Every finding on record at Medilodge of Mt. Pleasant

This citation pertains to intake 2739875.Based on observation, interview, and record review, the facility failed to 1) ensure transmission-based precautions were ordered for one resident with scabies (R90), 2) ensure a barrier was used for medication administration for one resident (R15), 3) ensure appropriate precautions were implemented for three residents (R22,R32 and R64) and 4) ensure proper handling of medication for one resident (R22) Findings include: R90 Review of a Face Sheet revealed R90 initially admitted to the facility on [DATE], readmitted on [DATE], and discharged on 5/9/2026 with pertinent diagnoses which included hypertension, traumatic subdural hemorrhage (bleeding near the brain that can be caused by a head injury), and atrial fibrillation (irregular and often very fast heart rhythm). In an interview on 8/11/2026 at 1:40 PM the Infection Control Preventionist (ICP) C reported R90 had been treated for scabies that initiated on 4/18/2026 and ended on 5/3/2026. ICP C reported that contact precautions were initiated on 4/18/26 and discontinued on 4/19/26. ICP C reported that the scabies infection for R90 had resolved on 4/26/2026. ICP C provided typed documentation that revealed scabies treatment was completed twice, once on 2/1/2026 and then again on 4/26/2026. ICP C reported physician orders should be in R90's Electronic Medical Record (EMR) for contact precautions (isolation precautions for the prevention of the spread of an infectious agent) for the duration of R90's scabies treatment. Review of R90's Medication Administration Record (MAR) dated February 2026, reveal a physician order for 2/1/2026 for Permethrin (medication used to treat scabies) which had been marked 6 on the MAR which meant R90 was not administered the ordered treatment due to hospitalization. Review of R90's MAR dated March 2026, revealed a physician order for athlete's foot spray twice daily for dry, irritated skin initiated on 3/7/2026 with discontinuation on 5/11/2026. Further review reveals a physician's order dated 3/6/2026 for anti-fungal spray twice daily for scant redness with a discontinue date of 5/11/2026 and Triamcinolone cream (used for itching) to bilateral arms topically every morning and at bedtime for post-scabietic pruritus initiated on 3/3/2026 and discontinued on 3/17/2026. Review of R90's MAR dated April 2026, revealed a physician's order and an administration for Permethrin cream to R90 on 4/16/2026 and 4/26/2026 for the treatment of scabies. Review of R90's MAR dated May 2026, revealed a physician's order and an administration for Permethrin cream to R90 on 5/2/2026 for the treatment of scabies. Review of R90's EMR on 8/11/2026 at 3:30 PM, revealed no physician orders or care planning interventions for R90 to be in contact precautions during his scabies treatments on 2/1/2026, 4/16/2026, 4/26/2026, or 5/2/2026. In an interview on 8/11/2026 at 4:12 PM, the Director of Nursing (DON) and ICP C reported that he should have been in contact precautions for each initiation of scabies treatment. The DON and ICP C reported that they thought there were orders for R90 to be in contact precautions. Review of facility policy/procedure Transmission-Based (Isolation) Precautions, dated 8/13/2020 revealed .donning (putting on) personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens.contact precautions require gloves whenever touching the patient's intact skin or surfaces and gowns whenever anticipating that clothing will have direct contact with the patient or potentially contaminated surfaces.scabies require contact precautions until 24 hours after the initiation of treatment. R15 Review of an Face Sheet revealed R15 admitted to the facility on [DATE] with pertinent diagnoses which included type II diabetes with hyperglycemia (high blood sugar). During a medication observation on 8/11/2026 at 7:53 AM in room B02-2, Registered Nurse (RN) H was observed removing two different eye drop medications from the medication cart, taking them out of their protective sleeves, and placing them on the medication cart. RN H then entered R15's room and placed both eye drop containers on R15's overbed stand. RN H administered each eye drop then set each container back onto the overbed stand. RN H utilized gloves during the administration of the eye drops. RN H afterward retrieved both eye drops, returned them to their respective plastic sleeves, and placed them back into the medication cart. In an interview on 8/11/2026 at 8:10 AM, RN H reported he had forgotten to use a barrier. In an interview on 8/11/2026 at 12:45 PM, the DON was informed of the medication observation regarding RN H not utilizing a barrier for the two eye drop medications in R15's room. The DON reported a barrier should have been used. In an interview on 8/11/2026 at 1:55 PM, ICP C reported when mediations are removed from the medication cart and administered in a resident's room, a barrier should be utilized between medication containers and surfaces. Review of facility policy/procedure Medication Administration, reviewed 10/30/2020 revealed . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. R22 Review of the Electronic Medical Record (EMR) reflected R22 originally admitted to the facility 10/9/2025 and had current pertinent diagnoses that included Bacteremia (the presence of a viable bacteria circulating in the bloodstream), and Escherichia Coli (E-Coli) infection. Review of the Doctor's Orders for R22 reflected place resident in contact-based precautions related to diagnosis of: Sepsis with., E Coli bacteremia. Review of the policy provided by the facility titled Transmission-Based (Isolation) Precautions dated 12/31/2025 reflected It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission.Definitions. Contact Precautions refers to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment . 10. Contact Precautions-.c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. On 8/12/2026 at 10:06 AM an observation was conducted in R22's room. A sign posted on the door of R22 reflected that Contact Precautions were to be implemented in the Resident's room. The signage reflected that staff were to wear gloves and a gown when providing care. Certified Nurse Aide (CNA) E was observed in the room with the curtain pulled obscuring visibility of R22 and most of the Resident's bed. CNA E was observed wearing gloves but was not wearing a gown while providing care. CNA E was observed removing bedding and clothing and placing the soiled items in a large plastic bag. CNA E was observed placing clean bedding on the bed, retrieving clean clothes from the Resident's closet, touching items in the room, assisted dressing, fixing the hair, and repositioned the Resident without a change of gloves. On 8/12/2026 at 10:19 AM CNA E was interviewed while exiting the room of R22. CNA E was observed degloving one hand and carried the plastic bag with soiled linens from the Resident's room. CNA E reported R22 had thrown up on herself in the bed and needed the bedding changed and assistance getting cleaned up. CNA E deposited the bag of soiled linens in the soiled utility room and degloved. CNA E was not observed washing or using hand sanitizer before walking down the hall. R22 continued On 8/11/2026 at 8:36 AM a review was conducted in the wet medication room with Registered Nurse (RN) D. During the review RN H entered the room and retrieved a medication for R22 from the electronic medication back-up device located in the medication room. RN H was observed to retrieve a pill from the device, place it in the bare hand, drop the pill into a medication cup with the bare fingers, and leave the room. R32 Review of the EMR reflected R32 admitted to the facility 8/24/2025. Review of the Doctor's Orders for R32 reflected the Resident was receiving enteral feeding (gastrostomy tube in the stomach), tracheostomy care, and had Enhanced Barrier Precautions in place. Review of a sign on the door of R32 reflected Enhanced Barrier Precautions were to be implemented when direct care was provided to the resident and included wearing gloves and a gown. On 8/10/2026 at 10:07 AM CNA's J and G were observed performing direct morning care to R32 in his room. It was observed that both CNAs were wearing gloves, but neither were wearing a gown during this care. On 8/12/2026 at 12:03 PM an interview was conducted with the Director of Nursing (DON). The DON reported that contact precautions are implemented when a resident has a contagion that staff can spread. The DON reported that Enhanced Barrier Precautions indicated a resident had a device or a wound. The DON reported during shift-change report both nurses and CNA were informed which residents are under precautions and indicated staff were expected to adhere to the infection control measures as indicated by the signage on the resident's door. On 8/12/2026 at 12:08 PM an interview was conducted with the DON in the wet medication room. The DON explained how the electronic medication back-up device worked. The DON indicated that, when retrieving medication from the device, touching the medication with bare hands was not necessary and inconsistent with facility practice and expectations. R64 Review of the Electronic Medical Record (EMR) reflected R64 re-admitted to the facility 07/01/2026 with pertinent diagnoses that included Cerebral infarction, nondisplaced fracture of right tibia, fibromyalgia, pulmonary embolism and Type 2 Diabetes Mellitus with diabetic neuropathy. Review of the Minimum Data Set (MDS – a tool used to determine a resident's status) 5-Day dated 7/23/2026 revealed R64 was cognitively intact. During an initial interview on 8/10/2026 at 11:36 AM, R64 revealed she had not been sleeping well because of painful itchy spots all over her back. Resident further revealed she needed medication to help relieve her symptoms and her pain level was 6. Review of the Resident Matrix (formally known as Centers for Medicare and Medicaid Services CMS- 802 Roster/Sample Matrix form is a tracking document used in long-term care facilities. It lists all current residents, and maps out their specific clinical conditions, diagnosis, and care needs.) dated 8/10/2026 reflected R64 had areas of concern that included Was on medication for Antibiotics, fall, indwelling catheter, infection noted as SHING. Observation of R64's door to her room on 8/10/2026 at 11:36 AM revealed a sign that one of the residents in the room required Enhanced Precautions when providing Care to a resident. During an interview on 8/10/2026 at 11:55 AM, Certified Nurse's Aide (CNA) A revealed he was not aware if he had to wear a gown when providing care for (Name of R64) and that he cared for her often. During an interview on 8/10/26 at 11:59 AM, License Practical Nurse (LPN) A stated she believed Name of R64 has a UTI (Urinary Tract Infection) going on and had recently given her (Name of a prescription opioid medication) for her pain. LPN A during the interview revealed she was unaware of the resident having Shingles. Upon looking in the resident's Electronic Medical Record (EMR), she stated it was unclear if she had shingles only found one mention of it (the condition). When asked about the painful itchy rash on residents' back she revealed she hadn't seen it but thought the rash was from her UTI. Review of Physician Orders for R64 revealed the following order (Name of Antiviral Medication) HCL Tablet 1GM Give 1 tablet by mouth three times a day for Shingles for 7 Days-Start Date 08/03/2026 1400. On 8/10/2026 at 12:02 PM, CNA A came back into the room due to a call light being on and stated, I am supposed to be wearing PPE when caring for (Name of R64). CNA A revealed he had not been informed of it until today. During an observation for R64 on 8/11/2026 at 3:20 PM, with ICP C revealed a sign on the door for contact precautions. ICP C revealed they put her in contact precautions yesterday even though her antibiotics had ended. ICP C stated the resident would remain on contact precautions until 8/13/26. The upper half of R64's entire back was observed to be bright angry red, with raised white areas of dead skin where the blisters had popped. The resident stated during the observation the area has been itchy and painful. The following observations and interviews took place on the C-Hallway on 08/12/2026 from 10:10 AM - 10:35 AM. The door to R64's room revealed a contact precautions sign. The cart/bin that contained Personal Protective Equipment PPE Equipment/precautions used to prevent transmission of pathogens worn by staff when caring for R64. The PPE bin located across from R64's room was observed not to have any gowns or gloves. While conducting an interview w/another staff member, an aide was observed walking into R64's room, saying R64's name upon entry and asking how they could help her. The Aide had not donned PPE prior to entering the residents' room. During an interview with Registered Nurse (RN) H stated he was informed this morning by the 3rd shift nurse that (Name of R64) had Shingles. RN H further stated he had not been informed prior to today that the resident had Shingles, and he had observed her playing bingo in the main dining room last week. RN H observed that aide went into R64's room without PPE. During an observation/interview at 10:32 AM, R64 revealed she was feeling unwell, and that the pain in her foot/leg was more painful than the pain and itching in her back. Resident further revealed that she had not known that shingles were contagious. During the interview resident stated, staff had not been wearing gowns and gloves when providing care (since she was diagnosed with Shingles) and only some of the staff were gowning up since yesterday but not all the staff. During an observation on 8/12/26 at 11:51 AM, PPE cart/bin located across the hall from R64's room was noted not to contain any gowns or gloves. During an interview on 8/12/26 at approximately 12:30 PM with Regional Director of Operations (RDO) P stated, We removed the sign for contact precautions from R64's door and she is now back on Enhanced Barrier Precautions due to blisters drying up/scabbing over. RDO P further revealed staff were going around and they were refilling the PPE carts/bins.

This citation is related to intake # 3056729 Based on interview and record review, the facility failed to initiate wound care orders at admission for one of three residents ( Resident #86) reviewed for pressure wounds. Findings: Resident #86 (R86)Review of a Face Sheet revealed R86 was a [AGE] year-old male, originally admitted to the facility on [DATE] following a 34 day stay at a local acute care hospital for a stroke and a heart attack. Review of a Nursing admission Evaluation-part 1 for R86, dated 05/29/26, revealed the resident was admitted to the facility with a pressure wound on his left buttock and his right buttock. Review of an Electronic Treatment Administration Record (E-tar) for R86, dated June 2026, revealed that orders to treat the residents pressure wounds were not put into place until 06/02/26. During an interview on 08/11/26 at 3:40 PM, the Director of Nursing stated that wound care orders for R86 should have been placed on the E-tar the day of admission.

This citation pertains to intake# 2685190Based on observation, interview, and record review, the facility failed to store medication and biologicals in accordance with manufacturer's recommendations.Findings include:On 2/10/2026 at 9:35 AM a review of the C Hall medication cart was conducted with Registered Nurse (RN) H. During the review an in use, opened and undated insulin pen was identified. RN H reported she did not know when the insulin pen had been placed in service and acknowledged this date should be evident as this device has a shortened use life after placed into service. On 2/10/2026 at 9:45 AM a review of the wet medication room was conducted with RN H. During the review two undated and opened vials of Purified Protein Derivative (PPD) solution were discovered in the medication refrigerator. RN H reported these medications should have been dated by nursing when the vials were placed in service.Review of the manufacturer's product information sheet for PPD solution reflected A vial of (PPD solution) which has been entered and in use for 30 days should be discarded. This indicated that the date a vial has been placed in service must be known to nurses so a discard date, in accordance with manufacturer's recommendation, can be calculated.The policy provided by the facility titled Medication Storage last revised 1/30/2024 was reviewed. The policy reflected It is the policy of this facility to ensure all medication housed on our premise will be stored according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

710 Physician servicesThis citation pertains to intake #s 2638540 2724503, 2676090Based on interview and record review, the facility failed to ensure the medical provider adequately supervised the care of one Resident (R103) of four residents reviewed for physician services. Findings include:Review of the Electronic Medical Record (EMR) admission record reflected R103 admitted to the facility 12/10/2024 with pertinent diagnosis that included Diabetes Mellitus.Review of the EMR Progress Notes for R103 revealed an entry dated 1/13/2026 at 4:55 PM of a new wound, diabetic foot ulcer on the left lateral mid foot. The documentation reflected Wound acquired in-house which was measured and dressed. The entry did not reflect the medical provider was notified of the new wound or its characteristics.Review of the medical record Physicians Orders for R103 reflected a new ordered treatment of left foot pressure injury-betadine and white border gauze in the morning with a start date of 1/14/2026.Review of the EMR Progress Notes for R103 reflected documentation by the Medical Provider of encounters with the Resident on 1/16/2026 at 8:00 AM, 1/21/2026 at 8:00 AM, and 2/3/2026 at 8:00 AM. The documentation of these encounters reflected the Medical Provider addressed constipation and left thumb pain. However, the documentation did not reflect a physical assessment by the Medical Provider of the new wound or an acknowledgement of the new condition. Review of the Care Plan for R103 reflected that a nursing Care Plan for the new wound identified on 1/13/2026 was not formulated until after the survey was initiated on 2/9/2026. This indicated that, prior to 2/9/2026, the Medical Provider and nursing had not collaborated to formulate a comprehensive care plan for the new wound.On 2/9/2026 at 3:32 PM an interview was conducted with Unit Manager (UM) D in the conference room. UM D was informed that no documentation was in the EMR that the Medical Provider had evaluated the new wound on the left foot of R103. UM D reported that mid- level providers will review the photographs but acknowledged that no Medical Providers had charted that they had reviewed any photographs. UM D was informed that the Progress Notes reflected three Medical Provider encounters with R103, but no physical assessment or documentation of the left foot wound was located. UM D was unable to provide any additional information or documentation.As of survey exit on 2/10/2026 no additional information had been provided by the facility.

This citation pertains to intake #2685190Based on observation, interview and record review, the facility failed to consistently ensure the readiness of the nurse's emergency crash cart. Findings include:On 2/10/2026 at 10:30 AM a review of the emergency crash cart was conducted with RN I. RN I reported that the emergency equipment was checked daily by night shift nursing. RN I reported the checks included an inspection for outdated supplies and to ensure the readiness of the Automatic External Defibrillator (AED - a portable life-saving device used to analyze for an abnormal heart rhythm and deliver an electric shock to restore normal heart rhythm). The document accompanying the emergency cart titled Crash Cart Daily Check Off Log was reviewed. The document listed twenty- eight items to be checked daily with a Nurse Initials box for nurses to verify the readiness of the emergency cart. Review of the checklists for November 2025 through February 9, 2026, revealed 62 days the cart readiness had not been verified as ready by nursing. The Daily Check Log's included 10 periods of 3 to 5 days without checks. Additionally, the review reflected one gap of 11 days (November 7- 17/2025) and another gap of 8 days (January 20-27/2026) during which the readiness of the cart and AED device had not been verified by a nurse.Review of the undated job description for Registered Nurse (RN) provided by the facility reflected Summary: Plans, coordinates and provides total nursing care for residents and provides supervision to clinical staff members. The job description reflected Essential Functions: that included: Ensures that supplies are utilized economically and that equipment is clean and maintained in a safe manner,Assures that inventory and supplies are maintained on the unit. Assists with or institutes emergency measures for sudden adverse developments in residents,Review of the undated job description for 'Licensed Practical/Vocational Nurse (LPN) provided by the facility was also reviewed. This job description includes many of the same Essential Functions of the RN but with an expectation of practice within the scope of an LPN.As of survey exit on 2/10/2026 no additional information had been provided by the facility.

This citation pertains to intake #s 2638540 and 2676090Based on interview and record review, the facility failed to ensure clear and concise documentation in the Electronic Medical Record for one Resident (R103) of three residents reviewed for medical record accuracy. Findings include:Review of the Electronic Medical Record (EMR) admission record reflected R103 admitted to the facility 12/10/2024 with pertinent diagnosis that included Diabetes Mellitus. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) (a tool used to determine a resident's cognitive status) score of 15 out of 15 which reflected the Resident was cognitively intact. Review of the EMR Progress Notes for R103 revealed an entry dated 1/13/2026 at 4:55 PM that a new wound, diabetic foot ulcer was identified on the left lateral mid foot of the Resident. The documentation reflected Wound acquired in-house which was measured and dressed. The Treatment Administration Record (TAR) for R103 for January and February 2026 were reviewed. The TARs reflected a treatment described as left foot pressure injury-betadine and white border gauze in the morning with a start date of 1/14/2026 at 7:00 AM. The TAR revealed that between 1/14/2026 and 2/9 /2026 there was no documentation by nursing (initials) this was completed for 11 of the past 27 days the treatment was in place. (1/17, 1/21,1/23, 1/26, 1/27, 1/30, 2/1, 2/4, 2/6, 2/8, 2/9/2026). Review of the Progress Notes for R103 did not reflect documentation by nurses why the treatments were not performed as ordered or documentation that the Medical Provider was notified or aware of interruption or rejection of care by the Resident.Review of the Care Plan for R103 reflected that a nursing Care Plan for the new wound identified on 1/13/26 was not formulated until after the survey was initiated on 2/9/2026. This indicated that, prior to 2/9/2026, nursing had not updated the medical record to include a revised Care Plan for the new wound.On 2/9/2026 at 3:32 PM an interview was conducted with Unit Manager (UM) D in the conference room. UM D reported that R103 would dictate when and who does his care. UM D acknowledged the undocumented dressing changes on the TARs and reported he assumed the Resident had refused or had asked staff to delay treatment to a more convenient time. UM D acknowledged that the medical record did not contain information on why nursing had not performed, delayed, or documented the treatments. On 2/9/2026 at approximately 4:10 PM the Director of Nursing (DON) was informed of the un-initialed TARs for the daily dressing changes and that no nursing notes had been entered that might have provided data on why the ordered treatments were refused, delayed or were, in fact, completed. The DON reported R103 would delay care or only allow specific staff to provide care. The DON could not provide information that the Medical Provider had been informed by nursing through documentation of the delay or refusal of ordered treatments or documentation that the Resident had been educated on the potential effects of treatment delays or refusals. The DON reported she absolutely expected nursing to document when ordered care is or is not completed. Review of the undated job description for Registered Nurse (RN) provided by the facility reflected Summary: Plans, coordinates and provides total nursing care for residents and provides supervision to clinical staff members. The job description reflected Essential Functions: to include: Initiates and leads team conferences in the development of individual nursing care plans, Assesses and documents the resident's condition and nursing needs, Accurately and promptly implements physician's orders, Administers medications, starts IVs (intra venous access) and performs treatments for assigned residents and documents that treatment as required (by) company, and local, state, and federal rules and regulations. Reports and records pertinent observations and reactions regarding residents,Review of the job description for Licensed Practical/Vocational Nurse (LPN) provided by the facility was also reviewed. This job description holds the same Essential Functions implementation and documentation of care of the RN but with an expectation of practice within the scope of an LPN.As of survey exit on 2/10/2026 no additional information had been provided by the facility on the nursing care of R103 or of the duties and expectations of nursing.

Citation pertains to intake #2676090Based on interview and record review, the facility failed to notify the medical provider of a new open wound for one resident (R103) of 4 residents reviewed for notifications when one resident (R103) developed an open wound. Findings include:Review of the Electronic Medical Record (EMR) admission Record reflected R103 admitted to the facility 12/10/2024 with pertinent diagnosis that included Diabetes Mellitus.Review of the EMR Progress Notes for R103 revealed an entry dated 1/13/2026 at 4:55 PM that a new wound, diabetic foot ulcer was identified on the left lateral mid foot of the Resident. The documentation reflected Wound acquired in-house which was measured and dressed. The entry did not reflect that the physician was notified of the new wound or its characteristics.On 2/9/2026 at 3:32 PM an interview was conducted with Unit Manager (UM) D in the conference room. UM D acknowledged that the medical record did not contain information that the medical provider had been notified of the new wound identified on 1/13/2026. UM D reported that mid- level providers will review the photographs but acknowledged that that no Medical Providers had charted that they had reviewed any photographs. The policy provided by the facility titled Notification of Changes last revised 1/1/22 was reviewed. The policy reflected Policy. The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, Resident's representative when there is a change requiring notification, The policy further reiterates a need to notify the physician by defining circumstances requiring notification which include . 1. B. Potential to require physician intervention, and 3. New treatment. Review of the undated job description for Registered Nurse (RN) provided by the facility reflected Summary: Plans, coordinates and provides total nursing care for residents and provides supervision to clinical staff members. The job description reflected Essential Functions: which included: Reports and records pertinent observations and reactions regarding residents,Review of the job description for Licensed Practical/Vocational Nurse (LPN) provided by the facility was also reviewed. This job description holds this same Essential Function expectation of recording and reporting.As of survey exit on 2/10/2026 no additional information had been provided by the facility.

This citation pertains to intake #s 2676090 and 2658540Based on interview and record review, the facility failed to revise the comprehensive care plan and formulate goals and interventions when one facility Resident (R103) developed an open wound of four residents reviewed for care plans. Findings include:Review of the Electronic Medical Record (EMR) reflected R103 admitted to the facility 12/10/2024 with pertinent diagnosis that included Diabetes Mellitus.Review of the EMR Progress Notes for R103 revealed an entry dated 1/13/2026 at 4:55 PM that a new wound, diabetic foot ulcer was identified on the left lateral mid foot of the Resident. The documentation reflected Wound acquired in-house which was measured and a dressing applied.Review of the Care Plan for R103 reflected that a nursing Care Plan for the new wound identified on 1/13/26 was not formulated until after the survey was initiated on 2/9/2026. This indicated that, prior to 2/9/2026, nursing had not revised the comprehensive Care Plan to formulate goals/ benchmarks for care or devised nursing interventions for the new wound.On 2/9/2026 at 3:32 PM an interview was conducted with Unit Manager (UM) D in the conference room. During this interview UM D reported that R103 did have a Care Plan for the new wound but acknowledged the Care Plan was not initiated until 2/9/2026.

Based on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen. Findings include: On 07/29/2025 at 9:55 AM, during the initial walkthrough of the kitchen it was observed that the drain line for the ice machine did not have an air gap, the drain line was below the flood rim of the drain. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 07/29/2025 at 11:25AM, Dietary [NAME] H was observed using the hand sink to fill water pitchers, pitchers were then observed being placed in refrigerator. On 07/30/2025 at 12:22 PM during interview with Certified Dietary Manager (CDM) K, when asked where pitchers were filled, CDM K indicated the process was to fill pitchers from the prep sink. According to the 2022 FDA Food Code section 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. (B) A HANDWASHING SINK may not be used for purposes other than handwashing. (C) An automatic handwashing facility shall be used in accordance with manufacturer's instructions.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and to spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility. Findings include: On 7/29/2025 at 1:32 PM, observation noted at time of walkthrough of the facility with Maintenance Director (MD) F and Maintenance Director (MD) B; in the shower room on B Hall, there were water lines coming out of the wall and not attached to any equipment. MD B indicated that the lines were previously used for a tub, but it had been removed and were unaware of the lines used for other purposes. MD B and MD F were asked at that time if there was a flushing schedule for the facility. MD B stated there was no set flushing schedule for the facility but that the lines for the residents' rooms were flushed when the room had been empty and a resident was going to now occupy the room, and the facility lines were flushed if there was a positive Legionella sample. On 7/29/2025 at 1:50 PM, observed in shower room on D Hall, curtained off area that is plumbed as a shower but was currently in use as storage for a lift and 2 shower chairs. MD F was unaware if this shower was in use and if not in use if the lines were being flushed. On 7/31/2025 Operations Maintenance and Control Limits document, undated, from the water management plan was provided for review, this written document indicates that there is a flushing schedule for facility.

Based on interview and record review the facility failed to accurately document narcotic administration for one of three residents (Resident #4) reviewed for pharmacy services. Findings:Review of an admission Record revealed R4 was a [AGE] year-old-female, last re-admitted to the facility on [DATE]. with pertinent diagnoses of pneumonia and chronic pain syndrome. Review of a Controlled Substance Record (CSR) for R4 and for the medication (Norco) hydrocodone-apap 10-325 mg (milligrams) one tab every 4 hours as needed for pain, revealed documentation that one tablet was given to R4 on 07/31/25 at 10:00 AM. The review of the record occurred on 07/31/25 at 8:50 AM. During an interview on 07/31/25 at 8:54 AM R4 stated that she was positive that she received a Norco this morning, around 7:30 AM, with her other morning medications. Further review of the same CSR for R4 and the prescribed Norco showed that the previous dose of Norco was given that morning at 6:00 AM by the night nurse (RN O). During an interview on 07/31/25 at 9:00 AM Registered Nurse (RN) D stated that she had given R4 a dose of Norco this morning around 7:30 AM but wrote in 10:00 AM on the CSR to correct the time interval between the doses. RN D also stated that at shift exchange this morning and while reconciling (counting) narcotics, the night nurse (RN O) had not written in a time that a Norco tablet was given during the night shift, so RN O wrote in a time of 6:00 AM. At this point the surveyor called for the Director of Nursing (DON). It was determined through further interviews with R4 and nursing staff that the resident had in fact received the correct doses of Norco and thus ruled out the possibility of misappropriation of narcotics. During an interview on 07/31/25 at 9:25 AM, the DON indicated that nurses were expected to document the precise time a medication was given, especially a controlled substance. During an interview on 07/31/25 at 10:46 AM, RN I stated that it was very important for nurses to document accurately when narcotics are given because many of the narcotics are given for pain or anxiety and keeping them on schedule helps ensure the resident gets maximum control of the pain or anxiety provided by the medication.

Based on interview and record review, the facility failed to notify the resident's representative of a fall with injury for 1 resident (R2) of 2 residents reviewed for falls.Findings include:Review of an admission Record revealed R2 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and muscle weakness. Further review revealed R2 had two activated medical Power of Attorney's (POA).Review of R2's Un-witnessed Fall report dated 1/11/2025 at 6:45 PM revealed R2 fell in his room and sustained a superficial cut to his right eye and was experiencing wrist pain. Further review revealed nursing staff contacted the on-call nurse and physician but there was no documentation that the medical POA was contacted.In a telephone interview on 7/31/2025 at 10:14 AM, POA of R2 A reported she did not receive notification from the facility on 1/11/2025 when he fell.Review of R2's fall follow up Standards of Care Meeting documentation, dated 1/13/2025 at 2:57 PM, revealed documentation that R2's responsible party was notified of the fall with injury on 1/11/2025. Further review of R2's progress notes revealed no confirmation that the responsible party was notified the evening of 1/11/2025.In an interview on 7/31/2025 at 10:44 AM, the Director of Nursing (DON) reviewed documentation from the electronic medical record and reported she did not have any documentation to verify R2's responsible party was contacted at the time of his fall with injury on 1/11/2025. The DON reported that the responsible party should have been notified at the time of this fall with injury.Review of facility policy/procedure Notification of Changes, revised 8/29/2024, revealed .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. circumstances requiring notification include. accidents resulting in injury.

Based on interview and record review, the facility failed to implement care planned fall interventions for 1 resident (R2) of 2 residents reviewed for falls.Findings include:Review of an admission Record revealed R2 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and muscle weakness. Review of a current risk for fall Care Plan intervention for R2, initiated 8/25/2023, revealed R2 was to have grip strips in front of the toilet in his bathroom.In an observation on 7/30/2025 at 3:29 PM in R2's bathroom there were no grip strips in front of the toilet.In an interview on 7/31/2025 at 10:26 AM, the Director of Nursing (DON) reported she was not aware grip strips were not in R2's bathroom. The DON reported the floor might have been waxed and the grip strips not replaced afterwards.Review of facility policy/procedure Comprehensive Care Plans, revised 6/30/2022, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident.

Based on observation, interview, and record review, the facility failed to correctly label an ordered tube feeding for one resident (Resident #69) out of three residents reviewed for tube feeding. Findings: Resident #69 (R69)Review of an admission Record revealed R68 was a [AGE] year-old male, last admitted to the facility on [DATE], with pertinent diagnoses of acute respiratory failure that required a tracheostomy and tube feed for nutrition and hydration. During an observation on 07/29/25 at 1:09 PM, the tube feed bag for R69 contained the following information on the bag: (a) 07/28/25, and (b) 1600 (4 PM). During an interview on 07/31/25 at 8:20 AM, Unit Manager/Registered Nurse (UM/RN) N indicated that the expectation for labeling tube feed bags included the nurse's initials, the date and time the feed was started, the ordered rate of the feed, the residents name, and the type of formula used.

Based on observation, interview, and record review, the facility failed to (a) offer ordered nebulizer treatments and (b) adequately clean nebulizer equipment for one resident (Resident #1) out of two residents reviewed for respiratory care. Findings:Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old female, last re-admitted to the facility on [DATE] following a hospitalization for a bowel obstruction and pneumonia. During an observation on 07/29/25 at 10:32 AM, R1's nebulizer mouthpiece, with the medicine cup attached, sat in a clear plastic bag on the resident's bedside nightstand. Moisture could be seen inside the bag and on the nebulizer equipment. R1 indicated that she had just received a breathing treatment, and staff had not taken it apart and washed it. Rather, staff placed the whole thing in the bag right after she completed the treatment. During an interview on 07/31/25 at 7:26 AM, R1 stated that she had not received any breathing treatments (nebulizer) yesterday or so far today. R1 stated that staff had not offered her the breathing treatments. I was getting them every four hours and then nothing. R1 stated that a breathing treatment was always helpful as she was still recovering from pneumonia. R1 also stated that she had not refused any breathing treatments. Review of an electronic medication administration record (Emar) dated July 2025, for R1 revealed the resident had not received a breathing treatment (nebulizer) since 6:00 PM on 07/29/25. Documentation provided by nursing as to why the nebulizer treatments had not been given to R1 reflected that the resident had refused the treatments. The order for the nebulizer treatment was for 1 treatment every 6 hours. R1 had not received the last six breathing treatments that were available to her as ordered by the physician. Review of the facility policy Small Volume Nebulizer reflected the following steps for cleaning the nebulizer equipment: (1) twist open the nebulizer cup and dump out any residual remaining from treatment, (2) rinse nebulizer cup and components with water, (3) allow nebulizer cup and components to airdry on a clean absorbent towel, and (4) once dry store the nebulizer cup and mouthpiece in a bag and label.

Based on observation, interview, and record review, the facility failed to ensure call lights were in reach for 2 dependent residents (R5 and R20) of 4 residents reviewed for availability of call lights. Findings include:R5Review of an admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included difficulty in walking and generalized anxiety disorder.Review of current activities of daily living Care Plan interventions for R5, initiated 10/1/2023, directed staff to place the resident's call light within reach and encourage the resident to use the call light to request assistance as needed.In an observation and interview on 7/29/2025 at 10:43 AM in R5's room, R5 was in her bed and her call light was under the end of her bed and out of reach. R5 reported she was able to use her call light to request assistance but sometimes the call light was left out of her reach.In an interview on 7/31/2025 at 11:44 AM, Certified Nursing Assistant (CNA) C reported R5 was able to use her call light to call for assistance.R20Review of an admission Record revealed R20 admitted to the facility on [DATE] with pertinent diagnoses which included overactive bladder and anxiety.Review of current activities of daily living Care Plan interventions for R20, initiated 7/27/2023, directed staff to place the resident's call light within reach and encourage the resident to use the call light to request assistance as needed.In an observation and interview on 7/29/2025 at 10:31 AM in R20's room, R20 was in her bed and her call light was hanging off the head of the bed behind the headboard and out of reach of the resident. R20 reported she was normally able to use her call light but could not find it.In an interview on 7/31/2025 at 11:44 AM, Certified Nursing Assistant (CNA) C reported R20 was able to use her call light to call for assistance.Review of facility policy/procedure Call Lights: Accessibility and Timely Response, Revised 12/28/2023, revealed .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Staff are educated in the proper use of the resident call system, including how the system works and ensuring resident access to the call light.

Based on observation, interview, and record review, the facility failed to provide adequate smoking supervision and monitoring for 5 of 14 residents (Resident #25, #1, #27, #26, and #13) reviewed for accidents and safety. Findings: Review of the facility Acknowledgment of Facility Smoking Policy signed by residents deemed appropriate for smoking revealed, .1) Oxygen use is prohibited in smoking areas for the safety of residents. The facility will have a system for removal of the oxygen container, tubing, etc. while the resident is in a smoking area. These items will be kept at least 5 feet away from any smoking area. 2) Smoking items (Cigarettes, lighters, etc.) will be kept secured in a designated area with limited staff access. Residents shall not keep any smoking materials in resident rooms. 3) A list of smoking times will be given to those residents identified with smoking privileges. Residents will also be allowed to smoke in the designated smoking areas during off-scheduled times with a family member or visitor who is able to appropriately supervise the resident for smoking safety. 4) Only facility provided ashtrays shall be used. 5) The attending Physician and the Director of Nursing Services (DNS) shall have the authority to make the determination as to what restrictions, if any, will need to be placed on the resident's smoking privileges. 6) Any resident with smoking privileges shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period. 7) Residents with smoking privileges will be discouraged from smoking outside during inclement weather including storms and temperature extremes. 8) To promote safety for all residents and staff, residents with smoking privileges agree to allow staff to search the resident and resident room/belongings for smoking materials if the facility reasonable suspects smoking materials may be present in those locations. If smoking materials are located, they shall be secured in the facility designated location for smoking materials . Resident #25 (R25) Review of an Admission Record revealed R25 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: left and right above knee amputation, dementia, and nicotine dependence. R25 was his own responsible party/decision maker. Resident #1 (R1) Review of an Admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: polyneuropathy (nerve pain), adjustment disorder with mixed anxiety and depressed mood, and chronic pain syndrome. R1 was his own responsible party/decision maker. Review of R1's Care Plan revealed, Keep oxygen away from smoking materials. Ensure removal prior to resident smoking .Date Initiated: 09/26/2023. Review of R1's Nursing Quarterly/Significant Change Evaluation dated 7/30/24 revealed, .Safe Smoking Evaluation- 1. Does the resident currently smoke, use e-cigarettes, or tobacco products? No . Resident #27 (R27) Review of an Admission Record revealed R27 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: legal blindness, difficulty in walking, intellectual disabilities, convulsions, and muscle weakness. Review of R27's Nursing Quarterly/Significant Change Evaluation dated 6/14/24 revealed, .Safe Smoking Evaluation- 1. Does the resident currently smoke, use e-cigarettes, or tobacco products? No . Review of R27's Electronic Health Record revealed R27 had a court appointed guardian. There was no documentation reflecting that the guardian consented to R27 smoking cigarettes or that they consented to R27 leaving the facility to smoke cigarettes unsupervised. During an observation on 08/27/24 at 11:08 AM, R25 exited the facility through the front entrance in his motorized wheelchair and lit up a cigarette approximately 25 feet away in the center of the driveway. There were no staff, family, or visitors with him. During the observation a compact SUV drove down the driveway causing R25 to move to the sidewalk within 30 feet from the front door next to the D Wing. At 11:10 AM, R1 exited the facility through the front doors on his motorized wheelchair with an oxygen tank attached to the back and lit up a cigarette in the garden area of the circular driveway. There were no staff, family, or visitors with him. At 11:14 AM, R25 finished his cigarette and flicked the white cigarette filter on the woodchips outside of a resident window on the D Wing directly next to the building. There were greater than 10 white cigarette filters observed directly where R25 discarded his cigarette filter. R1 was observed nodding off (appearing sleepy, head dropped down towards his chest, and jerked awake) and then proceeded to ash his cigarette onto the woodchips in the garden area of the circular driveway. When R1 finished his cigarette, he flicked the cigarette until the ember of the cigarette fell to the pavement and unintentionally dropped the cigarette butt on the ground. R1 then stood out of his motorized wheelchair, bent over to pick up the cigarette butt causing him to stumble. R1 did not fall, obtained the butt and placed it in his cigarette container. At 11:24 AM, R1 reentered the facility. There were no staff, family, or visitors with him while he was outside smoking a cigarette. R1 did not utilize the smoking pavilion. At 11:32 AM, R25 reentered the facility. There were no staff, family, or visitors with him while he was outside smoking a cigarette. R25 did not utilize the smoking pavilion. At that time (11:32 AM), R27 exited the facility to smoke a cigarette utilizing the smoking pavilion. The pavilion did not contain a fire extinguisher or other fire suppression tools (fire blanket, fire alarm, etc). At 11:44 AM, R27 reentered the facility. There were no staff, family, or visitors present while he was outside smoking a cigarette. This writer followed R27 back into the facility. At 11:46 AM, a conversation between the front office staff and the Hospitality Aide (HA) F was heard. A front office staff member asked HA F if the smokers (R25, R1, and R27) had signed out of the book (leave of absence book/sign out sheet reflecting a residents location and the time they signed out and back in). HA F reported to the front office staff members that she was not aware that residents were required to sign out if they were not leaving the facility property and were going out to smoke. The Leave of Absence (LOA) logbook was reviewed for R25, R1, and R27 and did not reflect the date, time, and reason for exiting the building/location during the smoking observation period. HA F exited the front office and opened the LOA logbook to R27's record and confirmed that R27 did not sign himself out before exiting the building to smoke a cigarette. HA F reported that if a resident forgets/refuses to sign themselves out to smoke, then a staff member should document the date, time, and reason for leaving for the resident. At 11:54 AM, Scheduler (S) Q and Corporate Nurse (CN) R reported that staff were to keep residents smoking paraphernalia (cigarettes and lighters) locked up in the smoking cart and reported that residents that go out to smoke alone were to sign out of the LOA logbook. Resident #26 (R26) Review of an Admission Record revealed R26 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: alcohol abuse, neuropathy, and need for assistance with personal care. R26 was his own responsible party/decision maker. Review of R26's Nursing Quarterly/Significant Change Evaluation dated 6/17/24 revealed, .Safe Smoking Evaluation- 1. Does the resident currently smoke, use e-cigarettes, or tobacco products? No . Review of R26's Care Plan revealed, .Resident will often refuse to return cigarettes to staff once done smoking. Staff to only given resident one cigarette at time, instead of entire pack Date Initiated: 08/26/2024. During an observation on 08/26/24 at 10:31 AM, R26 was in his room sitting on the side of his bed. There was a pack of cigarettes in the front pocket of his t-shirt. During an observation on 8/28/24 at 7:50 AM, R26 was exiting the facility to smoke a cigarette. R26 did not sign out of the LOA book. At 9:09 R26 was observed in his wheelchair in the hallway. Review of the LOA logbook on 8/28/24 at 9:15 AM revealed R26 was not signed out at the time he exited the facility to smoke or the time he returned related to above observation. Resident #13 (R13) Review of an Admission Record revealed R13 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke affect the left side and epilepsy. R13 was her own responsible party/decision maker. During an observation on 8/28/24 at 07:50 AM, R13 exited the facility to smoke a cigarette. During an observation on 8/28/24 at 8:25 AM, R13 had returned to her room and was receiving her morning insulin. Review of the LOA logbook on 8/28/24 at 9:15 AM revealed R13 was not signed out at the time she exited the facility to smoke or the time she returned related to above observation. During an interview on 8/28/24 at 8:11 AM, Registered Nurse (RN) J reported that resident cigarettes were to be locked up in the smoking cart and residents were to sign themselves out of the LOA logbook if they were going out to smoke independently. During an interview on 08/28/24 at 02:02 PM, NHA confirmed that R1, R26, and R27's Safe Smoking Evaluations were not completed per the facility policy due to incorrect documentation (documented that they were non-smokers). NHA reported that the Director of Nursing would update the Safe Smoking Evaluations for R1, R26, and R27 by the end of the day. During an interview via email on 08/28/24 at 01:42 PM, Nursing Home Administrator (NHA) stated, (R27's) guardian (name omitted) is aware that he smokes and that he goes out alone. In the past she has not had any concerns related to this. My Social Worker (name omitted) called the office today to reconfirm that it's still okay that he does this. There remain no concerns. Confirming there was no documented consent to smoke by R27's guardian. Review of R27's Physician Progress Note dated 8/28/24 revealed, This author contacted (guardian name omitted) voluntary guardian and reconfirmed that (R27) can leave the facility independently if or shopping, banking and independent smoking. Review of the facility policy Smoking Safety last revised 11/28/17 (provided in the resident smoking binder on 8/27/24) revealed, . 1. The facility will have a designated smoking area for residents in accordance with Federal, State and other entities having jurisdiction laws. This area must be one that does not infringe upon the rights of the non-smoker. 2. Designated smoking areas will be equipped with a fire extinguisher which will be mounted in an area to allow free access by staff. 3. Smoking areas will have ashtrays made of noncombustible material and safe design as well as metal containers with self-closing covers into which ashtrays will be emptied at the conclusion of smoking sessions . 4. Oxygen use is prohibited in smoking areas for the safety of residents. The facility will have a system for removal of the oxygen container, tubing, etc. while the resident is in a smoking area. These items will be kept at least 5 feet away from any smoking area. 5. Smoking items (cigarettes, lighters, etc.) will be kept secured in a designated area with limited staff access. 6. All residents will be screened as part of the admission evaluation for smoking practices . 8. Each resident who chooses to smoke will be assessed to determine smoking safety. This may include, but not be limited to: *Cognitive patterns and safety awareness *Communication/hearing/vision *Physical abilities/deficits *Observations of the resident's physical and cognitive abilities 9. The smoking assessment will be completed upon admission, quarterly, with a significant change in status related to smoking, or anytime the facility determines it is warranted . 11. A comprehensive plan of care will be developed in conjunction with the Resident Assessment Instrument process . 13. Residents who smoke will have their specific interventions identified on the resident Kardex for staff review . Review of the facility policy Smoking Policy Smoking Campus-Residents dated July 2017 (provided in the resident smoking binder on 8/27/24) revealed, .5. Any resident with smoking privileges shall not be permitted to smoke without the direct supervision of a responsible staff member, family member, visitor or volunteer worker and direct supervision must be provided throughout the entire smoking period . 1. Smoking privileges shall be reviewed at least quarterly by the Director of Nursing Services, the Attending Physician, and/or the Care Planning Team. 2. A list of smoking times will be given to those residents identified with smoking privileges. 3. Residents will be allowed to smoke, in the designated smoking area, during off-scheduled times with a family member or visitor. The family member/visitor must agree to stay with the resident during the entire smoking period . 1. This facility shall have the authority to make periodic checks to determine if residents have any smoking articles that are in violation of our smoking regulations .

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) were in place and followed for 3 residents (Resident #64, #217, and #21) of 4 residents reviewed for Precautions, resulting in the increased potential for cross-contamination, bacterial harborage and spread of infection throughout the facility. Findings include: Resident #64 Review of an Admission Record revealed Resident #64 (R64) admitted to the facility on [DATE] with pertinent diagnoses which included nontraumatic intracranial hemorrhage, hemiplegia (paralysis on one side of the body), and dysphagia (difficulty swallowing). Review of R64's Physician's Orders, started 7/26/2024, revealed she received enteral feeding (intake of food via the gastrointestinal tract) through a gastric tube. In an observation on 8/26/2024 at 11:10 AM, Certified Nursing Assistant (CNA) A and CNA B entered R64's room, transferred R64 from her geriatric chair to her bed, changed her brief, and transferred her back into her geriatric chair without donning a gown. There was no signage on R64's door to notify staff that she required EBP's. In an interview on 8/27/2024 at 2:12 PM, Registered Nurse (RN) Unit Manager D reported R64 required EBP because of her gastric tube and should have signage on her door to notify staff of required Personal Protective Equipment (PPE). In an observation and interview on 8/28/2024 at 9:07 AM, R64's room door had EBP signage directing staff to use a gown and gloves with high contact activities such as dressing, bathing, transferring, changing linens, providing hygiene, and changing briefs. CNA B reported the EBP signage was new and placed the day before as R64 required this because of her gastric tube. Review of R64's Electronic Health Record (EHR) on 8/28/2024 at 9:10 AM revealed no active Physician's Order for EBP's. In an interview on 8/28/2024 at 9:19 AM, RN Unit Manager D reviewed R64's EHR and reported there was no Physician's Order or Care Plan intervention for EBP's. RN Unit Manager D reported R64 should have a Physician's Order and a corresponding Care Plan intervention for EBP's. Review of facility policy/procedure Enhance Barrier Precautions, revised 3/26/2024, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . employs targeted gown and gloves use during high-contact resident care activities . enhanced barrier precautions will be obtained for residents with any of the following . wounds . indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes) . Resident #217 Review of an Admission Record revealed Resident #217 (R217) admitted to the facility on [DATE] with pertinent diagnoses which included right femur fracture and enterocolitis due to clostridium difficile (C-diff). Review of a current C-diff Care Plan intervention for R217, initiated 8/23/2024, directed staff to use contact isolation precautions. Review of R217's Physician's Orders, active 8/26/2024, revealed she was in contact precautions related to C-diff infection. In an observation on 8/27/2024 at 11:16 AM, 2 CNA's removed a gown and gloves after providing care to R217 in her room and performed hand hygiene using hand sanitizer. They did not wash their hands with soap and water after providing care. In an interview on 8/27/2024 at 1:44 PM, the Director of Nursing (DON) reported staff were required to wash hands with soap and water instead of using hand sanitizer when caring for residents in contact isolation for C-diff. The DON reported she would educate staff regarding this. In an observation on 8/28/2024 at 9:00 AM, R217's room door had signage that read .wash hands on way in with soap and water. Wash hands on way out with soap and water . In a telephone interview on 8/28/2024 at 10:10 AM, CNA C reported she was working with Resident #217 the morning of 8/27/2024. CNA C reported she was educated on 8/28/2024 that she was required to wash hands with soap and water instead of using hand sanitizer when caring for residents with C-diff. CNA C stated, I was not doing this right before. Review of facility policy/procedure Transmission-Based (Isolation) Precautions, revised 12/27/2023, revealed .It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission . An order for transmission-based precautions/isolation will be obtained . Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room . Type and Duration of Transmission-Based Precautions Recommended for Selected Infections and Conditions . Clostridioides difficile, formerly known as Clostridium difficile . precaution . contact . duration . duration of illness . comments . hand hygiene with soap and water . In an interview on 8/28/2024 at 11:20 AM, the DON reported Resident #21 was tested early that morning for C-diff. The DON reported he should be in contact isolation until test results returned negative. The DON reported she had not yet placed signage on Resident #21's door regarding the need for staff to wash hands with soap and water instead of using hand sanitizer. In an interview on 8/28/2024 at 11:38 AM, Housekeeping Supervisor P reported he typically found out about residents in isolation at the morning team meetings. Housekeeping Supervisor P reported he was not aware Resident #21 was being tested for C-diff until the DON notified him just a few minutes ago. 39056 Per the Centers for Disease Control and Prevention (CDC), .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html (Article dated 4/3/24). Per the Centers for Disease Control and Prevention (CDC), .C. diff sheds in feces. Any surface, device or material that becomes contaminated with feces could serve as a reservoir for the C. diff spores. Examples include: *Commodes *Bathtubs . C. diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. *Isolate patients with possible C. diff immediately, even if you only suspect CDI (clostridium difficle infection) . https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html (Article dated 3/5/24). Resident #21 (R21) Review of an Admission Record revealed R21 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: acute osteomyelitis of the right ankle and foot (requiring the long-term use of intravenous antibiotics). Review of R21's Nurses' Note dated 8/19/24 revealed, Resident tested positive for COVID 19 . During an observation on 08/26/24 at 10:44 AM, the door to R21's room was closed with a sign posted. The sign contained the following: TRANSMISSION BASED PRECAUTIONS-What you should be wearing before entering room: N95 Mask .Gown .Gloves .Face Sheild. The sign did not indicate the type of Transmission Based Precaution (TBP) R21 was in (contact, droplet, and/or airborne). Review of R21's Provider Note dated 8/28/24 revealed, Notified by nursing that patient has watery brown stools, c/o (complaints of) generalized abd (abdominal) pain. No fever, + chills x once. Meds reviewed, patient is on IV antibiotic. Orders given to obtain stool for c-diff (Clostridium difficile) . Review of R21's Nurses' Note dated 8/28/24 at 1:07 AM revealed, Provider notified resident is having increased abdominal pain and watery brown stools since Sunday (8/25/24). Resident was diaphoretic [NAME] asleep .Orders received for stool for c diff . Per the CDC, R21 should have been placed in contact isolation at this time. Review of R21's Pertinent Charting-Infections/Signs Symptoms note dated 8/28/24 at 5:31 AM revealed, Site of originally identified infection: right foot wound .lab work and c diff stool sample being sent. Review of R21's Order Summary dated 8/28/24 at 01:51 AM revealed, stool for diff (Clostridium difficile) x 1 one time only for water stool . Review of R21's Medication/Treatment Administration Record revealed the c-diff stool sample was obtained on 8/28/24 at 4:13 AM. During an observation on 08/28/24 at 10:30 AM, the door to R21's room was closed with a sign posted. The sign contained the following: TRANSMISSION BASED PRECAUTIONS-What you should be wearing before entering room: N95 Mask .Gown .Gloves .Face Sheild. The signage did not reflect that contact precautions were to be implemented (contact precautions required for c. diff.) During an interview on 08/28/24 at 11:35 AM, Director of Nursing (DON) was notified that R21's door signage did not reflect contact precautions. DON reported she would ensure signage that reflected R21's presumptive positive c. diff infection. During an observation on 08/28/24 at 2:45 PM, the door to R21's room was closed with the same sign observed at 10:30 AM along with an additional printout posted reading wash hands with soap and water going into room and leaving room. There was no signage indicating R21 was in contact precautions in order for staff to ensure proper infection control practices were followed. During an interview on 8/28/24 at 10:34 AM, Laundry Staff (LS) M reported R21 was in isolation for COVID-19. During an interview on 8/28/24 at 10:40 AM, Certified Nursing Assistant (CNA) I reported R21 was in isolation for COVID-19 only. During an interview on 8/28/24 at 10:44 AM, Unit Manager (UM) N reported R21 was in isolation for COVID-19 and would be taken out of isolation on 8/29/24. UM N did not indicate that he was placed in contact isolation at the time c. diff was suspected. R21's Order Summary Report was reviewed on 8/28/24 at 2:45 PM and revealed an order for Enhanced Barrier Precautions (EBP) related to acute osteomyelitis and transmission-based precautions related to positive or suspected COVID-19 status. There was no order for contact precautions related to the presumptive positive c. diff infection. Resident #36 (R36) Review of an Admission Record revealed R36 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: a stroke and the use of a gastrostomy tube (feeding tube). R36 was ordered to be in EBP due to his feeding tube and his tracheostomy. Review of R36's Order Summary dated 2/29/24 revealed, every 4 hours .Flush (gastrostomy) tube with (335) ML's H20 (water) . Water bolus/flush to be administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM (6 times a day). During an observation on 08/28/24 at 11:20 AM it was identified that R21 and R36 had a shared bathroom. There was no signage on the door to the bathroom from R36's room indicating that R21 was in contact precautions for a c. diff infection. At 11:22 AM an attempt was made to open R36's bathroom door. The door was unlocked but R21 was sitting on the toilet having a bowel movement at that time. During an interview on 08/28/24 at 11:33 AM, RN K reported that the facility practice was for nurses to fill a graduated cylinder with tap water from R36 and R21's shared bathroom sink to administer the every 4 hour ordered flushes. RN K reported R21 was in isolation for COVID-19 and had not been notified of any other type of isolation precautions for R21. During an observation on 08/28/24 at 12:33 PM, RN K donned PPE per R36's ordered EBP and entered his room. RN K brought R36's graduated cylinder to R36 and R21's shared bathroom sink and filled it with tap water. There was a smear of feces noted on the bathroom floor near the toilet and the toilet contained fecal waste and used toilet paper. RN K connected a syringe (with no plunger) to the feeding tube port/adapter and poured the tap water from the graduated cylinder into the open syringe, administering the ordered amount of the water bolus/flush. RN K then capped off the feeding tube port/adapter and set the graduated cylinder back down in R36's room. Review of R36's Medication Administration Record revealed that on 8/28/24 R36 was administered a water bolus/flush at 4:00 AM, 8:00 AM, and 12:00 PM (R21's order for stool testing for c. diff was documented on 8/28/24 at 1:07 AM and contact precautions were not implemented). Indicating 3 times that R36 was exposed to c. diff spores from the nurse touching the contaminated surfaces in the bathroom, holding the graduated cylinder and syringe, and connecting the syringe directly to the feeding tube port. During an interview on 8/28/24 at 2:47 PM, R21 was not in his room. Housekeeping Staff (HS) L was in R21's room and reported that he was informed about an hour and a half ago that R21 was being tested for c. diff and was directed by management to clean R21's room and bathroom following the most severe protocol (terminal cleaning per the CDC guidelines to kill c. diff spores). During an interview via email on 08/28/24 at 1:30 PM, Nursing Home Administrator (NHA) stated, It (stool sample) was sent to (laboratory name omitted) this morning. They sent it out for processing and stated at the earliest it would be this afternoon or evening; tomorrow if not today. As of 08/28/24 at 4:45 PM the Clostridium difficile stool sample had not been resulted by the laboratory. R21's Clostridium difficile status was unknown and therefore presumed positive per the CDC. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Antibiotic use alters the normal flora in the GI tract. A common causative agent of diarrhea is Clostridium difficile (C. difficile), which produces symptoms ranging from mild diarrhea to severe colitis. The Infectious Diseases Society of America (IDSA) identified C. difficile as the most common health care-related infection in America. Patients acquire C. difficile infection in one of two ways: by antibiotic therapy that causes an overgrowth of C. difficile and by contact with the C. difficile organism. Patients are exposed to the organism from a health care worker's hands or direct contact with environmental surfaces contaminated with it. Only hand hygiene with soap and water is effective to physically remove C. difficile spores from the hands. Older adult patients are especially vulnerable to C. difficile infection when exposed to antibiotics, and higher mortality and morbidity are observed in this age-group .To decrease the spread of infection, patients with C. difficile are placed on contact/enteric isolation precautions. A private room with a dedicated toilet is preferred to help prevent transmission to other patients. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 1278-1279). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to assess, monitor, and care for a resident receiving tube feedings per facility policy and professional standards of care for 1 of 3 residents (Resident #61) reviewed for the care of tube feedings. Findings: Resident #61 (R61) Review of an Admission Record revealed R61 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: adult failure to thrive and dysphagia (difficulty swallowing). Review of R61's Order Summary dated 7/15/24 revealed, Enteral Feed Order every day and night shift Check tube placement prior to administration of medications & tube feeding/flush. During an observation on 08/27/24 at 12:08 PM, Registered Nurse (RN) H had prepared medication to administer to R61 via his peg tube (feeding tube). RN H did not assess R61's gastric residual or peg tube placement. RN H then drew up the medication in a syringe (approximately 60 ml of liquid), connected the syringe to the peg tube port/adapter, and firmly pushed the plunger of the syringe until the medication was administered (less than 15 seconds). RN H did not remove the plunger of the syringe, connect the open syringe to the feeding tube port/adapter, and pour the water into the syringe allowing the water to flow in utilizing gravity. During an interview on 8/27/24 at 7:15 AM, RN S reported that the placement of a feeding tube and gastric residual should be assessed prior to the administration of medications and water boluses. During an interview on 8/28/24 at 8:22 AM, RN K reported that medication administration and water boluses should be administered using gravity and should not be pushed. RN K reported that the placement of a feeding tube is assessed prior to administering medications by using the syringe to inject air into the feeding tube while listening for a gurgling sound with a stethoscope of the peg tube site. During an interview on 8/28/24 at 7:10 AM, RN J reported that the placement of a feeding tube and gastric residual should be assessed prior to the administration of medications and water boluses. RN J reported that medication administration and water boluses should be administered using gravity and should not be pushed. During an interview on 8/28/24 at 2:07 PM, Director of Nursing (DON) reported that the licensed nurses were expected to follow the facility policy and procedures when administering medications via peg tube. DON was notified that the facility policy did not reflect how licensed nurses were to assess peg tube placement. DON reported she would review the policy and provide documentation of the procedure the facility nurses were to follow. DON did not provide clarification to the facility's procedural guidelines/policy verbally or in writing prior to survey exit (8/28/24 at approximately 5:00 PM). During an interview on 08/28/24 at 03:30 PM, Corporate Nurse (CN) R reported that unless otherwise ordered, licensed nurses should allow medications and water boluses to flow by gravity when utilizing the peg tube. CN R reported that she had recently updated the facility policy and procedures regarding the assessment of peg tube placement due to the change in the standards of practice and was waiting on corporate's (upper managements) approval to implement the changes and educate the licensed nurses. Review of the facility policy Feeding Tubes last reviewed/revised 6/30/22 revealed, .10. In accordance with facility protocol, licensed nurses should: a. Monitor and check that the feeding tube is in the right location (e.g., stomach or small intestine, depending on the tube) b. Tube Placement will be verified before beginning a feeding and before administering medications . 12. Direction for staff regarding how to manage and monitor the rate of flow will be provided: a. Use of gravity flow. b. Use of a pump . Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, PROCEDURAL GUIDELINES Administering Medications Through an Enteral Tube (Feeding Tube) .10. Before administration of enteral medications, verify placement of feeding tube according to agency policy and determine that tube is placed in the stomach or small intestine correctly .22. Check for gastric residual volume (GRV). Draw up 10 to 30 mL of air into a 60-mL syringe and connect syringe to feeding tube. Flush tube with air and pull back slowly to aspirate gastric contents . 25. Administer dose of first liquid or dissolved medication by pouring into syringe. Allow to flow by gravity. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 651-652). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Historically nurses confirmed placement of feeding tubes by injecting air into the tube while auscultating the stomach for a bubbling or gurgling sound or by asking the patient to speak. Current evidence shows that these methods are ineffective in verifying tube placement. Currently, the most accurate method for verification of tube placement is x-ray film examination. At the bedside, nurses test the pH of secretions withdrawn from the feeding tube to confirm tube location on an ongoing basis .PROCEDURAL STEPS: Review agency policy and procedures for frequency of irrigation and frequency and method of checking tube placement. Do not insufflate air into tube to check placement .CLINICAL JUDGMENT: Listening for insufflated air instilled through tube to check tube tip position is unreliable . [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1198-1199). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to administer the pneumococcal and influenza vaccination to 1 resident (Resident #29) of 5 residents reviewed for immunizations, resulting in the potential for residents to contract and spread preventable diseases. Findings include: Resident 29 Review of an Admission Record revealed Resident #29 (R29) admitted to the facility on [DATE] with pertinent diagnoses which included dementia and peripheral vascular disease. Further review revealed R29 had an activated medical Power of Attorney (POA). Review of a Minimum Data Set (MDS) assessment for Resident #29, with a reference date of 8/1/2024 revealed a Brief Interview for Mental Status (BIMS) score of 1, out of a total possible score of 15, which indicated Resident #29 was severely cognitively impaired. Review of R29's immunization record revealed the facility documented he refused the influenza and pneumococcal vaccinations. In an interview on 8/27/2024 at 1:44 PM, the Director of Nursing (DON) reported R29's POA consented to the influenza and pneumococcal vaccinations but could not find documentation that these were administered or refused. Review of R29's Influenza Vaccine Consent Form revealed his POA consented to the influenza vaccine on 11/7/2023. Review of R29's November 2023 Medication Administration Record revealed the influenza vaccine was ordered and scheduled to be given on 11/9/2023 or 11/10/2023 and the boxes were blank, indicating the vaccination was neither given nor refused. In an interview on 8/28/2024 at 10:20 AM, the DON reported she was unable to find documentation that R29 had received or refused the influenza and pneumococcal vaccinations. Review of facility policy/procedure Influenza Vaccination, revised 10/26/2023, revealed .It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza . Review of facility policy/procedure Pneumococcal Vaccine (Series), revised 10/30/2023, revealed .It is our policy to offer our residents, staff, and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations .

Based on observation, interview and record review, the facility failed to prevent the development and worsening of pressure ulcers for 1 resident (Resident #5) out of 2 residents reviewed for pressure ulcers. Findings: Review of an Admission Record reflected R5 admitted to the facility on [DATE] with diagnosis that included type 2 diabetes, seizures, adjustment disorder with mixed anxiety and depressed mood, mild intellectual disabilities, repeated falls, need for assistance with personal care, muscle weakness, difficulty walking and cognitive communication deficit. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R5 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11/15 and required substantial/maximal assistance (helper does more than half the effort) for sitting to standing, chair/bed transfers and toilet transfers. The MDS assessment indicated R5 was at risk for developing pressure ulcers but did not have any pressure ulcers or other skin conditions such as Moisture Associated Skin Damage (MASD). Review of a Care Plan initiated on 9/29/23, revised on 10/02/23 indicated R5 was at risk for impaired skin integrity related to diabetes, neuropathy, seizures, reduced mobility and intellectual disability. The focus indicated R5 had a history of red buttocks and coccyx. Interventions to keep R5's skin intact included Complete skin inspection weekly and as needed and Notify nurse of any new areas of skin impairment noted during bathing or daily care (e.g., redness, blisters, bruises, discoloration, impairment related to medical device/tubing). Review of a Skin Assessment - V4 dated 9/14/23 indicated R5 did not have any existing abnormal skin areas and comments specified Skin intact. Review of a Skin Assessment - V4 dated 9/21/23 indicated R5 did not have any existing abnormal skin areas and comments specified No skin concerns noted. Review of Nurses' Notes dated 9/30/23 at 3:07 PM reflected R5 did not feel well and tested positive for Covid-19. Review of a Skin Assessment - V4 dated 10/2/23 (more than a week after the previous assessment) documented by RN C at 4:41 AM reflected R5 had new abnormal skin areas that were described as Redness and excoriation related to commode on R5's sacrum and left buttock. No further assessment details or comments were noted. During a telephone interview on 12/6/23 at 3:11 PM, RN C recalled discovering R5's wounds on 10/2/23 and reported she thought it looked like he had been left on a bedpan for too long based on the size, shape and location of the wounds. RN C said that she was working with Unit Manager/Wound Nurse RN F on 10/2/23 and reported her concerns and the findings to her. RN F instructed RN C to document the skin assessment. RN C said she did not observe R5 on the commode and documented redness and abrasion from commode because that is what RN F thought had caused the pressure injury. RN C said she did not do anything further because she felt she had reported her concerns appropriately to her Unit Manager and Wound Nurse RN F. Review of a Wound Evaluation dated 10/2/23 documented by Unit Manager/Wound Care Nurse, Registered Nurse (RN) F at 12:51 AM reflected R5 had an in-house (facility) acquired Skin Tear - Category II: <25% Partial Tissue Loss on the left gluteus that was 14.79 cm squared, 8.63 cm long and 2.55 cm wide. The evaluation noted the wound appears as semi-circular skin tear, possible from getting up from commode. No drainage, no redness, no odor, no s/s (signs/symptoms) of infection. Treatment put in place. Review of the Treatment Administration Record (TAR) for the month of October 2023 revealed the following order: -Monitor and place zinc oxide to resident's left buttock and excoriated areas until healed two times a day for excoriation to buttocks was started on 10/2/23 at 7:00 AM and discontinued on 10/10/23 at 2:30 PM. Review of all Progress Notes from 10/01/23-10/3/23 did not reveal documentation pertaining to R5's new skin alterations identified on 10/2/23. Review of an Other Skin incident report dated 10/4/23 at 2:00 AM reflected RN U was called to R5's room by a Certified Nurse Aide (CNA) who was performing personal care on resident including brief change after incontinence of urine. New skin issues observed to left buttock and right upper back side of thigh. The report included Other Info which indicated Resident more incontinent of urine with onset of new covid positive status. Areas discovered during personal care after episode of urinary incontinence. CNA T provided a witness statement The resident used the urinal and put the call light on, his bed was wet, so I rolled him to change his brief and the bed sheet. I was changing the residents brief and doing personal care after he was incontinent of urine. When I removed his brief, he said ouch and that's when I noticed the skin issue and notified the nurse. Review of Nurses' Notes dated 10/4/23 at 2:53 AM reflected Resident with new skin issues, abrasions to left buttocks, proximal 11 cm (centimeters) L (long) x 5 cm W (wide), right 2.5 cm W x 2.5 cm L 1.5 cm L, left 1 cm W x left rear, upper thigh with L shaped abrasions with clear fluid filled areas, 11 cm L x 2.5 cm W. During a telephone interview on 12/5/23 at 1:22 PM, CNA T confirmed the statement included in the incident report. CNA T said she observed red marks and blisters on R5's buttocks that seemed like they had been there a while and did not look new. CNA T said she reported the observation to the nurse immediately. During an interview on 12/5/23 at 1:54 PM, RN U reported that she completed the Other Skin incident report upon notification and assessment of R5's wounds. RN U said that prior to her observations on 10/4/23, she was not aware R5 had any skin breakdown and did not obtain updated orders for treatment at that time. Review of a NH Visit (Nursing Home) note dated 10/3/23 documented by Nurse Practitioner (NP) V indicated R5 was not feeling well due to testing positive for Coronavirus on 9/30/23. The note reflected R5 was limited assist for bed mobility but required extensive two-person assistance with transfer, ambulation, and toileting. The Review of Systems reflected R5's skin was warm and dry no open areas. The Physical Examination documented by NP V also indicated R5's skin was warm, pale, thin, dry, absent of any lesions or open areas. Review of a NH Visit note dated 10/24/23 reflected NP V saw R5 for a review of labs. The Review of Systems and Physical Examination indicated R5's skin was intact, absent of open areas or lesions. Review of a NH Visit note dated 11/15/23 reflected NP V saw R5 to review his blood sugars which were consistently elevated. The Review of Systems and Physical Examination indicated R5's skin was intact, absent of open areas or lesions. During an interview on 12/5/23 at 2:08 PM, NP V reported she would review wounds weekly when she was at the facility based on a list provided to her by nursing staff. NP V said that RN F would take the pictures and measurements which were available in the Electronic Medical Record (EMR). NP V said that she did not document a treatment plan or acknowledgment of R5's wounds because she saw him to specifically address other issues such as R5's Covid-19 diagnosis, labs and blood glucose levels. NP V said her progress notes auto-fill the Review of Systems and Physical Examination sections and are not necessarily accurate. NP V said that she would only document specifically about skin and wounds if the resident was not healing or progressing toward healing. NP V did not express concern for why or how R5 progressed from redness and excoriation to the development of unstageable pressure ulcers because the wounds were improving. Further review of the October 2023 TAR revealed the following order, indicating R5's wounds had worsened: -Left gluteus, Right rear thigh, Left rear thigh: Cleanse with wound cleaner, pat dry, apply DermaSyn (an amorphous hydrogel used on partial- and full-thickness dry to minimally draining wounds including pressure ulcers, diabetic ulcers, abrasions, lacerations, minor burns, minor cuts and sunburn) to areas, cover with border foam dressing at bedtime for wound was stared on 10/10/23 at 8:00 PM and discontinued on 11/07/23. Review of the November 2023 TAR revealed the following orders: - Left gluteus and Left rear thigh: Cleanse with wound cleaner, pat dry, Collagen (a dressing that can stimulate growth of new tissue in wounds and is indicated for wounds that have stalled healing, partial-or-full-thickness wounds, wounds with minimal to heavy exudate, infected wounds, provided the infection is managed locally or systemically) to wound beds only, cover with border foam dressing at bedtime for wound was started on 11/14/23 and discontinued on 11/26/23. This same order was restarted on 11/26/23 to be completed on the night shift rather than at bedtime. - Right rear thigh, pressure area: Cleanse with wound cleaner, leave open to air at bedtime for wound was started on 11/07/23 and discontinued on 11/22/23. During an observation on 12/5/23 at 11:30 AM, Unit Manager/Wound Care Nurse, RN F assessed and photographed R5's wounds and provided wound care. The wound at the rear left thigh was open and classified as unstageable. The wound on the left lateral gluteus was observed and had a distinct curved shape to the alteration/scar that could line up with pressure from a bed pan or toilet seat. R5 did not have excess loose skin in the buttock/thigh area that could easily be pulled or get pinched. RN F reported that R5's skin impairment certainly looks like it could come from a bed pan. During an interview on 12/6/23 at 8:24 AM, the DON reported she was the first person to observe the wound on 10/3/23 after an unknown aide reported a soiled dressing covering R5's buttocks. According to the DON, when she assessed R5 on 10/3/23, the dressing covering the area was an 8 x 8-inch bordered foam dressing that matched the linear/curve of the reddened and blistered area, and thought the wound was likely the result of irritation from the dressing adhesive. The DON could not explain why a large dressing had been applied to R5 and had not investigated to determine who had applied the large dressing without an order. The DON was not aware that R5's wounds were currently treated with bordered foam dressing with the same adhesive speculated to have caused the skin breakdown. During the interview with the DON on 12/6/23 at 8:24 AM, the EMR was reviewed to validate when R5's wounds were first documented. The Skin Assessment - V4 dated 10/2/23 was reviewed again. This assessment indicated the sacrum and left buttock had Redness and excoriation related to commode, the day before the DON discovered the wounds. The DON reported she did not document an investigation into how R5 could have become injured while using the commode or possibly a bedpan which led to the unstageable pressure ulcers and did not know if the wounds were related to a staffing concern (being left unattended on a bedpan or the commode for an extended period of time) or R5's actions. A care plan Focus initiated on 10/19/23 revealed Resident (R5) has impaired skin integrity as evidenced by: Unstageable to bilateral buttocks, Pressure to right back, right ischial, right upper thigh. Interventions added to the care plan on included Assist resident with turning and repositioning; complete skin inspections weekly and as needed; Complete wound evaluation to observe the progress of the resident's skin condition; Encourage good nutrition and hydration, assist as needed; Encourage resident to reposition self as able; Notify Nurse of any new areas of skin impairment noted during bathing or daily care (e.g., redness, blisters, bruises, discoloration, impairment related to medical device/tubing); Notify Physician/NP (nurse practitioner)/PA (Physician Assistant) of signs/symptoms of infections (new or change in type/amount/color/drainage, bleeding, foul odor); Pressure redistribution mattress to bed. Interventions specific to the suspected etiology of the pressure ulcers (reducing the potential for friction or shear during transfers or toilet/commode/bedpan use or caution with medical adhesive) were not listed in the care plan.

Based on observation, interview and record review, the facility failed to assess/evaluate pain and its cause, intervene appropriately to find the root cause of the pain, manage, and prevent pain during care, update the care plan for onset of pain, and provide diagnosis/indication for newly prescribed pain medication for 1 (Resident #6), resulting in a lack of a root cause analysis for pain and the resident crying out in pain with movement, transfers, and cares. Findings include: Resident #6 (R6) Review of a Face Sheet revealed R6 originally admitted to the facility on [DATE] with pertinent diagnoses of chronic kidney disease (stage III), dementia and history of a kidney transplant. Review of the Minimum Data Set (MDS) dated [DATE] revealed R6 is severely cognitively impaired and requires extensive assistance of 2 staff for transfers and cares. R6 is not on a pain control regimen per the MDS and is indicated to have a pain assessment interview. No chronic conditions indicating the need for pain medication. Review of the Care Plan for R6 revealed she is at risk for acute and chronic pain last revised on 4/14/23. Interventions included but not limited to: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, revised on 03/14/2022. Monitor/record pain characteristics on the following schedule (every shift) and as needed: Describe the quality of pain (e.g., sharp, burning); the Severity of pain (1 to 10 scale); Location of pain; Onset of pain; Duration of pain such as continuous or intermittent; Any aggravating factors; Any relieving factors, revised on: 08/15/2022. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain, revised on: 05/23/2023. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o pain or discomfort, revised on: 02/22/2023. (sic) Multiple Myeloma is on the care plan but not on the Face Sheet. During observations and interview on 8/22/23 at 11:12 AM, R6 was in bed sleeping. At 12:38 PM, R6 was in bed and observed with an untouched meal tray on the table in her room. Floor staff reported she was not feeling well and wanted to stay in bed. During an observation on 8/23/23 at 2:00 PM, R6 was observed in the activity room. During an observation and interview on 8/23/23 at 2:22 PM, R6 was observed being transferred to bed via Hoyer lift with 2 certified nursing assistants (CNAs). As R6 was being lifted in the sling out of her chair, she was crying out and complaining of pain in her right leg. As staff provided incontinence care, R6 continued to moan and cried in pain with any movement. CNA I reported the resident has been having pain in her right leg for a couple of days now. At this time the Unit Manager (UM) N was in the room and the Registered Nurse (RN) J was assessing the residents skin wound as R6 moaned and cried out in pain. RN J then asked the resident if she was having pain and told R6 she would get a Tylenol for her. R6 continued cry and moan it hurts, it hurts! The Unit Manager continued to assess the resident's skin and reposition her leg to assess the skin wound while asking R6 if it hurts from her knee to her hip. No physical assessment was done. The UM N reported R6 only complained of a headache the day before. When the nurses were done assessing the resident's wound, the resident continued to cry out in pain while the CNAs were repositioning her. The nursing staff did not thoroughly assess R6's pain. In an interview on 8/23/23 at 3:03 PM, RN J reported she did not know R6 had pain and had to talk to UM N to find out more information about R6 potentially needing an X-ray or something. R6 was revisited at this time and said her pain is just in her leg and the pain increased during incontinence care. In an interview on 8/23/23 at approximately 3:15 PM, CNA L reported R6 did not want to get out of bed because of her pain. The nurse gave her some tramadol because she complained of a migraine. Yesterday she did not eat much but today she ate 75% of her food. CNA L reported R6 did complain of pain on Monday and Tuesday and the nurses knew about the pain. That is when the nurses were able to get her some tramadol. In an interview on 8/23/23 at 3:17 PM, RN J reported she just gave R6 an Ultram (Tramadol), and the Director of Nursing (DON) is going to call the doctor about the pain. RN J reported when she came on duty, the off-going nurse before did not inform her of R6 having any pain and did not know why the resident has an order for Ultram. In an interview on 8/23/23 at 3:42 PM, the DON reported R6 often chooses to stay in bed. The DON reported they could not have a scheduled pain medication for R6 due to her poor kidney function. When queried what the Ultram was ordered for, the DON reported it was for varied pain in her legs or her back. The DON reported she expects the nurses to do an assessment for residents who have new pain to locate it, rate it, assess range of motion including internal and external, and assess her leg pain starting from the foot up to the knee then to the hip. Once assessment is completed, the nurses are expected to call the doctor. Review of the August Medication Administration Record (MAR) for R6 revealed an order dated 8/18/23 for 50 mg (milligrams) of tramadol for every 8 hours as needed for pain. R6 got her first dose on 8/19/23. There is no indication for this medication, and she received her last dose on 8/21/23 at 1:45 PM. Review of the Electronic Medical Records (EMR) for R6 revealed from 1/1/23 to 8/23/23, there is no thorough physical/pain assessments documented, documentation indicating the need for an order of tramadol, or diagnostic tests regarding new onset of pain or right lower extremity, interventions for pain. Review of Nursing Progress notes for R6 does not reflect the resident having any pain or the need for the tramadol that was ordered on 8/19/23. In an interview on 8/23/23 at 5:00 PM, the DON reported R6 is on palliative care but could not provide any documentation from the palliative care nurse or when they last visited her or provide an indication for tramadol that is prescribed for the resident.

Based on observation, interview and record review, the facility failed to develop and implement care plan for pressure ulcer prevention/healing and pain control for 1 Resident (R56) of 14 Residents reviewed for care, resulting in R 56 developing a pressure ulcer and having pain out of control during care. Findings include: Review of R 56's face sheet dated May 12, 2021 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not her own responsible party. Review of R 56's Brief Interview of Mental Status (BIMS) score dated 4/30/21 revealed a score of 5/15 indicating severe mental impairment. Review of R 56's admission Activities of Daily Living (ADL) assessment dated [DATE] revealed she required substantial/maximal assistance with transfers, toileting and hygiene. The assessment indicated she required the assistance of two people to transfer with a mechanical lift. Review of R 56' s admission nursing assessment dated [DATE] reveal no skin breakdown. Boxes were marked for floating heels, heels up cushion, pressure redistribution device to chair, and pressure redistribution mattress to bed. Review of R 56's Medical History and Physical dated 4/29/21 revealed she had a left foot wound ulcer. Review of R 56's skin assessment dated [DATE] at 21:30 (9:30 PM) revealed she had a 6 cm x 2.6 cm blister on her left inner heel. The heel was treated with soap/water. The wound was covered with [MEDICATION(S)] (medicated cream for wounds) and a dressing was placed over the area. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (all notes and observation indicated the left heel was the one with the pressure ulcer not the right as indicated in this order). Review of R 56's progress note dated 5/13/21 at 4:59 AM revealed, New dressing applied to left heel x 2 this shift due to being off. On 5/13/21 at 8:37 AM, R 56 was observed in bed. R 56 legs were on a very thin pillow. R 56 's had both heels in full contact of the mattress as the pillow was too thin to float her heels off the bed. R 56 had the head of her bed elevated, and her bed side table was in front of her with her breakfast tray on the bed side table. R 56 had not eaten her breakfast. Certified Nurse Aide (CNA) H attempted to get R 56 to eat her breakfast, but she complained of back pain. CNA H got CNA L to assist her with R 56. As the CNA's put the head of the bed down R 56's yelled out that her legs hurt. As the CNA's changed R 56 brief and did care, R 56 yelled out in pain with any movement. CNA H removed both of R 56's socks. R 56 right heel had no indication of skin breakdown. R 56's left heel had a dressing covering it with no date or initials. Heel protectors were not observed to be in R 56's room during this time. During an interview with the Director of Nursing, Unit Managers D and J on 5/13/21 at 10:30 AM, R 56's Nursing assessment dated [DATE] was reviewed and there was no indication of skin break down documented. The three nursing staff indicated the skin breakdown was discovered on 5/9/21 and the current order dated 5/11/21 ordered a dressing change every three days. The Surveyor reported the observation that morning of heels in full contact with mattress, no heel protectors in use or visible in the room and the dressing on the left heel had no date or initials. The nurses indicated the dressing should have been dated and initialed. The nurses reported R 56 will not keep heel protectors on and they were not aware that the pillow was not thick enough to float R 56's heels. The nurses were asked how they assess and monitor that the interventions for prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . They also indicated the CNA's should report if an intervention was not working. They all denied any report of the pillow not effectively floating R 56's heels. During an interview with the Director of Nursing, Unit Managers D and J on 5/13/21 at 10:30 AM, the Surveyor reported R 56 yelled out in pain with all movement during care that morning. The Surveyor asked how they assessed R 56's pain during care/movement as all pain assessments indicated R 56 pain was 0 on a scale of 1 - 10 most days. The nurses said the CNA's should report pain concerns during care. All 3 nurses denied any report of R 56 reporting pain during care. Review of R 56's care plan dated 4/26/21 revealed a care plan, The resident has potential impairment to skin integrity related to occ (occasional) incontinence, confusion, decreased mobility, impairment to left heel 5/10/21. Initiated 4/26/21 and revision on 5/13/21. Interventions included: Encourage resident to keep heels floated or wear soft protective boots when in bed, Initiated 5/10/21. According to the Medical History dated 4/29/21 R 56 had a wound ulcer on her left heel. (No intervention on treatment was documented to treat this until 5/10/21 (11 days after it was noted). This intervention was not observed in place on 5/13/21 at 8:37 AM. Review of R 56's care plan dated 4/26/21 and revision on 5/10/21 revealed, The resident at risk for chronic pain related to OA ([CONDITION(S)]). Interventions included: Administer pain medication as ordered. Give ½ hour before treatments or care. Evaluated the effectiveness of pain interventions on the following frequency. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Review of R 56's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R 56's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Aspercreame [MEDICATION(S)] Cream had not been given all month. During an interview with Registered Nurse (RN) N on 5/13/21 at 1:55 PM, he revealed R 56's medication was a little late on 5/13/21 as the hall was very busy. RN N opened the sign out sheet for R 56's [MEDICATION(S)] and he had documented he removed it from the narcotic box at 9:03 AM on 5/13/21. RN N denied getting any report from the CNA's that morning that would indicate R 56 had been experiencing pain during morning care. RN N said he started his shift at 6:00 AM and R 56 had already had her 6:00 AM dose of Acetaminophen before he started his medication pass. (On 5/13/21, R 56 did not receive pain medication ½ hour prior to care as indicated in her pain care plan).

Based on observation, interview, and record review, the facility failed to prevent and heal a pressure ulcer for 1 Resident (#56), of 4 Residents reviewed for pressure ulcers, resulting in R 56 developing an unstageable pressure ulcer. Findings include: Review of R 56's face sheet dated May 12, 2021 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was not her own responsible party. Review of R 56's Brief Interview of Mental Status (BIMS) score dated 4/30/21 revealed a score of 5/15 indicating severe mental impairment. Review of R 56's admission Activities of Daily Living (ADL) assessment dated [DATE] revealed she required substantial/maximal assistance with transfers, toileting and hygiene. The assessment indicated she required the assistance of two people to transfer with a mechanical lift. Review of R 56' s admission nursing assessment dated [DATE] revealed no skin breakdown. Boxes were marked for floating heels, heels up cushion, pressure redistribution device to chair, and pressure redistribution mattress to bed. Review of R 56's Medical History and Physical dated 4/29/21 revealed she had a left foot wound ulcer. Review of R 56's skin assessment dated [DATE] at 21:30 (9:30 PM) revealed she had a 6 cm x 2.6 cm blister on her left inner heel. The heel was treated with soap/water. The wound was covered with [MEDICATION(S)] (medicated cream for wounds) and a dressing was places over the area. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (all notes and observation indicated the left heel was the one with the pressure ulcer not the right as indicated in this order). Review of R 56's progress note dated 5/13/21 at 4:59 AM revealed, New dressing applied to left heel x 2 this shift due to being off. On 5/13/21 at 8:37 AM, R 56 was observed in bed. R 56's legs were on a very thin pillow. R 56 had both heels in full contact of the mattress as the pillow was too thin to float them off the bed. R 56 had the head of her bed elevated, and her bed side table was in front of her with her breakfast tray on the bed side table. R 56 had not eating her breakfast. Certified Nurse Aide (CNA) H attempted to get R 56 to eat her breakfast, but she complained of back pain. CNA H got CNA L to assist her with R 56. As the CNA's put the head of the bed down R 56 yelled out that her legs hurt. As the CNA's changed R 56's brief and did care R 56 yelled out in pain with any movement. CNA H removed both of R 56's socks. R 56's right heel had no indication of skin breakdown. R 56's left heel had a dressing covering it with no date or initials. Heel protectors were not observed to be in R 56's room during this time. During an interview with the Director of Nursing, Unit Managers D and J on 5/13/21 at 10:30 AM, R 56's Nursing assessment dated [DATE] was reviewed and there was no indication of skin break down documented. The three nursing staff indicated the skin breakdown was discovered on 5/9/21 and the current order dated 5/11/21 ordered a dressing change every three days. The Surveyor reported the observation that morning of heels in full contact with mattress, no heel protectors in use or visible in the room and the dressing on the left heel had no date or initials. The nurses indicated the dressing should have been dated and initialed. The nurses reported R 56 will not keep heel protectors on and they were not aware that the pillow was not thick enough to float R 56's heels. The nurses were asked how they assess and monitor that the interventions for prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . They also indicated the CNA's should report if an intervention was not working. They all denied any report of the pillow not effectively floating R 56's heels. Review of R 56's care plan dated 4/26/21 revealed a care plan, The resident has potential impairment to skin integrity related to occ (occasional) incontinence, confusion, decreased mobility, impairment to left heel 5/10/21. Initiated 4/26/21 and revision on 5/13/21. Interventions included: Encourage resident to keep heels floated or wear soft protective boots when in bed, Initiated 5/10/21. According to the Medical History dated 4/29/21 R 56 had a wound ulcer on her left heel. (No intervention on treatment was documented to treat this until 5/10/21 (11 days after it was noted). This intervention was not observed in place on 5/13/21 at 8:37 AM.

This citation pertains to MI 690: Based on interview, and record review, the facility failed to prevent abuse and neglect for 1 of 3 residents (Resident #2) reviewed for abuse and neglect, resulting in Resident #3 not getting needs met as punishment for his behavior which resulted in the resident exhibiting immediate escalating behaviors. Findings include: Review of Resident #2's face sheet and electronic medical record revealed he admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 has a guardian in place to make medical and financial decisions. Review of Resident #2's care plan revealed a focus area with initiated date 01/06/2019: The resident has potential to become verbally and physically aggressive towards staff at times. Resident does have DX: Impulse Disorder and [MEDICAL CONDITION] Disorder. Resident also has Mild Intellectual Disabilities. He may be resistive with cares, yell at staff and intimidate staff by invading their personal space. Resident has a history of becoming defensive if he feels criticized. Interventions included: Assess and anticipate the resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Provide empathy and voice understanding of his feelings. When the resident becomes agitated: Intervene before agitation escalates . Also in Resident #2's care plan is resident may have his evening soda with his snack. Per the facility provided summary of Facility Reported Incident on 5/19/2019: Facility staff (Registered Nurse (RN) T) failed to provide pop/soda to (Resident #2) when he requested it; due to it not being the time for the snack/beverage, (8pm) that was formally requested by the Resident's Legal Guardian, and due to the Resident's combative behavior. Review of the progress note entered in Resident #2's electronic medical record (EMR) by RN T revealed Resident was pleasant and cooperative until after dinner. As usual he reminded staff about his snack and soda pop at 2000 multiple times. He came out of his room as soon as the snack cart came through around 1930 and chose pudding and a spoon, again reminding staff of his pop at 2000. at 1950 and demanded his pop(sic) . He was redirected back to his room, reminding him to wait until it was time by this nurse. He approached the med cart and tried grabbing the computer, drinking glasses, pudding cup, med plus drink, and then at this nurse while laughing at himself. The nurse gave him the option to stop his behaviors, or will add 5 minutes of wait time for his pop. He continued despite adding several minutes. This nurse informed him he would not get his pop for his behavior, and continued attempts to redirect him did not stop him. He became loud, shouting unkind names like ugly, fat', mean, and f word, and threatening to tell his sister. He would not return to his room, and began striking out trying to hit the CENA's as they led him to his room. Within minutes he was back out in the hall naked with his brief and pants at his ankles. He was redirected to his bathroom by a CENA, and he came right back out within a couple minutes again naked with his brief halfway down, pants around his ankles. CENA assisted him back to his room and he redressed. Shortly after he was spotted inside the nurse's station. When CENA's tried to redirect him back to his room, he began striking out, hitting at CENAs and punched (Certified Nursing Assistant (CNA) P) in the right breast, and purposely grabbed at her inappropriately in the crotch area. He then returned to his room. This nurse called administrator (NHA) at 2030 to report and to seek direction on managing his behavior. She advised to keep a staff person in the hall at all times to guard resident from hurting any residents, and that if there are any more inappropriate behaviors, to call her regardless of the time. His behaviors will be addressed tomorrow. Resident stayed quiet in his room without any further behaviors or demands for his pop until the end of the shift. He will be offered an alternative if he asks again. During an interview on 7/2/2019 at 4:10 PM with RN T, she reviewed her account of the incident. RN T stated that she was passing meds that evening and Resident #2 came out of his room demanding a snack around 7:30 or 7:40 PM. He also wanted his nightly pop, which she was trained that he gets exactly at 8:00 PM, so RN T told Resident #2 that he would have to wait and would not get it until 8:00 PM. RN T stated he started throwing things and grabbing things on the cart and she could not get Resident #2 to stop or redirect him. RN T stated she then tried a time-out for Resident #2 and told him every time he grabbed something it would be 5-10 more minutes until he got his pop. RN T stated I didn't want to reward him for bad behavior. RN T stated Resident #2 went back to his room but then came back again and it was still before 8:00 PM and I said he may not even get his snack. RN T stated Resident #2 was laughing and although he is impaired he knows what he is doing when he misbehaves. RN T said Resident #2 was redirected to his room and came out with his pants down again and when redirected he hit and grabbed at staff. RN T stated that she did not know what to do, so she called the NHA who told her that she did the right thing and should not give the resident the pop. RN T was asked to clarify that she was told to not give Resident #2 his pop and she then stated that the NHA called the Director of Nursing (DON) and called her back later and RN T was told she should follow the plan. RN T stated she did not give Resident #2 his pop that night. RN T stated that she was called the next day and was put off of work for emotional abuse and then a couple days later she was fired for emotional abuse. RN T confirmed that when the DON called her, RN T was told she emotionally abused a resident. RN T stated that she remembered this clearly because she was very upset at this finding and had never been accused of abuse before. RN T stated that she didn't think withholding a pop from a mad patient was emotional abuse. RN T stated that Resident #2 is definitely mentally slow, but he knows what he is doing and he's child like at times. RN T says she has previous experience with adults with similar [DIAGNOSES REDACTED]. During an interview on 7/3/2019 at 11:08 AM with CNA O, she reviewed her account of the incident. CNA O stated she was called from another hall to assist another CNA taking Resident #2 to his room and she got hit in the breast while assisting. CNA O stated that RN T told them that Resident #2 needed to be in his room because he was a threat to other residents. Resident #2 was out of his room a bit later and she was again asked to help get him to his room and Resident #2 hit her again in the arm. CNA O did not know everything that happened, but stated that Resident #2 seemed to be upset about a pop and he kept saying that he wanted a pop. CNA O stated that she has previously worked with Resident #2 and that he can be combative at times, mostly in the shower. CNA O stated that when he wants snacks, he usually wants them ASAP and that sometimes giving him something to eat or drink will decease his behaviors. During an interview on 7/3/2019 at 11:53 AM with CNA P, she reviewed her account of the incident. CNA P stated that Resident #2 was having a pretty good day, but that he can get agitated quickly with certain things. CNA P stated that he can get antsy and impatient before getting his nightly snack. CNA P stated that she was trying to help Resident #2 lay down and he was yelling I want my pop repeatedly. CNA P stated that RN T told her that Resident #2 wasn't going to get a pop and CNA P did not know why. CNA P stated that the nurses oversee giving Resident #2 the nightly pop that his guardian supplies for him. CNA P stated Resident #2's demeanor escalated and he was yelling, hitting and grabbed at her in the vagina. CNA P stated Resident #2 has frequent behaviors but that he likes snacks, and this can help him calm down at times. CNA P felt Resident #2's escalating behaviors could have been avoided that night if he was just given his pop. During an interview on 7/3/2019 at 2:30 PM with CNA U, she reviewed her account of the incident. CNA U stated that Resident #2 was having a lot of behaviors that day and sometimes he has days like that. CNA U stated that she knew Resident #2 wanted his 8:00 PM pop and had not gotten it. CNA U stated that when she was helping redirect the resident she got hit by him and Resident #2 went for her coworker's throat. CNA U stated she had to take a break after she was hit and she heard that when she was on break Resident #2 acted out again and sexually touched her coworker. CNA U stated that the CNAs were directed to put Resident #2 in his room, which didn't make sense to her because when he is upset walking helps him calm down. Further review of Resident #2's EMR revealed multiple progress notes entered by RN T on various dates but with event date 04/03/2019: Resident was yelling out at start of shift. is (sic) sister was here visiting, and she told him to behave or he was not to get his soda pop at 8 pm. This nurse administered scheduled [MEDICATION NAME] at 1455, and he was calm for the rest of the shift and Resident became loudly demanding and argumentative with staff at approximately 1930 through 2000 about getting pudding and his pop. He quieted down after receiving his snack. No PRN [MEDICATION NAME] (anxiety medication) was needed Review of facility provided Performance Improvement Form dated 5/21/19 and signed by the DON and NHA revealed that RN T was discharged due to Employee Conduct: 6.1.24 Any action that is considered to be threatening to the health or well-being of others or the continued productivity or standards of The Company. The form further revealed: It was brought to the facilities attention through the investigation process that a poor employee to resident interaction occurred. Very poor customer service was exhibited. After the conclusion of the investigation it was determined that this nurse had an unsuccessful probationary period. Review of facility provided Quality Assessment & Assurance Investigation Report included in the incident investigation packet revealed: Documentation reviewed from 5/19. Reveiled (sic) staff member failed to give resident requested pop. Documentation showed agitation of resident due to refusal. Review of the NHA statement included in the incident investigation packet dated 5/20/19 revealed: I started quizzing her (RN T) on why (Resident #2) was behaving this way as it is out of character to be sexually inappropriate. She explained to me that he was upset that it was not time for his snack and pop so he was yelling and 'pestering' the staff .(RN T) explained that he gets this way when he doesn't get what he wants. I educated her that is he asks for something that we are required to provide it to him as long as it is not detrimental to his health. Review of facility provided policy Abuse Prevention Program with no written or revised date revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint no required to treat the resident's symptom. In the section Reporting and Response: Our facility will not condone resident abuse by anyone, including staff members . In the section Elder Justice Act, the definition of Abuse is documented: Abuse- The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Additionally, 'Mental abuse' is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. The definition of Neglect is also documented: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish or mental illness. On 7/3/19 at 10:20 AM, the incident and facility response were reviewed during an interview with the DON. The DON stated that on 5/19/19 RN T chose not to give Resident #2 pop, she kept telling him to wait and RN T said she was adding 5 minutes to the resident's wait after he grabbed items off the RN's cart. They terminated the staff member due to poor customer service since she did not understand withholding pop could be a form of abuse. The DON was asked if withholding pop is a form of abuse, why the nurse was not terminated for abuse. The DON stated that the decision was a team effort with human resources and the NHA. During review of the facility policy with the DON, she was directed to the definition of abuse. The DON noted that the situation included deprivation of an individual and agreed that the incident included punishment of the resident's behavior. On 7/3/19 at 10:30 AM, the incident and facility response were reviewed during an interview with the NHA. The NHA stated that RN T's termination was for customer service concerns because the staff was adamant they were sticking to the guardian's wishes regarding the time the pop was given. RN T had called the NHA during the incident and NHA had instructed RN T to give the resident the pop and RN T did not follow the instructions. The facility abuse policy was quoted to the NHA and they acknowledged that they could understand how the incident could be considered abuse. During a follow up interview on 7/3/19 at 3:40 PM, the NHA acknowledged that they had concerns regarding the incident and completed abuse training with the staff immediately after the incident. The NHA stated that when she read the nursing note completed by RN T the day after the incident she was very concerned about potential abuse. The NHA stated that the decision to terminate RN T for customer service was a joint decision with legal and upper management.

This citation pertains to MI 690: Based on interview and record review, the facility failed to implement their abuse policy and recognize abuse and neglect towards 1 (Resident #2) of 3 reviewed for abuse and neglect, resulting in the potential for continued unrecognized abuse and neglect of residents. Findings include: Review of Resident #2's face sheet and electronic medical record revealed he admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 has a guardian in place to make medical and financial decisions. Review of Resident #2's care plan revealed a focus area with initiated date 01/06/2019: The resident has potential to become verbally and physically aggressive towards staff at times. Resident does have DX: Impulse Disorder and [MEDICAL CONDITION] Disorder. Resident also has Mild Intellectual Disabilities. He may be resistive with cares, yell at staff and intimidate staff by invading their personal space. Resident has a history of becoming defensive if he feels criticized. Interventions included: Assess and anticipate the resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Provide empathy and voice understanding of his feelings. When the resident becomes agitated: Intervene before agitation escalates . Also in Resident #2's care plan is resident may have his evening soda with his snack. Per the facility provided summary of Facility Reported Incident on 5/19/2019: Facility staff (Registered Nurse (RN) T) failed to provide pop/soda to (Resident #2) when he requested it; due to it not being the time for the snack/beverage, (8pm) that was formally requested by the Resident's Legal Guardian, and due to the Resident's combative behavior. Review of the progress note entered in Resident #2's electronic medical record (EMR) by RN T revealed Resident was pleasant and cooperative until after dinner. As usual he reminded staff about his snack and soda pop at 2000 multiple times. He came out of his room as soon as the snack cart came through around 1930 and chose pudding and a spoon, again reminding staff of his pop at 2000. at 1950 and demanded his pop(sic) . He was redirected back to his room, reminding him to wait until it was time by this nurse. He approached the med cart and tried grabbing the computer, drinking glasses, pudding cup, med plus drink, and then at this nurse while laughing at himself. The nurse gave him the option to stop his behaviors, or will add 5 minutes of wait time for his pop. He continued despite adding several minutes. This nurse informed him he would not get his pop for his behavior, and continued attempts to redirect him did not stop him. He became loud, shouting unkind names like ugly, fat', mean, and f word, and threatening to tell his sister. He would not return to his room, and began striking out trying to hit the CENA's as they led him to his room. Within minutes he was back out in the hall naked with his brief and pants at his ankles. He was redirected to his bathroom by a CENA, and he came right back out within a couple minutes again naked with his brief halfway down, pants around his ankles. CENA assisted him back to his room and he redressed. Shortly after he was spotted inside the nurse's station. When CENA's tried to redirect him back to his room, he began striking out, hitting at CENAs and punched (Certified Nursing Assistant (CNA) P) in the right breast, and purposely grabbed at her inappropriately in the crotch area. He then returned to his room. This nurse called administrator (NHA) at 2030 to report and to seek direction on managing his behavior. She advised to keep a staff person in the hall at all times to guard resident from hurting any residents, and that if there are any more inappropriate behaviors, to call her regardless of the time. His behaviors will be addressed tomorrow. Resident stayed quiet in his room without any further behaviors or demands for his pop until the end of the shift. He will be offered an alternative if he asks again. During an interview on 7/2/2019 at 4:10 PM with RN T, she reviewed her account of the incident. RN T stated that she was passing meds that evening and Resident #2 came out of his room demanding a snack around 7:30 or 7:40 PM. He also wanted his nightly pop, which she was trained that he gets exactly at 8:00 PM, so RN T told Resident #2 that he would have to wait and would not get it until 8:00 PM. RN T stated he started throwing things and grabbing things on the cart and she could not get Resident #2 to stop or redirect him. RN T stated she then tried a time-out for Resident #2 and told him every time he grabbed something it would be 5-10 more minutes until he got his pop. RN T stated I didn't want to reward him for bad behavior. RN T stated Resident #2 went back to his room but then came back again and it was still before 8:00 PM and I said he may not even get his snack. RN T stated Resident #2 was laughing and although he is impaired he knows what he is doing when he misbehaves. RN T said Resident #2 was redirected to his room and came out with his pants down again and when redirected he hit and grabbed at staff. RN T stated that she did not know what to do, so she called the NHA who told her that she did the right thing and should not give the resident the pop. RN T was asked to clarify that she was told to not give Resident #2 his pop and she then stated that the NHA called the Director of Nursing (DON) and called her back later and RN T was told she should follow the plan. RN T stated she did not give Resident #2 his pop that night. RN T stated that she was called the next day and was put off of work for emotional abuse and then a couple days later she was fired for emotional abuse. RN T confirmed that when the DON called her, RN T was told she emotionally abused a resident. RN T stated that she remembered this clearly because she was very upset at this finding and had never been accused of abuse before. RN T stated that she didn't think withholding a pop from a mad patient was emotional abuse. RN T stated that Resident #2 is definitely mentally slow, but he knows what he is doing and he's child like at times. RN T says she has previous experience with adults with similar [DIAGNOSES REDACTED]. During an interview on 7/3/2019 at 11:08 AM with CNA O, she reviewed her account of the incident. CNA O stated she was called from another hall to assist another CNA taking Resident #2 to his room and she got hit in the breast while assisting. CNA O stated that RN T told them that Resident #2 needed to be in his room because he was a threat to other residents. Resident #2 was out of his room a bit later and she was again asked to help get him to his room and Resident #2 hit her again in the arm. CNA O did not know everything that happened, but stated that Resident #2 seemed to be upset about a pop and he kept saying that he wanted a pop. CNA O stated that she has previously worked with Resident #2 and that he can be combative at times, mostly in the shower. CNA O stated that when he wants snacks, he usually wants them ASAP and that sometimes giving him something to eat or drink will decease his behaviors. During an interview on 7/3/2019 at 11:53 AM with CNA P, she reviewed her account of the incident. CNA P stated that Resident #2 was having a pretty good day, but that he can get agitated quickly with certain things. CNA P stated that he can get antsy and impatient before getting his nightly snack. CNA P stated that she was trying to help Resident #2 lay down and he was yelling I want my pop repeatedly. CNA P stated that RN T told her that Resident #2 wasn't going to get a pop and CNA P did not know why. CNA P stated that the nurses oversee giving Resident #2 the nightly pop that his guardian supplies for him. CNA P stated Resident #2's demeanor escalated and he was yelling, hitting and grabbed at her in the vagina. CNA P stated Resident #2 has frequent behaviors but that he likes snacks, and this can help him calm down at times. CNA P felt Resident #2's escalating behaviors could have been avoided that night if he was just given his pop. During an interview on 7/3/2019 at 2:30 PM with CNA U, she reviewed her account of the incident. CNA U stated that Resident #2 was having a lot of behaviors that day and sometimes he has days like that. CNA U stated that she knew Resident #2 wanted his 8:00 PM pop and had not gotten it. CNA U stated that when she was helping redirect the resident she got hit by him and Resident #2 went for her coworker's throat. CNA U stated she had to take a break after she was hit and she heard that when she was on break Resident #2 acted out again and sexually touched her coworker. CNA U stated that the CNAs were directed to put Resident #2 in his room, which didn't make sense to her because when he is upset walking helps him calm down. Further review of Resident #2's EMR revealed multiple progress notes entered by RN T on various dates but with event date 04/03/2019: Resident was yelling out at start of shift. is (sic) sister was here visiting, and she told him to behave or he was not to get his soda pop at 8 pm. This nurse administered scheduled [MEDICATION NAME] at 1455, and he was calm for the rest of the shift and Resident became loudly demanding and argumentative with staff at approximately 1930 through 2000 about getting pudding and his pop. He quieted down after receiving his snack. No PRN [MEDICATION NAME] (anxiety medication) was needed Review of facility provided Performance Improvement Form dated 5/21/19 and signed by the DON and NHA revealed that RN T was discharged due to Employee Conduct: 6.1.24 Any action that is considered to be threatening to the health or well-being of others or the continued productivity or standards of The Company. The form further revealed: It was brought to the facilities attention through the investigation process that a poor employee to resident interaction occurred. Very poor customer service was exhibited. After the conclusion of the investigation it was determined that this nurse had an unsuccessful probationary period. Review of facility provided Quality Assessment & Assurance Investigation Report included in the incident investigation packet revealed: Documentation reviewed from 5/19. Reveiled (sic) staff member failed to give resident requested pop. Documentation showed agitation of resident due to refusal. Review of the NHA statement included in the incident investigation packet dated 5/20/19 revealed: I started quizzing her (RN T) on why (Resident #2) was behaving this way as it is out of character to be sexually inappropriate. She explained to me that he was upset that it was not time for his snack and pop so he was yelling and 'pestering' the staff .(RN T) explained that he gets this way when he doesn't get what he wants. I educated her that is he asks for something that we are required to provide it to him as long as it is not detrimental to his health. Review of facility provided policy Abuse Prevention Program with no written or revised date revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint no required to treat the resident's symptom. In the section Reporting and Response: Our facility will not condone resident abuse by anyone, including staff members . In the section Elder Justice Act, the definition of Abuse is documented: Abuse- The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Additionally, 'Mental abuse' is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. The definition of Neglect is also documented: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that is necessary to avoid physical harm, pain, mental anguish or mental illness. On 7/3/19 at 10:20 AM, the incident and facility response were reviewed during an interview with the DON. The DON stated that on 5/19/19 RN T chose not to give Resident #2 pop, she kept telling him to wait and RN T said she was adding 5 minutes to the resident's wait after he grabbed items off the RN's cart. They terminated the staff member due to poor customer service since she did not understand withholding pop could be a form of abuse. The DON was asked if withholding pop is a form of abuse, why the nurse was not terminated for abuse. The DON stated that the decision was a team effort with human resources and the NHA. During review of the facility policy with the DON, she was directed to the definition of abuse. The DON noted that the situation included deprivation of an individual and agreed that the incident included punishment of the resident's behavior. On 7/3/19 at 10:30 AM, the incident and facility response were reviewed during an interview with the NHA. The NHA stated that RN T's termination was for customer service concerns because the staff was adamant they were sticking to the guardian's wishes regarding the time the pop was given. RN T had called the NHA during the incident and NHA had instructed RN T to give the resident the pop and RN T did not follow the instructions. The facility abuse policy was quoted to the NHA and they acknowledged that they could understand how the incident could be considered abuse. During a follow up interview on 7/3/19 at 3:40 PM, the NHA acknowledged that they had concerns regarding the incident and completed abuse training with the staff immediately after the incident. The NHA stated that when she read the nursing note completed by RN T the day after the incident she was very concerned about potential abuse. The NHA stated that the decision to terminate RN T for customer service was a joint decision with legal and upper management.

This citation pertains to intake MI 096. Based on observation, interview, and record review, the facility failed to prevent sexual abuse in 1 of 4 residents (Resident #2) reviewed for abuse. This deficient practice resulted in Resident #2 being subjected to sexual abuse by Resident #1 who had demonstrated a history of inappropriate [MEDICAL CONDITION], impaired judgement, insight, impulse control and impaired memory. This placed Resident #2 in immediate jeopardy for psychosocial and/or physical harm based on the reasonable person standard. Findings include: The facility provided a copy of the Abuse Prevention Program that was last revised on 7/21/17. The policy reflected, Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents .The protection of residents during abuse investigations .An ongoing review and analysis of abuse incidents; and the implementation of changes to prevent future occurrences of abuse .Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues .Sexual abuse is non-consensual sexual contact of any type with a resident .Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident's clothing or linen. Do not take special items from the area in which the incident occurred. Call the police immediately) .The individual conducting the investigation will, as a minimum: review the resident's medical record to determine events leading up to the incident .Review all events leading up to the alleged incident. 27. Information around abuse investigations will be reviewed and trended for submission to the facility QAPI. Root cause analysis of trends will be completed by the QAPI Committee for recommendations and development of process improvement plans . Resident #1 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 4 out of 15 which represents Resident #1 had severe cognitive impairment. Resident #1 required staff assistance with all activities of daily living and transfers. Resident #2 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 0 out of 15 which represents Resident #2 had severe cognitive impairment. Resident #2 required staff assistance with all activities of daily living. The facility provided the written statement (dated 3/15/19) by Activity Adie J for the sexual abuse. The statement reflected, I walked into C3's (name of Resident #2) room to see if anyone wanted to attend activities. I observed (name of Resident #1) in his w/c (wheelchair) by the window and (name of Resident #2) was on her chair by the door/bathroom. I walked out to see if anyone else wanted to attend and less than a minute later went back into room [ROOM NUMBER] and observed (name of Resident #1) in his w/c in front of but to the left of (name of Resident #2's) chair with his right hand in her pants between her brief and skin, he was rubbing her peri area. I immediately notified the nurse. Activity Adie J was interviewed by telephone on 3/22/19 at 2:56 PM. Activity Aide J stated that the nurse was just outside the room and heard me call out don't do that, that's inappropriate from the hall and came right in. Activity Aide J stated that the nurse wheeled Resident #1 out in his chair, and she followed them. Activity Aide J stated that she asked Resident #2 if she was alright and she did not verbally answer. Activity Aide J stated, (Name of Resident #2) doesn't speak much. Her speech is random and unable to understand. I don't think the police were able to understand either .I did not see her after that because I stayed with (name of Resident #1) in the activity room. (Name of LPN K) got him a wash cloth and had him wash his hands. Activity Aide J stated that she received education on either 3/18 or 3/19 by the DON, not to allow male residents in female rooms. When asked if there was a facility wide in-service regarding males in females' rooms, Activity Aide J stated, No, just privately with me. When asked is she was aware of Resident #1's history of sexual inappropriate behaviors, Activity Aide J stated, Yes, he has behaviors of grabbing staffs' butts and private areas. The facility provided the written statement dated 3/15/19 by LPN K for the sexual abuse. The statement reflected, I was called into room C3 by (name of Activity Aide J). (Name of Resident #1) was sitting in w/c next to (name of Resident #2's) chair. I immediately removed (name of Resident #1) from the room. He was placed on a 1:1, NHA (Nursing Home Administrator) was notified. LPN K was interviewed on 3/22/19 at 2:29 PM. LPN K stated she had been standing at the medication cart near room [ROOM NUMBER], heard the Activity Aide J call out and immediately entered the room. LPN K stated that when she entered the room Resident #2 was in her chair, Resident #1 was in his w/c and had his hands in his lap. LPN K stated, I told (name of Resident #1) we had to leave and wash your hands. As I wheeled (name of Resident #1) toward the door I saw (name of Resident #2 stand, walk towards the bathroom then turned and continued to walk about in the room. I noticed that her cloths were intact, and I left the room with (name of Resident #1). I got (name of Resident #1) a soapy wash cloth and told him to wash his hands, then placed him in the activity room to be watched by the activity aide. I left the wing to report the incident to management. I couldn't find (name of Unit Manager L) right away because she was in a room with another resident .(Name of Unit Manager (UM) L) and I assessed (name of Resident #2) standing in the bathroom .I did not assess (name of Resident #1) after the incident because he was transferred off the unit soon after the incident happened to the A wing, so that nurse may have. LPN K stated that the DON educated her after the incident not to allow male residents in female rooms. When asked if that was a facility wide in-service, LPN K stated, No, I don't think so. This surveyor entered the facility on 3/22/19 at approximately 12:25 PM and an entrance conference was done with the DON. Observations and interviews of residents were conducted with the DON at approximately 12:30 PM. Resident #1 was seated in a wheelchair eating his lunch in the main dining room of the facility. Resident #1 stated that things were going good for him now that he received his pill. When asked what the pill was for, Resident #1 stated, My [MEDICAL CONDITION]. Resident #1 stated, Do you see that woman standing over there? That's my new wife. She is younger but that's okay. Resident #1 had pointed to another female resident that was standing/ambulating in a combo walker (a stand-up safety walker) on the other side of the dining room. All other residents and staff were seated at the time. The DON stated that Resident #1 often thinks he is married to other women. The DON stated that Resident #1 forgets that he is currently married and that his spouse frequently visits him. When asked if Resident #1 had a history of [REDACTED]. At approximately 12:30 PM, the DON led this surveyor to the locked C wing to meet with Resident #2. Resident #2 was seated, alone in her room (C3) eating her lunch. Resident #2 had nonsensical speak and was unable to answer specific questions regarding the sexual abuse. On 3/22/19 at approximately 1:15 PM, Resident #1 was observed propelling himself in his wheelchair on the B wing hall. At approximately 1:35 PM, this surveyor along with Registered Nurse (RN) G observed Human Resource W guide Resident #1 out of her office which was at the end of the B wing. RN G stated that Resident #1's room is on the A wing, but he often wanders about the facility. At approximately 3:10 PM, Resident #1 was observed propelling himself mid-way down the B wing hall. An interview was conducted with Resident #1's assigned nurse LPN F on 3/22/19 at approximately 1:15 PM. LPN F states that Resident #1 was moved Friday (3/15/19) from the C wing to the A wing. LPN F stated that Resident #1 was confused, had aggressive behaviors, inappropriate touching behaviors and wanders the facility in his wheelchair. When asked about his current level of supervision for the behaviors and wandering, LPN F stated that he was placed 1:1 on Friday (3/15) and that was discontinued on Sunday (3/17). LPN F stated that he is currently on routine 30-minute checks. An interview was conducted with Certified Nurse assistant (CNA) E on 3/22/19 at approximately 1:10 PM. CNA E stated she was helping cover the A wing while Resident #1's assigned CNA D was assisting another resident with their meal. CNA E stated that Resident #1 was on routine 30-minute checks and the staff chart any behaviors. An interview was conducted with CNA H on 3/22/19 at approximately 1:17 PM. CNA H stated that he was assigned to the A wing, together with CNA D. CNA H stated that Resident #1 was confused and wandered about in the facility. CNA H stated that Resident #1 was on routine every 30-minute checks and has behaviors such as grabbing female staff in the private areas. The facility provided a copy of Target Behavior: Sexual inappropriate from 2/21/19 - 3/21/19 for review. Resident #1 had exhibited the inappropriate sexual behavior and was documented on the following dates and times: 2/21/19 at 15:31 2/23/19 at 04:42 2/25/19 at 01:42 2/25/19 at 15:37 2/25/19 at 22:45 2/27/19 at 19:23 2/28/19 at 19:48 3/2/19 at 20:21 3/3/19 at 02:20 3/5/19 at 13:43 3/6/19 at 15:47 3/8/19 at 05:58 3/8/19 at 09:50 3/8/19 at 19:48 3/9/19 at 02:27 3/9/19 at 14:32 3/11/19 at 13:29 3/11/19 at 19:35 3/13/19 at 20:23 3/15/19 at 13:59 3/16/19 at 11:02 3/17/19 at 21:59 3/21/19 at 21:10 Record review of a progress note dated 3/8/19 at 5:56 AM reflected, Resident woke up and immediately started grabbing staff inappropriately. Resident trying to put his hands down staff members pants and hugging them and touching their chests and bottoms. Very difficult to redirect. Record review of a Behavioral Health Evaluation dated 3/11/19 was reviewed. The evaluation reflected, Complaint: Increased Sexual Behaviors .Last seen by NP (nurse practitioner) on 10/26/18 .Per staff and progress notes, patient has been sexually inappropriate with staff. He grabbed staff, kissed staff, and attempted to put his hands down one staff's pants .Assessment & Plan .Patient exhibits impaired judgement, insight, impulse control and memory. Patient also exhibits hyper-sexual behaviors and inappropriate behaviors .[MEDICATION NAME] (medication) is not working for [MEDICAL CONDITION] and patient is still expressing depressive symptoms. Recommend cross-titration to [MEDICATION NAME] (medication). Will GDR (gradual dose reduction) [MEDICATION NAME] to 20 mg daily for one week, then every other day for one week, then d/c (discontinue). The second week of GDR may start [MEDICATION NAME] 10 mg daily. Continue to monitor and document changes in mood and behavior. Record review of the (MONTH) 2019 Medication Administration Record [REDACTED]. The facility provided a copy of the completed investigation for the sexual abuse that occurred on 3/15/19 at 10:50 AM for review. The DON was interviewed on 3/22/19 at approximately 1:20 PM. The DON was questioned regarding missing information (times of events and resident's whereabouts before the incident) in the investigation. The DON stated she was unaware of how long Resident #1 had been in Resident #2's room prior to the incident. This surveyor noted that there were monitoring cameras in each of the halls of the facility and requested to review the recordings. When asked if she had reviewed the recordings for this information, the DON stated, No, I haven't. The DON telephoned the NHA. The NHA was interviewed on speaker phone with the DON. The NHA stated that she had already attempted to review the incident on the recordings but was unable to. When asked why the recording did not capture the events of the incident, the NHA stated that the camera equipment was replaced about 2-3 weeks ago by the facility Maintenance Director DD and it only works intermittently. When asked if the equipment was checked when it was installed 2-3 weeks ago, the NHA stated, Yes, maintenance did. On 3/22/19 at 1:24 PM the State Survey Manager was advised by telephone of the situation. At 1:49 PM the DON notified this Surveyor that the C wing video was available for review. The DON stated that the video could not be sped up or slowed down, it could only run in 5-minute segments at real time. The DON also stated that the time on the video did not match the time that the staff used for the incident, as they may have used a different clock. The following was a timeline observed from the video with the DON: 10:43 - Resident #1 is seated in his wheelchair, propelling himself in the hall near Resident #2's room. Resident #1 is seen propelling himself into the doorway of the room as UM L walks by the room in the hallway. Resident #1 propels himself into Resident #2's room and remains there. 10:48 - UM L passes back up the hall and does not turn her head to look into Resident #2's room. Resident #1 remains in the room with Resident #2 unsupervised. When asked if it was alright for Resident #1 and Resident #2 to be alone in Resident #2's bed room, the DON stated, Yes, it's his right to talk with people. 10:50 - UM L passes back down the hall and does not turn her head to look into Resident #2's room. Resident #1 is still in the room. 10:53 - Activity Aide J entered the unit and walks in to the Activity room at the front of the wing. 10:54 - Activity Aide J exits the activity room, walks down the hall and enters Resident #2's room. 10:55 - only Activity Aide J exits Resident #2's room. Resident #1 is still in the room. LPN K pushed the medication cart from down the hall up closer to Resident #2's room and parks it in the hall midway up the hall. 10:56:44 - Activity Aide J comes back up the hall and reenters Resident #2's room. 10:56:51 - LPN K enters Resident #2's room. 10:57:23 - LPN K exits the room pushing Resident #1's wheelchair and Activity Aide J follows directly behind. 10:58:01 - LPN K parks Resident #1 in the hall near the activity room and walks out of view. Another female resident propels herself in a wheelchair out of the activity room and stops next to Resident #1. LPN K returns and provided Resident #1 with a wash cloth and he is seen washing his hands. Activity Aide J comes back out from the activity room and stands next to Resident #1. 10:58:38 - LPN K leaves the unit. 10:59:17 - Resident #1 makes his way with Activity Aide J into the activity room. 11:03 - LPN K re-enters the unit and passes by Resident #2's room to the nurses station at the end of the hall. 11:06 - LPN K and UM L exit the nurses station, walked up the wing past Resident #2's room and exited the wing. Neither staff members look into Resident #2's room. 11:07 - CNA's N and O along with two visitors enter the wing and walk down the hall, past Resident #2's room. Confirmed with the DON that from 10:57 - 11:07, Resident #2 remained alone in her room, and the DON stated, Yes. When asked by whom and when were Resident #2 and Resident #1 assessed for injuries after the incident, the DON stated, I don't know the time, but I can find out. Subsequent interviews were conducted with the DON on 3/22/19 at 3:25 PM and 4:47 PM. The DON stated that according to the video recording LPN K and UM L entered Resident #2's room at 11:47 to assess for injuries (approximately 1 hour after the incident occurred). The DON stated Resident #1 was transferred off the C wing to the A wing around on 3/15/19 at about 12:30 PM. The DON was unable to locate Resident #1's assessment from the electronic medical record. According to the abuse policy both residents should be assessed after an incident. The DON stated the facility placed Resident #1 with 1:1 supervision, moved him from the C wing to A wing, placed a WanderGuard (device used to detect elopement) and his medications were changed. The DON stated Resident #1 remained 1:1 until Sunday (3/17) at approximately 3:30 PM, according to the SW U's note. The DON stated that she had spoke to SW U on Saturday (3/16) and on Sunday (3/17) over the telephone. SW U had reported that Resident #1 was adjusting well and had one episode of inappropriate sexual behavior with staff and no more with residents during the 1:1 supervision period. The DON stated, We decided that we would remove the 1:1 and change it to general observation. When asked what general observation entailed and the DON was stated, Assure all resident whereabouts every 30 minutes. When asked if it was okay for Resident #1 to visit alone with other female residents, the DON stated, We try not to let him (Resident #1) after that incident. When asked how the A wing staff and other staff throughout the building (where Resident #1 wanders) would know this, the DON stated, I don't recall any special instructions about that. When asked if it would be documented anywhere, the DON stated, Yes, on the care plan or Kardex (resident care guide). The DON reviewed Resident #1's behavior care plan and Kardex with a print date of 3/22/19 and stated, I don't see it. When asked if the care plan and Kardex was updated to reflect that Resident #1 now had a history of [REDACTED]. When asked if the care plan and Kardex reflected that Resident #1 thinks he is married to other people (staff and female residents), the DON stated, It doesn't. According to the abuse policy the facility will develop and implement care plans to prevent abuse. When asked how the facility is ensuring the safety of other female residents, the DON stated, I'll update the care plans today. On 3/22/19 at 5:45 PM the DON, Consultant C and FF was notified of the Immediate Jeopardy (IJ) that began on 3/15/18 at 10:50 AM, as a result of the facility's failure to protect Resident #2 from sexual abuse by Resident #1 who was observed in Resident #2's room (unsupervised) with his hand in Resident #2's brief rubbing her peri area on 3/22/19 at 10:50 AM. Resident #1 was removed from the locked C wing and was placed on 1:1 supervision by staff from the 3/15/19 - 3/17/19. The facility failed to identify and implement interventions to prevent the re-occurrence of this incident. On 3/22/19, Resident #1 was observed wandering throughout the building. The care plans nor Kardex reflected that Resident #1 had sexually abused another female resident at the facility, was not allowed to be unsupervised with other female residents, believed he was married to other people (both staff and residents), and continued to exhibit hypersexual inappropriate behavior. This deficient practice placed all other female residents at the facility at risk for sexual abuse. On 3/25/19 at 1:30 PM, the Immediate Jeopardy was removed as of 3/22/19, when the surveyor verified the following: Based on those findings the facility took the following actions: -Resident #1 was placed on one on one supervision immediately and will remain on one to one until the interdisciplinary team determines he is no longer a threat to other residents. -Resident #1's plan of care has been updated with interventions of staff to provide 1:1 with resident, if resident becomes sexually inappropriate -do not leave him to get a nurse, use phone, walkie talky, call light, etc. to notify for assistance, resident is not to be left unattended with other female residents, staff not to encourage physical touch with resident, staff to be between resident and other residents if others are present, to monitor for inappropriate behaviors and to report to nurse immediately. -Resident #2 has been reviewed by the Social Services and found to be at baseline with no observable behaviors as a result of the event. -All direct care staff present have been educated that Resident #1 is a 1:1 at all times, staff must be next to him. During meals seat him at a table with all male resident or a table by himself which ever he prefers, monitor for sexually inappropriate behaviors and document, staff can find all interventions in the Kardex. -All remaining direct care staff will be educated at the start of their shift prior to providing care to residents. This education will include Resident #1's care plan for supervision and behaviors. -An Ad-hoc QAPI meeting was held at 5:55pm, on 3/22/19 with the Facility's NHA, DON, Regional nurse, Regional Director of Operations, Senior VP of clinical and operations to review the plan. -The Medical Director was made aware of the identified concerns and the plan of action and agreed with the plan. Although the Immediate Jeopardy (IJ) was removed on 3/22/19, the facility remained out of compliance at a scope of isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency.

This citation pertains to intake number MI 906. Based interview and record review the facility failed to assess and address nutritional status and implement pertinent interventions for 1 of 3 residents (Resident #1), reviewed for hydration/nutrition, in a total sample of 5 residents. The deficient practice resulted in Resident #1 sustaining a decline in nutritional status, significant weight loss of greater than 5% in 30 days and greater than 7.5% in 90 days (7.1%/30 days and 18.7%/90 days), and a functional decline with hospitalization . Findings include: The facility provided a policy for Weight Assessment and Intervention undated with a revision date of 2/2018 for review. The policy reflected, The nursing staff and the Dietitian will collaborate to prevent, monitor and intervene for undesirable weight loss for our residents .The nursing staff will measure resident weights on admission and weekly .Any weight change of greater than or less than 5 pounds since the prior weight will be retaken the next day for confirmation with licensed nurse confirming the reweigh. If the weight is verified, nursing will notify the physician, make referral to the dietician and noted on the 24 hour report for follow-up. Attending physician will be notified of unplanned significant weight changes . The facility provided a protocol for Nutrition (Impaired)/Unplanned Weight Loss undated with a last revised date of 6/20/16 for review. The protocol reflected, The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time .4. the Physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition .Cause Identification .The Physician will review possible causes of anorexia or weight loss with the nursing staff and/or Dietitian before ordering interventions .b. For individuals with recent or rapid weight loss the staff and physician should consider possible fluid and electrolyte imbalance as a cause. Fluid deficits can result in rapid weight loss .The Physician, with input from the staff, will determine the most appropriate intervals for weight assessments . Resident #1 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #1 was a [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Brief Interview for Mental Status (BIMS), reflected a score of 0 out of 15 which represents Resident #1 had severe cognitive impairment. Resident #1 required staff assistance with all activities of daily living. Resident #1 did not reside at the facility during the onsite survey. The following weight measurements were provided by the facility for review: 9/30/17 312.3 11/27/17 312.5 11/29/17 282.2 (down 30.3 lbs from usual body weight and no reweigh was taken to verify per policy) 12/11/17 273.6 12/18/17 273.8 12/25/17 274.3 1/1/18 259.0 (down an additional 15.3 lbs and no reweigh was taken to verify per policy) 1/8/18 254.2 (down an additional 4.8 lbs) The facility provided a copy of Resident #1's meal acceptance log from 12/28/18 that reflected meal acceptance of less than 10% or refused: 12/28/17 dinner - refused 12/31/17 lunch - refused 1/3/18 dinner - refused 1/4/18 dinner - 5% taken 1/5/18 lunch - refused 1/6/18 lunch - refused dinner - refused 1/7/18 lunch - refused dinner - refused 1/8/18 breakfast - refused lunch - refused dinner - 10% taken 1/9/18 breakfast - refused dinner - refused An interview and record review was conducted with the Registered Dietitian (RD) E on 3/19/18 at 9:40 AM. When asked about the refused meals, RD E stated that nursing should document this in the progress notes and was unable to locate any of notation for the refused meals. When asked if Resident #1 was weighed in the month of (MONTH) (YEAR), RD E checked the computer and stated, No, she was not and had an order to be weighed once monthly at that time. The record reflected that Resident #1 was transferred to the hospital on [DATE] and readmitted on [DATE]. When asked what her readmission weight was, RD E checked the record and stated nursing should have obtained that as part of the readmission assessment but did not record it. The record reflected that Resident #1 was again transferred to the hospital on [DATE] and was readmitted on [DATE] after a stroke and again RD E stated that nursing should have obtained a weight but did not. Record review of the RD note dated 11/30/17 reflected a weight loss of about 30 lbs (9%) in 90 days and indicated notification was made to the nurse practitioner (NP) and reweigh was requested. RD E stated that the record did not reflect a reweigh and could not find indication of the notification to the NP. The RD note dated 1/3/18 reflected a weight loss of about 23 lbs (8%) in 30 days and the RD discussed tube feed with resident but she declined. The RD recommended a dietary supplement of 2 cal 4 oz BID. According to the physician orders [REDACTED]. The RD E stated again that she should have notified the physician but could not locate any documentation that it was done. According to the physician orders [REDACTED]. Record review of the nutritional care plan dated 5/9/17 reflected an intervention of, Provide and serve diet as ordered: Regular, no added salt, no added sugar. Monitor intake q (every) meal and record which was lasted revised on 5/9/17. The RD E stated that intervention was incorrect and should have been updated. The facility failed to follow the policy to obtain weights as ordered (monthly for (MONTH) (YEAR)), obtain weights on readmission (11/3/17 and 11/21/17) and notify the physician of significant weight loss. The physician progress notes [REDACTED]. On interview and record review was conducted with the DON B on 3/14/18 at 4:45 PM. A copy of only two physician notes dated 11/7/17 and 11/28/17 were provided for review. The DON B stated that she believed the Physician or extender did see Resident #1 in the month of (MONTH) (YEAR) but was unable to locate the progress note before the exit of this survey on 3/19/18. Neither note contained an assessment of the significant weight loss. When asked about the meal acceptance and nursing notes, DON E stated that certified nurse assistants should report this to their charge nurse and the nurse is expected to assess the resident, document it and report to the physician if indicated. Record review of the nursing notes 12/28/17 - 1/9/18 did not reflect any notation of the refused meals and there were no notifications to the physician for potential for decline in nutrition/hydration status. According to the note dated 1/10/18 at 12:14 AM, it reflected, Resident with shallow, non labored respirations, lethargy observed, sao2 (oxygen saturation) with o2 (oxygen) varies from 85% to 96%. No s/s (signs and symptoms) of pain. Skin pink, warm, and dry. Hob (head of bed) elevated. Decreased urinary output noted. Will continue to monitor for change. No s/s of [DIAGNOSES REDACTED]. Record review of a SBAR (Situation, Background, Assessment, Recommendation) dated 1/10/18 at 3:48 AM reflected the following information. Resident #1 had a change in condition with increased lethargy, shallow respirations, low blood pressure and high blood sugar. Resident #1 was noted to have a rapid decline during the shift with possible dehydration [MEDICAL CONDITION]. Resident #1 was transferred to the hospital for emergency evaluation and treatment. According to the EMS run sheet dated 1/10/18 the EMS received a call from the facility at 3:05 AM with a complaint of Resident #1 having breathing problems. Resident #1's vital signs reflected blood pressure 50/35, heart rate 99 and weak, respirations 10 weak/agonal (gasping or abnormal breathing), and oxygen saturation was 87% on room air. Glucose was checked and read high. The narrative reflected, When was she last seen to be her normal self? Staff reported about 2:00 PM yesterday. EMS transported Resident #1 to the emergency room at 3:36 AM. According to the Emergency Department Physician Record dated 1/10/18 at 3:38 AM reflected the following information. Provisional Diagnosis: [REDACTED].