:44 a.m., observed R58 sitting in the dining room in a night gown, hair not groomed, no sweater, no socks, no shoes with both feet on the floor. R58 was asked if she wanted to be dressed for breakfast in the dining room. R58 responds with yes and no answers. R58 said yes to being cold and expressed wanting to be dressed at the breakfast table. According to the medical record, R58 was admitted into the facility on [DATE] with diagnoses of muscle weakness (generalized), major depressive disorder, anxiety disorder, and Alzheimer's disease. R37's quarterly Minimum Data Set (MDS) with a reference date of 9/15/2023 indicated R37 had severe cognition impairment with a BIMS (brief interview for mental status) score of 03/15. Review of the 11/15/2023 Activity Daily Living (ADL) care plan revealed, Resident has an ADL self-care performance deficit related to weakness, impaired mobility, seizure disorders, diabetes mellitus, intellectual disabilities, anxiety, depression and bipolar. Interventions: Transfers and dressing one person assist. On 2/14/2024 at 10:53 a.m., the Director of Nursing (DON) was interviewed regarding residents being properly dressed in the dining room for meals. The DON said the residents should be dressed in the dining room at mealtime. 39958 R3 In an observation and interview on 2/11/24 at 1:09 p.m., R3 sat in a wheelchair in the room and wore a gown. R3 reported the staff took their clothes without asking or let them know that they were taking them. R3 reported wanting to go to the dining room but did not have any clothes. Review of an Admission Record revealed, R3 admitted to the facility on [DATE] with pertinent diagnoses which included Depression. Review of a MDS assessment, with a reference date of 12/4/23 revealed R3 had mild cognitive impairment with a BIMS score of 11, out of a total possible score of 15. R54 In an observation and interview on 2/11/24 at 10:19 a.m., R54 sat in a wheelchair in the hallway and wore a gown with no socks or footwear. R54 reported they took all the clothes to wash them. R54 expressed there was a scheduled doctor's appointment the following day at 9:40 a.m. and currently did not have clothes to wear to the appointment. Review of an Admission Record revealed, R54 admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included schizoaffective disorder. Review of a MDS assessment, with a reference date of 2/5/24 revealed R3 had no cognitive impairment with a BIMS score of 15, out of a total possible score of 15. In an observation and interview of 2/12/24 at 8:18 a.m., R54 sat in a wheelchair in the hallway and wore a gown. R54 reported I still do not (have) clothes and has an appointment this morning. R54 reported the staff gave her other residents clothes and R54 did not have a bra. In an interview on 2/12/24 at 8:20 a.m. Certified Nursing Assistant (CNA) G reported the clothes provided to R54 came from the lost and found. In an interview on 2/12/24 at 8:32 a.m., R54 reported feeling like s**t because R54 was not wearing her own clothes. In an interview on 2/12/24 at 8:33 a.m., CNA G reported R54 clothes are still in laundry, and they are working to get the clothes back because there is a lot of clothes. In an interview on 2/12/24 at 9:54 a.m., Laundry Aide B reported personal clothes are returned to residents in 72 hours. Laundry Aide B then reported all the resident personal items were sent to laundry a few days ago. In an observation on 2/13/24 at 8:37 a.m., R54's closet contained one blouse and several empty hangers. A sign on the closet door read, Laundry by Family. According to the facility's 10/26/2023 Promoting/Maintaining Resident Dignity policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality . 9. Groom and dress residents according to resident preference.

Based on observation, Interview, and record review the facility failed to (1) ensure the ice scooper was properly stored during water pass and failed to (2) ensure proper hand hygiene was performed for one (R31) of one resident observed during care, resulting in the potential for the spreading of microorganisms throughout the facility. Findings include: On 2/11/2024 at 8:45 A.M., during an observation on the two hundred hall, Nurse Aide C and Nurse D was observed preparing ice water for the residents. Three pitchers filled with ice were observed on the ice cart with ice scooper on the side of the ice chest. The ice scooper was uncovered and not placed in an ice caddy/container to protect it from microorganisms or environmental contaminants. Nurse Aide C reported the pitchers of ice were going to be used for the residents and the ice cart had been brought to the unit from the kitchen around 7:45 A.M. Nurse Aide C was asked about the ice scooper being uncovered and placed in the opened side slot. Nurse Aide C indicated the old ice chest had a cover for the ice scooper and thought this Ice cart/container should have some kind of cover, but it only had the attached, opened, slot for storage. On 2/12/24 at approximately 3:50 P.M. on the three hundred hall staff was observed using an ice scooper that was not covered or stored in an ice caddy/container. Staff on this unit passed/offered ice water to the residents on the unit. The ice scooper was stored on the outside of the ice cart without any protection/covering or being placed in and ice caddy or container. On 2/14/2024 at 11:53 A.M. during an interview with the Director of Nursing (DON) concerning the exposure of the ice scoop to microorganisms and possible contamination of the ice from residents wandering the halls, the DON stated the facility had recently purchased several Ice Chests and was unaware of the ice scooper not being protected or placed in an ice caddy or container. In a subsequent observation of the ice storage bin stationed in the main dining room, the DON was presented with the concern related to the storing of the ice scooper outside of the ice cart without any protection. The DON explained the new carts were purchased with the attached opened storage slots but was unaware of the difference in the storage bins for the ice scooper. The DON thought the new ice storage/bins were the same as the previous ones used for passing ice. According to the Code of Federal Regulation, Title 21, Volume8, section 1250.28 Ice Scoops should be stored in a clean container, outside of the ice supply. When the scoop is not being utilized keep it covered and protected from contamination. 39958 R31 Review of an Admission Record revealed, R31 admitted to the facility on [DATE] with pertinent diagnoses which included Obstructive and Reflux Uropathy (blockage in the urinary tract) and Neuromuscular Dysfunction of Bladder (bladder malfunction which results in difficulty urinating). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R31 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 6, out of a total possible score of 15 and required an indwelling catheter. In an observation on 2/12/24 at 9:25 a.m., Certified Nursing Assistants (CNA) I and J provided ADL and catheter care for R31. In an observation on 2/12/24 at 9:32 a.m., Staff Development Coordinator (SDC) A entered the room, applied gloves, and did not perform hand hygiene before application. In an observation on 2/12/24 at 9:35 a.m., SDC A picked up cough drops and a cup off the floor with gloved hands. With the same gloves, SDC A then walked to R31's bed and touched R31's suprapubic catheter (catheter inserted through the stomach and into the bladder). In an observation on 2/12/24 9:50 a.m., SDC A removed the gloves and exited the room while carrying bags of soiled linen. SDC A did not perform hand hygiene after glove removal. In an interview on 2/12/24 at 9:51 a.m., SDC A reported gloves should be changed if they are soiled and between task to reduce contamination. SDC A reported gloves should be removed and hand hygiene performed after picking items up off the floor. In an interview on 2/14/24 at 11:16 a.m., the Director of Nursing (DON) reported hand hygiene should be performed before and after glove use. The DON then reported gloves should be changed and hand hygiene performed after picking items up off the floor. Review of a Hand Hygiene policy revised on 12/13/23 documented the following, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . The use of gloves does not replace hand hygiene. If your ask requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

This information pertains to intake MI00142266. Based on interview and record review the facility failed to maintain privacy for one resident (R66) of two residents reviewed for privacy, resulting in the exposure of R66 on social media via video and texted message. Findings include: R66 Review of the medical record revealed R66 initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses of Alzheimer's disease, schizoaffective disorders, moderate protein-calorie malnutrition, major depressive disorder, and anxiety disorder. R66's Minimum Data Set (MDS), with a reference date of 12/13/2023, indicated R66 had severe cognition impairment with a BIMS (brief interview for mental status) score of 03/15. MDS assessment documented R66 was not able to be interviewed. Review of the Activity Daily Living (ADL) care plan with revision date 2/12/2024, revealed Resident has an ADL self-care performance deficit related to weakness, impaired mobility, Alzheimer's disease, schizoaffective disease order, anemia, chronic pain, insomnia, anxiety, and depression. Interventions: Provide cues and assist as needed to accomplish daily tasks. On 2/11/2024 at 9:56 a.m., R66 was observed asleep in bed with family at bedside. A concerned family member O said R66 had a decline in status and was not responding to anyone. On 2/12/2024 at 12:00 p.m., an attempt to interview Family Member O regarding a complaint received by the State of Michigan of a video circulating on social media of R66 was made. However, Family Member O explained they were not available for a full interview due to the status of R66 but confirmed there was a video he had seen on social media of (R66). Family Member O explained he did not like it and said it was a violation of R66's privacy rights. On 2/12/2024 at 12:15 p.m. the Facility Investigation Report revealed the following: On 2/19/2024 at 9:20 p.m. Nursing Home Administrator (NHA) received a phone call from Licensed Practical Nurse (LPN)/Afternoon Supervisor (N) stating that an anonymous caller called the facility and wanted to speak to the administrator in regard to a concern that involved a resident. On 2/10/2023 the administrator .was informed that a snapchat video had been sent out to three people. The Snapchat video included resident (R66) . In the video it shows (CNA L) her walking in to the residents room, shutting the door and stating let me introduce you (R66) . (CNA L) walking over to (R66) bed and trying to feed him with a spoon .The resident did not want to eat and the employee (CNA L) was just laughing. On 2/14/2024 at 12:24 p.m., Concerned Person M confirmed CNA L text messaged the video to Concerned Person M and posted the video on a social media application of R66 in bed while assisting R66 at mealtime and announcing the resident's name prior to recording the video. On 2/14/2024 at 11:42 a.m., an interview was conducted with the administrator and the Regional Director of Operation (RDO) K regarding an alleged circulating video of R66 on social media. The administrator was asked to recall an incident called in to the facility of a video circulating on social media of R66. The administrator stated, Yes, I am aware, and it happened before I started working in the facility. RDO K explained the facility received a phone call that asked for the administrator on 2/19/2024 at approximately 9:00 p.m. RDO K said the administrator P that received the call is no longer employed at the facility. Administrator P contacted the caller back and the caller indicated that there was a video of the resident (R66) on a social media application and the video was reviewed by the caller and is in their possession. The caller indicated that an employee (Certified Nursing Assistant, CNA L) of the facility posted a video on social media and via text message of R66 lying in bed at mealtime being assisted with eating. Administrator P asked to review the video immediately, suspended the staff involved and started an investigation. Administrator P reviewed the video and substantiated that there was a video of R66 on social media and there was a social media policy violation. Administrator P terminated the employee. The former administrator (P) had the video. RDO K was asked did she reviewed the video. RDO K stated, I did because we met with the family (family member) and the resident's (R66)'s (spouse). RDO K said I was aware the family reviewed the video, I saw the CNA (CNA L) attempting to encourage the resident to eat one time, he kind of pushed the spoon away. RDO K added the CNA announced the resident's name prior to recording the video. RDO K was asked how often the employees receive in-services on resident rights and abuse. RDO K said upon hire, annually and as needed, they are trained on resident's right, privacy and abuse and they are adherent to that. RDO K said it was not reported to the State of Michigan (SOM) because it was a social media violation (violation of privacy) for my understanding. According to the facility's Social Media policy, revised date 1/1/2022, documented the following in part: Do not use Social Media to post, upload, send, or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law . This prohibition includes . photos or video where the resident is easily identifiable.

Based on observation, interview, and record review, the facility failed to effectively clean and maintain the physical plant effecting 91 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination. Findings include: On 02/07/23 at 04:35 P.M., An interview was conducted with Licensed Practical Nurse (LPN) Unit Manager H regarding the 2007 ARJO Spa Tub. (LPN) Unit Manager H stated: The spa tub leaks and has been out of service for approximately 1-1.5 weeks. On 02/08/23 at 09:00 A.M., A common area environmental tour was conducted with Director of Maintenance K. The following items were noted: 200 Hall Restroom A: The commode base caulking was observed (etched, cracked, stained, separated). Director of Maintenance K indicated he would have staff replace the damaged caulking as soon as possible. Janitor Closet: The flooring surface was observed soiled with accumulated and encrusted dust and dirt deposits. Miscellaneous items (three plastic resin chairs, one plastic crate, damaged floor mop, etc.) were also observed stored within the disorganized janitor closet. Shower Room: 3 of 6 overhead 48-inch-long fluorescent light bulbs were observed non-functional. The return exhaust ventilation grill was also observed soiled with accumulated dust and dirt deposits. The commode grab bar was additionally observed loose-to-mount. The 2007 ARJO Spa Tub was further observed with damaged and leaking water jets (2). The Spa Tub handheld wand assembly swivel connection was also observed loose-to-mount. The water supply control valve was additionally observed semi-seized, making the valve assembly very hard to actuate. 500 Hall Staff Break Room: The microwave oven interior was observed (etched, scored, corroded, particulate). Director of Maintenance K indicated he would have staff remove and replace the damaged microwave oven as soon as possible. Janitor Closet: The flooring surface was observed soiled with accumulated and encrusted (dust, dirt, grime). One extremely frayed broom was also observed resting on the soiled flooring surface. 400 Hall Laboratory: The return exhaust ventilation grill was observed heavily soiled with dust and dirt deposits. Janitor Closet: The flooring surface was observed soiled with accumulated and encrusted (dust, dirt, grime). The mop sink basin was also observed heavily soiled with accumulated and encrusted dust/dirt deposits. Shower Room: One of two shower stall grab bars were observed loose-to-mount. Director of Maintenance K indicated he would have staff secure the grab bar as soon as possible. 100 Hall (Service Corridor) Staff Locker Room: The floor metal heating duct cover was observed heavily corroded and particulate. Director of Maintenance K indicated he would replace the corroded heating duct cover as soon as possible. 300 Hall Shower Room: The water pressure was observed low at the shower wand assembly dispensing head. The wand assembly dispensing head was also observed mineralized with calcium and lime deposits. The shower wand assembly connection was additionally observed missing an atmospheric vacuum breaker. The hand sink was further observed loose-to-mount. The space between the hand sink basin and wall surface measured approximately 0.5 - 1.0 inches wide. On 02/08/23 at 10:45 A.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance K. The following items were noted: 203: The commode base caulking was observed (etched, scored, stained). The hand sink was also observed soiled, adjacent to the faucet perimeter. 204: The hand sink was observed soiled, adjacent to the faucet perimeter. 205: The hand sink was observed soiled, adjacent to the faucet perimeter. 206: The hand sink basin was observed draining slowly. The commode base caulking was also observed (etched, scored, stained, particulate). 210: The Bed B overbed light plastic protective cover was observed cracked and broken. 212: The Bed B and Bed C overbed light pull string extensions were observed missing. 309: The Bed B lower 48-inch-long fluorescent light bulb was observed non-functional. 311: The hand sink basin was observed draining slowly. The restroom over sink light assembly was also observed non-functional. 312: One of two hand sink basin support legs were observed resting against the restroom wall. 501: The commode base caulking was observed (etched, scored, stained, particulate). 505: The hand sink was observed soiled, adjacent to the faucet perimeter. 506: The hand sink was observed soiled, adjacent to the faucet perimeter. 508: One acoustical ceiling tile was observed stained from a previous moisture leak, adjacent to Bed B. The hand sink was also observed soiled, adjacent to the faucet perimeter. On 02/08/23 at 12:25 P.M., An interview was conducted with Director of Maintenance K regarding the facility work order system. Director of Maintenance K stated: We have the TELS work order system. On 02/08/23 at 01:35 P.M., Record review of the Direct Supply TELS Work Orders for the last 39 days revealed no specific entries related to the aforementioned maintenance concerns. On 02/08/23 at 01:45 P.M., Record review of the Policy/Procedure entitled: Daily Patient Room Cleaning dated 06/2016 revealed under Timing & Method: (C) 2) Horizontal Dusting: With a cloth & disinfectant wipe all horizontal (flat) surfaces. On 02/08/23 at 01:50 P.M., Record review of the Policy/Procedure entitled: Bathroom Cleaning dated 06/2016 revealed under Timing & Method: (B) WET Steps: 4) Sanitize sink, light, mirror, fixtures, and pipes. 5) Sanitize commode, tank, bowl & base. Use brush for inside of bowl.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe, and sanitary condition and ensure proper cooling of time/temperature control for safety food, homemade vegetable soup, resulting in the increased potential for food-borne illness. These deficient practices had the potential to affect residents eating from the kitchen. Findings include: During an observation and interview on 1/25/2022 at 9:45 AM in the facility kitchen with Certified Dietary Manager (CDM) C, the following occurred: - Food crumbs and debris were observed in three drawers located in the cook's preparation table where various cooking and serving utensils were stored. - A broken glass bulb was observed over the stove. The CDM stated, Glass could fall down into the food cooking on the stove. - Two kitchen scales were covered with plastic bags. Both bags were soiled with food debris. - A soiled and not thoroughly cleaned six-quart pan was stacked with the cleaned pots and pans. - A large container of vegetable soup, dated 1/24/22 - 1/26/22, was observed in the walk-in cooler. CDM C said she did not have a cooling log for the vegetable soup, nor did a cook ask for one yesterday. The morning cook, Cook D, stated, I cooked the vegetable soup from scratch yesterday (1/24/2022). I didn't cool the soup, the (afternoon) cook did. During an interview on 1/25/2022 at 1:20 PM, the afternoon cook, Cook E, stated, I put the soup in a tub of ice for two hours to cool it down. Cook E said the size of the container of soup was four to five gallons and the temperature of the soup was 176 ºF (Fahrenheit) when it was placed in the ice bath. Cook E said the temperature of the soup was 80 to 90 degrees after the first hour and at the end of the second hour the temperature of the soup was 39 degrees. Cook E stated, I stirred the soup every now and then. It's rare that I have to cool food down and I failed to document the cooling temps. During an interview on 1/26/2022 at 3:09 PM, when the reported cooling temperatures of the soup were discussed with CDM C, she said, I don't know how it would get to (those temperatures at those times). I don't think that's possible. CDM C acknowledged without documentation of the cooling log, there was no way to ensure the vegetable soup was cooled properly. The facility documents, Kitchen Sanitation and Food Preparation and Service, both dated 1/1/2021, were reviewed and revealed the following: - Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions open seams, cracks and chipped areas that may affect their use or proper cleaning. - Equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. - The following internal cooking temperatures/times for specific foods should be reached to kill or sufficiently inactivate pathogenic microorganism: Fresh, frozen or canned fruits/vegetables - 140 ºF. - Potentially hazardous foods should be cooled rapidly. This is defined as cooling from 135 ºF to 70 ºF within two hours and then to a temperature of 41 ºF or below within the next 4 hours. The total cooling time between 135 ºF and 41 ºF is not to exceed 6 hours. According to the 2013 FDA Food Code: Time/temperature control for safety food definition includes: (a) An animal food that is raw or heat-treated; a plant food that is heat-treated . Section 3-501.14: Cooling - (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135ºF to 70°F; and (2) Within a total of 6 hours from 135ºF to 41°F or less. Section 4-601.11: Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Section 4-602.11: Equipment Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be cleaned (5) at any time during the operation when contamination may have occurred. Section 4-602.13: Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Section 6-202.11: Light Bulbs, Protective Shielding. (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed food; clean equipment, utensils, and linens; or unwrapped single-service and single use articles.

Based on observation, interview, and record review the facility failed to follow the standards of infection control with Transmission Based Precautions, for two residents (Residents #75, #88) and residents residing on Unit 200 and 500 of residents reviewed for infection concerns, resulting in the potential for cross contamination and the spread of disease to a vulnerable population. Review of an Personal Protective Equipment policy with a revised date of 10/8/21 revealed, Policy: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff .5. Sequence of donning/removing PPE when using multiple types . b. Remove PPE in this order: gloves, goggles or face shield, gown, then mask or respirator. Perform hand hygiene immediately after removing all PPE . Resident #88 Review of an Admission Record revealed, Resident #88 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/8/22 revealed Resident #88 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12, out of a total possible score of 15. In an observation on 1/25/22 at 11:20 a.m., Resident #88 room door had signage which indicated resident Droplet Precautions. Signage on Resident #88's door included, Droplet Precautions Everyone Must: Clean their hands, including before entering and when leaving the room . Review of a Progress Notes with a date of 1/24/22 at 12:00 a.m. for Resident #88 revealed, . Droplet precautions Antibiotic continues for ear, no adverse reactions. Droplet precautions started due to cough/sore throat. Awaiting chest Xray. Review of an Order Summary revealed, Resident #88 had an order, Resident on Transmission-Based Droplet Precautions for potential exposure to respiratory infection. All meals and therapy in room. every shift (sic) with a revised date of 1/24/22. In an observation on 1/25/22 at 11:31 a.m., Certified Nursing Assistant (CNA) P exited Resident #88's room and wore a gown, gloves, face shield and mask. CNA P then removed the PPE (Personal Protective Equipment) in the hall and placed it in the trash can near Resident #88's room. CNA P did not perform hand hygiene and entered another resident's room. In an interview on 1/25/22 at 11:32 a.m., CNA P was unsure of where PPE should be discarded. CNA P stated, I will get back with you. In an interview on 1/25/22 at 11:34 a.m., Licensed Practical Nurse (LPN) Q reported PPE should be removed in the room before exiting. In an interview on 1/25/22 at 11:35 a.m., CNA P reported PPE should be taken off in the room and then discarded in the biohazard bin in the hall. CNA P then reported she should wash her hands after removing gloves. In an interview on 1/25/22 at 2:15 p.m., LPN Q reported Resident #88 had droplet precautions for a cough and sore throat. Resident #75: On 1/25/22 at 2:50 PM a sign on R75's door indicated the residents in this room were on 'Droplet Precautions' and staff were required to wear N95 mask, face shield, gown, and gloves prior to entry into the room. The call light above the doorway was on. R75 was observed seated in his room in a wheelchair with an N-95 mask on. Upon inquiry R75 said he needed to go to the bathroom and needed to use the big bathroom next door because the bathroom in his room was too small for him. Certified Nursing Assistant (CNA) O had a N-95 mask and face shield on, but did not put a gown or gloves on when she wheeled R75 in the hallway and into the 'big bathroom' next door. CNA O remained in the 'big bathroom' for a few minutes and then exited. CNA O did not have any gown or gloves on. Upon inquiry CNA O was asked if she should have put a gown and gloves on prior to assisting R75 into the bathroom. CNA O said, I didn't perform any care to the resident. I just assisted him into the bathroom and positioned him near the toilet. He is mostly independent with toileting after we get him into the bathroom. On 1/25/22 at approximately 3:10 PM Infection Preventionist, Licensed Practical Nurse M was asked about 'Droplet Precautions', LPN M said that R75's roommate had been diagnosed with RSV (Respiratory Syncytial Virus) and both residents in that room were currently on 'Droplet Precautions'. LPN M confirmed that CNA O should have donned a gown and glove prior to taking R75 to the community bathroom to assist him (R75) with toileting. According to R75's Electronic Medical Record he was ordered to be on 'Droplet Precautions' on 1/15/22 due to exposure of RSV.

Based on observation, interview, and record review the facility failed to accurately assess or provide treatment to 'skin breakdown areas' for one (R32) of two residents reviewed for 'Quality of Care' when R32's left foot/toes injury were not identified, assessed or treated in a timely manner and two 'opened areas' in the groin/abdominal skin folds and four scalp [CONDITION(S)] were not identified or assessed resulting in skin irritation, delayed treatment, and the potential to develop a skin infection. Findings include: On 1/25/22 at 2:50 PM R32 was observed seated in a wheelchair in his room with his bare feet on a white bath towel on the floor. R32's left foot had an approximated 2 inch long scratch on the top of his foot and several small abrasions on his left second and third toe. There were smears of dried dark red blood across the scratch and the toes. The left foot had slight purple mottling. R32 had a right foot stump with and old intact scar where the right toes had been surgically amputated. The right foot stump was clean, dry with slight purple mottling. Upon inquiry R32 said, My toes (right) were amputated awhile back, but I scraped my foot (referring to left foot) on the bed or the wheelchair yesterday. I'm not sure exactly how I did it. When I told the nurse, she put this towel under my feet and was going to come back to look at it, but she hasn't yet. I also asked her to put the skin cream on my scalp, but she said to wait until I had a shower. I have not got a shower yet. My scalp is really itching me. There is also something going on in my left groin area. It's irritating me. Observation of R32's scalp revealed four approximated dime-sized dry reddened scaly patches on his left temple and behind his left ear and an approximated 1 inch by 2 inches irregular shaped dry reddened scaly patch extending across the lower occipital region of his scalp. There was no visual observation of cream or lotion on the reddened areas of the scalp. R32's groin area could not be observed due to him being seated in the wheelchair. An Electronic Medical Record (EMR) review revealed R32's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R32's Minimum Data Set, dated dated dated [DATE] he had no cognition deficits and required extensive assistance from one person for bed mobility and transfers. R32 was identified to be 'at risk' for pressure ulcers and a care plan was initiated. Section M indicated that R32 had no skin ulcers, wounds, rashes or skin problems. An admission skin assessment dated [DATE] indicated R32 had no identified skin conditions or wounds. A review of R32's last two skin assessments dated 1/17/22 at 7:50 PM and 1/24/22 at 7:50 PM indicated that R32 had no existing or new abnormal skin issues. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There are no skin treatments ordered for the left foot/toes area. A review of R32's progress notes from 1/1/22 through 1/24/22 revealed there was no documentation to indicate R32's left foot scratch/abrasion, scalp [CONDITION(S)] or abdominal/groin skin fold areas had been identified as a concern or assessed. There was no treatment documented for the left foot/toes area. On 1/26/22 at 11:00 AM R32 was observed seated in a wheelchair in his room with his bare feet on a white bath towel on the floor. The top of his left foot had a small smear of red blood coming from the scratch on the top of his left foot and a small amount of red blood oozing from his left toes. R32 confirmed that no staff had assessed his left foot/toes injury. On 1/26/22 at 2:30 PM R32 was observed seated in a wheelchair in his room with his bare feet on a white bath towel on the floor. The top of his left foot had a smear of dried dark red blood around the scratch on the top of his left foot and toes. R32 reported that no staff had addressed his left foot injury at this time. R32 said, They haven't put the cream on my scalp yet either, and there is a rash or some blisters in my left groin area and under here (resident pointed to his left abdominal skin fold area). A review of R32's EMR on 1/26/22 at 2:30 PM revealed there was no progress note, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/26/22 at 2:24 PM, Director of Nursing (DON) B was asked if there was any skin assessment or incident report for R32's left foot skin injury. DON B reviewed R32's EMR including R32's last skin assessment dated [DATE] and confirmed there was no documentation to indicate R32 had any skin concerns with his left foot. DON B called unit manager, Licensed Practical Nurse (LPN) L on the phone from her office and asked if there was any 'Incident report' for R32. DON B said that LPN L had no knowledge of R32's foot injury. On 1/26/22 at approximately 2:30 PM with DON B, R32 was observed seated in a wheelchair in his room with his bare feet on a white bath towel on the floor. DON B confirmed that R32 had a scratch and abrasion on his left foot and toes with dried and smeared blood on it. Upon inquiry R32 told DON B about his skin irritation in his scalp and discomfort in his left groin/abdominal skin fold area. On 1/26/22 at 3:00 PM a progress noted included the following; L groin 0.5 cm x 0.5 cm excoriation L Abdominal fold 0.5 cm x 0.5 cm excoriation. A skin assessment dated [DATE] locked at 6:14 PM identified four abnormal skin areas: 1) Left groin 0.5 cm (centimeter) x 0.5 cm excoriation 2) Left Abdominal fold 0.5 cm x 0.5 cm excoriation 3) TWO 0.5 cm x 0.5 cm abrasions of left toes 4) Left top of foot 4 cm x 0.3 cm abrasion. On 1/27/22 at approximately 8:30 AM, DON B provided an 'incident report' dated 1/26/22 at 2:30 PM that indicated R32 had three abrasions on his left foot and the areas were cleansed and covered with a dry dressing. DON B said R32 had sustained the injuries to his left foot when he tried to move his wheelchair closer to the bed during a transfer from the bed to the wheelchair. DON B confirmed that R32 also had two new open areas in the left groin/abdominal folds observed on 1/26/22 during a skin assessment.

Based on observation, interview, and record review the facility failed to clean and maintain [CONDITION(S)] equipment and oxygen tubing in a sanitary manner or use a humidifier with oxygen administration on concentrators for one (R32) of two residents reviewed for oxygen therapy, resulting in the potential for respiratory infections, dried irritated nasal and throat membranes, and discomfort. Findings include: According to the facility's policy for 'Oxygen Concentrator' implemented on 1/1/2021, the purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. An oxygen concentrator is a medical device that [MEDICATION(S)] oxygen from the room air by filtering out or separating [MEDICATION(S)] from the oxygen. The oxygen passes through the filter system and is then stored within the device for delivery based on the flow meter. 5. Use of the Concentrator: e .use a disposable humidifier. g. iii. Observe for bubbles in the humidifier reservoir. 6. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. According to the facility's policy for Oxygen Administration implemented on 1/1/2021; 2. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists. 5. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. According to the facility's policy for [CONDITION(S)]/[CONDITION(S)] Cleaning implemented on 1/1/2021; 2. Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. 5. Clean mask frame daily after use with [CONDITION(S)] cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. 9. Replace equipment routinely in accordance with manufacturer recommendations. General guidelines: a. face mask and tubing - once every 3 months. c. disposable filters - twice monthly On 1/25/22 at 2:50 PM a sign on R32's door indicated the residents in this room were on Droplet Precautions and staff were required to wear N95 mask, face shield, gown, and gloves prior to entry into the room. R32 was observed seated in a wheelchair in his room with oxygen tubing going into his nose (nasal cannula) connected to an oxygen concentrator set at 4 liters per minute without any humidification. The oxygen tubing was dated 1/15/22 (10 days ago). A [CONDITION(S)] machine was on R32's bedside dresser with the face mask laying on the bed, open to air. The face mask had some dried clear sputum on it and a dingy piece of white paper tape wrapped around the tubing had no date on it. There were several small drops of moisture in the [CONDITION(S)] tubing system. Upon inquiry, R32 said that his [CONDITION(S)] mask always sits on his bed like that when he is not using it. R32 said he uses the [CONDITION(S)] mask at night and has never put it in a plastic bag. R32 said his [CONDITION(S)] equipment had never been cleaned and confirmed the face mask had never been changed. There was a crumpled plastic bag on the floor between R32's waste receptacle and the oxygen concentrator. On 1/26/22 at 11:02 AM, R32 was observed in his room in his wheelchair with the [CONDITION(S)] face mask resting on the bed, nasal cannula oxygen tubing dated 1/15/22 and the clear plastic bag crumpled on the floor between the oxygen concentrator and waste receptacle. Upon inquiry R32 said he was diagnosed with a respiratory infection a week ago, had a dry nose and throat, and had coughed up a little blood a couple days ago. An Electronic Medical Record (EMR) review revealed R32's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/15/22 R32 had signs and symptoms of an upper respiratory infection and tested positive for RSV (Respiratory Syncytial Virus). R32 and his roommate were placed on 'droplet precautions'. According to R32's Minimum Data Set, dated dated dated [DATE] he had no cognition deficits and required extensive assistance from one person for bed mobility and transfers. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/24/21 the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Cleanse [CONDITION(S)] mask q (every) morning with soap and water and allow to air dry. Place in plastic bag once dried. Empty humidifier chamber and wipe dry one time a day. Wash [CONDITION(S)] headgear/straps in warm, soapy water and air dry. Wash tubing with warm, soapy water and air dry one time a day. On 1/26/22 at 2:11 PM during an observation with the Director of Nursing (DON) B she confirmed that R32's oxygen tubing was dated 1/15/22 and his [CONDITION(S)] mask remained laying on the bed. R32 confirmed that he had not seen any staff member clean the [CONDITION(S)] mask, or place it inside a plastic bag. On 1/27/22 at 8:40 AM the Director of Nursing (DON) B confirmed that R32's oxygen tubing should have been changed on 1/21/22 or 1/22/22. DON B said oxygen tubing is changed weekly on Friday. DON B confirmed that humidification was placed on R32's oxygen concentrator and that he will be on 30 minute checks to ensure that his [CONDITION(S)] mask is appropriately stored inside a plastic bag to maintain sanitary conditions.

This citation pertains to MI 879 and MI 525. Based on observation, interview and record review, the facility failed to notify the Physician of missed doses of medication and refill medications timely for three residents (#43, #51, #247) of four residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken. Findings include: Review of a Ordering and Receiving Non-Controlled Medications policy with a revised date of 08/20 revealed, Medications related products are received from the pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. I. Ordering Medications from the Pharmacy . 2. Repeat medications (refills) are written on a medication reorder form . or requested via facility's EHR (Electronic Health Record) system and ordered as follows . Reorder medications based on the estimated refill date ([NAME]) on the pharmacy RX label, or at least three days in advance, to ensure an adequate supply is on hand. When ordering medication that requires special processing, order at least seven days in advance of need . Resident #43 Review of an Admission Record revealed, Resident #43 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 11/30/21 revealed Resident #43 had mild cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12, out of a total possible score of 15. In an observation and interview on 1/26/22 at 9:30 a.m., Licensed Practical Nurse (LPN) Q prepared medications for Resident #43. LPN Q placed four medications in a med cup. LPN Q reported Resident #43's [MEDICATION(S)] was not in the medication cart. LPN Q then reported the medication was order yesterday and she would call the pharmacy to check on it. Review of a Order Summary Report revealed, Resident #43 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note with a date of 1/26/22 at 12:35 p.m. for Resident #43, revealed, [MEDICATION(S)] [MEDICATION(S)] 0.5 % Solution Instill 1 drop in left eye two times a day . Per pharmacy med will be delivered today written by LPN Q. In an interview on 1/27/22 at 3:48 p.m., Resident #43's [MEDICATION(S)] was reordered yesterday (1/26/22) per DON B. Resident #51 Review of an Admission Record revealed, Resident #51 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 12/10/21, revealed Resident #51 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. In an observation and interview on 1/26/22 at 9:45 a.m., LPN Q prepared medications for Resident #51. LPN Q reported Resident #51's [MEDICATION(S)] (stool softener used to treat liver disease) was not re-ordered. LPN Q then poured 40 ml's of [MEDICATION(S)] in a medication up. LPN Q reported the dose for [MEDICATION(S)] was 45 ml's. LPN Q reported Resident #51's medication was ordered yesterday from the pharmacy. Review of a Order Summary Report revealed, Resident #51 had an order change on 1/26/22 for [MEDICATION(S)] Solution 10 GM/15ML ([MEDICATION(S)] [CONDITION(S)]) Give 60 ml by mouth four times a day Review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note with a date of 1/26/22 at 1:32 p.m. for Resident #51, revealed, [MEDICATION(S)] Solution 10 GM/15ML Give 60 ml by mouth four times a day . per pharmacy med to be in next delivery, written by LPN Q. In an interview on 1/27/22 at 2:14 p.m., LPN Q reported she did not call the Physician to notify them that Resident #43 and #51 medications were not available. LPN Q then reported the Physician should have been notified. In an interview on 1/27/22 at 2:16 p.m., Director of Nursing (DON) B reported the nurse should reorder medications. Medications are reordered through PCC (Point Click Care). DON B then reported when a medication is not available the nurse should call the pharmacy and Physician. In an interview on 1/27/22 at 3:58 p.m., Unit Manager K reported the nurse should reorder medications when they realize there are a few doses left. Resident #247 Review of an Admission Record revealed, Resident #247 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 10/30/21 revealed Resident #247 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. Review of a Order Summary Report revealed, Resident #247 had an order [MEDICATION(S)] (treats nerve pain) Tablet 600 MG, Give 2 capsule by mouth three times a day, with an order date of 10/26/21. Review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note with a date of 11/27/21 at 4:19 p.m. for Resident #247 revealed, [MEDICATION(S)] Tablet 600 MG Give 2 capsule by mouth three times a day . not avail. on order Review of a Progress Note with a date of 11/27/21 at 10:57 p.m. for Resident #247 revealed, [MEDICATION(S)] Tablet 600 MG Give 2 capsule by mouth three times a day . Not avail, on order.

This citation pertains to intake MI 544 This citation contains two deficient practice statements. DPS#1 Based on interview and record review the facility failed to assess, monitor, and treat a resident for dehydration (clinically significant loss of total body water) in a timely manner for 1 of 17 residents (R911) reviewed for quality of care, resulting in R911 admitted to the hospital with dehydration. Findings include: Record review on 10/5/21 of R911's face sheet revealed admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], R911 had impaired cognition and required extensive assist with most Activities of Daily Living. During interview on 10/5/21 at 2:43 PM with R911's spouse, it was confirmed that R911 was admitted to hospital with dehydration. It was confirmed that intravenous (IV) hydration was not declined by spouse during R911's admission at facility. Record review of hospital emergency records dated 5/25/21 at 7:20 PM documented the following: Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: [CONDITION(S)] and dehydration. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Laboratory sheet (form used by laboratory with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of laboratory results collected on 5/19/21 at 19:00 revealed a BUN (blood urea [MEDICATION(S)]) of 68 (normal range at this laboratory was 5-27). [MEDICATION(S)] was documented as 1.60 (normal range at this laboratory was 0.70 - 1.20). Record review of Nurses Notes created by Registered Nurse (RN F) dated 5/20/21 at 16:14 (4:14 PM) documented Results of blood work reviewed with Physician C. No new orders at this time. Resident's wife also informed of normal labs obtained. During interview on 10/6/21 at 10:04 AM with Physician C, it was confirmed that R911 should have been started on IV hydration related to the above laboratory results. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician C confirmed that these abnormal laboratory results would indicate the start of [CONDITION(S)]. Physician C confirms he did not recall a nurse calling him but would have started IV hydration. During interview on 10/6/21 at 12:00 PM with RN F, It was confirmed that the laboratory results on 5/19/21 were abnormal. It was confirmed that no orders were given to start hydration. It was confirmed that R911's spouse should have not been informed that laboratory results were normal. RN F confirmed that R911 should have had more fluids for a BUN of 68. During interview on 10/6/21 at 1:15 PM with Director of Nursing (DON) B, she confirmed that when test results are ordered they should be done at next day that laboratory comes to collect. DON B confirmed that when laboratory tests are ordered and not collected, the midnight nurse should put it on the '24-hour' board. DON B confirmed that the test results were not collected in a timely manner. DON B confirmed that resident's family should not have been told the results were normal when they were abnormal. DON B confirmed that laboratory results on 5/19/21 indicated that R911 should have been encouraged to drink more oral fluids and possible IV hydration. DON B confirmed awareness of labs not being drawn in a timely manner. DON B confirmed that facility has a laboratory policy to follow. Record review of laboratory results collected on 5/25/21 at 5:05 AM, revealed a BUN of 109 and a Creatinine of 4.02. Record review of Nurses Notes dated 5/25/21 at 8:30 AM, created by RN F, documented Lab called and reported critical BUN/CR lab results. Physician C notified and order received for nephrology consultation and to increase fluid intake as tolerated. During interview on 10/6/21 at 10:04 AM with Physician C, it was confirmed that related to the critical labs on 5/25/21, R911 should have been ordered to go to emergency room for evaluation and treatment. Record review revealed no orders given at that time. During interview on 10/6/21 at 12:00 PM with RN F, It was confirmed there was no recall of receiving an order at 8:30 AM to send R911 to hospital or start IV hydration. RN F stated, No orders were given until around 3:00 PM to send R911 to emergency room . Record review of SBAR (situation, background assessment and recommendation) Communication and progress note dated 5/25/21 at 15:00 (3:00 PM) documented the following: Resident continues with lethargy.Physician C orders transfer to hospital due to overall condition and critical labs. During interview on 10/6/21 at 1:15 PM with DON B, it was confirmed that related to laboratory results on 5/25/21 that R911 was in Severe Dehydration. It was confirmed that R911 was not transferred to the hospital until later in the day, after receiving critical labs at 8:30 AM. DON B confirmed that the facility had a hydration policy. Record review of Laboratory and Diagnostic Guidelines revised on 10/1/20, documented the following: . #9. The physician should be notified of all refused lab/diagnostic test orders and reason why. 10. The physician should be notified if the lab/diagnostic is unable to be completed, reason why, and request for new orders. Record review of Hydration policy implemented on 1/1/21 documented the following: Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Protocol: 1. As part of the initial assessment, the physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). a. The physician will distinguish various types of fluid and electrolyte imbalance (for example, [CONDITION(S)], [CONDITION(S)], pre-renal azotemia, etc.) from true dehydration (clinically significant loss of total body water). 1. The staff, with the physician's input, will identify individuals with signs and symptoms (for example, [CONDITION(S)], lethargy, increased thirst, etc.) or lab test results (for example, [CONDITION(S)], azotemia, etc.) that might reflect existing fluid and electrolyte imbalance. a. They will report this information promptly to the Attending Physician 1. The physician and staff will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance; for example, those with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well. 2. The physician will help identify the cause(s) of existing fluid and electrolyte imbalance or help the staff document why the individual should not be tested or evaluated. a. A limited review for causes (for example, based on the clinical situation and a basic metabolic profile [BMP]) may be appropriate even if an extensive work-up is not. 1. The physician will manage significant fluid and electrolyte imbalance, and associated risks, appropriately and in a timely manner. a. Timeliness depends on the severity, nature, and causes of the fluid and electrolyte imbalance. b. For minor, uncomplicated fluid and electrolyte imbalance, oral rehydration may suffice. For more severe or complicated fluid and electrolyte imbalance, subcutaneous (hypodermoclysis) or intravenous rehydration may be needed. c. If medications are contributing to fluid and electrolyte imbalance, they should be tapered or stopped (at least temporarily), or the physician should provide clinically valid reasons why they cannot or should not be changed, even temporarily. 1. The staff will provide supportive measures such as providing fluids and adjusting environmental temperature. 2. The physician will help monitor for the development, progression, or resolution of fluid and electrolyte imbalance in at-risk individuals. a. For example, replacement may be adequate if the resident is clinically stable, not having [CONDITION(S)], voiding at least every 3-4 hours, and the urine specific gravity (where attainable) is less than 1.015. 1. The physician will adjust treatments based on specific information (lab results, level of consciousness, etc.) relevant to that individual. This citation pertains to intake MI 544 DPS#2 Based on interview and record review the facility failed to correctly transcribe (to copy) a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Record review on 5/10/21 of R911's face sheet revealed admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) dated [DATE], R911 had impaired cognition and required extensive assist with most Activities of Daily Living. During phone interview on 10/5/21 at 2:43 PM with R911's spouse, it was confirmed that R911 was only supposed to receive [MEDICATION(S)] (Medication used for mood enhancement) once a day. Record review on 10/5/21 of Medical Administration Record (MAR) for the month of April 2021 documented the following order: 4/28/21 at 21:00 (9:00 PM) - [MEDICATION(S)] Sprinkles Capsule Delayed Release Sprinkle 125 MG ([MEDICATION(S)]) Give 2 capsules by mouth, two times a day related to unspecified dementia without behavioral disturbances. Record review of admitting medications list (no title) sent from primary physician in community revealed fax time stamp of 3/31/21 at 11:12 am to facility. It revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Take 2 capsules (250 mg total) by mouth every evening. Start 1 capsule nightly for 7 nights, then 2 capsules nightly after that. Then at the bottom of list the following order was documented: [MEDICATION(S)] ([MEDICATION(S)] SPRINKLES) 125 mg. Take 2 capsules (250 mg total) by mouth every evening. Start 1 capsule (Discontinued) nightly for 7 nights, then 2 capsules nightly after that Record review of Medication Error Report dated 5/13/21 documented the following: Date of error- 4/28/21- Description of error - [MEDICATION(S)] was to be ordered 250 mg (milligrams) daily. Order was misinterpreted and ordered for twice a day. Further review revealed that Administrator A, Attending Physician C and Director of Nursing (DON) B all signed bottom of form on 5/13/21. Record review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No adverse effects noted. Document was signed by Physician C. During interview on 10/6/21 at 11:43 AM with DON B, it was confirmed that nursing should clarify orders with prescribing physician if not sure of dosage. It was confirmed that medication was transcribed incorrectly and R911 received medications from 4/28/21 until 5/13/21.

Based ob observation, interview and record review the facility failed to ensure prescription medication (inhaler) was properly stored for one sampled resident (R#63) from a total sample of 34 residents reviewed for medication, resulting in unsecured medication and the potential for access to unauthorized persons to the medication. Findings include: Resident #63 On 10/20/20 at 10:07 AM, during a tour of the 300 nursing unit observation was made of a [MEDICATION NAME] Inhaler at the bedside for R#63. R#63 was asked about the inhaler to which she responded, Oh. I've had that. I use it about twice a day. Record review revealed that R#63 was admitted into the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The 8/14/20 Quarterly Minimum Data Set Assessment (MDS) indicated the residents cognition was severely impaired and required set up assistance with all activities of daily living. At 10:15 AM, Nurse A observed the unsecured inhaler and was queried regarding the facility's policy on medication storage at the bedside to which she responded, This is not suppose to be here at her bedside. Review of the facility's undated policy titled, Self-Administration of Drugs documented, 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents.

Based on observation, interview and record review the facility failed to safely secure an oxygen cylinder for one sampled resident (R#76) from a total sample of 34, resulting in the potential for hazardous accidents. Resident #76 On 10/20/20 at 10:53 AM, during a tour of the 300 nursing unit observation was made of an oxygen cylinder laying on the seat of the wheelchair for R#76. Record review revealed that R#76 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The recorded indicated the resident was admitted into hospice service on 10/17/20. The 10/6/20 Admission Minimum Data Set Assessment (MDS) indicated the residents cognition was moderately impaired and required extensive assistance with all activities of daily living. At 11:15 AM, Nurse A observed the unsecured oxygen cylinder and was queried regarding the facility's policy on oxygen storage to which she responded, Oxygen soul be secured in a sleeve on the back of the wheelchair or in a secured holder. Review of the facility's undated policy titled, Oxygen Cylinders documented, Cylinders must be properly secured in a cylinder holder.

Based on observation, interview, and record review the facility failed to follow the standards of infection control while performing wound care for one residents (Resident #603), out of three sampled residents reviewed for wound care (hand washing, glove use, barriers), resulting in the potential for wound infection and cross contamination and the spread of disease to a vulnerable population. Findings include: Resident #603 Review of an Admission Record revealed, Resident #603 originally admitted to facility on 1/17/20 and readmitted on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, with a reference date of 6/12/20, revealed Resident #603 had minimal cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12, out of a total possible score of 15. Resident #603 had a Stage 2 and Stage 3 pressure ulcer. In an observation on 6/23/20 at 10:48 a.m., Resident #603 sat upright in chair and watched television (TV). Resident #603's room door had a droplet precaution sign. In an interview on 6/23/20 at 10:58 a.m., Certified Nursing Assistant (CNA) A reported Resident #603 had a wound on the right buttock and he was going to assist the nurse with the wound change. In an observation on 6/23/20 at 11:03 a.m., Nurse C entered Resident #603's room an wore googles, gloves, a gown and mask. Nurse C carried wound supplies which included, packages of gauze, cream in a med cup and cotton applicators. Nurse C then placed the wound supplies on Resident #603's bedside table with no barrier. The bedside table was not cleaned before Nurse C placed wound supplies on the table. The bedside table had an open cup of juice and milk. Nurse C then exited the room and did not remove gloves. In an observation on 6/23/20 at 11:11 a.m., Nurse C entered Resident #603's room an wore googles, gloves, a gown and mask. Nurse C did not perform hand hygiene performed. Resident #603 had a dressing with a date of 6/22/20 on the right buttock. In an observation on 6/23/20 at 11:16 a.m., Nurse C removed the dressing from Resident #603's right buttock. Nurse C then removed gloves and applied new gloves and did not perform hand hygiene before application of new gloves. Resident #603 had a small open area on the right buttock that was packed with gauze. Nurse C poured normal saline (NS) on Resident #603's open area and removed the gauze. Nurse C then removed gloves and applied new gloves and did not perform hand hygiene before application of new gloves. Nurse C cleaned the open area with NS and gauze. Nurse B packed [MEDICATION NAME] gauze in Resident #603's open area on the right buttock, placed on a new dressing, removed gloves and did not perform hand hygiene. Nurse B then placed a date of 6/23/20 on the dressing. In an observation on 6/23/20 at 11:25 a.m., Nurse C removed gloves and performed hand in Resident #603's bathroom, then exited the room. In an interview on 6/23/20 at 11:26 a.m., Nurse B reported wound supplies should be laid on a barrier. In an interview on 6/23/20 at 11:44 a.m., Nurse C reported staff should wash their hands every time gloves are changed. In an interview on 6/23/20 at 12:47 p.m., Unit Manager E reported there should be a barrier between wound supplies and bedside table. Unit Manager E then reported hand hygiene should be performed after removal of gloves and from dirty to clean procedures. In an interview on 6/23/20 at 1:02 p.m., The Director of Nursing (DON) reported there should a barrier between the bedside table and wound supplies. The DON then reported hand hygiene should be performed between glove changes. Review of a Hand Hygiene policy with a revised date of 5/28/20 revealed on 6/23/20 at 1:25 p.m., revealed Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility with the exception to food prep areas .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on observation, interview, and record review, the facility failed to: 1. Ensure foods were stored appropriately to prevent freezer burn (condition that occurs when frozen food has been damaged by dehydration and oxidation, due to air reaching the food) and contamination; 2. Ensure food products were properly date labeled; 3. Ensure food-contact surfaces and non-food-contact surfaces were adequately cleaned; 4. Consistently implement proper food safety practices. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 5/29/18 at 8:35 AM, during the initial tour of the kitchen with the Dietary Manager (DM), the following was observed: A bag of chocolate chip cookie dough was left opened to the freezer air in the walk-in freezer. The DM said, Freezer burn could occur or stuff (debris) could fall in the bag. Two undated bags of hot dog buns, which had previously been opened, were observed in the dry food storage area. One bag had not been reclosed. When the DM was queried about the opened and undated bags of hot dog buns, she said, Who knows how long they are good for (without an indication of an opened or use-by date). When queried about the bag of hot dog buns that was not reclosed, the DM said, The buns could get hard and stale and things (pests) could get in there. On the shelf where clean pots and pans were stored, a twelve-quart pot and small mixing bowl were stored right side up. The DM said, They should be stored right side down to prevent things from falling in them. Fried tator tots were observed in the grill catch tray. The DM indicated tator tots had not been cooked for breakfast. AM Cook, Staff I said, Tator tots were cooked last night. The DM said, The catch tray should have been cleaned after it was used. Three sheet trays, stored with cleaned trays, were observed dripping with a substance that appeared oily. The DM said, It looks like oil. The DM indicated the area underneath the cook's prep table was a clean pan storage area. Dried food debris, resembling food residue that remains when muffins are baked without the use of muffin paper cups, was observed on four of the muffin tins stored underneath the cook's prep table. Three of the muffin pans were stored with oily residue in the muffin cups/molds. The DM said, Who ever used then, should have cleaned them. On 5/29/2018 at 11:51 AM, during lunch meal observation, Dietary Aide, Staff H was observed standing behind the steam table plating food for the residents eating in the rehab dining room. While plating the residents' food, Staff H was observed handling the residents' plates with her bare hands. Staff H's thumbs were observed touching the eating surface of the plates. During this lunch meal observation, there were approximately fifteen residents that were dining in the rehab dining room. Payroll Manager, Staff F and Certified Nurse Aide, Staff G were observed delivering plated food to the residents in the rehab dining room. Staff F and Staff G did not don gloves and were also noted placing their thumbs on the eating surface of the residents' plates. Several times during the lunch meal observation in the rehab dining room, Dietary Clinician, Staff E, was observed scooping ice out of the ice machine using a ice scoop. Staff E held on to the scoop handle with her bare hands and when done using the ice scoop would store it inside the ice machine. When Staff H and Staff E were queried if the ice scoop should be stored inside the ice machine, Staff H said, No and proceeded to remove the scoop from inside the ice machine and place it on a dish on top of the counter. On 5/30/18 at 9:45 AM, when the DM was queried about the storage of the ice scoop inside of the ice machine and the bare hand contact on the food contact surfaces of residents' plates, she stated the ice scoop should not be stored in the ice machine because of cross contamination and infection control and staff should avoid touching resident food contact surfaces with their bare hands. On 5/29/18 at 10:00 AM, the facility policy titled, Environment, revised 9/2017, documented the following: All food contact surfaces will be cleaned and sanitized after each use. The facility policy titled, Ice Machines and Ice Storage Chests, revised 6/23/16, documented the following: e. Keep the ice scoop in a covered container when not in use. The 2009 Michigan Modified Food Code was reviewed and revealed the following: 3-305.11, Food Storage. (A) Except as specified in (paragraphs B and C) of this section, food shall be protected from contamination by storing the food: (2) Where it is not exposed to splash, dust, or other contamination; 3-101.11, Safe, Unadulterated, and Honestly Presented, Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. 4-602.11, Equipment food-contact surfaces and utensils, Equipment food-contact surfaces and utensils shall be cleaned at any time during the operation when contamination may have occurred. 3-301.11: Preventing Contamination from Hands, § 3-302.15 or as specified in (section) (D) of this section, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. (D) Food employees not serving a highly susceptible population may contact exposed, ready-to-eat food with their bare hands if: (1) the permit holder obtains prior approval from the regulatory authority;

Based on interview and record review, the facility failed to demonstrate professional standards of practice by failing to monitor resident's blood sugar for six of ten days as ordered for one (#38) resident reviewed for physician's orders [REDACTED]. Findings include: A review of the R38's clinical record documented an initial facility admission on 3/1/18 with a readmission date of [DATE]. R38's [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented intact cognition. On 5/31/18 at 10:30 AM, when License Practical Nurse, Staff A, was queried about when is it appropriate to perform accuchecks on a resident diagnosed with [REDACTED]. When queried about why checking blood sugars was important, Staff A said, The fingerstick is to check blood sugar levels; to make sure the blood sugar is not too high or too low. When queried if she would perform an accucheck on a resident not prescribed insulin, Staff A said, Yes, if they had an order. On 5/31/18 at 10:55 AM, a review of the R38's clinical record was conducted with Unit Manager, Staff B. R38's 5/9/18 physician's orders [REDACTED]. On 5/31/18 at 3:00 PM, R38's (MONTH) (YEAR) Medication Admission Record (MAR) was reviewed with the Director of Nursing (DON). The review documented that between the period of 5/9/18 to 5/31/18, twice daily accucheck blood sugar values were not documented as ordered for the following dates: 5/9/18, 5/11/18, 5/14/18, 5/16/18, 5/18/18, and 5/21/18. The DON said, We're not seeing the (blood sugar) values. When queried if this was a concern that the blood sugar results were not available, the DON said, Yes, because we do not have the information to call the doctor regarding blood sugar concerns. On 5/31/18 at 9:30 AM, the facility policy titled, Nursing Care of the Resident with Diabetes Mellitus, revised 4/2018, documented the following: The physician will order the frequency of glucose monitoring.

Based on interview and record review, the facility failed to review and revised as necessary a comprehensive care plan related to diabetes management for one (#38) resident reviewed for care plans, resulting in the potential for unmet care needs. Findings include: On 5/30/18 at 11:50 AM, a review of the Medication Administration Record (MAR) for Resident #38 (R38) was reviewed and R38's order for fast acting insulin, administered per a sliding scale, was discontinued on 5/8/18. Since 5/8/18, R38 had not been prescribed, nor received, anti-diabetes medication. A review of the R38's clinical record documented an initial facility admission on 3/1/18 with a readmission date of [DATE]. R38's [DIAGNOSES REDACTED]. A Minimum (MDS) data set [DATE] documented intact cognition. On 5/31/18 at 10:55 AM, a review of R38's clinical record was conducted with Unit Manager, Staff B. R38's order for blood sugar monitoring indicated, accu check twice a day without coverage two times a day every Monday, Wednesday, Friday related to diabetes mellitus When queried about the meaning of without coverage, Staff B said, That means he's not on an insulin sliding scale. He's not getting any insulin. Staff B confirmed that R38's insulin order was discontinued on 5/8/18. Staff B added the insulin order was stopped because R38's had demonstrated stable blood sugars. A review of R38's clinical record with Staff B did not reveal a clinical note from nursing or the doctor regarding the change in the medical management of R38's diabetes mellitus. Staff B stated there should have been some type of documentation from the nurse or doctor regarding this change. When asked why?, Staff B said, Because it's a change in medication; the change in sliding scale insulin in very important. R38's care plan for diabetes management was reviewed with Staff B which revealed that his diabetes mellitus care plan was last reviewed/updated on 3/9/18. When Staff B was queried if his care plan should have been updated to reflect the change in the medical management of his diabetes, she said, Yes, because he is not on any diabetes medication. When queried, Who was responsible for updating the care plan?, Staff B said, The MDS nurse. When queried if they had to wait until his next MDS review for the care plan to be updated, Staff B said, No. When Staff B was queried if his current diabetes care plan reflected the current state of his diabetes management, she said, No. On 5/31/18 at 12:18 PM, when R38's (MONTH) (YEAR) MAR and diabetes management care plan were reviewed with the Director of Nursing (DON), she said, Care plans should be reviewed when there is any kind of change in the resident's care. If a resident has a medical change, the care plan should be reviewed and revised as indicated. When the DON was queried, if R38's care plan should have been reviewed and revised as necessary, she said, Yes. On 5/31/18 at 9:30 AM, the facility policy titled, Diabetes - Clinical Protocol, revised 6/2017, documented the following: The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the Medication Administration Record and care plan.

Based on observation, interview, and record review, the facility failed to ensure Preadmission Screening (PAS)/ Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and/or DCH-3878) documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for intellectual/ developmental disability needs for one (#14) of one sampled residents reviewed for PAS[DIAGNOSES REDACTED], resulting in the potential for unmet intellectual/ developmental disability care needs. Findings include: On 5/29/18 at 2:44 p.m., R#14 was observed in the activities area working on a puzzle. R#14 appeared to have an Intellectual Disability exhibited by delay in speech and childlike behavior. When the Resident placed a puzzle piece in the correct spot, the Resident would say, YAYYY! and clap hands. R#14 also displayed poor attention span, poor eye contact, and poor comprehension of what was being asked. On 5/29/18 at 3:06 p.m., review of R#14's clinical record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. properly), [MEDICAL CONDITION], and dementia without behavior disturbance. According to the Minimum Data Set (MDS) assessment dated [DATE], R#14 was moderately cognitively impaired (BIMS score 8) and required extensive assistance with one to two-person assistance with activities of daily living (ADLs). Review of the Communication care plan date and revised 9/24/16 documented, Communication deficit related to ID/DD. On 5/29/18 at 3:06 p.m., the current PASSAR (3877 and/or 3878) and/or Level II OBRA (Omnibus Budget Reconciliation Act) evaluation was not in the electronic medical record. The most current documentation of the 3877 and/ or 3878 was dated 9/12/16. The most current Level II Determination was dated 11/7/16. Review of the DCH-3877 revealed YES was marked for number 6 There is presenting evidence of deficits in intellectual functioning or adaptive behaviors which suggests that the person may have an intellectual disability or a related condition under SECTION II. Under the explain any YES section documented, Pt has [DIAGNOSES REDACTED] and does have evidence of deficits in intellectual function. On 5/30/18 at 4:06 p.m., the Social Worker (SW) was interviewed. The SW was asked to locate a more current or annual 3877 and/ or 3878 and Level II Determination. The SW stated, There was not an annual one done because the Resident doesn't need one. It was my understanding the Resident didn't need one done annually unless there was a significant change. Review of the Level II Determination revealed, . This does not alter the nursing facility's requirement for completing the Annual Level I (DCH-3877) or reporting significant changes to the CMHSP or their contract agency . This statement was brought to the SW's attention. After reading the statement, the SW stated, I just started doing these recently. The doctors were completing these prior to me doing them. It was my understanding 3877s were done if there was a significant change. The Resident didn't need an OBRA screening because of the Dementia diagnoses. It was also brought to the SW's attention the Resident had a [DIAGNOSES REDACTED]. On 5/31/18 at 8:57 a.m., the SW presented a current (dated 5/30/18) 3877 and 3878 and stated, One should have been done in November. The documents were reviewed. The documents were not completed correctly. The 3877 only reflected the dementia [DIAGNOSES REDACTED]. The SW stated, I didn't know [DIAGNOSES REDACTED] was a developmental disability. On 5/31/18 at 2:53 p.m., the Administrator was interviewed. The Administrator was asked why the SW recently started reviewing and revising the PAS[DIAGNOSES REDACTED]. The Administrator stated, The SW has always done them, the physicians would sign them. The Administrator was then asked the reason PAS[DIAGNOSES REDACTED] were not completed annually. The Administrator stated, We were under the impression they were only done when there was a significant change. We are currently working on updating them all. According to the Preadmission Screening (PAS)/ Annual Resident Review (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification Instructions: The DCH-3877 is used to identify prospective and current nursing facility residents who meet the criteria for possible mental illness or intellectual disability .The 3877/3878 must be reviewed and revised annually. Review of the attached directions for completion of these forms documented, The person screened shall be determined to require a comprehensive Level II OBRA (Omnibus Budget Reconciliation Act) evaluation if any of the above items are YES UNLESS a physician certifies on form DCH-3878 that the person meets at least one of the exemption criteria .If any answer to questions 1-6 in SECTION II is YES send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative. DCH-3877 (8-17) Previous Editions Obsolete. Intellectual Disability/Related Condition: An individual is considered to have a severe, chronic disability that meets ALL 4 of the following conditions: a. It is manifested before the person reaches age 22. b. It is likely to continue indefinitely. c. It results in substantial functional limitations in 3 or more of the following areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living. d. It is attributable to: o Intellectual Disability such that the person has significant subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period; o [MEDICAL CONDITIONS], autism; or o any condition other than mental illness found to be closely related to Intellectual Disability because this condition results in impairment in general intellectual functioning OR adaptive behavior similar to that of persons with Intellectual Disability, and requires treatment or services similar to those required for these persons. Presenting evidence means the individual manifests deficits in intellectual functioning or adaptive behavior, which suggests the need for further evaluation to determine the presence of a developmental disability, causal factors, and treatment recommendations. These deficits appear to have manifested before the age of 22. NOTE: When there are one or more Yes answers to items 1 - 6 under SECTION II, complete form DCH-3878, Mental Illness/Intellectual Disability/Related Condition Exemption Criteria Certification only if the referring agency is seeking to establish exemption criteria for a dementia, state of coma, or hospital exempted discharge.

This citation pertains to intake #MI 610. Based on interview and record review, the facility failed to ensure a functioning safety device (fall defender - a device place on the bed which silently alarms/notifies the staff via pager that the Resident moved off the bed) was in place per plan of care for one (#701) of four sampled Residents reviewed for falls with injury in a total sample of four, resulting in the Resident falling without staff being aware, sustaining two lacerations to the right occipital lobe and a right hip fracture which required hospitalization and surgical intervention. Findings include: On 10/11/16 at 3:35 p.m., an interview was conducted by phone with the Resident's legal representative (LR). At that time, the LR expressed concern that Resident #701 had fallen on 9/27/16, sustained serious injuries which required hospitalization per family's request and subsequent surgical intervention for a total hip replacement. The LR further reported that Resident #701 no longer resided at the facility and was transferred following surgery to another nursing facility. On 10/12/16 at 9:30 a.m., review of Resident #701's hospital records documentation included: -Hip x-ray dated 9/27/16 noted an indication of Fall, right thigh pain. The findings included, There is an impacted right femoral neck fracture. There is 8 millimeters superior displacement of the major distal fragment . -CT (cat scan) head without contrast completed 9/27/16 noted an indication of Fall, laceration on the back of head. The findings included no acute intracranial hemorrhage. -Operative report dated 9/29/16 documented .The patient is [AGE] years old, fully ambulatory, has dementia, fell at the nursing home yesterday .and injured her right hip. The patient was brought back to the hospital, identified as having a right femoral neck fracture and was brought to the operating room today for the purpose of an elective bipolar right total hip arthroplasty . On 10/12/16 at 9:40 a.m., review of the clinical record revealed Resident #701 was initially admitted into the facility on [DATE], readmitted on [DATE] and had been discharged to the hospital on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] documented Resident #701 had significant cognitive impairment, no behavior concerns, required extensive assistance of two persons for bed mobility and transfers, and had a fall with major injury during this assessment period. Review of the fall risk evaluations completed 9/26/16 (upon readmission into the facility) identified a score of 28.0 which noted Interventions Required. The previous fall risk evaluation completed 7/6/16 identified a score of 10.0. Interventions identified were fall defender. On 10/12/16 at 10:00 a.m., review of the facility's investigation of Resident #701's fall with injury identified the unobserved fall occurred in the Resident's room on 9/27/16 at 11:00 a.m. when the Resident self-transferred from the bed, hit head on the corner of the television stand and sustained two lacerations to the right occipital lobe. The investigation further identified She had a fall defender on her bed and was properly connected though did not alert staff when she self-transferred. On 10/12/16 at 12:00 p.m. an interview and record review was conducted with the Director of Nursing (DON). At that time when asked about the Resident's fall on 9/27/16, the DON reported The housekeeper was the first person who found her and immediately went to get the nurse. I was doing a tour. When I came upon the unit, her room is just inside the doors, I saw Resident #701 on the floor by the bed and TV stand. She was trying to get up and sit up. Nurse F and Certified Nursing Assistant (CNA E) came in and we immediately began treatment. I applied pressure to the wound on her head. Range of motion was performed and there were no concerns. She had no complaints of pain to the hip area. She did touch her head. By the time we got her up, the bleeding had stopped. The nurse administered Tylenol. The Physician was contacted and ordered STAT x-rays and neurochecks. While we were in the room, Nurse F was on the phone talking with the Resident's daughter. At that time, Nurse F handed the phone to me and we spoke for about 30 minutes. We placed her in the dining room after changing her shirt so we could keep an eye on her. I sat in there to monitor her. At lunch, name of another daughter came in the dining room and was very upset. Kept asking why we didn't send her out. I explained that the Physician had ordered neurochecks and STAT x-rays and had been monitoring the Resident. The daughter requested to have the Resident sent to the hospital and shortly after transfer, the tech arrived to obtain the x-rays but the Resident was already gone. When asked about the fall defender and whether CNA E had received the alert when the Resident got up from the bed, the DON reported, I checked the pager and there was no notification. The fall defender was in place and properly hooked up, but there was a malfunction. We have implemented a facility wide assessment to make sure that doesn't happen again. The CNA E identified by the DON as the staff assigned to Resident #701 on 9/27/16 was attempted to be reached by phone multiple times without any return call by the end of the survey. The facility's Past Non-Compliance dated 9/27/16, identified a substantial compliance date of 9/30/16 which included: Description of Quality Concern (why and how did it happen): Resident #701 who was readmitted to the facility on [DATE] on the 400 unit with MI (heart attack) and UTI (urinary tract infection) was observed in her room near the front of her bed laying on her right side with her head at the near the corner of her television stand. She self-transferred from her bed and she reported that she got spun around and fell . She hit her head on the corner of her television stand and sustained 2 lacerations to her right occipital lobe. She had a fall defender on her bed and was properly connected though did not alert staff when she self-transferred. What improvement action(s) will be done for residents found to have been effected by the concern(s): -All residents' with safety interventions were assessed to ensure there is a physician order, that they are care planned, and that they are in place and functioning. -All nursing staff will be re-educated on reviewing the care plans of readmissions and ensuring that the safety interventions if still needed are ordered, care planned, in place and functioning. -Any nursing staff that did not receive the education will be re-educated prior to their next shift. How facility will identify other residents having potential to be affected by practice AND what improvement action will be taken: -Current residents have been re-assessed for fall risk, if any residents are found to be at risk safety interventions will be ordered, care planned, in place and functioning. What measures will be put in place or what systemic changes you will make to ensure that the practice does not occur: -A continued process is in place for nurses to sign out the safety orders every shift to ensure that they are in place. -Unit Managers will review any possible admissions that are coming to their unit for being at risk for falls. -Unit Managers will review any readmissions' fall risk care plans and ensure that the safety interventions are in place prior to the resident arriving. -Admitting nurse will assess residents' fall risk on admission and put additional interventions in place as needed. How the corrective action(s) will be monitored to ensure the practices will not recur. i.e. what quality assurance program will be put in place: -QAPI meeting will be held on October 11, 2016 to review the event as well as this plan. The plan was reviewed with the Medical Director by the administrator on September 29, 2016. Weekly the D.O.N/designee will conduct random audits to ensure that the safety intervention are in ordered, care planned, in place and functioning for eight weeks. -The Administrator/designee will monitor the morning stand up meeting to ensure that admissions' safety care plans are reviewed during the meeting. ( )

THIS CITATION REFERS TO INTAKE NUMBER MI 499 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE APPROPRIATE CARE (ASSESS AND TREAT A BURN IN A TIMELY MANNER) FOR 1 (#105) OF 7 RESIDENTS REVIEWED FOR INJURIES, FROM A TOTAL SAMPLE OF 8, RESULTING IN RESIDENT #105 SUSTAINING A SECOND DEGREE BURN. FINDINGS INCLUDE: RESIDENT #105, AN [AGE] year OLD MALE WAS ORIGINALLY admitted TO THE FACILITY IN 2007, AND readmitted IN 2009. RESIDENT #105'S [DIAGNOSES REDACTED]. PER THE MDS (MINIMUM DATA SET) ASSESSMENTS DATED 6/24/11 AND 3/2/12, HE REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING WHICH INCLUDED EATING. PER THE NUTRITIONAL CARE PLAN DATED 6/25/11 AND UPDATED 9/23/11, HE REQUIRED STAFF ASSISTANCE WITH MEALS. PER THE CARE PLAN FOR BEHAVIOR, DATED 6/25/11, HE COULD BE RESISTIVE TO CARE AND DISPLAYED AGITATED BEHAVIORS TOWARDS STAFF AT TIMES. PER THE FACILITY INCIDENT/ACCIDENT REPORT DATED 1/29/12 AT 6:35 P.M., AT THE DINNER MEAL, RESIDENT (#105) GRABBED A BOWL OF MAC & CHEESE OFF THE TABLE AS SOON AS IT WAS PLACED IN FRONT OF HIM. THE CNA (CERTIFIED NURSING ASSISTANT) ( # 5) IMMEDIATELY TRIED TO INTERVENE, BUT IT SPILLED IN HIS (RESIDENT #105) LAP. HE (RESIDENT #105) THEN BECAME AGITATED AND STARTED GRABBING EVERYTHING HE COULD REACH. CNAS (#5 AND #12) WERE ABLE TO TURN HIS CHAIR AROUND AND CLEAN OFF (RESIDENT #105'S) LAP WITHIN 60 TO 90 SECONDS. WHEN RESIDENT #105 WAS BEING PUT TO BED AT 6:35 P.M., CNA ( #7) NOTICED THE BURN AND BLISTER ON HIS RIGHT UPPER THIGH. THE ATTACHED ACCIDENT/INCIDENT INVESTIGATION "SKIN" SHEET DOCUMENTED THAT THE NURSE (#11) ASSESSED RESIDENT #105 AND DOCUMENTED A BURN TO RESIDENT #105'S RIGHT UPPER THIGH AS DESCRIBED THE BURN AS A 4" WIDE BY 1"- 2" LONG, RED, RAISED AREA WITH 1" X 1/2" INTACT BLISTER IN THE CENTER. NURSE #11 ASSESSED THE AGE OF THE BURN AS BEING 1-1/2 HOURS OLD. REVIEW OF THE CLINICAL RECORD REVEALED A PHYSICIAN ORDER DATED 1/29/12 FOR DRY GAUZE ON RIGHT UPPER THIGH OVER BURN TO PROTECT THE BLISTER. A physician progress notes [REDACTED]. ON 3/2/12 AT 2:35 P.M., DIETARY AIDE #4 SAID AT DINNER (APPROXIMATELY 5:30 TO 5:45 P.M.), ON 1/29/12, HE DELIVERED RESIDENT #105'S MEAL IN THE MAIN DINING ROOM. HE SAID THAT CNA (#5) WAS SITTING RIGHT NEXT TO THE RESIDENT WHEN HE ANNOUNCED THE MEAL AND SET IT ON THE TABLE. HE SAID RESIDENT #105 IMMEDIATELY GRABBED THE BOWL OF MACARONI & CHEESE AND CNA #5 ATTEMPTED TO GRAB IT FROM HIM BUT IT SPILLED INTO HIS (RESIDENT #105'S) LAP. DIETARY AIDE #4 SAID AS SOON AS THE MACARONI AND CHEESE LANDED IN HIS LAP, RESIDENT #105 STARTED GRABBING AT EVERYTHING. HE SEEMED AGITATED AND WAS GRABBING THE TABLE CLOTH AND PULLING OTHER FOOD ITEMS TOWARDS HIM. ACCORDING TO DIETARY AIDE #4, "WE WERE ABLE TO STOP HIM (#105) BUT THE MACARONI AND CHEESE WAS ALL OVER HIS RIGHT LEG." WHEN QUERIED BY THE SURVEYOR AS TO HOW LONG THE MACARONI AND CHEESE WAS IN RESIDENT #105'S LAP, DIETARY AIDE #4 ANSWERED "ABOUT 5 MINUTES." WHEN ASKED IF RESIDENT #105 APPEARED TO BE IN PAIN, DIETARY AIDE #4 SAID, "I HADN'T THOUGHT ABOUT THAT, BUT LATTER SOMEONE SAID MAYBE THAT WAS WHY HE GRABBED THE TABLE CLOTH." ON 3/2/12 AT 3:05 P.M. CNA #5, STATED THAT ON 1/29/12 AT DINNER (APPROXIMATELY 5:20 TO 5:25 P.M.), SHE WAS SITTING BETWEEN TWO RESIDENTS (RESIDENT #105 AND ANOTHER RESIDENT) BOTH WHO REQUIRED ASSISTANCE WITH MEALS. SHE SAID THAT DIETARY AIDE #4 SET THE OTHER RESIDENT'S FOOD DOWN FIRST, AND THEN RESIDENT # 105'S. CNA #5 SAID THAT SHE TURNED TOWARDS THE OTHER RESIDENT THEN BACK TOWARDS RESIDENT #105 AND WITHIN SECONDS HE (#105) GRABBED THE BOWL OF MACARONI AND CHEESE AND TURNED IT UPSIDE DOWN IN HIS LAP. THE CNA SAID (RESIDENT #105) STARTED TO BECOME AGGRESSIVE, PULLING THE TABLE CLOTH, "AND NOW I KNOW WHY, THE MACARONI AND CHEESE WAS HOT." CNA #5 SAID THAT ANOTHER CNA (#12) CAME TO ASSIST HER. CNA #5 SAID AT THE TIME SHE DID NOT REALIZE THAT THE MACARONI AND CHEESE WOULD BURN RESIDENT #105. SHE (#5) SAID, "WHEN THE BURN WAS DISCOVERED LATER, I THOUGHT THAT MAYBE THAT WAS WHY HE WAS GRABBING THE TABLE CLOTH AND PUSHING HIS CLOTHING PROTECTOR INTO HIS LAP." WHEN QUERIED BY THE SURVEYOR ABOUT RESIDENT #105 BEING ASSESSED AT THE TIME OF THE SPILL, CNA #5 SAID HE WAS NOT. ACCORDING TO CNA #5, "ONCE WE CLEANED IT OFF HE (#105) CALMED." SHE SAID THAT A NURSE WAS IN THE DINING ROOM AND HAD ASKED ABOUT THE MESS ON THE FLOOR, AND SHE (CNA #5) ASSUMED SHE KNEW WHAT HAD HAPPENED. CNA # 5 SAID, "HE HAD NO REACTION, DIDN'T APPEAR TO BE IN PAIN AND IT DIDN'T OCCUR TO US THAT HE WAS BURNED BY IT. HE JUST WANTED TO EAT." CNA #5 SAID THAT SHE FED HIM HIS DINNER, WHICH TOOK ABOUT 25 MINUTES. SHE SAID SHE DID NOT KNOW BY WHOM OR WHEN HE WAS RETURNED TO ROOM. CNA #5 SAID SHE WAS INFORMED BY CNA #7 AT APPROXIMATELY 7:00 P.M. OF THE BURN. CNA #5 SAID SHE WAS AWARE THAT RESIDENT #105 "GRABBED THINGS, THAT IS WHY WE SIT WITH HIM." SHE SAID THAT "DIETARY IS AWARE NOT TO GIVE HIM FOOD WITHOUT THE CNA THERE. I THINK THAT IS WHERE THE ERROR OCCURRED, HE (DIETARY AIDE #4) SET IT TOO CLOSE (TO RESIDENT #105)." ON 3/6/12 AT 1:00 P.M., PER PHONE, CNA #12 SAID SHE WAS IN THE DINING ROOM SITTING ONE TABLE AWAY FROM CNA #5 AND RESIDENT #105, WHEN SHE HEARD CNA #5 SAY, "NO (RESIDENT #105'S NAME)." CNA #12 SAID SHE LOOKED OVER AND RESIDENT #105 WAS PULLING AT THE TABLE CLOTH AND HAD SPILLED MACARONI AND CHEESE IN HIS LAP. CNA #12 SAID ONCE THEY (THE AIDES) WERE ABLE TO GET HIM (#105) TO LET GO OF THE TABLE CLOTH, SHE (#12) TURNED HIS WHEELCHAIR AWAY FROM THE TABLE AND WIPED THE FOOD OUT OF HIS LAP. CNA #12 SAID THE FOOD WAS IN HIS (#105) LAP ABOUT 5 MINUTES. CNA #12 SAID, "I DIDN'T REALIZE IT WAS HOT ENOUGH THAT HE HAD GOTTEN BURNED." SHE SAID WHEN SHE WAS LATTER TOLD HE HAD BEEN BURNED SHE REALIZED THAT WAS WHY RESIDENT #105 WAS AGITATED, "IT WAS HOT." ON 3/4/12 AT 4:15 P.M. CNA #7 STATED THAT SHE WAS ASSIGNED TO TAKE CARE OF RESIDENT #105 ON 1/29/12 ON THE AFTERNOON SHIFT. SHE SAID SHE DID NOT KNOW WHO RETURNED THE RESIDENT TO HIS ROOM FOLLOWING DINNER BUT AT APPROXIMATELY 6:30 TO 7:00 P.M., HE WAS IN HIS ROOM AND SHE OBSERVED A STAIN ON HIS RIGHT PANT LEG. CNA #7 STATED THAT WHEN SHE UNDRESSED HIM, HE DISPLAYED FACIAL GRIMACING. CNA #7 SAID SHE SAW A 2 TO 2 1/2 INCH RED AREA WITH A BLISTER ON HIS RIGHT THIGH. SHE SAID SHE INFORMED NURSE #11, WHO IMMEDIATELY ASSESSED HIM. CNA #7 SAID, "HE (RESIDENT #105) ALWAYS GRABS AT HIS FOOD. HE LIKES TO EAT, THAT'S WHY WE KEEP HIS FOOD AWAY FROM HIM." CNA #7 SAID, "WE ARE TRAINED THAT ANY HOT FOOD SPILLED ON A RESIDENT SHOULD BE REPORTED AND CHECKED OUT. THAT WAS MY CONCERN. WHY DIDN'T SOMEONE SAY SOMETHING? THE CNA (#5) SHOULD HAVE INFORMED SOMEONE. I WASN'T AWARE, AND NEITHER WAS THE NURSE UNTIL I PUT HIM TO BED." ON 3/6/12 AT 12:30 P.M. PER PHONE, NURSE #11 STATED THAT ON 1/29/12 AT APPROXIMATELY 6:30 P.M., SHE WAS INFORMED BY CNA #7 OF THE AREA ON RESIDENT #105'S RIGHT LEG. SHE (NURSE #11) STATED, "THE BURN WAS APPROXIMATELY 3 TO 3 1/2 INCHES OF MODERATELY RED SKIN AREA WITH A QUARTER SIZE INTACT BLISTER IN THE CENTER." SHE STATED SHE APPLIED A COOL CLOTH AND INFORMED THE PHYSICIAN, WHO ORDERED A DRY DRESSING PLACED." NURSE #11 SAID SHE THEN WENT TO THE DINING ROOM TO FIND OUT WHO HAD FED RESIDENT #105. SHE STATED CNA #5 THEN TOLD HER THE ACCOUNT OF THE INCIDENT. NURSE #11 SAID THAT CNA #5 TOLD HER (#11) AFTER THE MACARONI AND CHEESE SPILLED ONTO RESIDENT #105'S LAP, THE RESIDENT WAS PULLING HIS CLOTHING PROTECTOR AND THE TABLE CLOTH INTO HIS LAP. SHE (#11) SAID, "HE WAS CLEARLY TRYING TO GET IT OFF HIS LEG." NURSE #11 SAID THE CNA TOLD HER THAT ONCE RESIDENT #105 CALMED DOWN, SHE (#5) FED HIM, AND THAT SHE DID NOT THINK ABOUT THE FOOD BEING SO HOT THAT IT WOULD BURN THE RESIDENT. NURSE #11 STATED, "I WOULD HAVE PREFERRED TO BE NOTIFIED AS SOON AS IT HAPPENED. HE SHOULD HAVE BEEN ASSESSED AS SOON AS IT HAPPENED...SOMETHING COOL SHOULD HAVE BEEN PLACED ON IT." ON 3/2/12 AT 2:15 P.M., THE SURVEYOR MADE AN OBSERVATION OF RESIDENT #105'S RIGHT UPPER THIGH BURN WITH NURSE #2. THE BURN APPEARED TO BE APPROXIMATELY A 2 CM WIDE MODERATELY REDDENED AREA WITH A 1 CM SCAB IN ITS CENTER. NO SIGNS OR SYMPTOMS OF INFECTION WERE OBSERVED. THE RESIDENT DID NOT APPEAR TO DISPLAY SIGNS OF PAIN. TREATMENT WAS BEING PROVIDED PER PHYSICIAN ORDERS. PER THE FACILITY MEAL SHEET (UNDATED) (IDENTIFIED BY THE DIRECTOR OF NURSING TO BE FROM 1/29/12), THE TEMPERATURE FOR THE MACARONI AND CHEESE WHEN LEAVING THE KITCHEN WAS 170 DEGREES FAHRENHEIT. ON 3/2/12 AT 12:20 P.M. A TEST TRAY WITH MACARONI AND CHEESE WAS DELIVERED TO THE SURVEYOR. THE TEMPERATURE IN CENTER OF THE MACARONI AND CHEESE WAS FOUND TO BE 171.8 DEGREES FAHRENHEIT. A REVIEW OF THE FACILITY POLICY TITLED "DINING AND FOOD SERVICE" DATED 3/2008, AND THE "JOB ROUTINE FOR D1 DINING ROOM AIDE" REVEALED NO INSTRUCTIONS FOR RESIDENTS REQUIRING EXTENSIVE ASSISTANCE WITH MEALS OR PROCEDURES TO ADDRESS RESIDENTS SPILLING HOT FOODS ONTO THEMSELVES. ON 3/6/12 AT 1:10 P.M., THE DIETARY MANAGER #13 SAID SHE DID NOT HAVE A POLICY IN PLACE THAT ADDRESSED RESIDENTS WHO REQUIRED EXTENSIVE ASSISTANCE WITH MEALS OR FOR HOT FOOD SPILLS. ON 3/6/12 AT 1:55 P.M. THE DON (DIRECTOR OF NURSING) WAS ASKED FOR A NURSING POLICY THAT ADDRESSED RESIDENTS WHO REQUIRED EXTENSIVE ASSISTANCE WITH MEALS OR TO ADDRESS HOT FOOD SPILLS. SHE SAID SHE WAS NOT AWARE OF A POLICY ADDRESSING EITHER ISSUE. THE DON SAID SHE FELT THEY HAD FOLLOWED THEIR PLAN, THAT CNA #5 WAS AT THE TABLE BETWEEN TWO RESIDENTS THAT REQUIRED ASSISTANCE. THE DON SAID FROM CNA #5'S PERSPECTIVE, SHE (#5) HAD GOTTEN THE FOOD OFF THE RESIDENT AND HE WAS FINE. THE DON SAID AFTER THE INCIDENT SHE (THE DON) EDUCATED CNA #5, WHO SAID AT THAT TIME, "IN HIND SIGHT," SHE (#5) SHOULD HAVE TAKEN RESIDENT #105 TO THE NURSE TO BE ASSESSED. THE DON SAID, "I REALLY DON'T THINK THE 20 TO 30 MINUTE DELAY WOULD HAVE CHANGED THE FACT THAT HE HAD A BLISTER, BUT I DO AGREE IT SHOULD HAVE BEEN REPORTED AND ASSESSED IMMEDIATELY." THE SURVEYOR REFERRED THE DON TO THE FACILITY'S DOCUMENTATION OF THE INCIDENT WHICH REVEALED THE TIME DELAY FROM THE MACARONI SPILL INTO RESIDENT #105'S LAP AND ASSESSMENT AND TREATMENT WAS APPROXIMATELY 1 HOUR. ( )

This citation pertains to M 146 Based on observation, interview and record review, the facility failed to provide adequate supervision to protect from accidents one of two sampled residents (#502) with wandering behaviors from a total sample of four, resulting in the resident sustaining a fractured right thumb. Findings include: During a tour of the facility, on 10/26/2011 at 10am, Resident #502 was observed resting in bed. Resident #502, an [AGE] year old female, was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 10/26/11 at 2:15 p.m., review of resident #502's clinical record and MDS (Minimum Data Set) Assessments, dated 06/19/11 and 09/16/11, revealed that the resident had memory problems and her cognitive skills were severely impaired. The resident had a history of [REDACTED]. Review of Physician orders [REDACTED]. After reviewing the Resident Council meeting minutes for the months of July 2011 through October 2011, an interview was conducted with the Activities Coordinator on 10/26/11 at 10 a.m. The activities coordinator explained that the residents attending the council complained during the month of July, August and September that they had been disturbed by wandering residents entering their rooms. Resident #502 was identified as one of these wandering residents. The Activities coordinator explained that a resident's concern form is completed and forwarded to the appropriate department for a resolution. There was no concern form noted nor was there resolutions documented for the complaints regarding wandering residents. Review of nurses notes for Resident #502 revealed the following: 09/06/11 1:30 a.m. "Resident up wandering hall, becomes very agitated ..." 09/13/11 12:30 a.m. "CNA(Certified Nurse Aide) brought to my attention that the resident has a new bruise to the left hip, offered to ice it, resident refused" 09/13/11 10:30 a.m. "Large purple bruise continues to left hip...verbal order for hipster to be worn at all times." 09/19/ 0:10 p.m., "Resident was being verbally and physically aggressive toward a CNA. She punched at and called her a B****..." 09/21/2011 1:30 a.m., "No aggressive behaviors but was found trying to get in bed with another resident and cover up while resident was sleeping." 10/04/11 12 a.m., "Resident up ambulating around facility, in and out of residents rooms..." 10/07/11 3 a.m."CNA noticed resident right hand and thumb bruised very badly, sensitive to touch, x-ray ordered..." 10/07/11 2:30 p.m. "x-ray received, fractured first distal phalanx" 10/07/11 6 pm "thumb to the right hand continues to be slightly swollen and bruised..." 10/08/11 4:00 p.m., "Resident's left foot run over by another resident's wheelchair in transit with activity aide..." 10/10/11 & 10/11/11 10 p.m. "...resident continues with "look at me" for urinating in non-designated areas..." 10/24/11 1:00 a.m., "slightly restless, wandering in the hall..." On 10/26/11 at 11:45 a.m., an interview was conducted with the Director of Nursing (DON) who explained that she had only been in the DON position since the last week of July 2011. When asked what the facility concluded regarding Resident #502's injury, the DON stated that they could not conclusively determine nor explain how the resident sustained [REDACTED].#502 wandering in and out of their rooms, the DON stated, "we have implemented one hour checks that have been beneficial so we can know more of her whereabouts." However, the one hour checks were not implemented until after the resident sustained [REDACTED]. The DON admitted that "we have been a little reactive instead of proactive in regards to the resident's behaviors." On 10/26/11 at 12:30 p.m. an interview was conducted with LPN #6 who reported that Resident #502 "is anxious a lot of the time, is confused, and is in and out of residents rooms all of the time. She needs redirection, but is not easily redirected, she follows visitors in attempts to leave the building. She gets upset at times and can be verbally abusive. When she walks around she tries to take things belonging to others." When the LPN was asked about her behavior of "urinating in non-designated areas," she stated, "she would drop her pants anywhere and urinate." An interview was conducted with the facility Social Worker (SW) on 10/26/11 at 12:45 p.m. who reported that the resident was inially admitted for rehabilitation services, then her status changed to long term care because the family determined that they were unable to continue to care for her at home. The SW stated, "when she wanders she is usually in search for something. She made an elopement attempt before, tried to follow visitors out of the building, so a wanderguard was implemented. We were unable to conclude how the resident received the injury to her thumb." The SW further stated, "alternative placements have been researched for the resident since May 2011 for a more secured environment.' On 10/26/11 at 1:00 p.m., a telephone interview was conducted with LPN #8 (the nurse on duty the day that the injury was identified). LPN #8 reported that the resident "wanders a lot." When asked how the resident received the thumb fracture, LPN #8 was unsure. She stated, "the resident didn't know what happened, she said that it didn't even hurt. The resident was known to go into other peoples rooms...she would be confused and think that it was her room." On 10/26/11 at 1:30 p.m., an interview was conducted with CNA #9 who explained that prior to the discovery of the resident's thumb injury, the resident was observed, "basically walking around the unit, in and out of rooms. I took her to the bathroom. I was going to wash her hands because I thought they were dirty, but her thumb and pinky were black (bruised). She only showed pain when she tried to pull up her panties." When the CNA was asked about the residents mood, CNA #9 explained, "she will cuss at us and flail at us." During an interview with LPN #10 on 10/26/2011 at 3:30 p.m. (the assigned nurse on duty the evening shift prior to the discovery of the incident), LPN #10 reported that she didn't notice the bruise on the residents hand the night before it was discovered. According to LPN #10, "there is only one nurse and 2 CNA's assigned to each hall on the afternoon shift. The 400 hall usually has 19 residents and it get busy on the afternoon shift. The resident walked around a lot." The nurse further reported that supervision of Resident #502 was not always possible. On 10/26/11 at 3:50 p.m., an interview was conducted with CNA #11 who reported that he was not aware of the residents injury until the end of shift (around 11 pm) the next day after the injury was discovered. "The resident has 'no male care' so all I do for her is guide her back to her room. She wanders a lot. She's a freewheeler around here, it's tough to keep a finger on her. If she would have fell somewhere else in the building, we would not have known. She can get angry and aggressive. I've seen heated exchanges with residents who did not like her in their room. She was previously on another hall but was moved because of an incident with a male resident on that hall." Resident #502 was observed on 10/27/11 sitting in the day room with other residents. She was alert but unable to explain how she received the injury to her thumb. Review of Resident #502"s Care Conference Summary dated 06/23/11 revealed, "Impaired vision without glasses, BIMS=1 (Brief interview for mental status) (0-7 = severe impairment) ...trouble concentrating and easily annoyed. She has exhibited wandering 1-3 days. Supervision with walking in hall.." Review of the residents "Behavior" plan of care dated 04/06/11 revealed the following interventions: Provide verbal re-direction away from the area when she enters another room uninvited; Provide diversional activities; Monitor for the need for additional interventions. The DON was unable to explain why appropriate monitoring was not provided to Resident #502 prior to the injury. ( )