Every finding on record at Medilodge of Sterling

Based on observation, interview and record review, the facility failed to ensure the safety of 1 resident (Resident #46) during 3 transfer's using a mechanical lift (wrong sling size used, it was too large) for 1 of 1 resident reviewed for mechanical (Hoyer) lift, resulting in the residents lower back and bottom hanging out of the large opening on the backside of the sling, verbalizing of discomfort and fear while being transferred. Findings Included:Resident #46:Review of the Face Sheet, Material Data Set/MDS dated 9/25, care plans dated 9/1/25, and admission nursing assessment dated [DATE], revealed Resident #46 was [AGE] years old, alert, admitted to the facility on [DATE], incontinent of bowel and bladder with a Foley urinary catheter in place, totally dependent on staff for his Activities of Daily Living/ADL's, and was mechanical lift for all transfers. The residents diagnosis included chronic kidney disease, chronic systolic and diastolic heart failure, anemia, dysphagia (difficulty swallowing), aphasia (communication deficit), BPH, depression and anxiety. Review of Resident #46's facility ADL care plan dated 8/29/25, stated Transfers: with 2 person assist and use of full mechanical lift and green sling. The green sling was the proper size for the residents height and weight. Review of the facility Accidents and Supervision policy dated 12/27/2023, stated Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan.Observation was made on 9/2/25 at 10:38 a.m., of Nursing Assistant's/CNA's N and P using a Hoyer lift to transfer the resident from his wheelchair to his bed to do peri care. The CNA's used a large ( blue) Hoyer sling to hook him up to the lift. When he was in the air above his wheelchair, his bottom was falling out of the backside opening of the sling (it was too large for the resident). The right size sling (green) was sitting in his chair near his bed at the time. The CNA's did the residents peri care and continued to use the same (large blue) sling to transfer him back into his wheelchair for a shower. The resident was observed to be falling out of the backside of the opening of the sling for a second time.During an interview done on 9/2/25 at 10:45 a.m., CNA P stated he should be using the green one (the smaller green sling) and she pointed to the chair in the room with the green sling sitting in it.During a second observation done on 9/2/25 at 10:45 a.m., CNA/Shower Aide O had just brought the resident back from his shower and for a third time, he was lifted up from his wheelchair put back in his bed using the larger blue sling; he bottom was hanging through the large open area for a third time.During an interview done on 9/5/25 at 2:40 p.m., Resident #46 said he felt like he was going to fall when he was transferred on 9/2/25, and it hurt his lower back area.Review of the Hoyer sling measurement sheet (un-dated), revealed the height of the resident for the green sling was 50 in. and width was 35 in. of the opening in the backside, compared to the blue sling H-56 and W-37.Review of the facility Safe Lifting and Movement of Resident's policy dated 1/1/2022, stated Each resident is assessed through the Resident Assessment Instrument (RAI) and interdisciplinary team to determine lifting and movement assistance needs. At times, it is necessary to include the use of mechanical lifts to protect the safety and well-being of staff and residents, and to promote quality care. A sufficient number of slings, in the sizes required by residents in need, will be available at all times.

Based on observation, interview and record review, the facility failed to ensure appropriate use and administration of insulin with an insulin pen per manufacturer recommendations and professional standards of practice for one (#35) of two residents reviewed for insulin administration. Findings include: Resident #35:A medication pass observation for Resident #35 was completed with Licensed Practical Nurse (LPN) W on 9/5/25 at 8:32 AM. LPN W was observed preparing the Resident's medications including Lantus Solostar Insulin Pen (long-acting insulin in a prefilled insulin pen with a turn dial on the bottom of the pen to select the dose for administration). LPN W entered the Resident's room, administered their oral medications and then proceeded to administer the insulin using the Solostar Pen in the Resident's right upper abdomen. LPN W held the Solostar Pen in place for five seconds, including the time the administration injection button on the bottom of the Solostar Pen was depressed, prior to removing the pen from Resident #35's abdomen.An interview was completed with LPN W after exiting Resident #35's room. When queried how long they are supposed to hold the insulin pen in place after the dose has been administered, LPN W stated, Five seconds. When queried if holding for five seconds was the facility policy/procedure, LPN W verbalized the insulin pen has to be held in place, so the medication is absorbed. When asked if the time the injection button was held down counted towards the time the pen had to be held in place, LPN W did not respond. An interview was completed with the facility Administrator on 9/5/25 at 9:30 AM. The Administrator was informed of SoloStar insulin pen administration by LPN W and concern related to not holding the pen in place for 10 seconds and the potential for the Resident to not receive the entire dose. The Administrator verbalized understanding. A review of Lantus. How to use your Lantus SoloStar pen ([NAME]-Aventis, 2022), revealed, A step-by-step guide to using your Lantus SoloStar pen. Step 5. Inject Your Dose. Keep the pen straight, insert the needle into your skin. Use your thumb to press the injection button all the way down. When the number in the dose window returns to 0 as you inject, slowly count to 10 before removing. (Counting to 10 will make sure you get your full insulin dose.) Release the button and remove the needle from your skin.

Based on observation, interview and record review, the facility failed to ensure Enhanced Barrier Precautions/EBP were used, and handwashing was done after glove removal for 1 resident (Resident #46) of 13 resident's reviewed for handwashing and proper personal protective equipment usage, resulting in the protentional for cross contamination, resident and staff illness and increased antibiotic use.Findings Include: Resident #46:Review of the Face Sheet, Material Data Set/MDS dated 9/25, care plans dated 9/1/25, and admission nursing assessment dated [DATE], revealed Resident #46 was [AGE] years old, alert, admitted to the facility on [DATE], incontinent of bowel and bladder with a Foley urinary catheter in place, totally dependent on staff for his Activities of Daily Living/ADL's, and was mechanical lift for all transfers. The residents diagnosis included chronic kidney disease, chronic systolic and diastolic heart failure, anemia, dysphagia (difficulty swallowing), aphasia (communication deficit), BPH, depression and anxiety.Review of the residents facility EBP care plan dated 8/29/25, stated Utilize Enhanced Barrier Precautions when providing high contact resident care activities (transferring, personal hygiene, changing linens, urinary catheters).Observation was done on 9/2/25 at 10:38 a.m., of Nursing Assistant's/CNA's P and N transferring Resident #46 from wheelchair to bed and doing peri care. The resident had signage on the room door indicating EBP was to be used with all care (gloves, and gown) due to him having a urinary catheter in place. Neither CNA P nor N put any gown on due to EBP precautions; the plastic bin containing the EBP was just inside the room by the door. CNA N changed the resident, did peri care and catheter care, while CNA P assisted with resident positioning. When CNA N was done with care, she walked to the residents bathroom, removed her soiled gloves and put another pair on; she did not wash her hands after removing her gloves. CNAP assisted making his bed after a second transfer with her soiled gloves still on. CNA/Shower Aide O came in the room, did not gown up and after assisting with the transfer, removed her soiled gloves, threw them in the trash, opened the door touching the door knob and left the room, taking the resident to the shower room. Shower Aide O did not wash her hands after removing her gloves.Review of the facility Personal Protective Equipment policy dated 12/7/2023, stated Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material.Review of the facility Enhanced Barrier Precautions (EBP) policy dated 3/26/24, revealed resident's with urinary catheter's will have EBP equipment (gowns, gloves, mask) available for high-contact care activities which include, peri care, prosomal hygiene and handlining linens.Review of the facility Glove Use policy (un-dated), stated When task for which gloves are used is completed, remove gloves, turning inside out, and wash hands.Review of the facility Hand Hygiene dated 12/13/23, stated The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview and record review, the facility failed to ensure resident dignity by 1) not ensuring a dignity bag was covering 1 resident's (Resident #46) urinary catheter bag, and 2) acknowledge 1 resident (Resident #19) when yelling for help for 2 of 13 residents reviewed for dignity.Findings Include: Resident #46: Review of the Face Sheet, Material Data Set/MDS dated 9/25, care plans dated 9/1/25, and admission nursing assessment dated [DATE], revealed Resident #46 was [AGE] years old, alert, admitted to the facility on [DATE], incontinent of bowel and bladder with a urinary catheter (Foley) in place, totally dependent on staff for Activities of Daily Living/ADL's, and required a mechanical lift for all transfers. The residents diagnosis included chronic kidney disease, chronic systolic and diastolic heart failure, anemia (low iron), dysphagia (difficulty swallowing), aphasia (communication deficit), BPH, depression and anxiety. Review of the facility Catheter Care policy dated 12/28/2023, stated Privacy bags are used to cover catheter drainage bags while in use. Observation of Resident #46 was made on 9/2/25 at 10:10 a.m.; staff were transferring the resident from the wheelchair to bed. The resident had a Foley catheter in place; however, it did not have a privacy bag covering it. The resident was put in bed, peri care was done, and he was then transferred back in his wheelchair. The facility had a catheter privacy bag velcroid to the bottom of the wheelchair, no privacy bag on his bed. When he was put back in the wheelchair, the catheter bag was not put in the privacy bag. Review of the residents Indwelling Catheter care plan dated 8/30/25, stated Privacy cover to catheter bag.During an interview done on 9/3/25 at approximately 9:20 a.m., Infection Control Nurse, RN B said the did use urinary catheter privacy bags and he should have had one (on his bed) for his catheter. During an interview done on 9/5/25 at 12:52 p.m., MDS Nurse/Unit Manager, RN F stated They (staff) usually have one on the wheelchair (urinary catheter privacy bag) and one on the bed; they need one (privacy bag). Nurse Manager F said a Foley catheter bag should be kept in a privacy bag for dignity. During an interview done on 9/4/25 at 9:31 a.m., Social Worker, E stated They (a Foley catheter bag) should be in a privacy bag; in bed too. The resident required a catheter privacy bag on his wheelchair and his bed. During a second observation of the resident done on 9/5/25 at 2:15 p.m., Resident #46 was sleeping in bed, with his urinary catheter bag not in a privacy bag; the privacy bag was hanging on the opposite side of his bed. Also, the resident had a very strong urine odor at the time; his room smelled of urine. When this surveyor interviewed MDS/Unit Manager F on 9/5/25 at 2:25 p.m., she stated We are better than that. Nurse Manager F educated staff again immediately. Review of the facility Resident Dignity policy dated 10/26/2023, stated It is the practice of this facility to protect and promote resident rights and treat each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Maintain resident privacy. Resident #19 On 9/2/25 at 1:51 PM, Resident #19 was observed sitting in a wheelchair in their room. Upon entering the Resident's room, a prevalent and strong bowel movement odor was noted. The odor became stronger closer the Resident. When queried if they are treated in a respectful and nice manner by facility staff, Resident #19 replied, No. When asked how the staff did not treat them in a nice and respectful manner, Resident #19's response was unable to be completely understood. Resident #19 was then asked if they are able to use the bathroom by themselves or if they need assistance from staff and revealed they need assistance from staff. Resident #19 verbalized they were waiting for staff to help them because they had a bowel movement. When asked if staff knew they had a bowel movement and were waiting for assistance, Resident #19 revealed they asked for help and were told to wait in their room. At 2:24 PM on 9/2/25, Resident #19 was heard yelling, I need changed, I need changed from the hallway of the facility. Multiple staff members, including Certified Nursing Assistants (CNAs) and a Nurse were observed walking past the Resident's room and not stopping to acknowledge them while they were yelling for assistance. At 2:25 PM on 9/2/25, Resident #19 self-propelled themselves to the doorway of the room while yelling out for assistance. The facility staff in the hallway did not acknowledge the Resident. Resident #19 proceeded to propel themselves out of their room and down the hallway past staff members. Upon approaching the Resident, the odor of bowel movement remained intense. Record review revealed Resident #19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, intellectual disabilities, bipolar disorder, seizures, and cerebral palsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial to maximal assistance with toileting hygiene. Review of Resident #19's care plans revealed a care plan entitled, Resident has an ADL self-care performance deficit related to Alzheimer's Disease. Does not use call light appropriately to ask for assistance related to cognitive deficits. Staff to anticipate and meet needs (Initiated: 10/24/23; Revised: 6/18/24). The care plan included the intervention, Toileting: 2 person assist to using grab bars. Blue pads on bed (Initiated: 10/24/23; Revised: 11/11/24).

Based on interview and record review, the facility failed to implement and operationalize procedures to ensure follow-up assessment and monitoring of abnormal laboratory testing results of medications with for one (#19) of five residents reviewed. Findings include:On 9/2/25 at 1:51 PM, Resident #19 was observed sitting in a wheelchair in their room. A fall mat was observed on the floor next to the left side of the Resident's bed and they had a raised edge mattress in place on their bed. When queried if they had fallen at the facility, Resident #19 did not respond. Record review revealed Resident #19 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epilepsy, Alzheimer's disease, intellectual disabilities, bipolar disorder, and cerebral palsy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial to maximal assistance to complete Activities of Daily Living (ADLs) with the exception of eating and oral hygiene. The MDS further revealed the Resident had two falls, one with no injury and one with injury. Review of Resident #19's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the Resident was receiving the following medications with therapeutic levels:- Keppra (Levetiracetam) 1000 milligrams (mg) every 8 hours related to epilepsy (Start Date: 2/1/25) - Depakote (Valproic Acid- medication used to treat seizures and bipolar disorder) 500 mg three times a day due to epilepsy (Start Date: 6/15/23) Further review of Resident #19's HCP orders revealed the following orders for and/or related to laboratory testing:- Keppra level, Valproic acid level, hepatic (liver function), CBC (Complete Blood Count) . baseline and q (every) 6m (6 months) (Ordered: 12/22/23)- Send resident to (Hospital) for Keppra eval STAT for Keppra Level (Ordered: 1/29/25)- Send to ER for eval d/t abnormal Keppra level (Ordered: 1/30/25)- Repeat Keppra level on 2/6/25 (Ordered: 2/5/25) Review of Resident #19's Electronic Medical Record (EMR) revealed a care plan entitled, Resident has an impaired neurological status related to Alzheimer's Disease. epilepsy, seizure disorder. (Initiated: 10/24/23: Revised: 10/25/23). The care plan included the interventions:- Administer medications and treatments as indicated by orders (Initiated: 10/24/23) - Keep resident safe during seizures. Clear hard/sharp objects away from resident. Place resident on their side to keep airway clear. Notify Nurse if seizure activity occurs (Initiated: 10/24/23) - Observe labs/diagnostic testing per orders (Initiated: 10/24/23) A second care plan entitled Resident is at risk for falls/injury related to bladder incontinence, bowel incontinence, decreased strength and endurance, functional problems, generalized weakness, high risk of falls, history of falls, history of self-transfers, impaired cognition with decreased safety awareness, inability to use call light due to confusion, medication(s), needs assistance with ADLs. (Initiated and Revised: 10/24/23). The care plan included the interventions,- 2/22/25: Alert nursing staff when resident appears to be having seizure activity (Initiated: 2/24/25) - 3/19/25: Keppra (anti-seizure medication with a therapeutic range) Level (Initiated: 3/25/25). A review of the facility provided Incident and Accident (I and A) forms for Resident #19 revealed the Resident had two falls related to seizure activity since the last annual survey. A review of facility documentation for the falls related to seizure activity detailed the following: - 2/22/25 at 3:30 PM: Resident #19 was in the Activity room, sitting in their wheelchair, when they were observed starting to have a seizure by Activity Staff T. The Resident fell out of their wheelchair and hit their forehead. Activity Staff T paged overhead for assistance from nursing staff. Registered Nurse (RN) Q and Certified Nursing Assistance (CNA) R responded to the overhead page. RN Q assessed Resident #19, and the Resident was assisted back into their wheelchair and returned to their room by RN Q and CNA R. Resident #19 received Diazepam (Valium- controlled medication used as an emergency medical treatment for seizure activity) 20 milligrams (mg) rectally due to the seizure which was effective. The notes included on the I and A form detailed the intervention implemented following the seizure and fall included, asking for assistance from the nurse when seizure activity noted and neuro (monitoring) order put in place. - 3/19/25 at 4:45 PM: Resident #19 was observed laying on the floor in their room in front of their wheelchair having a seizure by CNA U. CNA U called Licensed Practical Nurse (LPN) V to the room. The Resident was assessed, assisted into bed, and rectal Diazepam was administered. The immediate intervention implemented following the seizure and fall was Keppra level to be drawn at next lab draw.Review of progress note documentation in Resident #19's EMR revealed the following additional information: - 12/29/24 at 11:35 AM: Activity Progress Note. Res. was up in wheelchair in activities started to have seizure activity CNA came and got the nurse. took to room and gave seizure med rectally. - 1/29/25 at 11:26 PM: Nurses' Notes. Resident had been sent to the ER d/t (due to) Keppra level being 109.6 at 8 pm this day on the afternoon shift. - 1/30/25 at 3:38 PM: Nurses' Notes. Provider notified that resident had returned to facility. New order to hold Keppra and to draw Keppra levels X 3. - 2/11/25 at 8:07 PM: Nurses' Notes. Resident's Keppra level reviewed with (Physician A). Continue same dose. - 3/19/25 at 7:41 PM: Resident observed lying on fall mat in front of w/c with eyes rolling back in head. Resident appeared to be attempting to raise head up and then it would suddenly drop as is usual for them when having a seizure. Resident laying on his right side with head toward bed. W/c brakes were not locked. Resident assessed for injury - no bruising, swelling, abrasions observed. Joints and long bones palpated with no abnormalities and resident denying pain. Resident assisted to bed via Hoyer (mechanical lift) Resident given Diazepam as ordered. No further seizure activity. NP (Nurse Practitioner) notified, no new orders. - 3/24/25 at 2:50 PM: Nurses' Notes. Resident refused blood draw. Physician aware. Reattempt with next draw. - 5/11/25 at 9:19 PM: Nurses' Notes. Resident with seizure activity this afternoon at 4pm. Resident has been resting in bed since. Resident chooses not to eat dinner. Meal alternatives and nutrition shakes provided, however resident continued to choose not to eat. - 5/23/25 at 6:31 PM: Nurses' Notes. At 3pm resident was observed with seizure activity - head dropping with eyes rolling back and long pauses while speaking. Resident assisted into bed and Diazepam given as per order. At 3:45pm resident began yelling out again. This nurse went to room and observed resident on the fall mat next to bed. - 6/12/25 at 5:42 PM: Nurses' Notes. Resident noted to be having seizure activity including head dropping, eyes rolling back, pauses while speaking and brief periods of non-responsiveness while in the dining room at 5pm. Resident assisted back to his room and given Diazepam rectally as ordered. No further seizure activity noted. Physician notified. A review of Resident #19's laboratory testing in the EMR revealed the following: - 2/11/25: Levetiracetam, Serum: 55.2 ug/mL (micrograms per milliliter) . Reference range: 3.0 to 60.0 ug/mL. - 3/25/25: Levetiracetam, Serum: 89.9 (elevated) ug/mL (micrograms per milliliter) . Reference range: 3.0 to 60.0 ug/mL. The laboratory results had an illegible signature and date which appeared to be 6/12/25 on the bottom of the scanned page. - 7/8/25: Valproic Acid 69 ug/mL [Reference range: 50.0-100.0 ug/mL] . Levetiracetam, Serum. Pending. An interview was completed with the Administrator and Acting Director of Nursing (DON) RN B on 9/5/25 at 12:35 PM. The Administrator and DON were queried regarding Resident #19's seizure and fall on 2/22/25 and both indicated they would need to review the Resident's EMR. When asked about the intervention of Alert nursing staff when resident appears to be having seizure activity following the Resident's fall on 2/22/25, the Administrator and RN B confirmed that was the intervention implemented. When asked why that intervention was not already in place, as the Resident had a history of seizures, the Administrator indicated it was intended to be a signs prior to a seizure occurring and stated, We failed that (intervention). Should have been more specific. When queried regarding the Resident's valproic acid levels were last drawn, RN B indicated they would need to review the Resident's EMR. When asked why the levels were not drawn following the seizure, RN B verbalized labs are completed per HCP orders. When queried regarding the Resident's seizure and fall on 3/19/25, RN B reviewed Resident #19's EMR and revealed the intervention was to draw a Keppra level. When asked why the Keppra level was not drawn until 3/25/25, the Administrator verbalized that the Resident may have refused to have their blood drawn at the next draw. Resident #19's lab testing results dated 3/25/25 were reviewed with RN B and the DON at this time. When queried regarding follow up to the the elevated serum Keppra level such as repeat laboratory testing and/or dosage adjustment, RN B reviewed Resident #19's EMR and stated, There was no redraw and no dose adjustment. RN B then stated, The doctor signed the lab results. When asked who signed the laboratory result and the date it was signed, RN B responded it was the HCP's signature, and the date was 4/12/25. When queried if nursing staff contacted the HCP regarding the elevated level and advocated for a redraw of the lab, RN B reviewed the EMR and responded that there were no notes reflecting nursing staff contacted the Health Care Provider. When asked why the HCP was not notified, further explanation was not provided. RN B and the Administrator were then asked to review Resident #19's labs dated 7/8/25. When queried what the Resident's serum Keppra level was on that date, RN B confirmed the results scanned in the EMR indicated the Keppra level was pending and they did not know the result. The Administrator indicated they would have someone contact the lab to obtain the result now. When asked why no one contacted the lab to obtain the results, RN B was unable to provide an explanation. With further inquiry regarding the Resident's level being elevated in March, not redrawn until July and the facility still not having the results in September, both RN B and the Administrator verbalized understanding of the concern. The Administrator verbalized a new process/procedure would be implemented pertaining to laboratory testing and follow up of abnormal results.

Based on observation, interview and record review, the facility failed to ensure nurse staffing information was posted in a clear and prominent place readily accessible to residents and visitors for all 39 facility residents. Findings include:The facility nurse staffing information was attempted to located in the facility on 9/2/25, 9/3/25, and 9/4/25 without success.An interview was completed with the facility Administrator on 9/4/25 at 1:09 PM. When queried where the facility nurse staffing data is posted, the Administrator proceeded to go to the front entrance of the facility and remove a clipboard from a bin on the wall. When queried if that is where the daily staffing is always kept, the Administrator responded it was. When queried regarding the information not being in a clear and prominent area for residents and visitors to view, the Administrator revealed they were unaware the staffing information had to be in a clearly visible area. The Administrator verbalized they would order something to be able to post the nurse staffing information in a clearly visible area.

Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program encompassing outcome and process surveillance, resulting in a lack of accurate and comprehensive infection control tracking including potential infections, surveillance and data monitoring/analysis, appropriate Personal Protective Equipment (PPE) use, lack of implementation of water management sample recommendations, contamination of linens, and the likelihood for spread of microorganisms and illness to all 37 facility residents. Findings include: An interview and review of facility Infection Control (IC) data was completed with IC Registered Nurse (RN) B and the Director of Nursing (DON) on 8/21/24 at 1:12 PM. When queried regarding process surveillance for January 2024, IC RN B provided six audit forms for hand hygiene as well as Verification Checklist-Therapy Gym Cleaning completed by Therapy Staff and Verification Checklist-Kitchen Observation forms completed by Dietary Manager G. Review of the hand hygiene audit forms revealed two of the audits were completed by Dietary Manager G for Dietary Staff and four audit forms were completed by facility nurses for Certified Nursing Assistants (CNA). When queried what shifts audits were completed, IC RN B revealed all the audits were completed on the day or afternoons shifts. An explanation was not provided when asked why audits were not completed on midnight shift. IC RN B was asked what is one of the most important things that people can do to prevent the spread of infection, IC RN B replied, Washing hands. With further inquiry regarding the facility process/procedure for process surveillance including what audits were completed on a monthly basis, IC RN B revealed they do not do hand hygiene audits every month but do complete surveillance monthly. When asked if laundry was completed in the facility, IC RN B confirmed it was. When queried if they completed process surveillance/audits of laundry facilities/procedures, IC RN B replied they do not do official audits. With further inquiry regarding how they determine if linen is processed, stored, and handled in a manner to prevent contamination and the spread of microorganisms, IC RN B verbalized they go in the laundry room but do not have an official audit. IC RN B was then queried regarding the facility policy/procedure related to Enhanced Barrier Precautions (EBP) and if Personal Protection Equipment (PPE) should be utilized when providing care for an indwelling urinary catheter, and stated, Yes, should. IC RN B then revealed they were aware staff had not worn PPE when providing care to a resident with EBP in place. The facility Outcome Surveillance data for January 2024 was reviewed with IC RN B at this time. IC RN B provided a handwritten form titled, Line Listing of Resident Infections, a printed Order Listing Report for Antibiotic Orders and an infection map. The number of resident infections included on the line list did not match the number of infections indicated on the mapping tool. When queried regarding the discrepancy, IC RN B reviewed the data and indicated they missed marking infections on the map. The line listing for January 2024 did not include any carry over infections from December 2023. However, a review of the December 2023 Line Listing of Resident Infections revealed there was one carry over infection into January 2024. Further review of the January 2024 Line Listing of Resident Infections included six Residents and seven infections including four Healthcare Acquired Infections (HAI). There were no residents with signs/symptoms of infections not receiving antimicrobial treatment included on the tracking/surveillance form. The Order Listing Report included two Residents not included on the Line List of Resident Infections. Per the Order Listing Report, the Residents not listed on the Line List of Resident Infections were receiving nystatin powder (anti-fungal medication) and rifaximin (antibiotic medication used to treat irritable bowel syndrome, travelers' diarrhea, and to reduce the risk of overt hepatic encephalopathy-liver dysfunction) with the indication for liver. When queried how they track and complete surveillance of residents with signs/symptoms of infection for identification and prevention of spread who are not receiving treatment, IC RN B replied, Not tracking signs/symptoms of potential infections. When asked why not, IC RN B indicated they track actual infections that are treated. With further inquiry related to outcome surveillance, IC RN B revealed they do not include residents who have orders for nystatin powder because it is not a real infection. When queried if a fungal infection on the skin is transmittable to others, IC RN B and the DON confirmed it could be. When queried if everyone with the common cold and/or other sign/symptoms of gastrointestinal illness always receives antimicrobial treatment, IC RN B verbalized they do not. When asked, IC RN B and the DON confirmed the pathogens/illnesses are able to be transmitted to others and cause illness. IC RN B and the DON verbalized understanding of the importance of surveillance and tracking of potential illness and signs/symptoms of infection. Review of the Monthly Analysis and Summary/QAPI Committee Infection Prevention/Control Report for January 2024 specified there were three HAI infections. IC RN B was then queried regarding their role in the facility water management plan including monitoring for and preventing the spread of waterborne pathogens including legionella and revealed they were not involved in the water management plan. With further inquiry, IC RN B stated, Maintenance does the water testing and would let know me if we have any issues. IC RN B was asked how frequently water testing is completed and stated, Not sure. The facility water management plan was requested at this time. Maintenance Director J provided the facility Water Management Plan binder. The binder included Legionella water sampling testing results titled, Certificate of Analysis. The collection dates of Legionella testing since the last annual survey were dated: 10/11/23, 4/15/24 and 7/23/24. The results for each date included Pre and Post results from the Central Bathroom. The form did not detail the source of the water from the central bathroom. When queried what pre and post meant, Maintenance Director revealed they obtain samples before and after allowing the water to run. The sample dated as collected 10/11/23 detailed a positive result of 0.4 CFU/mL (Colony-Forming Units/milliliter) of Legionella species was identified and grown in the Post water sample. The Certificate of Analysis testing result form detailed, Action Criteria for Legionella . Detectable, but < 1 . Suggested Remedial Action: Potable Water: 2 . Implement action 1. (Review routine maintenance program recommended by the manufacture of the equipment to ensure that the recommended program is being followed. The present of barely detectable number of Legionella represents a low level of concern.) Conduct follow-up analysis after a few weeks for evidence of further Legionella amplification. The level of Legionella represents little concern, but the detected indicated that the system is a potential amplifier of Legionella . When queried if they were aware of the positive water testing results with Legionella growth, both the DON and IC RN B verbalized they were unaware of the result. When queried what actions were taken and if follow-up analysis of the water was completed, both the DON and IC RN B indicated they did not know. Maintenance Director J was contacted by the DON and returned. When asked about the positive Legionella testing results collected 10/11/23 and actions taken following the results including follow up testing, Maintenance Director J verbalized retesting was not completed beyond routine testing and indicated they did not need to complete follow up testing. When queried regarding the Remedial Actions included on the Certificate of Analysis test results, Maintenance Director J did not provide further explanation. When queried why only the central bathroom was tested and why water samples were not obtained, an explanation was not provided. The DON confirmed remediation actions should have been completed and stated, It's a learning experience. When queried regarding respiratory illness signs and systems and potential Legionella infection, IC RN B and the DON verbalized understanding of the importance of coordination and active involvement of the IC Nurse in the Water Management program. Review of facility provided policy/procedure entitled, Infection Prevention and Control Program (Reviewed/Revised: 12/27/23) revealed, The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases . b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings . 12. Linens . staff shall handle, store, process, and transport linens to prevent spread of infection . 16. Water Management: a. A water management program has been established as part of the overall infection prevention and control program . Review of the facility provided policy/procedure entitled, Water Management Program (no date) detailed, It is the policy of this facility to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems . 1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing . 3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems . 39059 Linen: On 8/19/24, at 12:34 PM, CNA P was observed exiting the linen closet with a pile of clean linen in their right arm. The linen was touching their uniform and was uncovered. CNA P entered into room [ROOM NUMBER] and exited without the linen. CNA P gathered washcloths/clean linen and was asked what they planned to do with the 2 piles of linen they had carried into room [ROOM NUMBER] and CNA P offered, I'm changing her. Enhanced barrier: On 8/20/24, at 11:10 AM, Resident #20 was sitting in their wheelchair in their room which was an enhanced barrier room. They had a urinary catheter. CNA P entered the room to answer their call light. Resident #20 offered they wanted to sit in their recliner. Moments later, CNA P entered the room pushing a Hoyer lift with a bed pad in their right hand that was touching the Hoyer lift. CNA Q entered to assist. CNA Q placed gloves on but no gown. CNA P did not place gloves or a gown. The two CNA's assisted the resident into the recliner with their uniforms touching the bed and also the recliner. Once the resident was sitting in the recliner. CNA P entered the bathroom and placed gloves on, removed the urinary catheter bag and placed onto the recliner. CNA P then entered the bathroom and returned with paper towels and a graduate with the same gloves on. CNA P emptied the urine into the graduate and wiped the catheter bag tubing with a paper towel before they dumped it into the toilet. CNA P still did not place on a gown. On 8/20/24, at 11:45 AM, a record review of Resident #20's electronic medical record revealed an admission on 3/13/2024 with diagnoses that included muscle weakness, Chronic Obstructive Pulmonary Disease and [NAME] Prostactic Hyperplasia. A review of the physician orders revealed Use enhanced barriers while performing high-contact activity with the resident . Order Status Active Order Date 07/18/2024 . On 8/21/24, at 11:00 AM, the Director of Nursing (DON) was alerted of the lack of Personal Protective Equipment (PPE) during care of Resident #20 and the DON offered that they should have had PPE on and that Infection Control Nurse had already started education.

Based on observation, interview and record review, the facility failed to: 1. Properly label and date food and food products, 2. Dispose of expired food and food products, 3. Thoroughly dry dishes prior to stacking, and 4. Ensure air gap for ice machine drainage pipe, resulting in the potential for cross-contamination and foodborne illness. These deficient practices have the potential to affect 37 residents who receive food from the kitchen. Findings Include: During a tour of the facility kitchen on [DATE], beginning at 9:04 AM, the following items were noted: - Kitchen Aid stand mixer was uncovered and not in use. When the mixer was tilted back, chunks of dried food substances were observed. - The floor appeared dirty with a build up of unknown substances and dirt behind the tables, oven, and near the walls. A palpable film of grease was present on the interior lip of the stove/oven hood. Visible cobwebs and dust were observed in various areas of the interior of the oven/stove hood. - Open and Undated bottle of Apple Cider Vinegar. When queried if the product is supposed to be dated by dietary staff, Dietary Staff R indicated it was. Dietary Staff R confirmed the Apple Cider Vinegar was not dated and indicated they would need to discard it. A tour of the tall refrigerator in the main kitchen area was completed with Dietary Manager G. The following items were identified in the refrigerator: - Three open and undated 46-ounce (oz) containers of Thickened Lemon Water. Manager G was asked if the containers of thickened water are supposed to be dated when opened and confirmed they should be. Manager G did not provide further explanation but indicated the product was not able to be used and they would dispose of the product. - A 20 oz container of Apple Butter with Opened: [DATE]; Expired: [DATE] written on the container. When queried if the Apple Butter was expired, Manager G confirmed it was. When asked why the food product was still in the refrigerator, Manager G did not provide an explanation but indicated they would dispose of it. - A gallon of 2% milk with no open date on the container. When queried if milk is supposed to be dated when opened, Manager G verbalized is should be. When asked why it was not dated, an explanation was not provided. A tour of the dry storage area was completed with Dietary Manager G. The following items were identified: - Open 16 oz container of mustard with the date, Use by [DATE] on it. - Open 32 oz container of Vanilla with the date, Use by [DATE] on it. Dietary Manager G was asked about the mustard and Vanilla and verbalized the food products should have been thrown away on the date indicated on the packages. - A box of bananas was noted on a shelf in the dry storage room. The box had a black substance in it and the peel on one banana was split open. When queried regarding the bananas, Manager G disposed of the banana with the split peel and indicated the facility would be receiving their delivery the following day. The dishwashing and drying area was toured with Dietary Manager G. Cups with visible water and moisture were stacked on top of each other on a rack. When asked, Dietary Manager G revealed the area where the cups were stacked were for clean dishes. When queried regarding the visible water and moisture present in the stacked cups, Dietary Manager G stated, Not okay. Will have to rewash. Under the three-compartment sink, in the main area of the kitchen, the drain cover in the floor was pushed to the side, off the drain hole and a PVC pipe was positioned directly in the drain hole. A second, small piece of PVC pipe was connected to the PVC pipe positioned in the drain with a zip tie. The second piece was pushed to the side and appeared to be a makeshift stand for the drainage pipe. There was no air gap observed. Dietary Manager G was queried what the drainage pipe was for and why the drain cover was not in place over the drainage hole and replied, Not sure. When queried how long the pipe had been like that, Manager G and Staff R revealed it had been that way for quite a while but were unable to provide a specific timeframe. Dietary Manager G proceeded to move the drain cover back in place over the drainage hole. The PVC drainage pipe was then positioned directly on top of the drain cover with no air gap present. When queried what the pipe was for, Director G indicated they were unsure. Further visual inspection of the area under the three-compartment sink revealed multiple cobwebs in the area and in the corner. On [DATE] at 12:00 PM, an interview and observation of the kitchen drainage pipe and drain cover was completed with Maintenance Director J. When queried regarding the drainage pipe being positioned directly on top of the drainage grate with no air gap, Maintenance Director J stated, That is from the ice machine. When queried regarding the smaller PVC pipe connected to the drainage pipe with a zip tie, Maintenance Director J moved the smaller piece of PVC pipe around the pipe and stated, I think they put it to the side because it (drainage pipe) started sagging. Maintenance Director J proceeded to point out where the drainage pipe was attached to the wall and was sagging in areas. When queried regarding the drain cover being moved off the hole and the drainage pipe being positioned directly inside the drainage hole and why the drain cover was not secured, Maintenance Director J was unable to provide an explanation. An interview was completed with Maintenance Director J on [DATE] at 11:06 AM. Maintenance Director J indicated they worked on the drainage pipe and stated, Resecured it and made sure it has a downslope. It has an air gap now. When asked if the drainage pipe should have an air gap, Maintenance Director J stated, Yes. Maintenance Director J was then asked if they completed rounds in the kitchen and replied, Yes. When asked why the drain cover was moved to the side with drainage pipe was positioned in the drain hole when they are completing rounds in the kitchen, Maintenance Director J replied, Needed to be reattached. No further explanation was provided. An interview was completed with the facility Administrator and Director of Nursing (DON) on [DATE] at 4:00 PM. When queried regarding observations in the kitchen of undated/outdated food products, drain cover, drainage pipe/lack of air gap, cobwebs/dirt, grease, and cups stacked with visible water/moisture, the Administrator and DON verbalized understanding of concerns and indicated the concerns would be addressed. Review of facility policy/procedure entitled, Kitchen Sanitation (Reviewed/Revised: [DATE]) revealed, The food service area shall be maintained in a clean and sanitary manner . 1. Kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish . 2. Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . Review of facility policy/procedure entitled, Food Receiving and Storage (Reviewed/Revised: [DATE]) revealed, Foods shall be received and stored in a manner that complies with safe food handling practices . 1. Food Services . will maintain clean food storage areas . 7. Foods stored in the refrigerator or freezer will be covered, labeled and dated ('opened on and 'use by' date). Whole produce will have a received date and freshness will be monitored by texture and appearance and discarded as appropriate .

Based on observation, interview and record review, the facility failed to provide palatable and appealing food per preference for one resident (Resident # 35) of two residents reviewed and seven of seven confidential group Residents resulting in feelings of frustration and verbalization of discontentment. Findings include: Resident #35: On 8/19/24 at 2:13 PM, an interview was completed with Resident #35 in their room. When queried regarding the food in the facility, Resident #35 stated, Food is horrible. Resident #35 was asked what is horrible about the food and replied, It's cold and doesn't taste good. Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with left sided paralysis, epilepsy, depression, anxiety, dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance for hygiene, toileting, and transferring. 39059 Resident Council: On 8/20/24, at 3:46 PM, During resident council, the entire group complained of the following: no choice for food items the portion sizes are small the menu repeats they give you a time limit on picking an alternative the confetti eggs were awful, it was like wet custard but eggs with red and green sprinkles on top we don't get menus for our room you get what you get we don't get real butter we'd like real creamer for our coffee I want a whole banana; we get banana cut up in a dish we want fresh fruit we're sick of canned fruit we get lots of macaroni unless you look at the menu on the wall, you don't know what you're getting The entire group complained of not having menus and that they must look on the wall as to what is on the menu. They complained they do not have menus in their rooms. The group was asked if they could order from an alternative menu if they didn't like what they were served, and the entire group complained that there was a time cut off for making a second choice. The group was asked to explain what the time limit meant, and they complained that they have to pick by certain times in advance for a second choice. For example, the night before for breakfast. The group was asked if they changed their mind once the meal was served could they get something different and the group quickly responded, NO. They complained that the staff say it's too late for that. On 8/21/24, at 8:09 AM, a breakfast tray observation revealed the following items: 1 small scoop of eggs which appeared to be too moist as they were unable to be forked off the plate; hash brown patty with the center not crispy and slightly soggy; 1 piece of buttered wheat toast; a small bowl of corn flakes, 1 cup of milk, 1 cup of coffee that was luke warm, 2 sugar, 1 jelly and 3 dry creamer packs. There was no salt nor pepper provided. On 8/21/24, at 9:18 AM, Registered Dietician (RD) S was asked to explain food choices for the residents. RD S offered that there is an always menu they can select options from. RD S was asked if there were any rules with the always menu and RD S offered, they can talk to staff but unsure how they ordered from the alternative menu. RD S was alerted the residents would like fresh fruits and that they all complained about the taste and appearance of the confetti eggs. RD S was asked what type of eggs the facility provides and RD S stated, we have fresh and powdered eggs. On 8/21/24, at 1:51 PM, just prior to exit, two residents were in the hallway and were overheard making complaints about the lunch served that day. The overheard complaints were did you eat the lunch today? I didn't and No, it was junk I didn't eat either. On 8/21/24, at 2:30 PM, a record review of the facility provided Lunch and Dinner Alternatives document revealed Lunch requests must be made no later than 8:30 am Dinner requests must be made no later than 2:30 PM If a request is placed after cut off time, a sandwich of cook's choice will be served instead . Please note that depending on demand this menu could be subject to change and sometimes we may be out of a certain product. We strive to make you happy and will re-stock ASAP. A second document revealed Ala Carte Menu Great Alternatives for you to choose from Breakfast: breakfast requests must be in by 7 PM the evening before Hot Cereal- Oatmeal or cream of wheat served with syrup or brown sugar as requested Cold Cereal-Fruit loops, cheerios, or corn flakes Eggs-Scrambled, Hard Boiled or Fried with Toast and Jelly. A review of the recipe for CONFEET EGGS 1 0Z (ounce) . Whole liquid egg . 3 1/4 Quart GREEN PEPPERS, CHOPPED . 3/4 Cup DICED SWEET RED PEPPERS . 3/4 cup .COMBINE EGG, GREEN PEPPER, AND SWEET RED PEPPER. STIR UNTIL VEGETABLE ARE EVENLY DISTRIBUTED . Portion Size: 1/4 CUP .

Based on interview and record review, the facility failed to accurately record and obtain code status (level of medical interventions that an individual wishes to have enacted in a medical emergency situation) documentation for two residents ( Resident #29 and Resident #35) of three residents reviewed for Advance Directives (legal documentation enabling an individual to specify end-of-life care decisions), resulting in lack of accurate assessment and documentation of code status and the potential for a Resident to receive life sustaining medical treatment against their wishes. Findings include: Resident #29: Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included heart failure, anxiety, cognitive communication deficient, and dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to substantial assistance with bathing and dressing. Review of Resident #29's Electronic Medical Record (EMR) revealed the Resident's code status was DNR. Resident #29 did not have a care plan in place pertaining to code status. A Do Not Resuscitate Order Declarant (Resident) Consent form was noted in Resident #29's EMR. The form was signed by Resident #29 on 4/25/23 and Physician K on 5/1/23. Further review of Resident #29's EMR revealed a Decision Making Determination Form specifying Resident #29 was Uncapable of making decisions regarding medical treatment . based upon . inability to understand the disease process and implication of procedures and treatments, or refusal of treatment . The incompetency determination was signed by Physician L on 8/17/21 and 8/24/21. Resident #35: Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke) with left sided paralysis, epilepsy, depression, anxiety, dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required maximum to total assistance for hygiene, toileting, and transferring. Resident #35's EMR indicated Full Resuscitate as the Resident's code status. Review of Resident #35's EMR revealed a Decision Making Determination Form specifying the Resident was not capable of making medical treatment decisions. The form was signed by one Physician on 6/1/23 and a second, supporting Physician on 10/24/23. Additional documentation detailed, Family Member N was Resident #35's Durable Power of Attorney and patient advocate. Further review of Resident #35's EMR revealed a form titled, Advance Directive/Medical Treatment Decisions. Under the Advance Directive section of the form, Do Not Resuscitate was checked and initialed with the date 2/2/24. Another box was checked specifying, I do not choose to formulate or issue any Advance Directives at this time with Full Code written above the statement. The form was signed by Family Member N and a Facility Registered Nurse RN on 2/2/24. An interview was completed with Social Services Designee RN O on 8/21/24 at 8:42 AM. Social Services Designee RN O was asked if a Resident who has been deemed incompetent to make medical decisions is able to sign Advance Directive documentation to be a DNR, Social Services Designee RN O verbalized that if a Resident is deemed incompetent, their DPOA and/or guardian should sign the document. When queried regarding Resident #29's code status, Social Services Designee RN O indicated the Resident was a DNR. Resident #29's Do Not Resuscitate Order Declarant (Resident) Consent form and Decision Making Determination Form were reviewed with Social Services Designee RN O. When why Resident #29 signed the DNR order in 2023 when they were deemed incompetent in 2021 if a Resident who is deemed incompetent is not able to make medical decisions, Social Services Designee RN O confirmed the DNR order should have been signed by the Resident's Representative. Social Services Designee RN O revealed Resident #29 come to the facility from a different facility and stated they accepted the documentation from the other facility. When asked if they checked the documentation for accuracy, Social Services Designee RN O did not provide a direct response but reiterated the documentation was completed at another facility. Resident #35's Advance Directive/Medical Treatment Decisions form was reviewed with Social Services Designee RN O at this time. When queried regarding the form indicating the Resident was both a DNR and full code, Social Services Designee RN O verbalized they could not be. Social Services Designee RN O stated, Think an error on the form. When queried regarding the concern pertaining to the conflicting documentation of the Resident's code status on the form, RN O verbalized understanding. On 8/21/24 at 9:36 AM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #29 and 35's Advance Directive documentation and Code Status, the DON verified concern and verbalized understanding.

Based on observation, interview and record review, the facility failed to provide appropriate medication administration and storage of insulin for one resident (Resident #139) and two inhalers for one resident (Resident #23), resulting in the likelihood of decreased medication efficacy and side effects such as mouth discomfort and/or mouth infection. Findings include: On 8/21/24, at 7:52 AM, During medication administration task, Nurse I prepared medications for Resident #23 which included Breo Ellipta and Spiriva inhalers. Nurse I entered Resident #23's room and provided one puff of Breo Ellipta inhaler and then provided two puffs of the Spiriva inhaler 15 seconds later. The required one minute during the two inhalers was not provided. Nurse I did not offer to the resident to rinse their mouth after the inhaler use. Nurse I returned to the medication cart and placed the inhalers into their corresponding boxes for storage. On 8/21/24. At 8:11 AM, Nurse H prepared morning medications for Resident #139. Nurse H gathered the Lantus insulin via insulin pen. Nurse H removed the cap, cleaned with an alcohol wipe, attached the pen needle, dialed the pen to 40 units. Nurse H did not dial the pen to 2 units which is required to prime the needle. Nurse H administered the Lantus insulin pen into the center of the deltoid at a 90-degree angle. On 8/21/24, at 2:00 PM, a record review of Resident #139's electronic medical record revealed an admission on 08/06/2024 with diagnoses that included Diabetes, Morbid Obesity and Muscle Weakness. Resident #139 had intact cognition and required assistance with Activities of Daily Living. A review of the Physician orders revealed Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 40 unit subcutaneously . A review of the Lantus pen instructions revealed DO A SAFETY TEST Always perform the safety test before every injection. This removes air bubbles and ensures the pen and needle are working properly 1. Select a dose of 2 units by turning the dosage knob . After your safety test, make sure the dose window reads 0. On 8/21/24, at 2:30 PM, a record review of Resident #23's electronic medical record revealed an admission on 03/05/2024 with diagnoses that included Chronic Respiratory Failure, Heart Failure and Chronic Obstructive Pulmonary Disease. Resident #23 had intact cognition and required assistance with Activities of Daily Living. On 8/21/24, at 3:00 PM, the Director of Nursing (DON) was asked to provide the pharmacy instructions for administration on both the Breo Ellipta and Spriva inhalers. The DON was alerted Nurse I did not provide wait time between the puff of the two different inhalers nor offer to the resident to rinse their mouth. On 8/21/24, at 3:15 PM, Resident #23 was sitting in their room and was asked if they have ever rinsed their mouth after an inhaler and Resident #23 stated, no they never have told me. A review of the facility provided Inhalers - What You Need To Know information sheet revealed . If more than (1) puff is required, (whether the same or different medication), there should be a waiting time of approximately (1) minute between puffs . for steroid inhalers, provide a cup of water for resident to rinse and spit back into the cup . clean mouth piece with water and store following manufacturer's recommendations . A review of a provide email from the pharmacy to the DON revealed . Breo Ellipta - Inhaled corticosteroid . Wait 1 minute between Spiriva Respimat and Breo Ellipta

Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure prompt attending physician's review of pharmacy recommendations and documentation of rationale for lack of action related to pharmacy medication irregularity recommendation reports for one resident (Resident #11) of five residents reviewed for unnecessary medications, resulting in Resident #11 receiving double the recommended medication dosage, the potential for Adverse Drug Reactions (ADR), and additional medication errors despite pharmacy oversight. Findings include: Resident #11: Record review revealed Resident #11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Congestive Heart Failure (CHF), heart attack, anxiety, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, always continent of bowel and bladder, and was independent with Activities of Daily Living (ADL) with the exception of set-up to supervision for bathing and ambulation. Review of Resident #11's Electronic Medical Record (EMR) revealed Monthly Medication Reviews (MMR) were completed by pharmacy staff in a progress note. Any pharmacy recommendations related to medication regimen abnormalities were documented on a Note to Attending Physician/Provider and scanned into the EMR. Review of Note to Attending Physician/Provider from the pharmacy, dated 7/4/24 revealed Resident #11 was receiving Detrol LA (prescription medication used to treat overactive bladder) Oral Capsule Extended Release (ER) 24-hour 4 mg (milligram) . Give 1 capsule by mouth every day and evening shirt for bladder spasm. The pharmacy recommendation detailed, The maximum for ER caps is 4 mg QD (every day). The maximum for IR (Immediate Release) tablets is 2 mg BID (twice a day). Please review for reduction to Detrol LA (ER 24 hr) 4 mg once daily. The Physician/Prescriber Response on the form detailed, Continue same as ordered with no rationale and was signed by the provider on 8/6/24. On 8/8/24, the pharmacy sent another Note to Attending Physician/Provider pertaining to Resident #11's Detrol LA ER dosage of 4mg BID. The pharmacist added, The current regimen increases anticholinergic burden (associated with poor health outcomes, especially in the elderly, including increased risk of falls, dementia, and death) due to being double the FDA-approved maximum (dose). Please review for reduction to Detrol LA (ER 24 hr) 4 mg once daily. The Physician/Prescriber Response on the form was dated 8/13/24 and detailed, Change to 2 mg BID - IR tablets. An interview was completed with the Director of Nursing (DON) on 8/21/24 at 12:00 PM. When queried regarding Resident #11's Detrol LA order being double the recommended dosage and the Health Care Provider not providing a rationale for not following the pharmacy recommendation to reduce the ordered dosage, the DON did not provide an explanation. When queried regarding the facility policy/procedure related to the length of time providers have to review pharmacy recommendations, the DON indicated they believed they had a month. The DON was then queried regarding the pharmacy recommendation dated 8/8/24 related to the same reduction and asked why the medication was changed at that time but not previously and indicated they did not know as a rationale was not provided for continuing the medication by the provider on the July form. Review of facility policy/procedure entitled, Addressing Medication Regiment Review Irregularities (Reviewed/Revised: 12/28/23) revealed, It is the policy of this facility to provide a Medication Regiment Review (MRR) . to identify irregularities and respond in a timely manner to prevent the occurrence of an adverse drug event . 4. The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing and the reports must be acted upon . d. The Attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. e. The pharmacist does not need to document a continuing irregularity in the report each month if the attending physician has documented a valid clinical rationale for rejecting the pharmacist's recommendation. 5. The report should be submitted to the DON within 10 working days of the review. 6. Timeliness of the notification of irregularities depends on factors including the potential for or present of serious adverse consequences .

This Citation Pertains to Intake Numbers MI00141220 and MI00141312. Based on interview and record review, the facility failed to honor a resident's right to return to the facility following the hospitalization of one resident (Resident #702) of three residents reviewed for transfer and discharge, resulting in Resident #702 being transferred to the hospital for evaluation and treatment related to mental health, and not being allowed to return to the facility without an alternative placement arrangement, necessitating them to stay in the Emergency Department for six days. Findings include: Resident #702: Review of intake documentation revealed concerns that Resident #702 was taken to the hospital Emergency Department (ED) on [DATE] for a mental health evaluation due to aggressive behaviors. Per the intake, Resident #702 was not allowed to return to the facility after having been evaluated at the hospital and determined not to require inpatient mental health treatment. Per information included on the intake documentation, Resident #702 was collaboratively managed by the area Community Mental Health while at the facility and had been taken to five different Emergency departments since [DATE] for mental health evaluations due to behaviors and hospitalized on ce. Record review revealed Resident #702 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder, bipolar disorder, anemia, conversion disorder with seizures (mental health condition that causes real, uncontrollable physical symptoms), Traumatic Brain Injury (TBI), and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required limited-to-extensive assistance with dressing, personal hygiene, and toileting. The MDS further detailed the Resident displayed verbal behaviors directed toward others ,d+[DATE] days with no other behavioral symptoms. Resident #702 was discharged to the ED on [DATE] and did not return to the facility. Review of Resident #702's Electronic Medical Record (EMR) revealed the following documentation related to their final discharge from the facility: - [DATE] at 1:25 PM: SBAR Communication Form and progress note . The change in condition, symptoms, or signs I am calling about is/are: Resident has physical aggression toward staff x 4 staff. Resident also has a hx (history) of physical aggression toward residents x 2. This started on: [DATE]. Since this started has it gotten: Worse . Things that make the condition or symptom worse are: Triggers unknown, severe issues with impulse control . Things that make the condition or symptom better are: N/A . Treatment for last episode (if applicable): Resident has been sent to ER as well as in patient in [NAME] . Primary Diagnoses: Schizoaffective disorder, bipolar . pertinent history: Depression, Bipolar disorder . Mental Status Changes . New or worsening behavioral symptoms . Resident being physically aggressive toward staff and residents . Nursing Notes: On [DATE] resident was observed attempting to go into another residents room, when 2 staff members had to redirect him back to his room. On [DATE] the NHA and DON went down to the resident's room to discuss why he was attempting to go into another residents room when this resident grabbed the NHA by the neck and hair and threw her onto the bed. The DON and another staff member assisted to get this resident off of the NHA. NHA was observed with hair pulled out and red marks around face/neck and arm. Approximately 10 minutes later, this resident also came out into the hallway and grabbed the CNA who was doing one-on-one by the neck, also leaving red marks on his neck. Police notified. Clinical certifications completed . Scanned documentation in the EMR included Bed Holds for prior transfer/discharges but not the transfer/discharge on [DATE]. On [DATE] at 10:00 AM, an interview was completed with the DON and the facility Administrator. When queried regarding Resident #702's discharge from the facility on [DATE], the DON and Administrator verbalized that Resident #702 had an altercation with the Former Administrator causing injury. When asked, the DON revealed that the Police were called, facility physicians completed certifications for mental health, and the Resident was transferred to the ED. When queried what occurred after Resident #702 was transferred to the ED, the DON replied, They (ED Provider) said (Resident #702) could come back and did not qualify for inpatient mental health. The DON stated, We did not take (Resident #702) back. When queried why they did not take Resident #702 back, the DON revealed the Resident had two previous resident-to-resident altercations and they were concerned about safety. The DON verbalized the facility's corporate lawyers got involved and revealed an involuntary discharge was completed. When queried when the involuntary discharge document was given to the Resident, the DON stated, (CNA B) delivered to the hospital. When queried regarding the Resident's plan of care at the facility and interventions following the resident-to-resident altercations, the DON and Administrator revealed the Resident #702 had a one to one staff member and was seen by the county Community Mental Health (CMH). The DON and Administrator revealed CMH was working with the Resident find an Assisted Living Facility for the Resident to move to but had not found placement at the time of the incident involving the Former Administrator. The DON provided facility investigation documentation related to the incident involving Resident #702 on [DATE]. The provided documentation included: - Witness statements related to the incident involving Resident #702 and the Administrator - Typed Letter, signed by the DON detailing, Date of Notice: [DATE] . Hand Delivered. (Resident #702) Hospital Name (Note: Incorrect Hospital Identified) . Re: Immediate Involuntary Discharge . from (Facility) . This letter is to inform You that you will be immediately discharged on [DATE] . The specific reasons for your discharge are: Safety of other individuals in the facility is endangered due to clinical or behavioral status . - State of Michigan Probate Court, County of Gogebic (not county of facility) . Clinical Certificate . My determination is that the person has mental illness . recommend hospitalization on ly . Signed by facility Physician D on [DATE] at 3:01 PM. Note: The Clinical Certificate Form was not the most recent version of the form provided by the State of Michigan. - State of Michigan Probate Court, County of Gogebic (not county of facility) . Clinical Certificate . My determination is that the person has mental illness . recommend hospitalization on ly . Signed by facility Physician E on [DATE] at 3:01 PM. Note: The Clinical Certificate Form was not the most recent version of the form provided by the State of Michigan. - State of Michigan Probate Court (Blank) County . Petition of Mental Health Treatment . I request: the individual be examined at the hospital . I request . hospitalization on ly . Signed by the DON on [DATE]. - Lined piece of paper with the following written: [DATE] . ED Nurse . (Resident #702) belongings were dropped off by (Facility Name). Signed and dated [DATE] by hospital staff. - Pictures of the Former Administrator showing redness/bruising on face and arm. - Printed phone logs with unknown numbers. - Personal Protection Order (PPO) Application documentation for the Former Administrator against Resident #702 dated [DATE]. The documentation indicated the Former Administrator's statement of their reason for requesting the (PPO). The order was signed by the Judge on [DATE] but the facility premises was excluded from the order. A note on the on the order indicated the PPO was never served to Resident #702. A Police Incident number and business card was included in the documentation, but a Police Report was not provided. A copy of the Police Report was requested from the DON. An interview was completed with CNA B on [DATE]. When asked, CNA B confirmed they recalled Resident #702. When queried regarding the Resident, CNA B revealed they had been involved in a resident-to-resident altercations but then hit (Former Administrator) and was sent to the hospital. CNA B was asked if they were involved when Resident #702 was sent to the hospital and revealed they dropped off the discharge notification to the Resident at the hospital. When queried if Resident #702 signed the form, CNA B stated, No, the legal team had me deliver it. CNA B continued, I went to see (Resident #702) in the hospital and gave it to them. When asked if they said or explained anything when they gave Resident #702 the form, CNA B verbalized they told Resident #702, They wanted me to give this to you and left. CNA B added, Said I am sure you know what it is for. When queried if Resident #702 read and/or understood the form, CNA B revealed they did not know and were only instructed to deliver it. CNA B was asked when they went to the hospital to deliver the notice, CNA B revealed they did not recall. Review of Resident #702's Hospital Documentation revealed the Resident remained in the ED from [DATE] to [DATE]. Documentation included the following: ED Provider Notes: - [DATE] at 5:15 PM: Patient was sent over from (facility) due to violent behavior . hitting people and assaulting staff. When I asked the patient why . doing this says 'I do not know' . unwilling to talk to me further at this time - [DATE] at 11:43 PM: Patient . admits . was upset with the nursing staff at his facility due to the voice . understands that it is wrong for the hands another individual. I did discuss this as well with CMH . patient is not a candidate for mental health hospitalization . ED Notes: - [DATE] at 11:45 PM: Spoke with (nurse) from (facility) who stated . cannot accept this patient back to (Facility). This RN requested to speak to the nursing administrator and is awaiting a call back . - [DATE] at 8:29 PM: Per (Hospital Social Worker), the pet and cert (Mental Health petition and certification) sent by (Facility) is invalid due to being on an expired form . - [DATE] at 11:12 PM: This RN spoke with (Former Administrator) who states . cannot allow this patient to return to (Facility) due to violence that (Resident #702) has inflicted on herself and staff . states . placed a personal protective order on this patient and . has placed a formal complaints to the (County Police) to have this patient charged for assault and that this ED and BH (Behavioral Health) units have better ways to manage this patient. This RN explained to that the patient does not qualify for MH (Mental Health) unit placement per (CMH and Mental Health Provider) . (Former Administrator) stated will not speak with this RN on this matter anymore and that will be in contact with this ED manager in the morning regarding this patient's status at her facility and that the patient should go to jail. This RN offered to allow (Former Administrator) to speak with nursing supervision that was currently on and refused stating 'We will handle this all in the morning'. - [DATE] at 3:14 AM: (Police Dispatch) to infer on whether pt is to be released into Police custody due to reported charges being pressed against pt by (facility) staff. After talking with Deputy, (Resident #702) does not currently have any charges/investigations against them at this time . pt is not to be taken into police custody and the residence concern would be strictly between our ED and the (Facility). Pt will remain in ED . - [DATE] at 5:02 PM: Spoke with telehub (mental health) in regards to patient . doesn't meet criteria for mental health admission . if (Resident #702) is still here on Monday they will call a community meeting. Waiting to see when pt (patient) will be placed in AFC (Adult [NAME] Care) home . - [DATE] at 5:09 PM: Contacted by medical team regarding placement for patient. Reportedly patient is from (Facility) and is unable to return due to behaviors before this admission. (Psychiatric Provider, CMH .) determined patient is not appropriate for inpatient psychiatric care. Coordinated with (Facility Admission Director F) regarding patient's return. Patient was sent to ED after choking (Former Administrator) . (CMH) currently seeking placement at AFC . not appropriate for MHU (Mental Health Unit) placement . (Other CMH) also found . that patient does not meet criteria for mental health unit placement. Consulted with (Physician), who agrees with discharge to (Facility). - [DATE] at 5:18 PM: Patient's belongings were dropped off by (Facility). Review of Resident #702's Documentation Survey Report for [DATE] revealed documentation of Resident #702 having a Rapid change in mood once on [DATE] and also stayed in their room several times during the month. Review of Resident #702's Documentation Survey Report for [DATE] revealed the only behavior documented during the month was they stayed in their room several times. Review of Resident #702's Documentation Survey Report for [DATE] revealed documentation that Resident #702 stayed in their room several times. The report further detailed Resident #702 had a rapid change in mood, listened to others' conversations, and acted out on them, and yelled at staff and peers once on [DATE]. Review was conducted of the Arenac County Sheriff's Office Incident Report Sheet dated [DATE] at 10:42 AM. The report was related to an Assault and detailed, Complaint/Victim (Former Administrator) . Information: (Former Administration) stated they came to (Resident #702's) room to talk to them about being in another patient's room. After talking for a minute, (Resident #702) by their hair, pulling them towards their bed. (Former Administrator) stated they yelled for help and (Certified Nursing Assistant [CNA] A) and the Director of Nursing (DON) came in to the (Former Administrator) free. (Former Administrator) stated (Resident #702) yelled, 'Admit me now bitch.' (Former Administrator) stated they left the room and called the Sheriff's Office . Suspect: (Resident #702) . Information: Went into patients; room last night to get cards and had permission. (Resident #702_ stated (Former Administrator) came in telling them they were going to get admitted to mental health facility. (Resident #702) stated (Former Administrator) was yelling at them - being a 'bitch' with a authoritative problem. So, they grabbed (Former Administrator) b their neck and twisted. Once other staff came in and they let go . Witness Info: (CNA A): Walked into (Resident #702) had (Former Administrator) in a head lock and grabbing them by their hair . assisted (Former Administrator) on getting free alone with (DON) . Went in with (Former Administrator) to talk about incident last night. (Resident #702) grabbed a hold of (Former Administrator). (DON) and (CNA A) helped (Former Administrator) get away. (Resident #702) stated 'now admit me bitch.' Action Taken: Took report of assault. Notified Undersheriff of the assault and (Resident #702) mental status being schizoaffective disorder and bipolar. Undersheriff advised would not be taking (Resident #702) to jail. Contacted Centralized Intake . Advised to file mental petition with court and contact (Community Mental Health [CMH] Worker B) about new housing. (Facility) advised they were already in the process to change housing, but the state is taking too long . An interview was completed with the DON on [DATE] at 2:00 PM. When queried why Resident #702 was not allowed to return to the facility from the emergency room after being medically cleared for discharge and not provided an opportunity to appeal the involuntary discharge, the DON revealed it was related to safety concerns and the discharge form was authored and provided to the facility to deliver to Resident #702 by Corporate. An interview was completed with the Former Administrator on [DATE] at 3:08 PM. When queried if they recalled Resident #702, the Former Administrator confirmed they did. The Former Administrator was asked what occurred on [DATE] and stated, I was terrified. I went in to talk to them about going into other resident rooms and (Resident #702) became aggressive. The Former Administrator was asked to explain how Resident #702 became aggressive and what was said. The Former Administrator stated, It was so fast. I can't believe (Resident #702) moved that fast. The Former Administrator revealed the Resident was a 1:1 sitter at the time because of two prior resident-to-resident altercations which had occurred including one in which Resident #702 had hit another resident on their ear. When queried if they were alone in room, the Former Administrator indicated no one was directly in the room but responded quickly when they yelled out. The Former Administrator revealed the Resident pulled their hair and they had multiple areas of bruising on their face and arm. A follow-up interview was conducted with the Former Administrator on [DATE] at 5:12 PM. When queried regarding the PPO, the Administrator replied, It was never served (to Resident #702) because the Police said they couldn't find them. With further inquiry, the Former Administrator revealed they did not know how the Police were unable to locate the Resident and were unsure if the PPO was effective as it had not been served. The Former Administrator verbalized the PPO authorized by the court did not include the facility building/premises which was what they had requested and been most concerned about. When asked, the Former Administrator confirmed criminal charges were not pressed against Resident #702. When queried regarding Resident #702's discharge plan, the Former Administrator verbalized CMH was working with the Resident and the facility to find a different placement and had taken the Resident to visit different Assisted Living Facilities. An interview was conducted with CMH Staff B on [DATE] at 10:14 AM. When queried regarding Resident #702's stay and discharge from the facility, Staff B stated, (Resident #702) and I were going out and looking at AFC's but apparently we weren't moving quick enough. When asked what they meant, Staff B stated, (Former Administrator) was not happy and wanted (Resident #702) moved. (The Former Administrator) let everyone know they were not happy (Resident #702) was there and let it show. CMH Staff B was asked how the Former Administrator let it show that they were unhappy Resident #702 was there, Staff B stated, (The Former Administrator) called me all the time and wanted us to move faster but it takes time to get things going. CMH Staff B elaborated they were working to get Resident #702 set up with the waiver program. CMH Staff B stated, (The Former Administrator) would call me all the time and tell me over and over how much it cost (the facility) to have (Resident #702) on a 1:1 sitter. They did not want (Resident #702) there. When queried if they knew what occurred when the Resident was sent to the ED and did not return to the facility on [DATE], CMH Staff B stated, I wasn't there but they (facility staff) had moved (Resident #702) recently. When asked what they meant, CMH Staff B revealed they moved the Resident to a different room and indicated that was difficult for them due to their mental health diagnoses. CMH Staff B continued, (Resident #702) knew they were basically persona non grata and not wanted there. CMH Staff B revealed they were told Resident #702 had displayed aggressive behaviors toward the Former Administrator and the facility dropped (Resident #702) off in the ED and basically would not take them back. CMH Staff B verbalized they worked with the ED to locate temporary placement for the Resident as the facility would not take Resident #702 back and continue to work with them to find alternative permanent placement. Review of facility provided policy/procedure entitled, Transfer and Discharge (including AMA) (Reviewed/Revised: [DATE]) revealed, It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations . 6. Non-Emergency Transfers or Discharges- initiated by the facility, return not anticipated. a. Document the reasons for the transfer or discharge in the resident's medical record . document the specific resident needs that cannot be met, facility attempts to meet the needs and the service available at the receiving facility to meet the needs . b. At least 30 days before the resident is transferred or discharged , the Social Services Director will notify the resident . in writing in a language and manner they understand . 7. Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident . i. Provide e a notice of the resident's bed hold police to the resident . at the time of transfer . j. Provide transfer notice as soon as practicable to resident and representative .

Based on observation, interview and record review, the facility failed to ensure a clean ice machine, a proper functioning dish machine, a clean process for clean drying dish racks and a clean fan in the main kitchen, resulting in cross contamination of clean dishes and dish racks, a leaking dish machine with the likelihood of dirty dust particles likely to contaminate clean dishes on the dying rack and the likelihood of cross contamination for all residents using dishes in the facility. Findings include: On 9/20/2023, at 12:35 PM, observation of the main ice machine was conducted along with Dietary Manager DM D DM D lifted the lid and 3 orange perpendicular lines were observed as if they had been dripping in the ice. DM D was asked to wipe the bottom of the medal face plate which revealed orange and brown residue onto the white tissue. DM D was asked what color it was and DM D stated, it's brown debris with a bit of orange. DM D was asked who cleans the ice machine and DM D explained, the kitchen staff cleans it. On 9/20/23, at 12:50 PM, Kitchen Cook C along with DM D were interviewed at the ice machine. Kitchen Cook C explained how they clean the ice machine and that they would wipe down the medal face plate to include the plastic facing. DM D took another white tissue and wiped one of three orange line of debris which made the tissue bright orange in color. This did not appear as rust. DM D stated, I would say it needs to be recleaned. DM D took an additional white tissue and again wiped the bottom of the medal face plate which revealed a large amount of orange and brown residue. Kitchen Cook C was asked if they thought the ice machine was clean or dirty and Kitchen Cook C stated, it's dirty and we will clean it. On 9/20/23, at 1:17 PM, the Administrator was made aware of the orange and brown residue noted on the ice machine and the Administrator stated, maintenance is cleaning it. The Administrator was asked who's responsible for cleaning the ice machine and the Administrator stated, maintenance and they clean it monthly. The Administrator was asked to provide the cleaning schedule for the ice machine. On 9/22/23, at 1:48 PM, an observation of the dish room, dish machine and the circulating fan over the dry dish rack was conducted along with DM D. The circulating fan was stopped and there was a large amount of dust and debris noted to the fan cover and blades. DM D stated, they would get the fan cleaned. The dish machine had a gross amount of food debris and white residue noted to all corners and seams. DM D was asked to run the dish machine to ensure proper temperature cycle. While the dish machine was running during the washing cycle it was noted to leak water on all sides and onto a hanging pipe and handle to the back wall. The dirty water spurted out onto the drying counter and splashed onto a clean rack of dishes. The dish machine was noted to spurt the water during the rinse cycle onto the clean dishes also. DM D was asked how often the dish machine was cleaned and how long had it been leaking onto the clean dishes and DM D stated, we clean it every couple of days and that the buildup was normal. DM D was asked to explain where the clean dish racks go after cooling off and DM D stated, they get placed on the clean dish rack next to the cooling counter. The clean dish rack was observed to be plastic and have approximate 3 inch slots noted to all the shelves. DM D was asked to have the Administrator come to the dish room. On 9/22/23, at 2:00 PM, the Administrator entered the dish room and was asked if the dish machine was normally dirty and leaking and the Administrator stated, that they could clean the dish machine every day. The Administrator was made aware of the spurting dirty dish water onto the clean dishes and the Administrator stated, that the clean dish rack could be pushed farther down the drying counter, and they lifted an empty dish rack that revealed a large amount of dried food particles underneath the rack. As the Administrator pushed the clean dish rack away from the dish machine the dirty water that had spurted out onto the counter was pushed down farther on the clean drying counter. DM D was asked how they could ensure that the dry dish rack was not contaminated with the dirty dish water and food particles and the DM D did not respond. The Administrator was asked to provide the cleaning schedule and who was responsible for maintaining the dish machine. It was explained that the dish machine was rented and the DM D would contact the representative responsible. DM D was asked to provide the manufacturer recommendations on cleaning and maintenance of the rented dish machine and the facility's cleaning schedule of the kitchen. On 9/22/23, at 3:31 PM, a further observation of the dish machine with DM D was conducted. The dish machine was noted to be clean of food debris and clean of the white residue. DM D stated, that the white residue appeared to be lime buildup and used a lime cleaner to remove it. The pipe to the back wall over top of the dying counter was cleaned of all debris. DM D stated, that the fan was also cleaned and was placed back over top of the clean dish rack. The fan was observed to be clean of all debris. A review of the facility provided Commercial Dishwasher Cleaning Checklist THE ULTIMATE CHECKLIST FOR DAILY CLEANING guideline revealed . the food debris, grease and other dishware impurities don't just magically [NAME]. Some of it gets flushed away, but a significant amount gets stuck inside the dishwasher. Since you can't get clean dishes out of a dirty dishwasher, regularly cleaning it is equally important for prolonging your dish machine's life and having satisfactory cleaning results as providing regular service and maintenance . The facility did not provide the cleaning schedule or the last maintenance assessment of the dishwasher.

Based on interview and record review, the facility failed to ensure that the Director of Nursing (DON) worked fulltime/40 hours a week in the facility, resulting in the lack of a fulltime DON working 40 hours in the facility and with the likelihood of decreased oversight and management of resident care and assessment. Findings include: On 9/20/23, at 10:32 AM, During entrance conference, the Administrator stated that the Director of Nursing (DON) worked fulltime; 40 hours a week and that there were no nursing waivers. On 9/22/23, at 12:42 PM, The DON was asked if they worked fulltime at the facility and the DON stated, there are two days a week they go to another facility. The DON was asked to explain and the DON explained, they didn't want to be confusing and that they go right to the other facility from home. The DON explained the other facility was under survey so they went there but then had to come to this facility as a survey was being conducted. The DON was asked if there were set days they are at the other facility and the DON stated, usually Tuesdays and Thursdays. The DON was asked if they come in on the weekends to pass medications and the DON stated, No. On 9/22/23, at 3:18 PM, Payroll Benefits Coordinator (PBC) A was interviewed regarding the fulltime DON position and how many hours a week they work. PBC A explained that it varies and depends on how much the other facility needs the DON and that they have to fill out a transfer form so the other facility gets charged for the hours the DON works at their building. PBC A was asked who covers the DON when they are not in the building and PBC A stated, the Administrator has 2 hours a day as interim a day for don allocation. PBC A explained for form as they fill it out, the Administrator signs it and then the transferring facility administrator signs it also. On 9/22/23, at 3:20 PM, a record review of Employee Hours Transfer Form along with PBC A was conducted which revealed Date: Employee Name: Home Facility: Position: Pay Rate: Transfer Location: Number of Days Worked: Total Hours Worked: Home Administrator: Transfer Administrator: The Employee Hours Transfer Form were filled in with the following dates worked at the transferring facility and signed by both Administrator's: Date: 6-1-23 . Number of Days Worked: 5/31, 6/1 . Date: 6-8-2023 . Number of Days Worked: 1 day . Date: 6-15-2023 . Number of Days Worked: 1 day . Date: 6-21-2023 . Number of Days Worked: 1 day 6/21 . Date: 6-30-2023 . Number of Days Worked: 1 day . Date: 7-6-2023 . Number of Days Worked: 1 day . Date: 7-7-2023 . Number of Days Worked: 1 day . Date: 7-13-23 . Number of Days Worked: 1 day 7/13 . Date: 7-18-2023 . Number of Days Worked: 1 day 7/18 . Date: 7-25-2023 . Number of Days Worked: 1 day 7/25 . Date: 7-27-2023 . Number of Days Worked: 1 day 7/27 . Date: 8-1-2023 . Number of Days Worked: 2 days 8/1, 8/4 . Date: 8/8/2023 . Number of Days Worked: 2 days. 8/8, 8/10 . Date: 8/22/2023 . Number of Days Worked: 2 days 8/22, 8/25 . Date: 8-29-2023 .Number of Days Worked: 2 days 8/29, 8/31 . PBC A was asked to clarify the dates the DON transferred to the other facility to work was it for the weekend or during the week and PBC A stated, they are only during the week. A further review of the Employee Hours Transfer Form revealed the following dates the DON was transferred to the other facility: 9/6 9/7 and on 9/18 the DON was transferred to a third facility to work. During exit conference, the facility Administrator and the DON offered that they would provide additional documentation. The facility provided the DON's time sheet and a typed letter from the Administrator three days after survey exit. The letter read Full time Director of Nurses: As you will note, the requirement has been met by having a designated, full-time registered nurse serving as the director of nursing. Additionally, in regards to the guidance for PBJ, as defined by CMS, (see attached). (DON) RN, licensed in the State of Michigan, is the full time DON for (facility) (DON) is available to (facility), 24/7/365. As part of her DON functions and development, she has been assigned to learn from and assist other facilities, AND, consistently remains responsible and accessible to (facility). Additionally, through technology and company equipment, (DON) is able to receive input from and promptly respond to her team and NHA as needed. Her hours of connectedness to her facility well exceeds the minimum 40 hour work week. Please see attached payroll documents. The letter was signed the Administrator and Dated 9-25-2023.

Based on observation, interview and record review, the facility failed to provide a gait belt and walker during a toilet transfer for one resident (Resident #3), resulting in the care plan not being followed and an unsafe transfer. Findings include: Resident #3: On 9/21/23, at 9:24 AM, Resident #3 was sitting in their room in their wheelchair. Resident #3 pushed their call light for assistance. Shortly after, CNA H entered and offered Resident #3 assistance. The resident stated they needed to use the bathroom. CNA H pushed the resident into the bathroom and assisted the resident to stand up and then onto to the toilet. CNA H did not use a gait belt. CNA H left out of the room and came back a short time later. Resident #3 was in the bathroom on the toilet. CNA H assisted the resident out of the bathroom and back to their wheelchair. CNA H was asked why there was a gait belt hanging on a hook on the wall and CNA H stated, she doesn't always let us use it and often will say let me you do it myself. On 9/22/23, at 2:00 PM, a record review of Resident #3's electronic medical record (EMR) revealed an admission on 3/11/22 with diagnoses that included impaired balance, Limited mobility and seizure disorder. A review of the resident is at risk for falls related to . Date initiated: 03/11/2022 Revision on: 03/24/2022 The resident will be free of falls through the review date . Interventions . Use gait belt for transfers/walking Date Initiated: 03/11/2022 . A review of the the resident needs activities of daily living assistance related to: Activity Intolerance. Cognitive Deficits . Date Initiated: 03/11/2022 Revision on: 01/17/2023 . Interventions . Transfer with 1 assist with gait belt and front wheeled walker Date Initiated: 03/11/2022 Revision on: 04/13/2022 . A review of the the resident has a mood problem . Interventions . Provide care in unhurried manner Date Initiated: 03/24/2023 .

Based on observation, interview and record review, the facility failed to institute and operationalize policies and procedures to ensure comprehensive Range of Motion (ROM) monitoring, documentation, and implementation of a restorative nursing program for one resident (Resident # 1) of two residents,, resulting in a lack of restorative nursing services to maintain and/or prevent further decline in ROM, lack of quantitative assessment and documentation of ROM limitation, and the likelihood for increased ROM limitations, pain, and decline in independence and quality of life. Findings include: Resident #1: On 9/21/23 at 9:10 AM, Resident #1 was observed in their room, sitting in their bed. The head of the bed was elevated, and they were wearing a hospital style gown. An interview was completed at this time. During the interview, Resident #1 did not move either shoulder. The Resident was noted to only move their arms from the elbow joint. When queried if they were able to move their shoulders and lift their arms, Resident #1 replied, No and revealed they had arthritis. When asked if they were receiving Therapy, Resident #1 stated, No. With further inquiry, Resident #1 revealed they had previously received therapy but not currently. When asked if they were receiving Restorative Nursing to assist with ROM and movement, Resident #1 indicated they were not. With further discussion, Resident #1 indicated they would like to receive therapy and/or Restorative Nursing. Resident #1 verbalized a Restorative Nursing program had not been offered and/or discussed with them. When queried how they transfer and get out of bed, Resident #1 revealed the staff use a Hoyer (mechanical lift to transfer dependent individuals). Record review revealed Resident #1 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included heart failure, cerebral infarction (stroke) with resulting right sided hemiplegia and hemiparalysis (one sided paralysis), dysphagia (difficulty swallowing, and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance to complete all Activities of Daily Living with the exception of eating. The MDS further detailed Resident #1 had no upper or lower extremity ROM limitations. A comparative review of Resident #1's prior MDS assessments for ROM limitations revealed bilateral Upper Extremity (UE) impaired ROM was documented on the MDS assessments dated 9/7/22, 12/8/22, and 12/16/22. One sided Lower Extremity (LE) ROM impairment was documented on the MDS assessments dated 9/7/22, 12/8/22, 12/16/22, and 1/14/23. Review of Resident #1's current and discontinued care plans did not include a care plan related to limited ROM. Review of Resident #1's progress note documentation in the Electronic Medical Record (EMR) included the following: - 4/1/23 at 9:44 PM: Nurses' Notes . At dinner time res stated was having left shoulder pain . in rotator cuff . Resident crying when shoulder palpated lightly - no abnormalities felt. No swelling, discoloration, or injury. Denied recent injury or fall. Resident given Tylenol and gabapentin as ordered, and per resident request . - 4/1/23 at 11:49 PM: Nurses' Notes . Report received from RN at ER . X-ray of shoulder shows severe arthritis . - 8/16/23 at 3:27 PM: Physician Progress Note . Seen and evaluated this afternoon . sitting up in wheelchair and is doing well . is complaining of shoulders hurting with arthritis and is on Norco (narcotic pain medication) TID (three times per day) prn (as needed) . will continue with the present medications and will follow up. No new changes. Review of scanned therapy documentation in Resident #1's EMR revealed: - Occupational Therapy (OT) Evaluation & Plan of Treatment . dates: 6/7/23 -7/6/23 . Musculoskeletal System Assessment . UE ROM . RUE ROM = Impaired; LUE ROM = Impaired . RUE ROM . Shoulder = Impaired . Elbow/Forearm = Impaired . LUE ROM . Shoulder = Impaired . Elbow/Forearm = Impaired . AROM (Active Range of Motion) R Shoulder: Flexion = NA (decreased ROM, unable to obtain measurements secondary to increased fatigue) . - Physical Therapy (PT) Evaluation & Plan of Treatment . dates: 6/8/23 -7/16/23 . Musculoskeletal System Assessment . LE (Lower Extremity) ROM: RLE ROM= WFL (Within Functional Limits); LLE ROM = WFL . Assessment Summary . Barriers . None noted . Exercises Prescription . Purpose of Exercise = Range of Motion, Endurance, Strength . PT and/or OT discharge summary documentation were not noted in Resident #1's EMR. An interview was completed with Restorative RN K on 9/22/23 at 1:33 PM. When queried if Resident #1 had limited ROM in their shoulders, RN K revealed the Resident had arthritis. RN K was asked if the Resident was receiving Restorative Nursing and stated, No. When queried why Resident #1 was not receiving Restorative Nursing, RN K replied they had not received a referral from Therapy services for restorative. When queried regarding the facility process/procedure in which Restorative is initiated, RN K indicated most residents are referred after being discharged from therapy. When queried why Resident #1's therapy discharge documentation was not scanned into their EMR, RN K was unable to provide an explanation. A copy of the discharge documentation was requested at this time. Review of Resident #1's PT Discharge Summary for Dates of Service: 6/8/23 -7/16/23 revealed Therapy services did not recommend a functional maintenance or Restorative Nursing program upon discharge. Review of Resident #1's OT Discharge Summary for Dates of Service: 6/7/23 -7/18/23 revealed Therapy services did not recommend a Restorative Nursing program upon discharge. An interview was conducted with Therapy Manager L on 9/22/23 at 1:43 PM. When queried regarding Resident #1, Manager L confirmed the Resident was no longer receiving therapy services. Manager L was asked if Resident #1 had ROM limitations and confirmed they did. When asked why the Resident was not referred to the facility Restorative Nursing Program following therapy discharge to prevent further limitations and/or maintain current level of functioning, Manager L stated, Because (Resident #1) is non-compliant. When asked why they meant, Manager L stated, (Resident #1) said they will walk with therapy but not with aides. When asked if Therapy Staff worked with the aides to ensure the Resident felt safe when walking with them, Manager L did not provide a response. Manager L then stated, One time (Resident #1) complained of pain in their wrist and said it really, really hurt and indicated the Resident did not want to participate in therapy. When queried if therapy staff typically measure the degree of ROM to determine and identify the level of impairment, Manager L replied, We don't measure unless a specific reason. Manager L was then asked what impaired meant when documented for shoulder ROM and stated, Less than 90 degrees. When queried if less than 90 degrees could be 10 degrees or 80 degrees, Manager L confirmed and stated, It's vague. When asked how the facility determined and identified if a Resident's ROM was decreasing without measurements, Manager L indicated they understood but did not provide further explanation. A follow up interview was completed with RN K on 9/22/23 at 2:11 PM. When queried why the most recent MDS indicated Resident #1 had no limitations in ROM when the last PT/OT evaluations specified the Resident did have limitations, RN K reviewed the MDS and confirmed they had made an error during MDS completion. RN K was then informed of Manager L stating Resident #1 was not referred to Restorative Nursing due to being non-compliant and asked if that was acceptable. RN K verbalized it was not and indicated nursing staff are able to work with Residents in different ways than therapy. Review of facility policy/procedure entitled, Restorative Nursing (Implemented 1/1/21) revealed, The goal (s) of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility .

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure ongoing assessment, accurate documentation, and care coordination of pressure ulcer (wounds caused by pressure) wound care for one resident (Resident #2) of one resident reviewed resulting in inaccurate documentation, insufficient facility knowledge of pressure ulcer status, lack of wound status and assessment documentation from external wound care provider and the potential for inappropriate and/or delayed care/treatment, wound progression, and decline in overall health status. Findings include: Resident #2: Review of Resident #2's MDS (Minimum Data Set) Indicators indicated the Resident had a pressure ulcer. At 9:49 AM on 9/21/23, Resident #2 was observed ambulating independently with a walker, without staff assistance in their room. The Resident was walking away from their bed towards a wheelchair positioned near the room door. Resident #2 proceeded to sit in the wheelchair. A wound dressing was noted on the Resident's left lower extremity. The dressing was wrapped from the calf to the foot. The dressing was discernibly loose, and the Resident was observed pulling it upward, towards their knee. An interview was completed at this time. When queried regarding the dressing in place on their left lower leg, Resident #2 stated they had cellulitis and were being treated at the wound clinic. Resident #2 was queried regarding wound care provided by facility nursing staff and indicated facility staff did not address the wound because they were going to the wound care clinic. When asked if they had a pressure ulcer, Resident #2 stated they have never had a pressure ulcer. On 9/21/23 at 10:05 AM, Registered Nurse (RN) I was observed responding to Resident #2's call light. From the hallway, RN I was heard telling Resident #2 the dressing on their leg needed to stay in place. On 9/21/23 10:09 AM, an interview was conducted with Registered Nurse (RN) I. When queried regarding skin alterations and pressure ulcers, RN I replied, No pressure ulcers on 200 unit (Resident #2's unit). When queried regarding the wound dressing observed on Resident #2's left, RN I replied, (Resident #2) has an Unna boot (medicated, compression wrap dressing used to treat slow healing lower extremity wounds). RN I was asked when the dressing was due to be changes and stated, (Resident #2) typically goes once a week to wound care (clinic). When asked if the facility changed the Unna boot dressing, Resident #2 reiterated all their wound care treatments were supposed to be completed at the wound care clinic. When queried what wounds the Unna boots were being used to treat, RN I revealed the Resident had venous ulcers (wounds caused by lack of blood flow) on their legs. When asked if Resident #2 had a pressure ulcer, RN I responded they did not. Review of the facility provided CMS 802-Resident Matrix form detailed Resident #2 had an unstageable pressure ulcer (full thickness skin and tissue loss with unknown depth). Review of Resident #2's Electronic Medical Record (EMR) revealed the Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Left Lower Extremity (LLE) cellulitis (bacterial infection of the skin), heart disease, chronic kidney disease, Peripheral Vascular Disease (PVD), diverticulitis with perforation and abscess (inflammation and infection of formed pouches creating a hole in intestines), and colostomy (surgically created opening through the abdomen to allow passage of fecal material). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive assistance with bed mobility, transferring, ambulation, dressing, toileting, and bathing. The MDS further revealed Resident #2 had one stage three pressure ulcer (Full thickness tissue loss with exposed adipose tissue) and five venous/arterial ulcers. Review of Resident #2's current and discontinued care plans in the EMR revealed a care plan entitled, Resident is at risk for altered nutritional status related to . pressure ulcer, altered skin integrity, edema . (Initiated: 8/14/23; Revised: 9/20/23). A second care plan entitled, Resident is at risk for impaired skin integrity related to history of pressure ulcers, history of vascular ulcers . readmitted [DATE] (Initiated: 8/14/23; Revised: 9/19/23) was present in the EMR. This care plan included the following active and discontinued interventions: - Administer medications as ordered (Initiated: 8/14/23) - Complete skin inspection weekly and as needed (Initiated: 8/14/23) - Encourage/assist as needed to elevate heels off the mattress as tolerated (Initiated: 8/14/23) - Labs as ordered (Initiated: 8/14/23) - Complete skin inspection weekly and as needed (Initiated: 8/14/23) - Apply protective barrier cream after incontinent episodes (Initiated: 9/19/23) - RESOLVED: Pressure redistribution mattress to bed (Initiated: 8/14/23; Resolved: 9/19/23) Resident #2 had a third care plan entitled, Resident has impaired skin integrity as evidenced by: admitted with redness to buttocks/sacrum with open unstageable to left heel. Venous/stasis ulcers to left lower extremity. readmitted [DATE]. Unna boot remains in place to left lower extremity. Check placement every shift (Initiated: 9/19/23; Revised: 9/21/23). The care plan included the interventions: - Administer treatment(s) per orders (Initiated: 8/14/23) - Complete wound evaluation to observe the progress of the resident's skin condition (Initiated and Revised: 8/14/23) - 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) (Initiated: 9/19/23) Review of wound assessment documentation in Resident #2's EMR revealed the following: - 4/25/23 at 2:02 PM: Wound Evaluation . #3 Pressure- Unstageable (Slough and/or eschar) . Left Heel . Present on Admission . Wound Bed . Eschar . 100% . Exudate . Light . Serous . Area measuring 0.4 (centimeters [cm]) x 0.4 cm x UTD (Unable to Determine) . - 5/2/23: Wound Evaluation . #3 Pressure- Unstageable . Left Heel . Length: 1.3 cm . Width: 0.52 cm . - 5/15/23: Wound Evaluation . #3 Pressure- Unstageable . Left Heel . - 5/23/23: Wound Evaluation . #3 Pressure- Unstageable . Left Heel . Length: 0.37 cm . Width: 0.3 cm . - 7/17/23 at 2:37 PM: Wound Evaluation . #3 Pressure- Unstageable (Slough and/or eschar) . Left Heel . Resolved . Describe . Pressure . Unstageable Due to Slough and/or eschar . Present on Admission . Wound Age: Unknown . Continues to go to weekly wound clinic appointment at this time, weekly unna boot changes that are to stay in place until next appointment. Weekly wound clinic notes will be uploaded to chart . Review of progress note documentation in Resident #2's EMR revealed: - 5/30/23 at 3:30 PM: Nurses' Notes . Unna boot changed, wounds improving. Unna boot changed prior to weekly pictures. Resident request not to remove Unna boot for new pictures . Resident is getting setup with (outpatient wound care clinic), appointment 6/8/23. - 6/7/23 at 3:20 PM: SOC-LACE (Return to hospital risk) .Unna boot and outpatient wound care to left lower extremity . - 6/8/23 at 9:54 PM: Physician Progress Note . Patient seen and evaluated for a routine visit . Patient was seen at wound clinic and placed with [NAME] boot . - 6/21/23 at 11:18 AM: Resident's wound care appointment rescheduled for Friday 6/23/2023, leave Unna boot in place per wound care until appointment Friday. - 6/22/23 at 3:16 PM: SOC-LACE (Return to hospital risk) . weekly Unna boot changes at wound care clinic . patient has left leg ulcer which is healing slowly . Extremities: Edema in right and left distal lower extremities. Left leg compression stocking in place . - 6/29/23 at 12:06 PM: Physician Progress Note . seen and examined . continue wound care . - 7/5/23 at 4:18 PM: Nurses' Notes . Resident has Unna boot on LLE, wound evaluation completed weekly at wound clinic. See uploaded notes. - 7/12/23 at 3:41 PM: Nurses' Notes . Wound assessment completed weekly at wound clinic. Wound clinic sends notes weekly, Unna boot changed weekly at visit. Clinic does not take pictures of wounds weekly, when they do, they will send them to be uploaded into chart. - 7/13/23 at 11:13 AM: Nurses' Notes . returned from wound care clinic at this time. no new orders. - 7/19/23 at 1:14 PM: SOC-Nutrition/Hydration . Altered skin integrity to left lower leg and left heel. Wounds are being managed by outpatient wound clinic. Areas are improving per wound clinic . A review of scanned documentation in Resident #2's EMR revealed the following notes from the wound care clinic: - 6/6/23: Wound Care Clinic . Physician Order Details . Pressure Ulcer of Left Heel . Stage 3 . Wound #7 - Calcaneus (heel) . Left . Cleanser: Soap and water . 1 X Per Week . Primary Dressing: Medihoney . Telfa Non-adherent Dressing . Woven Gauze Sponge . Compression Wrap: CoFlex TLC Calamine Lite 2-layer Compression System (Unna Boot) 1 X Per Week . The scanned documentation did not include wound measurements and/or further description. - 6/13/23: Wound Care Clinic Multi Wound Chart Details . Wound Number: 7 . Left Calcaneus . Pressure Ulcer . Weeks of Treatment: 1 . Wound Status: Open . Measurements: 0.9 (cm) X 0.4 (cm) X 0.1 (cm) . Stage 3 . Exudate: Large . Serosanguineous . red, brown . Necrotic . 67-100 % . Exposed Structures . Fat Layer . Physician Order Details . Cleanser: Soap and water . 1 X Per Week . Primary Dressing: Medihoney . Secondary Dressing: Woven Gauze Sponge . Compression Wrap: CoFlex TLC Calamine Lite 2-layer Compression System 1 X Per Week . The scanned documentation did not include wound measurements and/or further description. - 6/23/23: Wound Care Clinic . Physician Order Details . Pressure Ulcer of Left Heel . Stage 3 . Wound #7 Calcaneus (heel) . Left . Cleanser: Soap and water . 1 X Per Week . Primary Dressing: Medihoney . Secondary Dressing: Woven Gauze Sponge . Compression Wrap: CoFlex TLC Calamine Lite 2-layer Compression System 1 X Per Week . The scanned documentation did not include wound measurements and/or further description. - 6/30/23: Wound Care Clinic . Progress Note Details . History of Present Illness (HPI) . Location . left heel. Severity: Wounds are moderate with exposed structure . 6/30/23: The patient's wounds continue to improve the exception of the anterior inferior ulcers. They continue to be significantly deep without granulation. All wounds are debrided. These 2 wounds are dressed with Medihoney. The remainder are dressed with collagen and a nonstick dressing . patient will continue with regular wound care . Assessment . Pressure Ulcer of left heel, stage 3 . Procedures . Wound #7 . Selective/Open Wound Non-Viable Tissue Debridement . Material removed includes Slough, biofilm, and fibrin/exudate . minimum amount of bleeding . Post Debridement Measurements: 0.8 cm length X 0.7 cm width X 0.1 cm depth . Post debridement . Stage 3 . Plan . Wound #7 - Calcaneus (heel) . Left . Cleanser: Soap and water . 1 X Per Week . Primary Dressing: Prisma (collagen based dressing for moist wound healing) . 1 X Per Week . Telfa Non-adherent Dressing . 1 X Per Week . Woven Gauze Sponge . 1 X Per Week . The fax date/time on the scanned note was 6/30/23 at 3:19 PM. The note also included the following recap of prior wound care clinic appointments/treatments under the History of Present Illness section: 6/23/23 . Heel ulcer appears to be resolved. We will continue with topical Medihoney and lower extremity compression . 6/6/23 . patient currently at (facility) and has had 3 weeks of Unna boot treatment . Stage 3 pressure ulcer of the left heel . Wound #7 . open . stage 3 . pressure ulcer Left Calcaneus . measures 0.8 cm length X 0.7 cm width X 0.1 cm depth . There is fat layer (subcutaneous tissue) exposed . Large amount of serosanguineous drainage . large (67-100%) amount of necrotic tissue with the wound bed including adherent slough . Selective/Open Wound Non-Viable Tissue Debridement performed . Post Debridement Measurements: 0.8 cm length X 0.7 cm width X 0.1 cm depth . Stage 3 . - 7/20/23: Wound Care Clinic . Progress Note Details . History of Present Illness (HPI) . Location . left heel . Wounds are moderate with exposed structure . Patient did mention that Unna boot feels tight sometimes . on the edge of appropriateness for compression. We will switch from the long stretch Coban to a 4-inch sterile which should be a little bit light compression . The note included the same recap of wounds included previously on note dated 6/30/23. No additional scanned documentation were present in Resident #2's EMR. Review of Resident #2's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for September 2023 revealed the following: - Change [NAME] boot dressing per wound care every day shift for 1 Day (Start Date: 9/1/23). Documented as completed on 9/1/23. - Place [NAME] boot to left lower extremity one time only for 1 Day (Start Date: 9/19/23). Documented as completed on 9/19/23. - Left Heel: Wound assessment, Document abnormal's in progress notes . every day shift every Tue for Weekly wound assessment with dressing change. Note site, provide notification and other details in the progress note . (Start Date: 5/30/23; Discontinued: 9/18/23). Documented as completed on 9/5/23 and 9/12/23. - Check placement of Unna boot q (every) shift. Changed weekly at wound care (clinic) . every shift for Wound Care (Start: 6/9/23; Discontinued: 9/18/23; Start: 9/21/23). Review of Resident #2's Healthcare Provider (HCP) orders, related to their left heel pressure ulcer, in the EMR including the following: - Cleanse area to left heel with wound cleanser. Pat dry, and apply skin prep to areas q shift every shift for wound care (Ordered: 4/25/23; Discontinued: 5/4/23, Ordered: 5/13/23; Discontinued: 5/15/23) - Cleanse left heel wound with normal saline, pat dry. Apply piece of Xeroform gauze to area, cover with gauze. Secure with kerlix q (every) night and prn (as needed) every night shift for tx (treatment) (Ordered and Discontinued: 4/21/23, Ordered: 5/3/23; Discontinued: 5/4/23) - Cleanse left heel wound with normal saline, pat dry. Apply piece of Xeroform gauze to area, cover with gauze. Apply A&D ointment all elsewhere to foot. Secure with kerlix q (every) night and prn (as needed) every night shift for tx (treatment) (Ordered: 5/4/23; Discontinued: 5/8/23) - Cleanse area to left heel with normal saline, pat dry and apply xeroform gauze, and wrap with kerlix every night shift. every night shift for wound care (Ordered: 5/15/23; Discontinued: 5/16/23) - Silvadene External Cream 1 % (Silver Sulfadiazine) (topical antibiotic cream). Apply to left heel topically every night shift for wound care Cleanse left heel with normal saline, apply Silvadene cream, cover with gauze and secure with kerlix q night and prn (Ordered: 5/16/23; Discontinued: 5/25/23) - Left Heel: Daily wound assessment, Document abnormals in progress notes. Surrounding Skin: skin Normal = N Abnormal = A Wound Pain: Pain Document level of pain at wound site Drainage/Exudate Present: Drain Yes = Y No = N Odor Present: Odor Yes = Y No - N Necrotic Tissue present: Necro Yes = Y No - N Infection present: Infec Yes = Y No = N every night shift Note site, provide notification and other details in the progress note . (Ordered: 5/15/23; Discontinued: 5/25/23, Ordered: 5/25/23; Discontinued: 9/18/23) - Cleanse left lower extremity below the knee to toes with wound cleanser or normal saline, pat dry with gauze, apply Unna boot to left lower extremity from toes to below the knee, wrap with kerlix and secure with coban. Apply 5/25 to be changed on Tuesday 5/30. Change weekly and PRN after 5/30. One time only for Wound Care for 1 Day (Ordered: 5/25/23) - Cleanse left lower extremity below the knee to toes with wound cleanser or normal saline, pat dry with gauze, apply Unna boot to left lower extremity from toes to below the knee, wrap with kerlix and secure with coban. Change weekly and PRN . (Ordered: 5/25/23; Discontinued: 6/8/23; Ordered: 6/8/23; Discontinued: 6/9/23) - Change Unna boot dressing per wound care. Every day shift for 1 Day (Ordered and Start: 7/28/23; End: 7/29/23) - Change Unna boot dressing per wound care. Every day shift for 1 Day (Ordered: 8/28/23; Start 9/1/23; End: 9/2/23) Note: Facility and treatments orders did not correlate with Wound Care Clinic recommendation/orders. On 9/22/23 at 8:41 AM, an interview was completed with Resident #2 in their room. A wound dressing was visible on the Resident's left lower extremity. When queried if the Unna boot had been applied by facility nursing staff after their return from the hospital, Resident #2 stated, I thought they were going to do it at the wound care clinic. Resident #2 then stated, It gets changed once a week but did not provide a response to the question. An interview was completed with MDS/Wound Care RN J on 9/22/23 at 10:41 AM. RN J was asked if Resident #2 had a pressure ulcer and stated, (Resident #2) came in with an unstageable on their left heel. With further inquiry regarding Resident #2's pressure ulcer, RN J stated, All (Resident #2's) wound are being treated by (external wound care clinic). When asked how often wound measurements are completed, RN J replied, Weekly. When queried why there was not weekly wound measurements and assessments in Resident #2's EMR, RN J indicated they should, unless they were in the hospital/out of the facility and/or refused. RN J proceeded to review the Residents EMR. The Director of Nursing (DON) joined the interview at this time. Review of Resident #2's clinical census with RN J and the DON revealed the Resident was out of the facility, in the hospital, from 5/4/23 to 5/13/23 and from 9/15/23 to 9/19/23. When asked why there was no facility wound assessment documentation from 5/23/23 to 7/17/23, RN J stated, I did not measure anymore when (Resident #2) started going to the wound clinic. When asked why no wound measurement /assessment documentation was completed on 5/30/23, RN J indicated the dressing had been completed prior to the wound pictures being obtained. When asked to elaborate, the DON revealed the floor nurse had removed and reapplied the Unna boot dressing before they went to complete the wound care measurements and treatment. The DON disclosed Resident #2 did not want to have the Unna boot removed for wound pictures as it had just been applied. When queried why as assessment was completed on July 17th if they were no longer measuring the wound, the DON stipulated they resolved the left heel pressure wound and assessment because the wound care clinic was performing all wound care measurements. When asked to clarify if Resident #2's left heel pressure ulcer was resolved because it was healed or because the wound care clinic, and not the facility, were completing the wound measurements/assessments, the DON confirmed it was resolved because the facility was not documenting on it. When asked why there was still a treatment in place on the TAR for assessment of the left heel pressure ulcer if it was not being assessed, the DON and RN J explained that resolving the wound in the assessment discontinued the assessment. The DON and RN J were asked what current pressure ulcers/wounds Resident #2 had and indicated the wound care clinic notes would need to be reviewed. When queried why the most recent wound clinic documentation present in Resident #2's EMR was from 7/20/23, both the DON and RN J revealed there should be more recent documentation from the wound clinic. A review of the scanned documentations in Resident #2's EMR was completed with the DON and RN J at this time. After review, both staff verified the last documentation from the wound care clinic in the EMR was dated 7/20/23. The staff were then asked the facility policy/procedure to ensure communication is maintained between the Wound Care Clinic and the facility, both the DON and RN J revealed the wound care clinic is supposed to send notes back with the Resident and staff member who accompanies them. RN J left the conference room to speak to other staff. Upon their return, RN J stated that another staff member was getting a copy of the wound care clinic documentation. RN J then stated the staff member who accompanies Resident #2 to their appointments asks (for the documentation) but does get them. When queried how they knew what wounds Resident #2 actually had without the documentation, an explanation was not provided. When queried how they knew the wound care orders were the same without documentation from the wound care clinic, both the DON and RN J relayed the clinic would call them if the orders were changed. When asked why the orders in the EMR did not match the orders/plan on the available wound care clinic notes in the EMR, a response was not provided. When queried why the wound care documentation in the EMR indicated the left heel pressure ulcer was healed on 6/23/23 while also specifying the pressure ulcer was debrided on 6/30/23, and lack of clarification documentation in the EMR, RN J indicated they would need to review the documentation. RN J was then asked why the MDS assessment dated [DATE] specified Resident #2 had a left heel pressure ulcer when the facility had not assessed the wound, documentation from the wound care clinic was unclear, and there was no clarification documentation, clarification was not presented.

Based on observation, interview and record review, the facility failed to assess, monitor and follow up on Pacemaker checks and a Pacemaker machine for one resident (Resident #3), resulting in no follow up for 17 months, no documented assessment of Pacemaker function, no Pacemaker machine found with the likelihood of Pacemaker complications going unnoticed. Findings include: Resident #3: On 9/21/23, at 9:34 AM, Resident #3 was sitting in their wheelchair and stated, yes, they had a pacemaker and that it had been a while since it was checked. On 9/21/23, at 4:08 PM, Resident #3 was in their room. CNA G assisted with looking in every drawer and in the closet. There was no pacemaker machine found in the room. On 9/21/23, at 4:13 PM, The Director of Nursing (DON) was asked where Resident #3's pacemaker check machine was and the DON stated, they would look into it. On 9/22/23, at 8:24 AM, the DON was again asked where Resident #3's pacemaker machine was and the DON stated, I will have to call the cardiologist this morning. On 9/22/23, at 11:30 AM, a record review of Resident #3's progress notes revealed 9/22/2023 08:49 Nurses' Note . Call placed to Dr. (cardiologist) to notify office on status of cardiac monitor. Reported that facility did not receive the monitor and we would like to schedule resident for follow up appointment to verify stable cardiac status as reported by facility physicians and to verify remote cardiac monitoring is still required . Appointment scheduled for 10/12/2023 at 8:00 am . On 9/22/23, at 2:00 PM, a record review of Resident #3's electronic medical record (EMR) revealed an admission on 3/11/22 with diagnoses that included impaired balance, seizure disorder and atrial fibrillation. A review of care plan the resident has a pacemaker r/t (related to) Atrial fibrillation. Date Initiated: 03/12/2022 Revision on: 03/24/2022 Goal The resident will maintain free of s/sx (signs and symptoms) of altered cardiac output through review date Date Initiated: 03/12/2022 Target Date: 12/17/2023 Interventions . Monitor/document/report to MD/Nurse PRN and s/sx of altered cardiac ouptue of pacemaker malfunction: dizziness, syncope, difficulty breathing (Dyspnea), pulse rate lower than programmed rate, lower than baseline B/P/ Date Initiated: 03/24/2022 The resident's Pacemaker information: Manufacture: Medtronic Model: . Serial # . Date implanted: 3/7/2022 . Date initiated: 03/24/2022 Revision on: 03/24/2022There was no information regarding the cardiologist managing the pacemaker. There was no information regarding the need for pacemaker checks. There was no information regarding having an electronic pacemaker machine that would read the pacemaker and ensure its function status. A record review of the miscellaneous tab in the EMR CONSULTATION APPOINTMENT SHEET Date: 4-27-22 revealed Resident #3 had been to the Pacemaker Device Clinic that day. The RESULTS OF EXAMINATION: Device (check) WNL (within normal limits) Remote scheduled 8-2-22. SERVICES RENDERED: Device (check) Please call (with) any questions r/t (related to) home monitor. The number was provided on the document. The consult sheet further read OTHER SUGGESTIONS: Please make sure monitor is connected when arrives. RETURN APPOINTMENT DATE AND TIME: 8-2-22 remote (check)

Based on observation, interview and record review the facility failed to complete consistent Activities of Daily Living (ADL) Care for six residents (Resident #3, Resident #5, Resident #15, Resident #18, Resident #27 and Resident #31), resulting in Resident #3 not receiving consistent showers, Resident #5, #15, #27 and #31 nail care and/or shaving not being completed and Resident #18's oral care not being completed. Findings Include: Resident #3: On 05/02/22 at 09:17 AM, an interview was conducted with Resident #3. The resident was observed in bed, comfortably watching television. She expressed when she initially arrived at the facility, she wasn't receiving her showers for about two months. When further queried if staff provided a bed bath instead, she started they did not. Resident #3 stated she continued to complain regarding showering, and they finally began to shower her on a regular basis. On 5/3/22 at approximately 11:15 AM, a review was completed of Resident #3's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical records yielded the following: Care Plan: Focus: The resident needs activities of daily living assistance related to: [CONDITION(S)], weakness, impaired mobility, muscle weakness . Interventions: .Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Bed Mobility: Extensive with assist of 2 staff members. Dressing: The resident requires extensive assistance with 2 staff members to dress. Review was completed of Resident #3's shower documentation from July 2021 to October 2021. Facility staff documented many refusals from the resident and there was no supporting documentation found regarding the resident's refusals and staff reapproaches. Additionally, staff documented NA on some of the entries which indicated, Not applicable. July 2021: Resident #3 was admitted on [DATE] and did not receive her first shower at the facility until 7/24/2021 (eight days after her admission). August 2021: Resident #3 refused showers on the following days: - 8/4/21, 8/7/21, 8/11/21, 8/14/21, 8/18/21 and 8/21/21. Her first shower in August was on 8/25/21 and there was no supporting documentation located regarding the six refusals, any reapproaches or having management speak to the resident regarding her continued refusals and reasons for them. September 2021: Resident #3 refused showers on the following days: - 9/11/21, 9/15/21, 9/18/21, 9/23/21, 9/25/21 and 9/29/21. There was no supporting documentation located regarding the six refusals. October 2021: Resident #3 refused showers on the following days: - 10/2/21, 10/6/21, 10/21/21 and 10/28/21 Facility staff documented NA on 10/7/2 and 10/16/21. It can be noted Resident #3 does not have a refusal care plan related to showers nor was there any subsequent documentation by staff that showed they offered more than once, offered a bed bath, or alerted their Charge Nurse, DON (Director of Nursing) or Unit Manager to the consistent refusals. There was no further follow-up on this matter by the facility that was documented in the resident's chart. On 5/3/22 at 10:00 AM, an interview was conducted the DON regarding facility practices for showering residents and refusals documentation. The DON expressed she would prefer residents received a shower rather than a bed bath. If they refuse a shower, staff should offer a bed bath and still complete a skin sheet. The DON reported staff should reapproach resident's three times after refusal of any care and document their efforts. The DON and this writer reviewed Resident #3's shower documentation from July 2021 to October 2021. It was pointed out it was documented the resident refused the majority of August 2021 and there and there was no subsequent documentation of this. It was added some of the staff are documenting NA for her showers as well. The DON expressed the resident is care planned to refuse some cares. This writer and DON reviewed the resident's care plan and there was nothing located related to her refusal of showers. The DON was further queried if showers are a consistent refusal has there been a root cause analysis as to why she refuses showers or further discussion and follow up. The DON expressed she reviewed everything and is certain the aides alert the nurses when residents refuse but there is no supporting documentation. Resident #31: During initial tour on 5/2/22 at 9:56 AM, Resident #31 was observed watching television in his room. The resident had an extremely long beard that reached his chest, his mustache covered his lips entirely and met his beard, at the chin. Resident #31 reported his mustache does make it difficult to eat soup as the particles become stuck in his beard. The resident continued he would like to his beard and mustache to be trimmed. When asked when the last time staff offered to cut his beard/mustache he reported it had been a few months since they offered this service. On 5/2/22 at approximately 4:00 PM, a review was completed of Resident # 31's record and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review was completed of Resident #5's ADL (Activities of Daily Living) charting and it indicated daily, facility staff were completing personal hygiene for the resident that included combing hair, brushing hair, shaving, applying makeup, washing/drying face, and hands. It is unknown how the charting indicated shaving was completed for the resident when she was observed to have chin hairs. Resident #15: During initial tour on 5/2/22, Resident #15 was observed resting in bed and there was multiple long (4-5 inches) and visible chin hairs on the resident. Additionally, underneath Resident #15's fingernails, (on both hands) multiple nails had a black/brown buildup underneath them. Resident #15 stated it has been a while since staff shaved her and cleaned underneath her nails. On 5/2/22 at approximately 3:45 PM, a review was completed of Resident #15's records and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 does require assistance with her personal hygiene. Resident #5: During initial tour on 5/2/22, Resident #5 was observed sitting in the Day Room watching television and drinking her coffee. She had multiple gray chin hairs that were 5-6 inches long. When questioned about the chin hairs she reported when her daughter visits, she will shave them. On 5/2/22 at approximately 3:30 PM, a review was completed of Resident #5's medical records and it revealed the resident was admitted to facility 12/4/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review was completed of Resident #5's ADL (Activities of Daily Living) charting and it indicated daily, facility staff were completing personal hygiene for the resident that included combing hair, brushing hair, shaving, applying makeup, washing/drying face, and hands. It is unknown how the charting indicated shaving was completed for the resident when she was observed to have chin hairs. Resident #27: During initial tour on 5/22/22, Resident #27, was observed resting in bed. She was observed to have visible chin hairs of varying sizes. When questioned regarding her preference she reported she would like to have them shaved but they have not offered by the staff. On 5/2/22 at 3:37 PM, a review was completed of Resident #27's medical record and it revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #27 requires assistance with her personal hygiene. Further review was completed of Resident #5's ADL (Activities of Daily Living) charting and it indicated daily, facility staff were completing personal hygiene for the resident that included combing hair, brushing hair, shaving, applying makeup, washing/drying face, and hands. It is unknown how the charting indicated shaving was completed for the resident when she was observed to have chin hairs. On 05/03/22 at 10:20 AM, this writer and the DON observed all residents with identified nail care and shaving concerns from initial tour the day prior. The following was observed: -Resident #3 was observed in her room and no longer had chin whiskers. The resident reported her daughter shaved her yesterday during her visit. -Resident #31 was observed resting in bed and still had his extremely long beard and mustache. The resident reported to the DON and this writer he would like to his mustache trimmed so he can eat soup and his beard cleaned up on the sides. -Resident #15 was observed in bed and no longer had whiskers, but her fingernails still had the same darkened substance underneath them. -Resident #27 was observed resting comfortably in bed and still had the multiple whiskers and unclean fingernails. After the observations of the residents the DON acknowledged the concern of this writer and shared the observations with the unit staff for them to address the care needs of the residents. On 5/4/22 at 12:53 PM, the DON reported they completed an audit on chin whiskers and nail care and completed the care on residents if needed at the time of the audit. Survey team member reported to the DON during the interview that they observed Resident #21 as she was eating this morning and she had dark brown/black substance underneath her pointer and index fingers. On 05/04/22 at 02:49 PM, this writer informed the Unit Manager E of the observations of the residents (#5, #15, #27 and #31) with unclean nails, unshaven beards, mustaches, and chin whiskers. Unit Manager E reported normally on shower days, nail care and shaving are completed for residents. The Unit Manager acknowledged the concern of this writer. On 5/12/22 at 4:00 PM, a review was completed of the facility policy entitled, Refusal of Treatment, implemented on 1/1/2021. The policy stated, .If a resident refuses treatment, the Unit Manager, Charge Nurse, or Director of Nursing Services will interview the resident to determine what and why the resident is refusing in order to try to address the resident's concern .Should the resident refuse to accept treatment, detailed information related to that refusal must be entered into the residents' medical record . On 5/12/22 at 4:15 PM, a review was completed of the facility policy entitled, Nail Care, implemented 1/1/2021. The policy stated, .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis . On 5/12/22 at 4:30 PM, a review was completed of the facility policy entitled, Activities of Daily Living (ADLs), revised 10/30/2020. The policy stated, The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain . grooming, and personal and oral hygiene . Resident #18: Review of the Face Sheet, Minimum Data Set (MDS, resident assessment tool dated 1/22), Care Plans dated 1/22 and Nursing Notes dated 1/22 through 4/22, revealed Resident #18 was [AGE] years-old, admitted to the facility on [DATE], was alert with confusion, dependent on staff for all Activities of Daily Living/ADL's, had muscle weakness and had his own natural teeth. The residents diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview of resident #18 was done on 5/4/22 at 12:19 p.m., he was in his room in his wheelchair with a family member with him. The resident stated to this surveyor, I have not brushed my teeth in a long, long time. Observation of the residents oral cavity revealed his teeth were yellow and had a thin shinny coating on them and his tongue was noted to be dry. Observation was made by this surveyor on 5/4/22 at 12:25 p.m., with resident and family permission of his room. This surveyor was unable to locate any toothpaste in the residents room. Three dry bristled toothbrushes in a dry baggie were found sitting in a brown paper box behind the TV. During observation and interview done on 5/4/22 at 12:54 p.m., Nursing Assistant/CNA I stated I didn't get to it today, we don't keep toothettes (soft sponge on a stick for oral care) in room (the residents room). CNA I then went and looked in the residents room for toothpaste and a toothbrush. CNA I found the three dry toothbrushes and was not able to find any toothpaste. During an interview done on 5/4/22 at 12:50 p.m., CNA/Resident Advocate H also looked in the residents room and was only able to find the three dry toothbrushes. CNA H stated I don't think there should be three toothbrushes in there, there should be one and dated and toothpaste. During an interview done on 5/4/22 at 1:00 p.m., CNA J said she had not brushed the residents teeth and stated they (residents) may not get their teeth brushed until after lunch. During record review done on 5/4/22 at 1:02 p.m., CNA H showed this surveyor the daily ADL charting that had already been done (dated 5/4/22 at 11:25 a.m.), revealing Resident #18's oral care had been documented as being completed by CNA I. The oral care box was green (color when completed) and it said yes (indicating completed). CNA I had documented she had completed Resident #18's oral care for the shift. Review of the facility Competency Skills Checklist dated 8/11/21, revealed CNA I had been checked off as competent in oral care. During an interview done on 5/4/22 at 2:30 p.m., the Director of Nursing/DON said the resident was able to answer questions and he was able to brush his own teeth with set-up. The DON stated, the residents teeth should be brushed a minimum of twice a day. Review of the facility Activities of Daily Living (ADL's) policy dated 1/1/21, stated A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE CARE AND SERVICES TO PREVENT THE DEVELOPMENT OF TWO PRESSURE SORES AND PROMOTE THE HEALING OF AN INFECTED PRESSURE SORE FOR ONE (#5) OF FOUR RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL SAMPLE OF 16 RESIDENTS RESULTING IN AN INFECTED STAGE THREE PRESSURE ULCER CAUSING DISCOMFORT AND POTENTIAL FOR CLINICAL COMPROMISE. FINDINGS INCLUDE: A REVIEW OF RESIDENT #5 CLINICAL RECORD DOCUMENTS RESIDENT #5 WAS AN [AGE] year OLD MALE RESIDENT WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #5'S ADMISSION NURSING ASSESSMENT INDICATED THE ONLY SKIN CONCERNS FOR RESIDENT #5 WERE CALLUSED AREAS ON THE RIGHT GREAT TOE AND THE LEFT FOOT. RESIDENT #5 DID NOT HAVE A PRESSURE SORE TO LEFT HIP OR RIGHT ISCHIUM UPON ADMISSION TO THE FACILITY. ON 10/26/11 BEGINNING AT 9:50 A.M. IN RESIDENT #5'S ROOM, OBSERVATION OF STAFF NURSE "4" PERFORMING DRESSING CHANGES AND TREATMENTS FOR RESIDENT #5'S PRESSURE SORES WAS DONE. OBSERVATIONS WERE MADE OF 2 PRESSURE SORES; ONE ON THE LEFT HIP AND ONE OF THE RIGHT ISCHIUM (THE LOWER AND BACK PART OF THE HIP BONE). THE PRESSURE SORE ON THE RIGHT ISCHIUM WAS NOTED WITH A REDDENDED AREA SURROUNDING THE PERIMETER OF THE WOUND WHICH MEASURED 1/2 INCH WIDE. STAFF "4" DESCRIBED THE DRESSING (WHICH WAS REMOVED/FALLEN OFF PRIOR TO OBSERVATION OF THIS TREATMENT) HAD STOOL/FECES ON IT AND WITH A FOUL SMELLING GREEN BROWN DRAINAGE ON IT. THE PRESSURE SORE ON THE RIGHT ISCHIUM WAS CLEANSED PER PHYSICIAN ORDER [REDACTED]. STAFF "4" STATED THIS WOUND HAD SHOWN IMPROVEMENTS AND DETERIORATION DUE TO INFECTIONS. ON 10/28/11 AT 9:07 A.M., AN INTERVIEW WAS CONDUCTED WITH THE DON RELATED TO RESIDENT #5'S RIGHT ISCHIUM PRESSURE SORE. THE DON STATED THAT THE "RIGHT ISCHIUM PRESSURE SORE WAS IDENTIFIED ON 7/20/11 (POST ADMISSTION) AND MEASURED 2.1 CENTIMETER(CM) BY 3.0 CM...WAS SUPERFICIAL WITH PERI WOUND PEELING AND HAD 1 TO 3 CM BOARDER...BLANCHING REDNESS, NO DRAINAGE OR WARMTH AND A PHYSICIAN ORDER [REDACTED]. (THERE WAS NO DRESSING BEING USED AT THAT TIME.) THE DON FURTHER STATED THAT ON 8/2/11, THE TREATMENT ORDER CHANGED TO EVERY OTHER DAY AND CHECK PLACEMENT EVERY SHIFT. FROM AUGUST 2-15, 2011 (13 DAYS), PER THE PHYSICIANS ORDERS THERE WERE A TOTAL OF 6 OPPORTUNITIES FOR THE DRESSING TO BE CHANGED. THE FACILITY FAILED TO PROVIDE THE WOUND CARE TREATMENT AND SERVICES AS ORDERED TWO TIMES WITHIN THIS 13 DAY PERIOD. NURSES NOTES ON 8/15/11 AT 3:30 A.M., READS, "DRESSING CHANGE TO RIGHT ISCHIUM (DATED 8/12/11), DRESSING SOAKED WITH TAN FOUL DRAINAGE. CENTER REMAINS BLACK WITH REDNESS SURROUNDING. MESSAGE LEFT ON 24 HOUR REPORT FOR WOUND CARE NURSE...". NURSES NOTES DATED 8/15/11 AT 10:25 A.M. FURTHER READS, "N.O. (NEW ORDER) CHANGE TX (TREATMENT) RT. ISCHIUM AREA: CLEANSE WITH NS (NORMAL SALINE), TOPICALLY APPLY SANTYL OINT. SKIN PREP TO PERI WOUND COVER WITH ALLEVYN...DRSG (DRESSING) BID (TWICE EACH DAY); RT ISCHIUM STAGE 3...". NURSES NOTES DATED 8/16/11 AT 7:15 A.M. READS, "...MAY OBTAIN CULTURE WOUND RT. ISCHIUM D/T (DUE TO) INCREASED WARMTH, INCREASED REDNESS, INCREASED SWELLING, INCREASED DISCOMFORT..". A PHYSICIAN ORDER [REDACTED]. THEN, ON 8/20/11, A PHYSICIAN ORDER [REDACTED]. FROM AUGUST 16-31, 2011 (15 DAYS) PER THE PHYSICIANS ORDERS, THERE WERE A TOTAL OF 32 OPPORTUNITIES FOR THE DRESSING TO BE CHANGED PER PHYSICIAN ORDER. THE FACILITY FAILED TO PROVIDE THE WOUND CARE TREATMENT AND SERVICES AS ORDERED FOUR TIMES WITHIN THIS 15 DAY PERIOD. A PHYSICIAN ORDER [REDACTED]. THEN, ON 8/20/11, A PHYSICIAN ORDER [REDACTED]. DURING THE REVIEW OF RESIDENT #5'S MEDICAL RECORD, THE physician's orders [REDACTED]. ACCORDING TO RESIDENT #5'S AUGUST 2011 MEDICATION ADMINISTRATION RECORDS (MAR), RESIDENT #5 WAS [MEDICATION NAME] MG BY MOUTH AT 8:00 A.M. AND 8:00 P.M. DAILY FROM AUGUST 20, 2011 THROUGH AUGUST 30, 2011. CONCOMITANTLY AT 8:00 A.M. THESE TEN DAYS, RESIDENT #5 WAS ALSO ADMINISTERED ONE TABLET OF MULTIVITAMINS WITH MINERALS, AS ORDERED BY THE PHYSICIAN ON MAY 10, 2011. AT 10:55 A.M. ON OCTOBER 28, 2011 IN FRONT OF THE 200 HALLWAY NURSING STATION, STAFF NURSE "8" WAS ASKED TO SHOW THE MULTIVITAMIN WITH MINERALS THAT WAS BEING ADMINISTERED TO RESIDENT #5. OBSERVED ON THIS LABELED OF "ONE DAILY MULTIVITAMINS WITH MINERALS FROM GERI CARE LABORATORY" WERE LISTED CONTENTS OF CALCIUM, IRON, MAGNESIUM AND ZINC. ACCORDING TO THE MANUFACTURER OF CIPRO,[MEDICATION NAME] TO BE ADMINISTERED AT LEAST 2 HOURS BEFORE OR 6 HOURS AFTER OTHER PRODUCTS CONTAINING EITHER CALCIUM, ZINC, IRON, MAGNESIUM, OR ALUMINUM BECAUSE OF POTENTIAL DECREASED ABSORPTION. THE FACILITY FAILED TO CHANGE WOUND DRESSINGS AS ORDERED BY PHYSICIANS, RESULTING PROLONGED TIME BETWEEN DRESSING CHANGES, AND FAILED TO ADMINISTER ANTIBIOTIC SEPARATE FROM MINERALS WHICH REDUCE THE ANTIBIOTIC'S EFFICACY RESULTING IN INCREASED SUSCEPTIBILITY TO INFECTION AND DELAYED HEALING. ( )

THIS CITATION PERTAINS TO MIOOO . BASED ON OBSERVATIONS, INTERVIEWS, AND RECORDS REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR 1 OF 5 SAMPLED RESIDENTS (#100), RESULTING IN RESIDENT #100 HAVING UNSUPERVISED WANDERING THROUGHOUT THE FACILITY AND RESULTING IN HARM TO RESIDENT #101, WITH THE POTENTIAL FOR REPEATED OCCURRENCES AND SERIOUS HARM. FINDINGS INCLUDE: REVIEW OF THE FACILITY INCIDENT REPORT AND SUMMARY DATED 3/14/11, REVEALED ON 3/12/11 AT 5:38 P.M., RESIDENT #101 CAME BACK FROM DINNER TO FIND RESIDENT #100 IN HIS ROOM. RESIDENT #101 WAS UP-SET, HE BLOCKED THE DOORWAY, STARTED YELLING AT RESIDENT #100 AND PUSHED HIM. RESIDENT #100 THEN PICKED UP A BOTTLE OF SHAMPOO AND HIT RESIDENT #101 IN THE FACE WITH IT. A NURSING ASSISTANT HEARD THE RESIDENT'S FIGHTING AND SEPARATED THEM. RESIDENT #101 HAD A "SMALL ABRASION TO BRIDGE OF NOSE AND A SMALL BRUISE TO LEFT EYE". THE REPORT REVEALED RESIDENT #101 GOT UP-SET EASILY BY WANDERING RESIDENT'S AND THE SOCIAL WORKER SPOKE TO RESIDENT #101 REGARDING HIS ACTIONS OF PUSHING RESIDENT #100. THE FACILITY ACTION WAS TO REPLACE RESIDENT #101'S DOOR GUARD (A STRIP OF MESH ATTACHED BY VELCRO TO THE DOOR, USED AS A BARRIER FOR WANDERING RESIDENT'S), STAFF STARTED SHUTTING STATION I'S (THE UNIT RESIDENT #100 WAS ON) FIRE DOORS AFTER THE EVENING MEAL AND RESIDENT #100 WAS RE-DIRECTED BACK TO STATION I WHEN FOUND ON STATION II. RESIDENT #100: REVIEW OF RESIDENT #100'S FACE SHEET, CUMULATIVE [DIAGNOSES REDACTED]. RESIDENT #100 AMBULATED THROUGHOUT THE FACILITY AND REQUIRED ASSISTANCE FOR ALL ADL'S. RESIDENT #100 HAD AN EXTENSIVE HISTORY OF ATTEMPTING TO ELOPE FROM THE FACILITY, WANDERING AND GOING IN OTHER RESIDENTS ROOMS. RESIDENT #100'S [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #100'S BEHAVIOR RAP DATED 8/4/10, STATED "RESIDENT IS PHYSICALLY ABUSIVE, VERBALLY ABUSIVE, WANDERS, AND RESISTS CARE. HE (#100) YELLS, SWEARS, HITS, KICKS, ENTERS HIS PEER'S ROOMS AIMLESSLY, AND TRIES TO EXIT THE BUILDING". REVIEW OF THE physician progress notes [REDACTED].#100) HAS ADVANCED DEMENTIA WITH PSYCHOSIS. HE GOES LIKE A BAT OUT OF HEAVEN FOR ABOUT 2 OR 3 DAYS AND THEN HE CRASHES FOR ANOTHER DAY OR TWO". REVIEW OF RESIDENT #100'S MOBILITY CARE PLAN DATED 8/5/10, STATED "NEEDS SUPERVISION WITH AMBULATION IN HALLWAYS R/T (RELATED TO) WANDERS. ESCORT AWAY FROM POTENTIAL DANGERS, OUT OF OTHERS ROOMS". REVIEW OF THE RESIDENTS BEHAVIOR CARE PLAN DATED 8/5/10, STATED "PROVIDE ACTIVITIES, RE-DIRECT RES. TO STATION I WHEN ON STATION II (DATED 2/9/11)", AND "RE-DIRECT FROM (RESIDENT #101'S ROOM)" DATED 3/14/11. REVIEW OF THE RESIDENTS WANDER CARE PLAN DATED 8/5/10, STATED "RE-DIRECT RESIDENT AS NEEDED WHEN IN OTHER RESIDENT ROOMS". REVIEW OF RESIDENT #100'S NURSE'S NOTES DATED 8/22/10 THROUGH 4/2/11, REVEALED DOCUMENTATION OF 18 ENTRIES OF THE RESIDENT IN ANOTHER RESIDENT'S ROOMS, AND SEVERAL ATTEMPTS TO ELOPE FROM THE FACILITY. OBSERVATION OF RESIDENT #100 WAS DONE THROUGH OUT THE INVESTIGATION (4/5/11 TO 4/6/11). THE RESIDENT WAS OBSERVED WALKING ON STATION I, EATING MEALS, AND IN HIS BED. THE SURVEYOR WAS UNABLE TO INTERVIEW THE RESIDENT DUE TO DECREASED COGNITION. RESIDENT #101: REVIEW OF THE FACE SHEET, MDS dated [DATE], CUMULATIVE [DIAGNOSES REDACTED].#101 WAS admitted to the facility on [DATE] FOR REHAB SERVICES, HE WAS ALERT WITH NO MEMORY LOSS, HAD INTACT MENTAL FUNCTIONING AND WAS ABLE TO MAKE DECISIONS FOR HIMSELF. THE RESIDENT WAS UNABLE TO BEAR WEIGHT, NON-AMBULATORY, USED A WHEELCHAIR AND REQUIRED EXTENSIVE ASSIST WITH ADL'S. RESIDENT #101'S [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #101'S BEHAVIOR CARE PLAN DATED 6/8/10 AND UP-DATED ON 3/14/11, REVEALED HE HAD BEEN VERBALLY ABUSIVE TO STAFF, RESISTED CARE AND STATED "REPLACE MESH DOOR GUARD WHEN GONE OR DOWN, KEEP RES. AWAY FROM (RESIDENT #100), MAY CLOSE DOOR WHEN ROOMMATE OUT OF ROOM (DATED 3/14/11)". OBSERVATION OF RESIDENT #101 AND INTERVIEW WAS DONE ON 4/5/11 (AT 9:00 A.M.) AND ON 4/6/11 (AT 10:50 A.M.). NO NOTICEABLE SIGNS OF CUTS, SCRATCHES, BRUISES, OR INJURIES TO HIS FACE WERE OBSERVED. THE RESIDENT WAS ALERT AND STATED "THIS HAS BEEN GOING ON FOR 5 TO 6 MONTHS. I CAME IN MY ROOM (ON 3/12/11) AFTER DINNER; HE (RESIDENT #100) HAD MY ROOMMATE'S SHAMPOO. I SAID "THAT'S NOT YOURS", I SHOVED HIM TRYING TO GET IT AWAY FROM HIM, AND HE STARTED HITTING ME IN THE FACE WITH THE BOTTLE, 3 TIMES. HE CUT MY NOSE AND I HAD A BLACK EYE. THE DOCTOR DIDN'T SEE ME. THE ONLY ONE WHO TALKED TO ME ABOUT IT WAS THE CHARGE NURSE. I HAD THE DOOR GUARD ON (ON 3/12/11, PRIOR TO THE INCIDENT), BUT (RESIDENT #104) TOOK IT. HE (RESIDENT #100) WAS IN MY ROOM EATING MY CANDY ON MONDAY (4/4/11). I CAME BACK FROM LUNCH AND (CNA #6) TOLD ME SHE GOT HIM OUT". AN INTERVIEW WAS DONE ON 4/6/11 AT 11:45 A.M., WITH CNA #6 (ON 4/4/11, ASSIGNED TO STATION II). CNA #6 STATED "ON MONDAY (4/4/11) AT 11:15 A.M., (RESIDENT #100) WAS WALKING IN (RESIDENT #101'S) ROOM, AND NO ONE WAS IN THE ROOM. HE TOOK SOME CANDY. THE YELLOW STRIP (DOOR GUARD) WAS UP, HE WALKS THROUGH IT. HE IS NOT TO BE ON UNIT II". REVIEW OF RESIDENT #101'S NURSING NOTES DATED 3/12/11, STATED "PT WAS VERY UPSET AND STARTED YELLING, WHEN ASKED WHAT HAPPENED, PT TOLD ME THAT HE TOLD (RESIDENT #100) TO GET OUT AND PUSHED HIM AND (RESIDENT #100) HIT HIM WITH THE SHAMPOO BOTTLE. HE SAID THE ONE RIGHT THERE AND POINTED TO ROOMMATES OVER THE BED TABLE WHERE A FULL BOTTLE OF MEN'S SHAMPOO WAS. I ASKED PT IF HIS DOOR GUARD WAS UP AND PT SAID "NO" THAT (RESIDENT #104) TOOK IT BEFORE SUPPER. HE SAID SEND THE CRAZY MAN AWAY, HOW LONG DO WE HAVE TO DEAL WITH THIS? I TOLD HIM THAT I WOULD NOTIFY THE DON AND ADMINISTRATOR. PT HAS PURPLE BRUISE ABOVE RT (RIGHT) EYE APPROX. 2 X 3 CM, BRIDGE OF NOSE 0.5 X 0.2 CM CUT, PT ALSO HAS RED MARK NEAR LT (LEFT) CORNER OF MOUTH. PT ALSO STATED THAT IF HE COULD OF REACHED (RESIDENT #100), HE WOULD OF HIT HIM HARD". REVIEW OF RESIDENT #100'S NURSING NOTES DATED 3/12/11, STATED "RES. IN (RESIDENT #101'S ROOM NUMBER). RES. (RESIDENT #101) CAME INTO HIS RM AND TOLD (RESIDENT #100) TO GET OUT AND PUSHED HIM. (RESIDENT #100) PICKED UP A BOTTLE OF SHAMPOO AND STRUCK (RESIDENT #101) IN THE FACE X 3, LEAVING SM CUT TO BRIDGE OF NOSE AND SIDE OF MOUTH". REVIEW OF NURSES NOTES DATED 3/14/11 AT 9:35 A.M., STATED "ID TEAM (INTERDISCIPLINARY TEAM) REVIEWED RESIDENT, WILL ATTEMPT TO KEEP RESIDENTS SEPARATED". AN INTERVIEW WAS DONE ON 4/6/11 AT 9:00 A.M., WITH NURSE #2 (ON 2/8/11, ASSIGNED TO STATION I). NURSE #2 REVEALED ON 2/8/11, RESIDENT #100 HAD AN INCIDENT WITH ANOTHER RESIDENT ON STATION II, AND HE WAS NOT TO BE ON STATION II PRIOR TO THE INCIDENT ON 3/12/11. NURSE #2 STATED "(RESIDENT #100) WAS IN (RESIDENT #103'S) ROOM. (RESIDENT #100) HAD (RESIDENT #103'S) GLASSES, AND THEN (RESIDENT #103) SHOVED (RESIDENT #100) IN THE MIDDLE OF HIS BACK AND WAS YELLING AT HIM. I CALLED THE ADMINISTRATOR AND DON, THEY DID NOT PUT HIM (RESIDENT #100) ON OBSERVATIONS OR CHECKS AFTER THE INCIDENT AND CURRENTLY HE IS NOT ON ANY CHECKS. (RESIDENT #103) ALREADY HAD A DOOR GUARD ON HIS DOOR AND IT WAS UP AT THE TIME. I DON'T KNOW WHO HAS DOOR GUARDS. IN OUR MINDS WE KNOW WHO HAS DOOR GUARDS, THERE IS NO LIST. AT NIGHT WE CLOSE THE FIRE DOORS ON STATION I, BUT (RESIDENT #100) CAN GET THE DOORS OPEN, EVERY NIGHT I WORK HE HAS TO BE BROUGHT BACK (FROM STATION II)". AN INTERVIEW WAS DONE ON 4/5/11 AT 2:04 P.M., WITH NURSING ASSISTANT CNA #1 (ON 3/12/11 SECOND SHIFT, ASSIGNED TO THE STATION RESIDENT #101 WAS ON). CNA #1 STATED "(RESIDENT #100) FREQUENTLY HE GOES DOWN THAT HALL (ON STATION II). THEY (MANAGEMENT) SAY THEY (RESIDENTS) CAN ROAM FREELY HERE, BUT IF THEY GO IN ANOTHER RESIDENT'S ROOM, GET THEM OUT. I DID NOT KNOW HE (RESIDENT #100) WAS NOT TO BE ON UNIT II. WE (THE CNA'S) NEED COMMUNICATION WITH OUR NURSES. NOW THEY SHUT THE DOUBLE DOORS (FIRE DOORS ON STATION I). (RESIDENT #100) STILL GETS PAST THE DOORS; HE WALKS UP AND PUSHES THE DOORS OPEN. LAST NIGHT (4/4/11, ON SECOND SHIFT) I SAW (RESIDENT #100) DOWN MY END ON STATION II. APPROXIMATELY 5 TIMES I TOOK HIM BACK (TO STATION I). SOMETIMES HE GETS COMBATIVE, YOU HAVE TO WATCH HIM. WE WERE NEVER INFORMED OR GIVEN A LIST OF RESIDENT'S WITH ROOM DOOR GUARDS. NO ONE EVER GAVE ME A ONE-ON-ONE IN-SERVICE OR EDUCATION ON ANY RESIDENT WITH BEHAVIORS. THE BEHAVIOR LOGS ARE NOT ALWAYS UP TO PAR". ON 4/5/11, THE SURVEYOR REQUESTED THE LIST OF RESIDENT'S WITH ROOM DOOR GUARDS FROM THE ADMINISTRATOR AND DIRECTOR OF NURSING. THE SURVEYOR WAS GIVEN A STICKY NOTE WITH ROOM NUMBERS OF RESIDENT'S WITH DOOR GUARDS ON IT. THE DIRECTOR OF NURSING SAID THERE WAS NO LIST OF RESIDENT'S WITH DOOR GUARDS AND SAID SHE DID NOT KNOW WHY. REVIEW OF RESIDENT #101'S STATUS SHEET (CNA CARE GUIDE) STATED, "REPLACE MESH DOOR GUARD WHEN GONE OR DOWN. MAY CLOSE DOOR WHEN ROOMMATE IS OUT OF ROOM. KEEP AWAY FROM (RESIDENT #100)", DATED 3/14/11. REVIEW OF RESIDENT #100'S STATUS SHEET STATED, "REDIRECT RES. TO STATION I WHEN ON STATION II ", DATED 1/9/11, AND "KEEP RES. AWAY FROM RES. (RESIDENT #101)", DATED 3/14/11. AN INTERVIEW WAS DONE ON 4/5/11 AT 3:15 P.M., WITH CNA #2 (ON 3/12/11, ASSIGNED TO THE STATION I). CNA #2 STATED "I WAS WITH (CNA #1), WE HEARD THE NOISE (YELLING FROM RESIDENT #101'S ROOM), WHEN WE GOT DOWN THERE, (RESIDENT #101) WAS IN THE DOORWAY, (RESIDENT #100) WAS IN THE ROOM. (RESIDENT #101) HAD SOME BLOOD ON THE BRIDGE OF HIS NOSE. I HAVE SEEN (RESIDENT #100) DOWN STATION II. ON 4/4/11 AT ABOUT 7:00 P.M. TO 7:30 P.M., HE WAS ON STATION II; HE KNOWS HOW TO OPEN THE DOORS (FIRE DOORS ON UNIT I). THERE WAS A SIGN PUT UP PRIOR TO 3/12/11 ON THE EMPLOYEE BACK DOOR INFORMING US TO KEEP (RESIDENT #100) AND (RESIDENT #101 ROOM) SEPARATED. IT SAID KEEP (RESIDENT #100'S ROOM NUMBER) AND (RESIDENT #101'S ROOM NUMBER) SEPARATED". ON 4/5/11 THE SURVEYOR ASKED THE ADMINISTRATOR IF THERE WAS A SIGN PUT UP ON THE EMPLOYEES BACK DOOR INFORMING STAFF TO KEEP RESIDENT'S #100 AND #101 SEPARATED PRIOR TO 3/12/11, AND SHE SAID "NO". ON 4/5/11, THE ADMINISTRATOR GAVE THE SURVEYOR A TYPED SIGN THAT STATED "ALL DOOR GUARDS MUST BE UP AT ALL TIMES. WE MUST REDIRECT (RESIDENT #100'S ROOM NUMBER) AWAY FROM STATION 2 EVERY TIME THAT ANYONE SEES HIM IN THAT DIRECTION. DOOR GUARDS MUST BE UP EVEN WHEN THE RESIDENT IS NOT IN THE ROOM". THE ADMINISTRATOR SAID THE SIGN WAS POSTED IN THE HALLWAY BY THE BACK DOOR ON "3/13/11". THE SURVEYOR WAS UNABLE TO INTERVIEW THE MANAGER OF UNIT II, AFTER SEVERAL ATTEMPTS PER PHONE. AN INTERVIEW WAS DONE ON 4/5/11 AT 2:30 P.M., WITH NURSE #1 (ON 3/12/11, SECOND SHIFT ASSIGNED TO UNIT II). NURSE #1 STATED "I GOT THE PAGE OVERHEAD AND I WENT DOWN TO STATION II. IT WAS ALL OVER BY THEN. I WENT TO (RESIDENT #101'S) ROOM; HE WAS UP-SET, YELLING, VERY UP-SET AND TOLD ME WHAT HAPPENED. HE TOLD (RESIDENT #100) TO GET OUT OF HIS ROOM AND PUSHED HIM, AND (RESIDENT #100) HIT HIM WITH A SHAMPOO BOTTLE. THE DOOR GUARD WAS MISSING; I KNEW IT WAS SUPPOSE TO BE UP. HE SAID (SAMPLED RESIDENT #104) HAD TAKEN IT. SHE DOES THAT A LOT; SHE WANDERS IN OTHER RESIDENT'S ROOMS TOO. (THE MANAGER OF UNIT II) AND THE DON (THE ADMINISTRATOR AT THE TIME OF THE INVESTIGATION) PUT UP A MEMO NOT TO LET (RESIDENT #100) ON OR NEAR STATION II BEFORE 3/12/11, IT WAS ALSO ON THE CNA CLIP BOARD AT THE DESK AND ON THE EMPLOYEES ENTRANCE DOOR. I REMEMBER IT WAS THERE, I DON'T KNOW WERE IT WENT". INTERVIEWS WERE DONE ON 4/5/11 (AT 9:10 A.M. AND 9:15 A.M.) AND ON 4/6/11 (AT 9:40 A.M.) WITH CNA #4, CNA #5 AND AN ACTIVITY AIDE. THEY REVEALED RESIDENT #100 OFTEN GOES TO UNIT II, IS OFTEN FOUND IN OTHER RESIDENT'S ROOMS, HE PUSHES OPEN THE FIRE DOORS ON UNIT I WITHOUT ANY PROBLEMS. THE ACTIVITY AIDE REVEALED RESIDENT #100 GOES ON UNIT II "ALMOST DAILY, IN THE MORNING, AFTERNOON AND EVENING". AN INTERVIEW WAS DONE ON 4/5/11 AT 11:55 A.M., WITH THE SOCIAL WORKER (SW). THE SW SAID ALL RESIDENT'S COULD "WANDER THROUGHOUT THE FACILITY FREELY". STAFF WAS MADE AWARE OF (RESIDENT #101'S) NOT WANTING (RESIDENT #100) IN HIS ROOM PRIOR TO 3/12/11. I DID NOT DO ONE-ON-ONE TEACHING WITH STAFF ABOUT WANDERERS". THE SW DENIED SHE INTERVIEWED EITHER RESIDENT AFTER THE INCIDENT ON 3/12/11, LOOK AT RESIDENT #101'S INJURIES, OR TALKED WITH THE RESPONSIBLE PARTIES OR PHYSICIANS. AN INTERVIEW WAS DONE ON 4/6/11 AT 8:10 A.M., WITH THE MDS NURSE. THE MDS NURSE CONFIRMED RESIDENT #101'S PHYSICIAN DID NOT SEE HIM AFTER THE INCIDENT ON 3/12/11 TO EVALUATE HIS INJURIES AND HE HAD A DOOR GUARD WAS IN PLACE PRIOR TO 3/12/11. THE MDS NURSE ALSO CONFIRMED RESIDENT #100 HAD NEVER BEEN PUT ON ANY WHEREABOUTS OR BEHAVIORAL CHECKS, AND A SIGN WAS PUT ON THE BACK ENTRANCE DOOR INSTRUCTING STAFF TO REDIRECT HIM BACK TO STATION I, PRIOR TO 3/12/11. THE MDS NURSE WAS UNABLE TO LOCATE INSTRUCTIONS TO CLOSE STATION I'S FIRE DOORS AFTER DINNER IN RESIDENT #100'S CLINICAL RECORD, CARE GUIDE, AT THE NURSES STATIONS, ON THE CNA CLIP BOARDS, OR ON THE EMPLOYEES BACK ENTRANCE DOOR. THE MDS NURSE STATED "HE (RESIDENT #100) GETS THROUGH THE DOORS AND THEY HAVE TO BRING HIM BACK". AN INTERVIEW WAS DONE ON 4/5/11 (AT 12:50 P.M.) AND ON 4/6/11 (AT 9:25 A.M.), WITH THE DIRECTOR OF NURSING (DON), THE ASSISTANT DIRECTOR OF NURSING ON 3/12/11. THE DON REVEALED SHE DID NOT INTERVIEW EITHER RESIDENT (#100 OR #101), LOOK AT RESIDENT #101'S INJURIES, TALK WITH THE RESIDENT'S RESPONSIBLE PARTIES, OR TALK WITH THE RESIDENT'S PHYSICIAN AFTER THE INCIDENT ON 3/12/11. THE DON SAID SHE DID NOT REMEMBER DISCUSSING THE INCIDENT ON 3/12/11 IN THE BEHAVIOR MEETING, BUT SHE WAS "IN AND OUT" OF THE MEETING. THE DON WENT THROUGH THE NURSING POLICY AND PROCEDURE BOOK FROM STATION I AND WAS UNABLE TO LOCATE POLICIES REGARDING WANDERING RESIDENTS, ROOM DOOR GUARDS, OR CLOSING THE FIRE DOORS TO KEEP WANDERING RESIDENT'S ON THEIR STATIONS. THE DON SAID A WANDERING RISK AUDIT HAD NOT BEEN DONE FOR RESIDENT #100. THE DON STATED "HE (RESIDENT #100) GETS ON STATION II, BUT ONLY ABOUT 4 TIMES" SINCE THE INCIDENT ON 3/12/11. THE DON AGREED RESIDENT #100 COULD EASILY OPEN THE FIRE DOORS, THE DOOR GUARDS DID NOT STOP HIM FROM ENTERING OTHER RESIDENT'S ROOMS, HE CONTINUED TO WANDER INTO OTHER RESIDENT'S ROOMS AFTER 3/12/11, IT WAS NOT SAFE FOR HIM TO WANDER ABOUT THE FACILITY, NO WHEREABOUTS OR FREQUENT OBSERVATION CHECKS HAD BEEN DONE ON THE RESIDENT, AND HE HAD A KNOWN HISTORY OF WANDERING THE FACILITY AND GOING INTO OTHER RESIDENT'S ROOMS. REVIEW OF THE FACILITY WANDERING RISK AUDIT TOOL DATED 10/23/07 ADDRESSED THE QUESTIONS, DID THE RESIDENT HAVE " MEANINGFUL ACTIVITIES PROVIDED " , DID THEY HAVE A " SAFE AREA TO MOVE ABOUT " , AND WAS THE " WHEREABOUTS OF THE RESIDENT FREQUENTLY MONITORED " . AN INTERVIEW WAS DONE ON 4/5/11 AT 1:25 P.M., WITH THE FACILITY ADMINISTRATOR AND THE DIRECTOR OF NURSING AT THE TIME OF THE INCIDENT ON 3/12/11. THE ADMINISTRATOR REVEALED SHE RECEIVED A PHONE CALL AT HOME ON 3/12/11 FROM CHARGE NURSE #1 INFORMING HER 2 NURSING ASSISTANTS HEARD YELLING FROM RESIDENT #101'S ROOM, AND WHEN THEY GOT TO HIS ROOM, RESIDENT #100 HAD PICKED UP A SHAMPOO BOTTLE AND HIT RESIDENT #101 IN THE FACE WITH IT. THE ADMINISTRATOR SAID SHE LOOKED AT RESIDENT #101'S FACE WHEN SHE CAME INto the facility on [DATE], AND HE HAD "A SCRATCH ACROSS HIS NOSE AND BRUISING STARTING IN THE CORNER OF HIS RIGHT EYE AND HALFWAY UNDER THE EYE". SHE SAID HIS PHYSICIAN DID NOT SEE HIM REGARDING HIS INJURIES, AND NO DRESSING OR TREATMENT WAS DONE TO HIS RIGHT EYE OR HIS CUT ON HIS NOSE. THE ADMINISTRATOR STATED "(RESIDENT #100) NEVER HAD ANY PROBLEMS PRIOR WITH (RESIDENT #101)", AND CLOSING THE FIRE DOORS ON STATION I WAS EFFECTIVE, RESIDENT #100 HAD NOT BEEN ON STATION II SINCE THE INCIDENT ON 3/12/11. THE ADMINISTRATOR REVEALED RESIDENT #100 HAD A SIMILAR PROBLEM WITH ANOTHER RESIDENT (SAMPLED RESIDENT #103) ON 2/8/11. THE ADMINISTRATOR AGREED AFTER THE INCIDENT ON 3/12/11, NEITHER RESIDENT SAW PHYSICIANS, OR WERE INTERVIEWED BY THE SOCIAL WORKER. THE ADMINISTRATOR ALSO REVEALED STAFF WAS NOT IN-SERVICED ON RESIDENT WANDERERS, OR RESIDENT'S #100 OR #101'S BEHAVIORS AFTER THE INCIDENT ON 3/12/11, AND MONITORING THE WHEREABOUTS OF RESIDENT #100 WAS NOT DONE. WHEN THE SURVEYOR ASKED THE ADMINISTRATOR HOW RESIDENT #100 GOT PAST RESIDENT #103'S ROOM TO RESIDENT #101'S ROOM ON 3/12/11, WHEN HE WAS CARE PLANNED NOT TO BE NEAR RESIDENT #103'S ROOM, NO ANSWER WAS GIVEN. THE ADMINISTRATOR WAS UNABLE TO LOCATE ANY DOCUMENTATION REVEALING RESIDENT #101 SAW A PHYSICIAN DUE TO THE INJURIES TO HIS FACE THAT OCCURRED ON 3/12/11. AN INTERVIEW WAS DONE ON 4/6/11 AT 11:00 A.M., WITH A NON-SAMPLED ALERT RESIDENT ON UNIT II. THE RESIDENT STATED "HE (RESIDENT #100) STANDS AT MY DOOR; HE COMES IN MY ROOM TOO. TODAY (4/6/11) WHEN I WAS GOING DOWN TO BREAKFAST AFTER 7:00 A.M., I TALKED TO THE AIDES ABOUT IT". THE RESIDENT TOLD THE SURVEYOR WHEN RESIDENT #100 ENTERS HER ROOM SHE GETS SCARED. AN INTERVIEW WAS DONE ON 4/6/11 AT 11:15 A.M., WITH THE PRESIDENT OF THE RESIDENT'S COUNCIL. THE PRESIDENT OF THE RESIDENT'S COUNCIL REVEALED THERE WERE SEVERAL RESIDENT'S AT THE FACILITY AT THE TIME OF THE SURVEY WHO WANDERED INTO OTHER RESIDENT'S ROOMS, AND MEMBERS OF THE RESIDENT'S COUNCIL HAD TALKED TO THE ADMINISTRATOR AND THE NURSES ABOUT THE PROBLEM. AN INTERVIEW WAS DONE ON 4/6/11 AT 12:15 P.M., WITH AN ALERT RESIDENT ON STATION I. THE RESIDENT STATED "HE (RESIDENT #100) OPENS THE DOOR GUARD AND COMES IN MY ROOM, OR GOES UNDER IT. ABOUT 2 DAYS AGO (ON 4/4/11), I WAS SLEEPING AND HE CAME IN MY ROOM. I TOLD HIM TO GET OUT. I COMPLAINED ABOUT IT IN THE RESIDENT'S COUNCIL MEETING". REVIEW OF THE FACILITY RESIDENT COUNCIL MEETING MINUTES DATED 9/2/10 THROUGH 3/15/11, REVEALED SEVEN CONSECUTIVE MONTHS OF DOCUMENTED CONCERNS FROM RESIDENT'S REGARDING OTHER RESIDENT'S WANDERING INTO THEIR ROOMS. REVIEW OF RESIDENT COUNCIL CONCERN FORM DATED 9/21/10, STATED "RESIDENT (RESIDENTS ROOM NUMBER) AND (SECOND RESIDENTS ROOM NUMBER) SAID RESIDENTS ARE COMING IN THEIR ROOMS, DOOR GUARD WAS MISSING". REVIEW OF RESIDENT COUNCIL CONCERN FORM DATED 10/27/10, STATED "RESIDENT'S THAT ATTENDED MEETING ALL AGREE ABOUT WANDERING RESIDENT'S IN THEIR ROOMS". REVIEW OF RESIDENT COUNCIL CONCERN FORM DATED 12/27/10, STATED "RESIDENT (RESIDENT'S ROOM NUMBER) STATES THAT (SECOND RESIDENT'S ROOM NUMBER) IS ENTERING HIS ROOM IN HIS WHEELCHAIR (W/C) THROUGHOUT THE DAY AND EVENING". REVIEW OF RESIDENT COUNCIL CONCERN FORM DATED 11/19/10, STATED "RESIDENT (RESIDENT ROOM NUMBERS, INCLUDED RESIDENT #100) WANDERING TO STATION II BY (RESIDENT ROOM NUMBER) ROOM LATE AT NIGHT TRYING TO GET OUT EXIT, SETTING OFF ALARM. STAFF WILL TRY TO REDIRECT RES. BACK TO STATION I". REVIEW OF RESIDENT COUNCIL CONCERN FORM DATED 2/17/11 (PRIOR TO INCIDENT ON 3/12/11), STATED "RESIDENT'S ARE CONCERNED ABOUT PEOPLE WANDERING INTO THEIR ROOMS AND THE POSSIBILITY OF ALTERCATIONS". REVIEW OF RESIDENT #101'S CLINICAL RECORD REVEALED NO DOCUMENTATION OF A PHYSICIAN ORDER [REDACTED]. REVIEW OF THE FACILITY REPORTING/RESPONSE PROGRAM AND POLICY (UN-DATED) PAGE 20 STATED, "SOCIAL SERVICES WILL PROVIDE FOLLOW UP COUNSELING WITH THE ABUSED RESIDENT". REVIEW OF THE FACILITY PREVENTION PROGRAM AND POLICY (UN-DATED) PAGE 11 STATED, "PHYSICAL PRESENCE CHECKS ARE INSTITUTED ON RESIDENTS EXHIBITING EXACERBATION OF BEHAVIORS WHICH MAY ELICIT OR PRECIPITATE AN ABUSIVE RESPONSE". REVIEW OF THE FACILITY BEHAVIOR PROGRAM (UN-DATED), STATED "OUR PURPOSE IS TO GAIN A BETTER UNDERSTANDING OF OURSELVES AND OUR RESIDENTS, IMPROVE INTERACTIONS AND EMPLOY EFFECTIVE WAYS FOR MANAGING BEHAVIORS. AN IN-DEPTH ASSESSMENT OF ANY RESIDENT BEHAVIOR IS REQUIRED TO DETERMINE IF THERE IS A CAUSE FOR THE BEHAVIOR THAT FACILITY INTERVENTION CAN PREVENT A POTENTIALLY NEGATIVE OUTCOME". REVIEW OF THE FACILITY ABUSE PROHIBITION PROGRAM (UN-DATED) PAGE 2 STATED, "MANAGEMENT AND SUPERVISORY STAFF ARE TRAINED TO IDENTIFY, CORRECT AND INTERVENE IN SITUATIONS IN WHICH RESIDENT RIGHTS ARE MOST APT TO BE VIOLATED". REVIEW OF THE FACILITY MANDATORY ABUSE IN-SERVICE DATED 3/10/11, TRAINING MANUAL STATED, "ALL PATIENTS HAVE A RIGHT TO BE FREE FROM ABUSE". REVIEW OF THE FACILITY SUMMARY OF THE INCIDENT DATED 3/12/11, STATED "AFTER INVESTIGATION WAS CONCLUDED THERE IS NO SUBSTANTIATED EVIDENCE OF ABUSE, NEGLECT OR MISTREATMENT", SIGNED BY THE DIRECTOR OF NURSING (THE ADMINISTRATOR AT THE TIME OF THE INVESTIGATION). ( )