Every finding on record at Medilodge of Tawas City

Based on interview and record review, the facility failed to ensure that two residents (Resident #9 and Resident #72) were adequately supervised to prevent falls out of 5 residents reviewed for falls, resulting in the likelihood of a fear of falling, skin tears, head injuries with hospitalization and repeated individual falls. Resident #9: Record review of the facility provided CMS-802 'Resident Matrix' identified Resident #9 as had a fall with injury. An observation and interview on 09/10/2025 at 10:19 AM with Resident #9 revealed that she was laying on the top of her bed with the room partition/privacy curtain pulled so that the resident could not be observed from the doorway of the room. Resident #9 stated that she did have a fall at her closet but could not recall when the fall had occurred. Resident #9 stated that she did have a broken arm from the fall and tailbone pain. identified a fall with major injury and resident stated that she had a fall at her closet. In an observation on 09/11/2025 at 10:34 AM, Resident #9 was noted to be lying in bed with the room partition curtain pulled between beds and the resident was not able to be seen from the hallway. Resident #9's legs and feet are off the bed, and she has taken her shoes off with no grippy socks noted. Shoes at bedside. Observation on 09/12/2025 at 10:36 AM- resident observed up in activity sitting outside in the sun on back patio area with 6 other residents and a volunteer. Resident appears a sleep and leaning to the left of WC. An interview and record review was conducted on 09/12/2025 at 11:30 AM with the Director of Nursing regarding Resident #9's repeat falls: Fall on 3/4/2025 fall with Fractured wrist and pelvis. Record review of Resident #9's 'Un-witnessed Fall' form dated 3/4/2025 at 5:45PM the Resident #9 was found on the floor by CNA in resident room. Resident #9 was then Hoyer-lifted off the floor. pain was noted, 2 days later she was sent to the ER hospital- x-rays of fractured wrist and pelvis. The state surveyor asked if the incident was reported to the state as it was an unwitnessed fall. DON did not know and referred the surveyor to the Nursing Home administrator. Observed on Floor fall on 4/22/2025 at 7:50PM Resident #9 was found on the floor in her room between her bed and wheelchair. Observed on Floor fall on 7/4/2025 at 00:20AM resident was observed to be lying on the floor on her stomach with a left side of her head resting on the floor with a laceration. Resident was not wearing any footwear. Resident complained of being very dizzy and did not feel good Sent to emergency room to be evaluated. Resident #9 received 2 sutures to the scalp laceration Record review of Resident #9's Care Plans pages 1-36 for updated fall interventions with the Director of Nursing revealed that there were no new interventions added to the fall/injury care plan after the 7/4/2025 fall with laceration to the head. Record review of Resident #9's 'Emergency Department provider Notes dated 3/6/2025 revealed: [AGE] year-old female who was sent in from her nursing home for treatment of a distal radius fracture on the left. Approximately 2 days ago the patient had a slip and fall at the facility and was having left shoulder and wrist discomfort there is bruising on the wrist and hand. they did x-ray and it showed a commuted fracture of the distal metaphysis of the radius, so they sent her in. In the Emergency Department she is also complaining of pain in the hand and also thinks her fingers might be broken as well, and she is also complaining of pain in the tailbone. CT scan exam revealed mildly displaced fracture of the right superior pubic ramus, mildly displaced fracture of the inferior pubic ramus on the left. In an interview on 09/12/2025 at 12:43 PM with the Nursing Home Administrator in regard to Resident #9's fall with fractures revealed that the facility did not report/turn in the fall with fractures (wrist/Pelvis) because the resident was her own person and she told the facility what happened. Resident #70: Record review of the facility provided CMS-802 'Resident Matrix' identified Resident #9 as had a fall with injury. Observation and interview on 09/10/2025 at 12:22 PM with Resident #70 revealed him to be lying in bed in the dark. Resident #70 was awake and complained of headache. Resident #70 stated that He did have a fall but could not state if it happened in the resident room but that his head got sewed up. Record review of Resident #70's 3-month fall/incident report look back revealed fall had occurred. Fall on 6/2/2025 at 8:45AM was a witnessed fall resulting in laceration to the head from fall off the bed with certified nurse assistant in the room. Fall resulted in laceration to the head and right elbow skin tear. Miami-J collar applied at the facility and sent to the hospital due to use of daily blood thinners with possible head injury. Fall on 6/4/2025 at 2:45PM un-witnessed fall in resident's room. Found on floor next to bed and the wheelchair next to him. No injury noted. Fall on 7/8/2025 at 1:55AM un-witnessed fall resulting in laceration to the head. Upon assessment staff noticed a puddle of blood, went and pulled the call light out of the wall to get assistance and grabbed some wet towels and applied pressure to his right eyebrow to help stop the bleeding. sent to emergency room for sutures to close laceration. Fall on 8/12/2025 at 5:50PM witnessed fall of resident toppled forward of the bed and hit his forehead. Fall report noted resident was getting up for meal and was observed to be lying on his back and crying that he had fallen and his forehead hurt. Root cause: sitting on edge of bed unattended. In an interview and record review on 09/12/2025 at 11:44 AM with the Director of Nursing (DON) regarding Resident #70's repeat falls with head injuries and blood thinner usage. The fall/injury related to generalized weakness, Lennox-Gastaut Syndrome, Cervical fracture and myelopathy car plan was reviewed with the DON. The DON acknowledged that there could be more interventions for prevention of falls. Resident #72: Review of Face Sheet, care plans dated 1/24, and Minimum Data Set (MDS), revealed Resident #72 was [AGE] years old, admitted to the facility on [DATE], was extremely confused with staff assistance required for all Activities of Daily Living/ADL's and had a history prior to admission and at the facility of falls. The residents diagnosis included, Dementia, stroke, malnutrition, depression, cognitive communication deficit, unsteadiness on feet, muscle weakness, and repeated falls (at home and facility). Observation was made on 9/10/25 at 12:40 p.m., of the resident on the Homestead Unit (Dementia unit) sitting in the day room. She had a thick crust of dried blood over her left eyebrow approximately 1 inch in length. The resident was unable to be interviewed due to decreased cognition and communication deficit. Review of the residents facility care plans dated 1/24, revealed she was unsteady, required one staff assist for all transfers and observation when in wheelchair, staff were to supervise closely with increased anxiety, and said she was impulsive and had a history of falls. Review of the facility nursing notes dated 8/14/25, stated Resident had witnessed fall in homestead dining area. She was running and tripped over her feet. Skin tear noted to left eyebrow, left side of nose, and left middle finger. Review of Hospital records dated 8/14/25, stated [AGE] year-old female with a history of dementia presents to the emergency department (ED) by ambulance for a fall, patient fell out of her wheelchair at the nursing home. The ED treated an abrasion to bridge of nose and laceration repair to left eyebrow area. During an interview done on 9/12/25 at 9:22 a.m., Nursing Assistant/CNA P stated She is not supposed to get up, we just keep a close eye on her. She does walk and run but now she is unsteady so we keep a close eye on her. We usually have 3 CNA's and a nurse on days. Review of Resident #72's Prior Fall's at Facility per Nursing Notes and Incident/Accident Reports: -On 12/23/24: Resident was running down hall and tripped and fell. The resident received a head injury from fall. Resident was sitting with another resident when they said something that upset her and she started to get anxious and pace back and forth down the hallway, she ran then went to sit back down and back up and started running down the hallway and tripped and fell and hit the left side of her face. This fall resulted in a head injury. -On 3/20/24: Resident was witnessed bending over to pick up crumb on floor and slowly leaned forward and fell, was laying near frig on left side. Bump on left side of head. She had been pacing in hall after dinner. This fall resulted in skin tear to left elbow and she hit her head. -On 4/14/25: Resident was sitting in dining area in a chair and slipped out of chair onto the floor, no injuries occurred with this fall. -On 5/7/25: Resident was standing in the dining area with other peers and staff when I looked away to check the computer and I heard a thud. I looked over and (Resident #72) is on the floor. Her back and head hit the floor the door when she fell. The resident had just had a shower and was standing in the day room; she had weakness after her shower. The resident hit her head on the door and floor. -On 6/5/25: Resident ambulating in hall when staff member noted resident was on buttocks in hallway. -On 6/8/25: Called to residents room, resident observed laying on her back next to her bed-CNA (Nursing Assistant) was behind her. CNA caught resident upper torso and managed to lower her to floor-resident was incontinent of bowel at the time of fall. -On 7/17/25: The resident was self-propelling in w/c (wheelchair) and then stood up while catching her pant pockets on the w/c causing her to lose her balance and fall to the floor. During an interview done on 9/12/25 at 8:55 a.m., CNA P stated We are to keep an eye on her, she gets upset and gets out of her wheelchair and runs. During an interview done on 9/12/25 at 9:00 a.m., Activity Aide Q stated She can get up and run, when ever she feels like she has the erg, she gets up and runs. She has had quite a few falls, we all just try to keep an eye on her. During an interview done on 9/12/25 at 9:32 a.m., Nurse, RN B stated She gets agitated and gets up and runs, if you tell her no, she gets agitated. She bangs on windows, and runs. Yes, she has had a lot of falls. The unpredictability of her response. We need to distract her when she is agitated. During an interview done on 9/12/25 at 9:37 a.m., CNA R stated She does get up in run, we sit with her and do one-on-one with her. We can tell when she starts getting agitated, she starts mumbling, her hands and fingers start going, and she tries getting up. During an interview done on 9/12/25 at 9:56 a.m., Infection Control/Nurse Manager, RN C stated We do have a fall/IDT committee, we have clinical daily, new behaviors, and falls and monthly (are reviewed by committee). I was in the dining area passing pills (regarding the fall on 8/14/25), I was looking at the computer and I heard the staff member say slow down [NAME] and then she fell in the dining room between two tables, she can get going pretty fast. We just need to come up a better plan of care. During an interview done on 9/11/25 at 11:26 a.m., the Director of Nursing/DON stated yes, there is an issue (with residents repeated falls at the facility), but she is impulsive; that's why her (Family Member) put her here. The DON said the facility was aware of the residents impulsiveness, increased anxiety when she gets upset and repeated falls. Review of the Facility Fall policy dated 11/2/2023, stated As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. Based on the assessment an initial plan of care will be developed and implemented to address identified risks. This will be revised as necessary. If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. Post fall analysis items to be considered (not all inclusive): The nurses notes Review for med changes in the last 30 – 90 days Review previous lab findings Review for other acute clinical changes Review staff and witness statements (to include last time resident seen, provided care, and what type of care) Review of care plan and CNA assignments/Kardex that were in place at time of fall Observe any equipment involved (i.e. wheelchair, bed, commode, shower chair, etc.) Observations of the resident's room or area of fall Reenactment

Based on interview, and record review the facility failed to implement and operationalize a comprehensive Antibiotic Stewardship Program including documentation and treatment for three residents (#31, #35, and #44) of three residents reviewed for antimicrobial treatment and the potential to affect all facility residents by means of unnecessary and inappropriate antibiotic and antimicrobial medication utilization, antibiotic resistance, and ongoing infection.Findings include:An interview and review of facility Infection Control (IC) and antibiotic utilization data was completed on 9/12/25 at 12:24 PM with IC Registered Nurse (RN) C. When queried what criteria the facility utilizes for antibiotic use and infections, IC RN C replied, McGeer (standardized criteria providing guidelines for antibiotic use). A review of the facility lC documentation for October 2024 was completed. The Monthly line listing documentation provided did not specify if the infection being treated with an antimicrobial medication met McGeer criteria. The IC Monthly Analysis and Summary for October 2024 included a section entitled, Antibiotic Stewardship. The section detailed, Antibiotic Use Reported to Prescribing Providers. Printed off and given to provider. The monthly analysis did not specify if any infections did not meet McGeer criteria. When queried how they were monitoring antibiotic use to ensure residents do not receive unnecessary treatment and receive treatment with the appropriate antimicrobial medication, IC RN C revealed the computer system identifies if an infection meets McGeer criteria when they enter the information. When queried if any of the listed infections did not meet criteria for treatment, IC RN C revealed they were not sure. IC RN C was asked what the Antibiotic Use Report provided to the Health Care Provider was and provided a list of antibiotics prescribed during the month. The provided list did not specify if the antimicrobial agent meet criteria for treatment. Review of the October 2024 line list revealed Resident #92 was listed twice for both a current and carryover infection. The information on the line list for the carry over infection specified, the Resident had a Healthcare-associated Urinary Tract Infection (UTI) with an onset date of 9/28/24 and resolved date of 10/12/24. The Resident received cephalexin (antibiotic) but the causative organism was not identified on the line list. When queried if Resident #92's infection met McGeer criteria. IC RN C indicated they did not know. When asked if the Resident had a urinalysis (UA) with Culture and Sensitivity (C&S), IC RN C stated, There was no (microorganism) growth. When queried if the antibiotic was stopped when the UA showed no growth, IC RN C reviewed the Resident's Electronic Medical Record (EMR) and revealed the antibiotic was continued. When queried regarding documentation that the antibiotic use was addressed with the Health Care Provider, IC RN C was unable to provide documentation. Resident #92 was included on the line list for a new infection in October. The line list specified Resident #92 was treated with Daptomycin, Daptomycin (antibiotic used to treat complicated bacterial infections). The General Comments sections specified, MRSA (Methicillin-resistant Staphylococcus aureus- antibiotic resistance bacteria) is right dialysis port. Resident is to receive IV (Intravenous) Vanco (antibiotic) and daptomycin at dialysis. When queried regarding the wound C&S and causative organism, IC RN C revealed the Resident went to the hospital on [DATE] and returned with the antibiotic orders. IC RN C revealed the C&S is most likely in the hospital records, but they did not have the information readily available in their IC tracking. Review of facility provided policy/procedure entitled, Antibiotic Stewardship Program (Reviewed/Revised: 12/13/23) revealed, Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Resident #31: Observation, interview and record on 9/10/2025 at 10:10AM estimated of Resident #31 during the initial screening process of the annual recertification survey the resident was verbal with confusion and could not recall having a urinary tract infection. Record review of Resident #31's 8/6/2025 Minimum Data Set (MDS) identified the resident with a Brief Interview of Mental status (BIMs) of 4 out of 15, severe cognitively impaired. Record review on 09/10/2025 at 2:34 PM of Resident #31's urology office visit note dated 7/9/2025 noted hematuria (blood in urine) and urinary tract infection. Ordered Macrobid 100mg capsule oral, one tablet twice daily for 30 capsules. Record review on 09/10/2025 at 2:39 PM of Resident #31's July Medication Administration Record (MAR) revealed that the resident received an antibiotic Macrobid 100mg twice daily for 15 days for UTI (Urinary Tract Infection). The antibiotic Macrobid was started on 7/10/2025 through 7/25/2025 twice daily orally. Record review of the facility July 2025 'Antibiotic Dispensed' report dated 7/1/2025-7/31/2025, noted Resident #31 received Macrobid 100mg capsule by mouth two times a day for UTI until 7/25/2025. Record review of the facility July 2025 'Antibiotic line Listing' form noted Resident #31 was admitted on [DATE] developed a urinary tract infection was treated with Macrobid 100mg oral for 15 days. Organism was noted as 'Null'. In an interview and record review on 09/11/2025 at 2:38 PM with Registered Nurse/Infection Control Preventionist C in regard to Resident #31's urinary Tract Infection in July 2025 revealed RN C to review the record and stated the urinary Tract Infection onset/start was 7/10/25 with signs/symptoms from urologist office visit and the urine came back positive, the urologist placed resident (#31) on Macrobid 100mg BID x15days. The state surveyor inquired about what organism was being treated. RN C stated that the urologist office did not identify an organism, and the facility did not do a Culture and Sensitivity (C&S). There was no risk vs benefit from physician found for medication of antibiotic with no culture within the medical record. RN C stated that there was not one done. Resident #35: In an interview and observation on 09/12/2025 at 9:42 AM with Resident #35 revealed that she does not want to go to the dining room and does not like the foods. During the interview Resident #35 was observed to get up from the bed and walked to the restroom and shut the door and in a few moments came back to lie on the bed. Resident #35 stated that she has been having bladder problems lately and was taking pills for it. Record review of Resident #35's progress notes dated 9/8/2025 at 9:30AM noted: 9/3/25 UA (urinalysis) positive UTI (Urinary Tract Infection). NP (Nurse Practitioner) aat facility. New order for Macrobid 100mg BID (twice daily) time 5 days. No organism was identified in the progress notes. Progress notes dated 9/10/2025 and 9/11/2025 noted Resident #35 complained of loose stools. (Side effect of antibiotic medication) Record review of Resident #35's electronic medical record revealed that there were no culture and sensitivity (C&S) found within the medical record. In an interview and record review on 09/11/2025 at 2:38 PM with Registered Nurse/Infection Control Preventionist C in regard to Resident #35's recent Urinary tract infection revealed: Registered Nurse C stated that the urinary infection started 9/3/25 when the facility urine sample for analysis was sent out for a Kidney/blood pressure appointment and it came back positive, and we have not received a culture back from the office yet. RN C stated that Yes, antibiotic was started with no organism known. It was Macrobid 100mg BID (twice daily) for 5days. Resident #35 would finish the antibiotic on 9/13/2025. RN C was asked about a facility risk vs benefit from physician and that none was found for the antibiotic medication with no organism or culture. RN C stated that there were no risk vs benefit statements for the residents because she was unsure of what to do when there is antibiotic use with no organism identified. Resident #44: Record review of Resident #44's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental status of 2 out of 15, severe cognitive impairment. Medical diagnosis included: atrial fibrillation, hypertension, renal insufficiency, arthritis, hemiplegia/hemiparesis, malnutrition, and stroke. In an interview and record review on 09/11/2025 at 2:38 PM with Registered Nurse/Infection Control Preventionist C in regard to Resident #44 revealed RN C stated that the urinary tract infection (UTI) started on 9/5/2025 when the resident #44 went to the emergency room (ER) for chest pain/shortness of breath (SOB) and came back with a UTI. The state surveyor inquired about what the Organism was that the facility was treating. RN C stated that We have to call the ER/hospital to get a culture, that needs to be done yet. RN C stated that there were no risk vs benefit statements for the residents because she was unsure of what to do when there is antibiotic use with no organism identified. Record review at the time of the interview revealed that there were no urine culture or sensitivity found within the medical record on 9/11/2025. RN C was notified that the state surveyor had identified three residents that received antibiotic therapy for urinary tract infections with no organisms identified. RN C stated i will have to track those cultures and organism down and I will as soon as I leave here. The state surveyor asked What happens if not treating the correct organism? RN C stated that we will create antibiotic resistant bugs (MDRO). MDRO- Multi-Drug-Resistant Organism. Record review of Resident #44's September 2025 Medication Administration Record revealed that on 9/5/2025 Cephalexin (Keflex) 500mg capsule by mouth three times daily for UTI for 10 days antibiotic was started on 9/5/2025 through 9/12/2025. On 9/12/2025 the antibiotic Cephalexin was changed to Ciprofloxacin (Cipro) 250mg tablet by mouth two times a day for UTI. Record review of the 'Facility Assessment tool' dated 7/2024 through 6/2025, presented by the facility revealed on page 15-16, Services and care based on Resident Needs: Infection Prevention and control- Identification and containment of infections, prevention of infections. Record review of the facility 'Antibiotic Stewardship Program' policy dated 12/13/2023, revealed it was the policy of the facility to implement an antibiotic stewardship program, as part of the facility overall infection prevention and control program. The purpose of the program was to optimize the treatment od infections while reducing the adverse events associated with antibiotic use. The infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program and receives support from the Nursing Home Administrator and other governing officials of the facility. The Medical Director, Consultant pharmacist, and attending physicians support the program via active participation in developing, promoting, and implementing a facility-wide system for monitoring the use of antibiotics. Antibiotic Use Protocols: Laboratory testing shall be in accordance with current standards of practice Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized.

Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing accurate outcome and process surveillance, accurate data collection/documentation/analysis, failure to ensure readily accessible hand hygiene supplies/equipment, and appropriate use of Personal Protective Equipment (PPE) for transmission-based isolation precautions, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis, a lack of hand hygiene completion, PPE use, and the likelihood for the spread of microorganisms and illness to all 73 facility residents.Findings include: Transmission Based Precautions (TBP) Resident #1 On 9/10/25 10:06 AM, a sign was noted outside of Resident #1's room specifying the Resident had Enhanced Barrier Precautions (EBP) in place. CNA T was asked why Resident #1 had EBP and replied, Has tube feeding. CNA T was observed entering the Resident's room. Resident #1 was awake in bed and their pants and bedding were visibly saturated with urine. CNA T began providing care and assisting the Resident while only wearing gloves. Med Tech CNA L entered the room wearing a gown, gloves, and mask as CNA T was assisting Resident #1 to the bathroom and told CNA T to go help a different resident. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included cerebral palsy, Angelman syndrome (genetic disorder that affects the nervous system and causes development delays, intellectual disabilities, problems with movement, and speech impairment), epilepsy, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment revealed the Resident was rarely/never understood and dependent upon staff to complete Activities of Daily Living (ADLs). The MDS further detailed Resident #1 had a feeding tube. Review of Resident #1's Electronic Medical Record (EMR) revealed a care plan entitled, Resident requires enhanced barrier precautions related to PEG (Initiated and Revised: 7/30/25). The care plan included the interventions: - Use gown and gloves when providing direct care. Face protection may be needed if performing activity with risk of splash or spray (Initiated: 7/30/25) - Utilize Enhanced Barrier Precautions when providing high contact resident care activities (dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care, dialysis) (Initiated: 7/30/25) Resident #2 On 9/10/25 at 10:14 AM, A Contact Precaution sign was observed on Resident #2's room door. Activity Aide S was observed in the hallway near the Resident's room. When asked if they knew the why Resident #2 had Contact Precautions in place, Activity Aide S stated, No. Certified Nursing Assistant (CNA) T was observed walking down the hall and was asked if they knew why Resident #2 had contact precautions in place and replied, (Resident #2) has a central line (PICC). When asked if the Resident had an infection, CNA T replied, No. When queried why a different resident (Resident #1) who residing on the hallway had Enhanced Barrier Precautions (EBP) in place, CNA T replied, (Resident #1 has a PEG (Percutaneous Endoscopic Gastrostomy- surgically created hole in the abdomen wall to the stomach in which a tube is placed for to allow for the introduction of nutrition ) tube. CNA T was asked to explain why Resident #2 was on Contact Precautions because they had a central line but no infection when Resident #1 was on EBP because they had a PEG tube and replied, I don't know. When queried what Personal Protective Equipment (PPE) is required to be worn by staff to enter Resident #2's room, CNA T revealed they wear PPE when touching the Resident but not if I just go in to grab something. An interview was completed with Resident #2 in their room on 9/11/25 at 8:20 AM. When asked if all facility staff wear PPE when they enter their room, Resident #2 replied, Not all. Record review revealed Resident #2 was most recently admitted to the facility on [DATE] with diagnoses which included infection, rheumatoid arthritis (RA), Post Traumatic Stress Disorder (PTSD), and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required set-up to substantial assistance to complete all Activities of Daily Living (ADLs). Review of Resident #2's Electronic Medical Record (EMR) revealed a care plan entitled, Resident has an infection as evidenced by MRSA (Methicillin-Resistant Staphylococcus Aureus – antibiotic resistant bacteria) Right Shoulder Abscess. Right Arm skin deficit. IV (intravenous) ABT (antibiotics) (Initiated: and Revised: 8/18/25). The care plan included the interventions: - Contact isolation precautions (Initiated: 8/15/25) - Review with resident the importance of good hand hygiene; assist as needed (Initiated: 8/15/25) Hand Hygiene Supplies/Completion On 9/10/25 at 9:59 AM, the hand sanitizer dispensers on the D Hallway of the facility were all observed to be empty. On 9/10/25 at 11:45 AM, the hand sanitizer dispensers on the B Hallway of the facility were all observed to be empty. On 9/10/25 at 12:00 PM, Central Supply Staff X was asked who the Infection Control (IC) nurse was and indicated they would get Registered Nurse (RN) D. An interview was completed with Nurse Educator Registered Nurse (RN) D on 9/10/25 at 12:10 PM. When queried regarding the hand sanitizer dispensers in the hallways not having any sanitizer in them, RN D confirmed the dispensers were empty and stated the hand sanitizer had been recalled. When queried if staff were provided with individual hand sanitizers to keep on their persons, RN D replied, No, did not give staff hand sanitizers. With further inquiry, RN D stated, They (staff) are supposed to wash their hands in resident rooms. When asked if the sink in resident rooms was in the bathroom which was shared by two rooms, RN D confirmed. When asked how staff are supposed to wash their hands if another resident is using the shared restroom and hand sanitizer was not provided to them by the facility, RN D did not provide an explanation. RN D then stated, There is a container in my office. When asked if their office is readily accessible to all staff working throughout the building 24 hours a day, RN D did not provide a response. With further inquiry regarding the hand sanitizer recall, RN D revealed Staff X would know more as they are in charge of ordering supplies. With additional discussion, RN D revealed they are no longer the IC Nurse for the facility and are now the Nurse Educator. RN D stated RN C was now the IC Nurse. An interview was completed with Central Supply Staff X on 9/10/25 at 12:15 PM. When queried regarding the hand sanitizer recall, Central Supply Staff X revealed multiple products produced by the company had been recalled due to bacterial contamination. Central Supply Staff X stated the facility switched from Purell brand sanitizer to the brand that had been recalled due to cost but were in the process of switching back to Purell. Central Supply Staff X was asked if the facility ordered and/or provided personal hand sanitizer dispensers for each staff member due to the hand sanitizer being removed from the building and replied, No. Central Supply Staff X then stated, I did order 48 four-ounce (oz) bottles of hand sanitizer but revealed the product had not been delivered in the last shipment. When asked if hand sanitizer dispensers had been placed in additional, convenient areas for staff access, Central Supply Staff X revealed they were unaware of additional hand sanitizer dispensers being placed in the facility. On 9/12/25 at 9:17 AM, CNA T was observed entering Resident #2's room without donning PPE. CNA T picked the oxygen tubing up from that Resident #2 had been wearing without wearing gloves and/or any PPE and proceeded to exit the room. CNA T did not wash their hands, nor did they perform hand hygiene prior to entering another Resident's room to provide care. Infection Control Program An interview and review of facility IC data was completed on 9/12/25 at 12:24 PM with IC RN C. When asked how many residents were in TBP, IC RN C replied, Only have one person on actual TBP, (Resident #2). When queried regarding observation of CNA T entering Resident #2's room without PPE, picking up their oxygen tubing off the floor, exiting Resident #2's room, and then entering another Resident's room without performing hand hygiene, IC RN C responded that CNA T should have worn PPE when entering the Resident's room. When queried regarding observation of CNA T not wearing PPE while proving direct care to Resident #1, when they were visibly soiled, IC RN C confirmed Resident #1 has EBP in place and PPE should be worn when direct care is provided. IC RN C was then asked what the most important thing that staff can do to prevent the spread of infection and stated, Hand hygiene. When queried regarding all the hand sanitizer dispensers in the facility being empty, IC RN C verbalized they were aware and that it was due to the sanitizer being recalled. When queried if individual hand sanitizers were provided to staff, IC RN C responded they did not know. IC RN C was informed that hand sanitizers were not provided to all staff and replied, But it is available on the (medication) cart and in PPE carts. When queried if those locations readily accessible to all staff, IC RN C indicated staff are also able to wash their hands in Resident bathrooms. When asked if some of Resident rooms have shared bathrooms, IC RN C confirmed they do. When queried how staff are able to wash their hands if another resident is in the bathroom, IC RN C did not provide an explanation. When queried how staff were ensuring their hands remained clean when performing hand hygiene in a resident's personal sink and then exiting through the resident room, no explanation was provided. IC RN C was asked again if hand hygiene supplies were readily available and was unable to provide further explanation. When queried if the facility had an infectious organism outbreak since their last annual survey, IC RN C replied, Yes, October of last year. When asked what the outbreak was, IC RN C stated, Covid. The October 2024 IC Monthly Analysis and Summary, employee call in documentation and line listing documentation for October 2024 was reviewed with IC RN C at this time. The Monthly Analysis and Summary specified there were 19 Healthcare-associated Infections (HAIs) and four Community Acquired Infections (CAI) during the month of October 2024 for a total of 23 infections. Per the analysis/summary, Communicable Disease Identified: 10 resident and 3 staff members tested positive for Covid. 1 resident has shingles. The analysis included the narrative summary for Explanation of Outliers/Trends. For the month of October there was a total of 23 overall infections. 19 were in house infections while there were 4 admitted to facility with. In house infections included 10 Covid positive, 2 pneumonia, 3 elevated WBCs (While Blood Cells – increase when there is an infection), 3 UTI (Urinary Tract Infections) and 1 Shingles. The admitted with infections included 1 pneumonia, 1 osteomyelitis (bone infection), 1 thrush (oral yeast infection) and 1 right knee infection. There were a total of 15 employee illness related call-ins. All were for 'Sick'. There was correlation between employee and resident infections noted at this time with a staff member testing positive for Covid after being exposed on the dementia unit. A review of the provided employee call in tracking list revealed 14 employee call ins with Staff Z listed twice 10/21/24. The reason listed for each of the employee call ins was sick or sick/sinuses. None of the employees were identified as having tested positive for Covid-19. When asked who the staff member was that tested positive for Covid, IC RN C stated, Does not say. I don't know if the report pulled over right. IC RN C revealed they were unable to recall the positive employees. When asked if a trend was identified and where they determined the infection originated from, IC RN C replied that the Covid outbreak was isolated to the locked dementia unit but was unable to provide further explanation. Review of the October 2024 line listing revealed 34 resident infections which included seven carry-over infections from September 2024 and 27 infections new infections for the month. IC RN C was asked to count the number of infections on the line listing, not including carry-over infections from September. IC RN C counted and confirmed there were 27 infections listed. Further review of the line list revealed the 27 infections involved 23 Residents. When asked if they were counting the number of infections or the number of residents who had an infection, IC RN C replied that they count the number of infections. The IC Mapping Tool for October 2024 was reviewed with IC RN C. Twenty seven infections were identified on the map. When queried regarding the discrepancy in the number of infections identified on the line list/map and Monthly Analysis/Summary, IC RN C stated, That was just me not knowing how to count. When queried regarding the accuracy of infection data reported for October 2024, IC RN C verbalized the analysis data for the month was inaccurate as the total number of infections for the month was inaccurate on the analysis. IC RN C revealed they were new in the IC role in October 2024. A more detailed analysis of the IC line listing for October 2024 revealed the line listing included the headings, Name, Type (resident or staff), admit date , Admit from, Acquired, Onset Date, Infection Category, Organism, Medication, Resolved, General Comments, Room/Bed. None of the residents included on the line list were identified as having Covid-19. Of the 27 infections for October 2024, Other was listed as the Infection Category for 17 of the resident infections and Covid was not listed as the Organism for any of the infections. When asked why Covid was not specified as the infectious organism for any of the infections, IC RN C revealed they use a program to complete their IC tracking and were unable to explain why the information was not on the list. Resident #92 was included on the line list for both a current and carry over infection. The line listing for the current infection specified Resident #92's admit date was 11/1/24 and the onset date of the infection was 10/24/24 with a resolved date was 12/12/24. The infection was listed as Prior and the category was other. The line listing detailed Resident #92 was treated with Daptomycin, Daptomycin (antibiotic used to treat complicated bacterial infections). The General Comments sections specified, MRSA (Methicillin-resistant Staphylococcus aureus- antibiotic resistance bacteria) is right dialysis port. Resident is to receive IV (Intravenous) Vanco (antibiotic) and daptomycin at dialysis. The carry over infection listed for Resident #92 specified the Resident was admitted to the facility on [DATE] and had a HAI UTI with an onset date of 9/12/24 and a resolved date of 10/12/25. Organisms were not listed for either infection. When queried when Resident #92 was admitted to the facility, IC RN C revealed they were unsure. A review of Resident #92's Electronic Medical Record (EMR) revealed the Resident was originally admitted to the facility on [DATE]. RN C was asked why the infection for October 2024 was listed as Prior and why the admission date was different for the infections. IC RN C reviewed Resident #92's EMR and stated, On 10/23/24, (Resident #92) was sent to ER. IC RN C revealed they were unsure why the admission dates were not the same as that information is generated by the computer system. When queried regarding the Resident's onset date of infection beginning on 10/24/25 if they were sent to the ER on [DATE], IC RN C stated the onset date was an error. When asked what the Resident's signs/symptoms of infection were, IC RN C reviewed the EMR and stated, Fever and change in mental status on 10/23. When queried if the infection was diagnosed at the hospital, IC RN C revealed it was. When asked why it was listed as Prior and not HAI, IC RN C indicated that was how it was set up in the computer tracking system. IC RN C was then asked if Cultures were completed and what the causative organism of the infection was and revealed they were unable to answer as the information was not included on the line list. The IC documentation for June 2025 was reviewed with IC RN C next. Review of the line listing for June 2025 revealed a total of 17 infections including eight new and nine carry over infections. Of the eight infections which occurred in June 2025 two were identified as HAI, three were identified as CAI, and three were listed as NA under the Acquired column. The June 2025 Mapping Tool identified 10 infections. The June 2025 Monthly Analysis and Summary detailed the total number of resident infections for the month was 10 with three HIA infections. When queried regarding the discrepancies in the number and classification of the infections, IC RN C confirmed the numbers did not match. When asked why some of the infections were listed as NA under the acquired column, IC RN C revealed some of the antibiotics were prophylactic and were not used to treat an actual infection. The line list did not include the resident signs and symptoms of infection on the line list. When did not include when treatment was initiated if the onset date was the date the signs and symptoms began. When asked, IC RN C verbalized understanding but further explanation was not provided. When queried why the specific infection type and location was not listed for each infection, IC RN C relayed they would need to look up each resident's medical record to provide the information as it is not included on the IC line list. Review of facility provided policy/procedure entitled, Hand Hygiene (Reviewed/Revised: 12/13/23) revealed, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table. When coming on duty. Between resident contacts. After handling contaminated objects. Before applying and after removing personal protective equipment (PPE), including gloves. Before and after handling clean or soiled dressings, linens, etc. Before performing resident care procedures. Before and after providing care to residents in isolation. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. When, during resident care, moving from a contaminated body site to a clean body site. After assistance with personal body functions. Review of facility provided policy/procedure entitled, Infection Prevention and Control Program (Reviewed/Revised: 10/24/22) revealed, Policy: This 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 for all residents, staff, volunteers, visitors, and other individuals. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions. Upon request for a policy/procedure related to transmission-based precautions, the facility provided a policy/procedure entitled, Personal Protective Equipment (Reviewed/Revised: 12/7/23). The policy specified, This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Policy Explanation and Compliance Guidelines: 1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 2. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. 3. Multiple factors determine the appropriate selection of PPE for a particular task: a. The type of exposure anticipated (e.g., splash/spray versus touch) b. The volume of fluid or tissue to which there is a potential exposure c. The likelihood of exposure d. The probable route of exposure (e.g., direct contact versus inhalation) e. The need for transmission-based precautions. Observation was made during medication pass on 9/10/25 at 11:30 a.m., of med tech L pass medications. Med Tech L gave eye drops wearing clean gloves; she entered the room, immediately put clean gloves on (the ones she had gotten from the med cart), when she was done giving the eye drops, she removed her gloves, walked directly into the hallway, tried to get hand sanitizer from the hallway container and stated, O ya, there is no hand sanitizer, it was recalled. She continued down the hallway, got to the medication cart, immediately entered the eye drops as given on the computer, and then used the hand sanitizer sitting on top of the cart. Med Tech L did not wash her hands prior to putting gloves on (in the residents room bathroom) and immediately after removing her contaminated gloves. Med Tech L said all the hallway hand sanitizer had been removed about 2 days' ago because it was recalled. No individual (smaller hand sanitizer container) was available for staff to use other than the larger container sitting on top of the medication cart in the end of C's hallway, in the alcove, leading to cross contamination. During an interview done on 9/10/25 at approximately 3:00 p.m., the Director of Nursing/DON stated yes, she should have washed her hands in the residents bathroom, we taught her that. Review of the facility Hand Hygiene policy dated 5/7/2020, 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. Review of the facility Medication Administration policy dated 1/17/2023, stated Wash hands using facility protocol and product. Review of the facility Personal Protective Equipment policy dated 12/7/2023, stated Change gloves and perform hand hygiene between clean and dirty tasks.

Based on interviews and record reviews, the facility failed to prevent facility-acquired urinary infections for 4 residents' (#31, # 35, #44, #70) of 4 sampled residents, resulting in likelihood for recurrent urinary tract infections with prolonged illness or hospitalization and antibiotic therapy.Findings include: Resident #31:Observation, interview and record on 9/10/2025 at 10:10 AM estimated of Resident #31 during the initial screening process of the annual recertification survey the resident was verbal with confusion and could not recall having a urinary tract infection. Record review of Resident #31's 8/6/2025 Minimum Data Set (MDS) identified the resident with a Brief Interview of Mental status (BIMs) of 4 out of 15, severe cognitively impaired. Record review on 09/10/2025 at 2:34 PM of Resident #31's urology office visit note dated 7/9/2025 noted hematuria (blood in urine) and urinary tract infection. Ordered Macrobid 100mg capsule oral, one tablet twice daily for 30 capsules.Record review on 09/10/2025 at 2:39 PM of Resident #31's July Medication Administration Record (MAR) revealed that the resident received an antibiotic Macrobid 100mg twice daily for 15 days for UTI (Urinary Tract Infection). The antibiotic Macrobid was started on 7/10/2025 through 7/25/2025 twice daily orally. Record review of the facility July 2025 'Antibiotic Dispensed' report dated 7/1/2025-7/31/2025, noted Resident #31 received Macrobid 100mg capsule by mouth two times a day for UTI until 7/25/2025. Record review of the facility July 2025 'Antibiotic line Listing' form noted Resident #31 was admitted on [DATE] developed a urinary tract infection was treated with Macrobid 100mg oral for 15 days. Organism was noted as 'Null'.An interview and record review on 09/11/2025 at 2:38 PM with Registered Nurse/Infection Control Preventionist C in regard to Resident #31's urinary Tract Infection in July 2025 revealed RN C to review the record and stated the urinary Tract Infection onset/start was 7/10/25 with signs/symptoms from urologist office visit and the urine came back positive, the urologist placed resident (#31) on Macrobid 100mg BID x 15days. The state surveyor inquired about what organism was being treated. RN C stated that the urologist office did not identify an organism, and the facility did not do a Culture and Sensitivity (C&S). There was no risk vs benefit from physician found for medication of antibiotic with no culture within the medical record. RN C stated that there was not one done. Resident #35:In an interview and observation on 09/12/2025 at 9:42 AM with Resident #35 revealed that she does not want to go to the dining room and does not like the foods. During the interview Resident #35 was observed to get up from the bed and walked to the restroom and shut the door and in a few moments came back to lie on the bed. Resident #35 stated that she has been having bladder problems lately and was taking pills for it. Record review of Resident #35's progress notes dated 9/8/2025 at 9:30AM noted: 9/3/25 UA (urinalysis) positive UTI (Urinary Tract Infection). NP (Nurse Practitioner) at facility. New order for Macrobid 100mg BID (twice daily) time 5 days. No organism was identified in the progress notes. Progress notes dated 9/10/2025 and 9/11/2025 noted Resident #35 complained of loose stools. (Side effect of antibiotic medication) Record review of Resident #35's electronic medical record revealed that there was no culture and sensitivity (C&S) found within the medical record. In an interview and record review on 09/11/2025 at 2:38 PM with Registered Nurse/Infection Control Preventionist C in regard to Resident #35's recent Urinary tract infection revealed: Registered Nurse C stated that the urinary infection started 9/3/25 when the facility urine sample for analysis was sent out for a Kidney/blood pressure appointment and it came back positive, and we have not received a culture back from the office yet. RN C stated that Yes, antibiotic was started with no organism known. It was Macrobid 100mg BID (twice daily) for 5days. Resident #35 would finish the antibiotic on 9/13/2025. RN C was asked about a facility risk vs benefit from physician and that none was found for the antibiotic medication with no organism or culture. RN C stated that there were no risk vs benefit statements for the residents because she was unsure of what to do when there is antibiotic use with no organism identified. Resident #44:Record review of Resident #44's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental status of 2 out of 15, severe cognitive impairment. Medical diagnosis included: atrial fibrillation, hypertension, renal insufficiency, arthritis, hemiplegia/hemiparesis, malnutrition, and stroke. In an interview and record review on 09/11/2025 at 2:38 PM with Registered Nurse/Infection Control Preventionist C in regard to Resident #44 revealed RN C stated that the urinary tract infection (UTI) started on 9/5/2025 when the resident #44 went to the emergency room (ER) for chest pain/shortness of breath (SOB) and came back with a UTI. The state surveyor inquired about what the Organism was that the facility was treating. RN C stated that We have to call the ER/hospital to get a culture, that needs to be done yet. RN C stated that there were no risk vs benefit statements for the residents because she was unsure of what to do when there is antibiotic use with no organism identified. Record review at the time of the interview revealed that there were no urine culture or sensitivity found within the medical record on 9/11/2025. RN C was notified that the state surveyor had identified three residents that received antibiotic therapy for urinary tract infections with no organisms identified. RN C stated i will have to track those cultures and organism down and I will as soon as I leave here. The state surveyor asked What happens if not treating the correct organism? RN C stated that we will create antibiotic resistant bugs (MDRO). MDRO- Multi-Drug Resistant Organism. Record review of Resident #44's September 2025 Medication Administration Record revealed that on 9/5/2025 Cephalexin (Keflex) 500mg capsule by mouth three times daily for UTI for 10 days antibiotic was started on 9/5/2025 through 9/12/2025. On 9/12/2025 the antibiotic Cephalexin was changed to Ciprofloxacin (Cipro) 250mg tablet by mouth two times a day for UTI. Resident #70: Observation on 09/10/2025 at 12:19 PM Resident appears sleepy and kept falling asleep during interview. Record review is receiving Macrobid 100mg capsules for UTI currently. Observation on 09/10/2025 at 3:26 PM Resident #70 seated up in wheelchair at nursing station with large thermal mug gray in color, Resident has on sunglasses and headphones over his ears. Resident #70 has an odor of yeast noted by surveyor. Record review of Resident #70's Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental status of 9 out of 15, moderate cognitive impairment. Section GG Functional Abilities: toileting hygiene as partial/moderate assist from staff. Record review of Resident #70's September 2025 Medication Administration Record revealed Macrobid 100mg capsule one by mouth two times a day for UTI for 7 days. Macrobid 100mg started on 9/4/2025 through 9/11/2025. Record review of Resident #70's progress note dated 9/4/2025 at 8:00AM noted Urinalysis with culture positive for Escherichia Coli (E.coli) , Macrobid 100mg BID (twice daily) for 7 days ordered. In an interview and record review on 09/11/2025 at 2:43 PM with Registered Nurse/Infection Control Preventionist C regarding Resident #70's development of facility acquired urinary tract infection revealed that a urinalysis collected on 9/3/25 and was positive for E.coli by culture and sensitivity (C&S), Macrobid (antibiotic) 100mg BID x7 days. S/S of had burning with urination, discomfort and odor. Record review of Resident #70's urinary incontinence task record from 8/14/2025 through 9/11/2025 (30 day look back) revealed 50 out of 57 documented incontinence episodes of urine. Task B&B: Bladder Elimination Description (question 2) revealed that the resident was on a check and change program. Record review of the 'Facility Assessment tool' dated 7/2024 through 6/2025, presented by the facility revealed on page 15-16, Services and care based on Resident Needs: Infection Prevention and control- Identification and containment of infections, prevention of infections. Record review of the facility 'Antibiotic Stewardship Program' policy dated 12/13/2023, revealed it was the policy of the facility to implement an antibiotic stewardship program, as part of the facility overall infection prevention and control program. The purpose of the program was to optimize the treatment od infections while reducing the adverse events associated with antibiotic use. The infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program and receives support from the Nursing Home Administrator and other governing officials of the facility. The Medical Director, Consultant pharmacist, and attending physicians support the program via active participation in developing, promoting, and implementing a facility-wide system for monitoring the use of antibiotics. Antibiotic Use Protocols: Laboratory testing shall be in accordance with current standards of practice Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized.

Based on observation, interview and record review, the facility failed to ensure safe medication storage for 2 residents (Resident #30 and Resident #33) of 18 residents reviewed for medications left in rooms, resulting in the potential for ingestion of medications. Findings include: Resident #30: On 9/10/25 at 10:53 AM, Resident #30 was observed sitting in a chair on the left side of their bed and an interview was completed. During the interview, a clear cup containing medication pills was observed sitting on a bedside dresser table next to a clear plastic cup of water on the right side of the Resident's bed. The medication cup contained several different size and colored pills. The number of pills in the cup was unable to be accurately counted due to the way the pills were in the cup. When queried regarding the medications, Resident #30 revealed the nurse had left them there for them to take. When asked if the nursing staff always leave their medications in their room, Resident #30 replied some nurses do and some nurses stay in the room and watch them take the medications. At this time, Resident #30's room was exited, and their nurse was attempted to be located. The Resident's assigned nurse was not in the hallway nor were any nurses present at the nurses' station. The Director of Nursing (DON) was not in their office. MDS Registered Nurse (RN) N was observed sitting in their office and asked to come to Resident #30's room. At 10:58 AM on 9/10/25, MDS Registered Nurse (RN) N was observed sitting in their office and asked to come to Resident #30's room. Upon entering Resident #30's room, MDS RN N confirmed the presence of the container of multiple pills in the room. Upon request, MDS RN N counted the medications and verbalized there were Eight pills in the cup. When asked if Resident #30 had been assessed for medication self-administration, MDS RN N revealed they did not believe they were but would check. When queried what the medications were, MDS RN N responded they would have to check as they did not have keys to the medication cart and there were no nurses present in the hallway and/or at the nurses' station. On 9/10/25 at 11:02 AM, MDS RN N returned to Resident #30's room and stated Resident #30 did not have a self-med admin assessment. When asked if that meant the Resident had not been assessed and deemed capable of administering their medications without nursing supervision, MDS RN N confirmed. MDS RN N verbalized they were still working on identifying the medications. On 9/10/25 at 1:00 PM, MDS RN N revealed they identified the medications found unattended at Resident #30's bedside and provided the following list of medications: - One Carbidopa-Levodopa 25/100 milligram (mg) tablet (medication commonly used to treat Parkinson's disease) - One Digoxin 125 microgram (mcg) tablet (commonly used to treat Congestive Heart Failure [CHF]) - One Doxycycline 100 mg tablet (antibiotic medication) - One Fluoxetine 20 mg capsule (commonly known as Prozac and used to treat depression) - One Actos 45 mg tablet (medication used to treat diabetes) - One Acidophilus capsule (over the counter probiotic medication used to support digestive health) - One Glipizide 10 mg tablet (medication used to treat diabetes) - Diltiazem Extended Release 120 mg capsule (medication used to treat high blood pressure and some cardia arrhythmias) Review of Resident #30's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses which included left femur fracture, diabetes mellitus, surgical infection, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision to total assistance to complete Activities of Daily Living (ADLs) with the exception of eating. Review of Resident #30's Medication Administration Record (MAR) revealed the medications listed were documented as being administered together daily at 8:00 AM every morning and had been documented as administered on 9/10/25 at 8:00 AM. Further review of Resident #30's Electronic Medical Record (EMR) revealed the Resident had not been assessed for self-medication administration. An interview was completed with the DON on 9/12/25 at 11:52 AM. When queried regarding the unattended medications observed in Resident #30's room, the DON indicated they were aware and verbalized the medications should not have been left at the Resident's bedside. No further explanation was provided. Review of facility policy/procedure entitled, Medication - Resident Self-Administration of (Reviewed/Revised: 1/30/24) revealed, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. 7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. Review of facility policy/procedure entitled, Medication Administration (Reviewed/Revised: 1/17/23) revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 15. Observe resident consumption of medication. Review of facility policy/procedure entitled, Medication Storage (Reviewed/Revised: 1/30/24) revealed, . Policy Explanation and Compliance Guidelines: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments (see attached listing). c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Resident #33: Review of the Face Sheet, care plans 5/22/23, Brief Interview for Mental Status (BIMS) dated 7/30/25, and physician orders dated 8/26/25, revealed Resident #33 was [AGE] years old, admitted to the facility on [DATE], totally dependent on staff for all Activities of Daily Living/ADL, received Hospice services, and was on the locked Dementia unit. The resident's diagnosis included, age-related nuclear cataract bilateral, Dementia, mood and behavioral disturbances and anxiety. Review of the BIMS dated 7/30/25, revealed that the resident's cognitive assessment score was 3, severely cognitively impaired with memory loss. Review of the physician order dated 8/26/25, stated Apply house fungal powder every shift to red area under left breast and belly button until resolved. Review of the residents impaired cognitive function/impaired thought care plan dated 5/22/23, revealed she required simple, one word, slowly spoken directions due to decreased cognition; she was safety awareness impaired. Observation was made during the initial Dementia unit's tour done on 9/10/25 starting at 10:00 a.m. In the resident's room was found an open bottle with no top within sight of Nystin Powder (anti-fungal powder) sitting on the left side of the bed on the windowsill. At the time, there were several residents on the unit walking around by themselves. The resident was walking in the hallway by herself at the time. This surveyor went and got the nurse on the unit (Nurse, RN M). During an interview done on 9/10/25 at 10:45 a.m., Nurse M stated There were two nurses on last night, they are the only one's who put it (Nystin powder) on. Nurse M said the top should have been on the bottle and it should not have been left in a resident's room.

Based on observation, interview and record review, the facility failed to identify skin breakdown for three residents (#3, #13, #70) resulting in the lack of implementation of interventions to prevent skin injury, the worsening of skin injuries, pain, discomfort, and the likelihood of prolonged illness or hospitalization.Findings include: Resident #3:An observation and interview on 09/11/2025 at 8:38 AM of Resident 3 revealed that there were sore spots to the resident's buttocks area and the nurses apply a cream to the area and take photos sometimes. During the survey the surveyor observed Resident #3 to be non-ambulatory related to Parkinson's disease and was able to self-propel wheelchair to the dining room. Resident #3 stated that he does use a WC for ambulation and does spend a lot of time in bed. Observed an air mattress in place to the bed. Resident #3 stated that he was the president of the resident council for residents' concerns and that he had no issues or concerns with the facility. Record review of Resident #3's 8/28/2025 Moisture associated Skin Damage (MASD) assessment with photo revealed a new wound, incontinence associated dermatitis. The photo revealed open skin areas to bilateral buttocks regions with scabs noted. Record review of Resident #3's skin progress note dated 8/28/2025 at 10:25 AM noted new skin issue: Location: Coccyx measurements of 1cm width X 1cm length with other red-purple areas with peeling of outer sites. Observation and interview on 09/12/2025 at 9:16 AM with Certified Nurse Assistant (CNA) K of Resident #3's coccyx region, soaked/wet brief lowered, and resident was rolled to his left side. Observation of the bilateral buttocks noted that there is no cream noted to area, bleeding was noted on brief from the skin that was beefy red with bleeding noted to the surface. The buttocks area had open and fragile areas along the cleft of the left buttock's region. An air mattress noted to bed, brief was wet with strong odor of urine. The CNA K was left with the resident to perform peri care and change the brief. Observation and interview on 09/12/2025 at 10:52 AM with Licensed Practical Nurse (LPN)/Wound Care Nurse F of Resident #3's left buttocks area. Upon entering the room Resident #3 was rolled to the right side. The state surveyor and the LPN F observed the wet/soaked brief still in place on the resident with strong odor of urine noted. Resident #3 stated that he was last changed about 1AM. Observation of Resident #3's bilateral buttocks region noted 2 sites of pressure on right upper buttocks and the left cleft of left buttocks region. LPN F with gloves on touched the areas for blanching of the skin. The state surveyor inquired about what was the difference between Moisture Associated Skin Damage (MASD) and the beginning stages of pressure ulcers. LPN F stated that she will have to make a change to classification and stage as pressure although not open yet, and that she had 3 areas of concern that are new areas as of that day for Resident #3's buttock region.Record review of Resident #3's 9/12/2025 'Pressure ulcer/injury' assessment revealed a coccyx pressure ulcer/injury, in the progress of deteriorating. Pressure ulcer staging: Stage 1 pressure ulcer with non-blanchable erythema with skin intact. Record review of Resident #3's skin issues progress note dated 9/12/2025 at 12:27PM noted: Stage 1 pressure ulcer/injury to the coccyx, non-blanchable erythema of intact skin. Wound acquired in-house. Wound is greater than 3 months old. Intermittent pain of aching was documented. Licensed Practical Nurse (LPN) F documented site has deteriorated in past 2 days. Two new areas of dark red purple are present. One to the left buttock and one to the right intergluteal fold. Continue barrier cream, air mattress to bed, encourage repositioning and hygiene during episodes of incontinence. Resident #13: In an interview on 09/10/2025 at 11:01 AM with Resident #13 stated that she has thin skin on her bottom and that there are several little sores in the butt crack, and in her groin area also that are open spots. The area gets damp, and the skin is fragile is what they tell her. Resident #13 did state that the areas do hurt and are uncomfortable.Record review of Resident #13's 'Skin Assessment and photos' noted Moisture associated Skin Damage (MASD) on 9/2/2025 with measurements of 1.32cm length X 1.08cm width.Observation on 09/11/2025 at 1:07 PM with Certified Nurse Assistant (CNA) V and W entered the room, gloved and lowered the head of the bed. Resident #13 was then rolled to her left side and her brief was lowered, to observe the rear left thigh with open areas, with bleeding noted in the brief. Resident #13 complained of discomfort with touching of the areas by CNA. The CNA V cleansed the area wet wash cloth and applied Chamosyn with manuka honey cream to the area, and a new brief was applied. During the observation the CNAs and surveyor observed 5 open small areas noted with bleeding. In an interview on 09/12/2025 at 10:40 AM with Licensed Practical Nurse (LPN) F wound care nurse regarding resident #13's MASD- Moisture associated skin damage. LPN F was asked if MASD damage bleeds. LPN F stated that yes, some do. That would mean it's open wound if bleeding. Stage II pressure ulcer- is an open skin with bleeding with discharge with more than the just the top surface missing. The state surveyor described the observation that took place on 9/11/2025 with CAN staff of Resident #13's buttocks observed with 5 open area with bleeding into brief. LPN F stated that the Treatment Chamosyn manuka Honey. The state surveyor inquired about the moisture associated with skin damage and pressure ulcer staging. LPN F stated that We discuss wounds weekly, on Tuesdays with photos and discuss if need to be reclassified. So far, we have not changed Resident #13's classification. Resident #70: Observation on 09/10/2025 at 3:26 PM Resident #70 is seated up in wheelchair at nursing station with large thermal mug gray in color, Resident has sunglasses on and headphones over his ears. Resident #70 has an odor of yeast noted by surveyor.Record review of Resident #70's urinary incontinence task record from 8/14/2025 through 9/11/2025 (30 day look back) revealed 50 out of 57 documented incontinence episodes of urine. Task B&B: Bladder Elimination Description (question 2) revealed that the resident was on a check and change program. The staff must change the residents brief and cleanse their skin with each incontinence episode. In an interview and observation on 09/12/2025 at 9:47 AM with Resident #70 was observed to be lying in bed on top of the covers. Resident #70 called to the state surveyor through his doorway to let the state surveyor know that his groin was sore and that it hurt between his penis and balls. Resident #70 stated it hurts a lot. No there is no cream for it. The whole area is on fire. Observation on 09/12/2025 at 9:50 AM with Certified Nurse Assistant (CNA) Y assisted with observation of Resident #70's peri area. Resident #70 was positioned on the bed and his pants and brief were removed. Observation of Resident #70's groin/peri area was noted to be red on both sides of the groin and behind the scrotum area with skin peeling at the edges. A strong yeast odor was noted. Resident #70 stated that it has been sore since he moved to this room, not all the time but once in a while. Brief wet and soaked. Observation on 09/12/2025 at 9:56 AM of Resident #70's groin redness with the Director of Nursing (DON) and Certified Nurse Assistant (CNA) Y observed with surveyor, area was noted red and the DON told CNA Y to wash with soap and water and pat dry and apply AD ointment. The DON stated that she was not aware of the skin issue. In an interview on 09/12/2025 at 11:03 AM with Licensed Practical Nurse (LPN) F wound/skin care nurse regarding Resident #70's complaint of groin pin/discomfort revealed that LPN F was not aware of the redness to the groin and has not been seen by wound nurse yet. In an interview on 09/12/2025 at 1:46 PM with Licensed Practical Nurse (LPN) F regarding Resident #70 skin issue revealed: I looked at his groin and testicles and it smells of yeast, so I called and updated the doctor and ordered Nystatin BID for 2 weeks. It is a smelly yeast with flaky edges and its spreading. I updated the orders and notes. Record review of Resident #70's nursing progress note dated 9/12/2025 at 1;30PM documented: Assessed groin, redness presents with edges of reddened areas round in shape. Noted odor, white yeast like on skin. Notified physician, new orders for Nystatin powder to groin and scrotum BID (twice daily) for 10 days.

Based on observation, interview, and record review, the facility failed to ensure that the appropriate backflow prevention was installed on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to a backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility.Findings include: On 09/10/2025 at 10:30AM during the kitchen tour, observed overhead spray nozzle sitting below the flood rim in the garbage disposal. During interview at this time with Certified Dietary Manager G, she stated she was just using it and forgot to put it back on the hook. On 09/10/2025 1:30PM - 2:30PM during interview with Regional Maintenance I, he stated they are in the process of replacing the sink and the overhead spray nozzle in the kitchen and proceeded to show the order for the parts. On 09/10/2025 between 1:30PM - 2:25PM observed a hose with a spray nozzle attached downstream of a hose bib atmospheric vacuum breaker on the outside spigot located near the front of the building. At this time, Regional Maintenance I was observed to remove the spray nozzle. On 09/10/2025 1:30PM - 2:30PM observed a hose with an attached spray nozzle downstream of a hose bib atmospheric vacuum breaker on the outside spigot located near the dining room/patio area. Observed Regional Maintenance I remove the spray nozzle from the hose. During interview at this time with Maintenance Director H and Regional Maintenance I, they stated that normally the hoses do not have the spray nozzle attached. According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).According to the 2008 Cross Connection Manual on atmospheric vacuum breakers, AVBs shall not be installed where they will be under continuous pressure for more than 12 hours (i.e. no downstream shutoff valve).

Based on observation, interview and record review, the facility failed to update/revise individualized, person-centered care plans to reflect changing care needs for 1 resident (Resident #9), of 18 residents reviewed for care plans. Findings include: Resident #9: Record review of the facility provided CMS-802 'Resident Matrix' identified Resident #9 as had a fall with injury. In an observation and interview on 09/10/2025 at 10:19 AM with Resident #9 revealed that she was laying on the top of her bed with the room partition/privacy curtain pulled so that the resident could not be observed from the doorway of the room. Resident #9 stated that she did have a fall at her closet but could not recall when the fall had occurred. Resident #9 stated that she did have a broken arm from the fall and tailbone pain. identified a fall with major injury and resident stated that she had a fall at her closet. Observation on 09/11/2025 at 10:34 AM of Resident #9 was noted to be lying in bed with the room partition curtain pulled between beds and the resident was not able to be seen from the hallway. Resident #9's legs and feet are off the bed, and she has taken her shoes off with no grippy socks noted. Shoes at bedside. Observation on 09/12/2025 at 10:36 AM resident observed up in activity sitting outside in the sun on back patio area with 6 other residents and a volunteer. Resident appears a sleep and leaning to the left of WC. In an interview and record review on 09/12/2025 at 11:30 AM with the Director of Nursing regarding Resident #9's repeat falls:Fall on 3/4/2025 fall with Fractured wrist and pelvis. Record review of Resident #9's 'Un-witnessed Fall' form dated 3/4/2025 at 5:45PM the Resident #9 was found on the floor by CNA in resident room. Resident #9 was then Hoyer lifted off the floor. pain was noted, 2 days later she sent to the ER hospital x-rays of fractured wrist and pelvis. The state surveyor asked if the incident was reported to the state as it was an unwitnessed fall. DON did not know and referred the surveyor to the Nursing Home administrator.Observed on Floor fall on 4/22/2025 at 7:50PM Resident #9 was found on the floor in her room between her bed and wheelchair. Observed on Floor fall on 7/4/2025 at 00:20AM resident was observed to be lying on the floor on her stomach with a left side of her head resting on the floor with a laceration. Resident was not wearing any footwear. Resident complained of being very dizzy and did not feel good Sent to emergency room to be evaluated. Resident #9 received 2 sutures to the scalp laceration Record review of Resident #9's Care Plans pages 1-36 for updated fall interventions with the Director of Nursing revealed that there were no new interventions added to the fall/injury care plan after the 7/4/2025 fall with laceration to the head. Record review of the facility 'Comprehensive Care Plan' policy dated 6/30/2022 revealed that it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure that respiratory care and oxygen therapy administration tubing was changed per Health Care Provider's (HCP) order for one resident (Resident #2) of one resident reviewed.Findings include:Resident #2:On 9/10/25 at 10:14 AM, A Contact Precaution sign was observed on Resident #2's room door. The Resident's door was open and they were laying in bed, on their back with their eyes closed. Resident #2 had supplement oxygen in place via nasal cannula (NC). Activity Aide S and Certified Nursing Assistant (CNA) T were observed in the hallway. When asked the reason Resident #2 had contact precautions in place, Activity Aide S verbalized they did not know and CNA T stated, (Resident #2) has a central line (PICC). When asked if the Resident had an infection, CNA T replied, No. On 9/11/25 at 8:20 AM, Resident #2 was observed in their room, sitting on the edge of their bed. The Resident's NC prongs (part of the tubing that oxygen comes out of and is supposed to be positioned in the nose) were positioned on the Resident's cheek and not in their nose. When asked about the position of their oxygen tubing, Resident #2 stated, Must have came out (of nose) when brushing hair. When queried, Resident #2 revealed they did not wear oxygen at home but have been wearing it around the clock at the facility. An observation of the oxygen concentrator revealed the oxygen administration rate was set at 2.5 Liters (L) per minute (min). The oxygen tubing had a sticker on it with the date, 8/24 on it. Record review revealed Resident #2 was most recently admitted to the facility on [DATE] with diagnoses which included infection, rheumatoid arthritis (RA), Post Traumatic Stress Disorder (PTSD), and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required set-up to substantial assistance to complete all Activities of Daily Living (ADLs).Review of Resident #2's Electronic Medical Record (EMR) revealed a care plan entitled, Resident has an impaired pulmonary/respiratory status related to COPD/Sleep apnea/chronic respiratory failure. frequently removes oxygen (Initiated: 8/15/25; Revised: 8/27/25). The care plan included the interventions:- Oxygen as ordered (Initiated: 8/15/25)- Provide oxygen as needed when resident exhibits signs/symptoms of difficulty breathing (Initiated: 8/27/25) Review of Resident #2's Health Care Provider Orders revealed the following orders:- Oxygen: RUN @ 2L (liters) NC (Nasal Cannula) at Noc (chronic) every night shift for Sleep Apnea, COPD (Start Date: 8/15/25)- Oxygen tubing/filter change every week via (external company) on Mondays (Start Date: 8/15/25) An observation of Resident #2's oxygen tubing was completed on 9/11/25 at 3:10 PM with Registered Nurse (RN) M and Licensed Practical Nurse (LPN) U. When queried how often oxygen tubing is supposed to be changed, both RN M and LPN U responded that oxygen tubing is supposed to be changed weekly by the external respiratory supply company that comes to the facility. When asked why the Resident's oxygen tubing was dated 8/24 if it is supposed to be changed weekly, both staff verbalized that the external company must not have changed it. With further inquiry, RN M specified that nursing staff should also check the oxygen tubing. An interview was completed with the Director of Nursing (DON) on 9/12/25 at 11:52 AM. When queried if oxygen should be administered per HCP orders, the DON verbalized it should. When asked how often oxygen tubing should be changed, the DON responded that it is changed weekly. When asked why Resident #2's oxygen tubing was dated 8/24/25 if it is supposed to be changed weekly, the DON did not provide further explanation. Review of facility policy/procedure entitled, Oxygen Administration (Reviewed/Revised: 10/26/23) revealed, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences. 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: a. Follow manufacturer recommendations for the frequency of cleaning equipment filters. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on observation, interview and record review, the facility failed to ensure that Peripherally Inserted Central Catheter (PICC) line care was provided, per professional standards of practice, for one resident (Resident #2) of one resident reviewed, resulting in a lack of sterile technique during dressing change and a lack of accurate measurement of arm circumference. Findings include:Resident #2:On 9/10/25 at 10:14 AM, A Contact Precaution sign was observed on Resident #2's room door. Activity Aide S was observed in the hallway near the Resident's room. When asked if they knew the why Resident #2 had Contact Precautions in place, Activity Aide S stated, No. Certified Nursing Assistant (CNA) T was observed walking down the hall and was asked if they knew why Resident #2 had contact precautions in place and replied, (Resident #2) has a central line (PICC). When asked if the Resident had an infection, CNA T replied, No. Record review revealed Resident #2 was most recently admitted to the facility on [DATE] with diagnoses which included infection, rheumatoid arthritis (RA), Post Traumatic Stress Disorder (PTSD), and Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required set-up to substantial assistance to complete all Activities of Daily Living (ADLs). The MDS further indicated that the Resident was receiving IV medications and had a midline (longer peripheral IV catheter inserted into the upper arm with the tip of the catheter located at or near the armpit) for IV access. Review of Resident #2's Electronic Medical Record (EMR) revealed a care plan entitled, Resident has an IV Peripherally Inserted Central Catheter (PICC) line LUE (Left Upper Extremity) inserted 8/8/25 45 cm (centimeters) length. ABT (antibiotic) for MRSA (Methicillin-Resistant Staphylococcus Aureus - antibiotic resistant bacteria) Right Shoulder/arm (septic- extreme reaction of the body to an infection which causes widespread inflammation and can lead to organ failure and death) (Initiated: 8/15/25). The care plan included the interventions:- Ensure that IV attachments are tight fitting with Luer lock (Initiated: 8/15/25)- Gently palpate areas around and over site for tenderness, phlebitis, inflammation, infiltration, occlusion, or leakage from insertion site (Initiated: 8/15/25)- IV catheter care, maintenance, and dressing changes per orders (Initiated: 8/15/25)- IV medications / flushes per orders (Initiated: 8/15/25) Review of progress note documentation in Resident #30's EMR consistently referred to the Resident's IV access as a PICC line with no documentation indicating the Resident had a midline catheter. The Nursing Evaluation Summary note dated, 8/15/25 at 6:47 PM specified, Arrived from (hospital). Right shoulder drain sites with drainage. IV ABT via PICC to LUE. No s/s infiltration. Drsg (dressing) changed 8/14. Single lumen PICC inserted 8/8/25. 45cm length. PICC insertion Paperwork in chart. An observation of Resident #2 in their room was completed on 9/11/25 at 8:20 AM. The Resident had a PICC line in their left upper arm. The insertion site of the PICC line was reddened and the dressing was dated 9/4/25. The PICC line was connected to a bag of IV antibiotics via an IV infusion pump. The IV infusion was complete, and the pump was turned off. Licensed Practical Nurse (LPN) U entered the Resident's room at this time and an observation of them disconnecting and flushing the Resident's PICC line was completed. When asked if the Resident's LUE IV access was a midline or a PICC line, LPN U responded that it was a PICC line. LPN U did not check for blood return while flushing and did not flush the PICC line using a pulsating or push/pause method. The clamp lock on the PICC line had Check Blood Return and Flush inscribed on it. After exiting Resident #2's room, an interview was completed with LPN U. When asked why they did not assess for blood return when flushing Resident #2's PICC line, LPN U stated, I am under the assumption that you only check for blood return before administer antibiotics. When asked about the instructions on the PICC line clamp to check blood return and flush, LPN U reiterated they were only aware of the need to check for blood return prior to administration of medications. When queried if best practice is to flush the PICC line using a pulsating or push/pause method, LPN U replied, Not taught to, just do a slow flush. When queried regarding the PICC line dressing change, LPN U responded that they were unable to complete a PICC line dressing change and Registered Nurse (RN) M would do it later in the day. Review of Resident #2's Medication Administration Record (MAR) revealed documentation that the PICC line dressing was changed on 9/3/25. There was no documentation on the MAR that the dressing was changed on 9/4/25. Review of Resident #2's Health Care Provider (HCP) orders revealed the order, Transparent dressing change every 7 days and as needed. Supplementary documentation includes Arm circumference in cm (centimeters). Catheter Length in cm. An observation of Resident #2's LUE PICC line dressing change was completed on 9/11/25 from 2:00 PM to 3:15 PM with RN M. During the dressing change procedure, RN M had to call for assistance several times from staff outside of the room due to need for additional supplies. RN M removed the current Tegaderm (clear, transparent) dressing using clean technique. RN M then proceeded to remove the StatLock (adhesive-backed device that adheres to the skin with a mechanism to hold the PICC line in place) securement device while wearing clean gloves. While removing the Statlock device, RN M touched the PICC insertion site with their clean gloves. RN M then opened the sterile PICC line dressing change kit and began removing items from the kit. RN M threw the sterile drape in the garbage and then moved items in the kit to obtain the new Statlock device, the chloraprep skin cleaner, and the sterile gloves. RN M touched multiple items in the kit while not wearing sterile gloves. The sterile gloves in the PICC line dressing change kit broke while RN M was putting them on, and they did not have an additional pair of sterile gloves. RN M had to call for assistance from another staff member while leaving the PICC line insertion site uncovered. A staff member brought a pair of gloves, which they stated were sterile but were not individually wrapped sterile gloves and appeared to have been removed from another sterile kit. When asked about the gloves, RN M verbalized they would have preferred to have individually wrapped sterile gloves to ensure they were sterile but due to being unable to leave the Resident, they were dependent on other staff to assist. After donning the gloves provided, RN M was unable to secure the PICC line to the Statlock securement device due to a device malfunction. RN M called for assistance to have another staff member obtain additional supplies while the PICC line site was uncovered. RN M then attempted to measure the circumference of Resident #2's left arm with no dressing in place over the PICC line insertion site. RN M placed the measuring tape directly over the uncovered PICC line insertion site. RN M was stopped and asked if that was the appropriate place to measure arm circumference for PICC line placement and replied, No. During the dressing change, the exposed PICC line insertion site was observed touching the Resident's upper body due to their inability to easily move and maintain their shoulder and arm outward and away from their body. Upon exiting Resident #2's room, an interview was completed with RN M on 9/11/25 at 3:15 PM. When queried regarding observations of breaks in sterile technique, RN M confirmed sterile technique was not maintained and verbalized frustration related to issues with the (dressing change) kit. When asked why they removed the StatLock device with clean gloves, as they touched the PICC line insertion site at that time, RN M validated they did and revealed they followed the order provided in their facility policy/procedure. RN M provided a Validation Checklist: PICC. Dressing Change list. The procedure included the numbered steps, 10. Opened sterile dressing change kit and laid out items using sterile technique. 11. Performed hand hygiene and donned clean gloves. 12. Removed old dressing. 14. Removed stabilization device. 16. Removed gloves, performed hand hygiene, and donned sterile gloves. 17. Measured external length of catheter from hub to skin entry. 18. Cleansed area with antiseptic solution. 21. Secured catheter with stabilization device. 22. Applied transparent semipermeable dressing to insertion site. The procedure provided did not identify measuring the circumference of the arm. An interview was completed with the Director of Nursing (DON) on 9/12/25 at 11:52 AM. When queried regarding Resident #2's PICC line dressing change and identified concerns, the DON revealed they were aware and did not have any questions. According to the Infusion Nurses Society (INS) Infusion Therapy Standards of Practice, Section Six: Vascular Access Device Management. 38. Flushing and Locking Practice Recommendations. 1. Use a single-use prefilled 0.9% sodium chloride syringe to slowly aspirate the VAD for free-flowing blood return that is the color and consistency of whole blood, an important component of assessing catheter function. F. Use positive-pressure techniques to minimize blood reflux into the VAD lumen. 3. Use a gentle pulsatile flushing technique to deliver flush into the catheter. G. Lock short and long PIVCs and midline catheters immediately following each use. 39. Vascular Access Device Post-Insertion Care. a. Remove nontransparent dressing to visually inspect site if patient has local tenderness or other signs of possible local infection; otherwise, use palpation for assessment. b. Measure the external vascular access device (VAD) length at each dressing change. c. Measure circumference of the extremity and compare to baseline measurement when clinically indicated to assess the presence of edema and possible catheter-associated deep vein thrombosis (blood clot) . I. Prepare skin for optimal skin health and dressing adherence. 1. Remove dressing and adhesive-based securement device, maintaining skin integrity and preventing VAD (Vascular Access Device) dislodgement. Use sterile gloves if there is a need to touch the insertion site. (2024, p. 137-149). Review of facility provided policy revealed, Care and Maintenance of Central Venous Catheter (Reviewed/Revised: 12/13/23) revealed, The facility will adhere to accepted standards of practice regarding the care and maintenance of central venous catheters. 4. Wear sterile gloves for dressing changes.Reference:Nickel, B., [NAME], L., [NAME], T., [NAME], A., [NAME], M., [NAME], S., [NAME], B., [NAME], M. J., Crickman, R., Ong, J., [NAME], S., & [NAME], M. E. (2024). Infusion Therapy Standards of Practice, 9th Edition. Journal of infusion nursing: the official publication of the Infusion Nurses Society, 47(1S Suppl 1), S1-S285. https://doi.org/10.1097/[NAME].0000000000000532

This Citation pertains to Intake Number 2580560.Based on interview and record review, the facility failed to ensure that professional standards of care were given (assess, monitor and promptly report to the physician a change of condition regarding surgical wounds) and follow the care plan for one resident (Resident #101) of 3 residents reviewed for professional standards of care resulting in sepsis, 2 surgeries (debridement's of sternum and left leg surgical wounds), antibiotics, and hospitalization stay.Findings Include:Resident #101:Based on Face Sheet, Minimum Data Set (MDS, dated [DATE], revealed Resident #101 was [AGE] years old, fully alert and able to make her own healthcare decisions and required assistance with Activities of Daily Living/ADL's. The resident was admitted to the facility on [DATE] post open heart surgery, for rehabilitation and was discharged to the local hospital for shortness of breath and dehiscence (opening of surgical wound) of 2 post-surgical wounds (sternum and left lower leg) on 7/7/25, was transferred to a hospital in another city and had wound debridement of the sternum and left leg vein [NAME] site. The resident's diagnosis included, post open heart surgery (Bypass Coronary Artery/CABG), Chronic heart and lung disease, Diabetes, Essential tremors, high blood pressure, sepsis from sternal wound infection, and stage 3 coccyx pressure ulcer.Review of the resident's facility Impaired Skin care plan dated 6/17/25, stated nursing were to assess for surgical site infection of the sternum and left lower leg and report any signs of infection (including eschar/dead narcotic tissue) promptly to the Physician or Nurse Practitioner/NP.Review of Resident #101's Emergency Department/ED hospital record dated 7/7/25, revealed she was diagnosed with Infection of wound of sternum with a consult to cardiothoracic surgery. The ED documentation stated, The patient is a [AGE] year-old female who had open heart surgery performed by (Surgeon) about a month ago.Review of hospital consultation notes dated 7/9/25, stated Status post sternal wound debridement for dehiscence; Sepsis related to above (infection and debridement of sternal wound). Also, contribution from urinary tract infection.Review of the hospital Operative Report dated 7/9/25, revealed Resident #101 had surgical debridement of the chest median sternal wound from open heart surgery on 7/9/25. The operative report stated all necrotic skin and tissue was debrided. Procedure #1 Bedside Debridement of Sterontomy (a surgical procedure to gain access to the heart) Wound. Patient states that she reported wound issues to (the facility) on several occasions but states they did not intervene in any way; she eventually complained of chest pain and was transferred to the ED based on that complaint. Documentation from the referring facility noted discovery of a sternal wound dehiscence (opening of the wound) upon arrival. Procedure #2: Indication: Delayed healing and partial dehiscence of open vein harvest site following CABG. The patient subsequently became septic; the patient was changed to cefepime and metronidazole for concern for osteomyelitis (infection of the bone). Patient will be discharged to skilled nursing facility with home hospice.Review of Physician progress note dated 6/18/25, stated Continue incisional care and continue to monitor for signs and symptoms of complications (infection and dehiscence).Review of the resident's Nurse Practitioner E's notes dated 6/21/25, revealed the surgical sites were well approximated (intact) with no signs of infection.Review of the nursing progress note dated 7/4/25, stated Sternal incision noted to have eschar (dead narcotic wound tissue) with cracks in it; shorter L (left) lower leg incision (vein [NAME] site) covered with eschar and is not draining.Review of the nursing progress note dated 7/6/25 (2 days after staff first noted eschar tissue), stated Sternal incision more open and will require close monitoring. No measurements of either site were documented by nursing.Review of nursing progress notes dated 7/4/25 through 7/7/25, revealed no complete wound assessment (no documentation at all of length, width, odor, warmth at site, discharge noted from wounds done by nursing with prompt transfer (when sternal and left leg wounds were found to have narcotic tissue on 7/4/25, no documentation of calling the Physician or NP upon observation of narcotic wound tissue (on 7/4/25), and delayed transfer to acute care for eschar tissue observed with infection which lead to sepsis (transferred to hospital for evaluation on 7/7/25, found narcotic dead tissue on 7/4/25).During a phone interview done on 8/12/25 at approximately 2:10 p.m., Nurse B was asked by this surveyor if she had called and informed the physician or NP on 7/4/25 and on 7/6/25, of the eschar tissue on the resident's sternum and she stated I don't remember calling them; I knew she had a up-coming appointment, I know she had labs done from the first time we sent her out for nose bleed (on 7/4/25, no hospital documentation of having observed the sternum or leg wound was found), I did not call for the labs. Nurse B said she did not call anyone and inform them of the resident's eschar, because the resident had a appointment, she thought she could wait. The resident had sepsis upon entry to the hospital emergency room from the infection of her sternal surgical wound.During an interview done on 8/12/25 at approximately 10:15 a.m., Nurse Practitioner/NP E stated They (staff) did not inform me of the eschar in the sternum surgical wound or the left leg, they should have.During an interview done on 7/12/25 at 12:11:00 p.m., Nurse Manager, RN C stated They (nursing staff) were considered about the nose bleeds, no one told me about the sternum wound or leg; they dropped the ball on that, I would have notified the provider.During an interview done on 7/12/25 at 12:47 p.m., Nurse Educator, RN D stated No one informed me of the resident's condition, I would of thought the nurse would of informed somebody. I educate them on assessment and documentation.During an interview done on 8/12/25 at approximately 11:40 a.m., Wound Nurse, LPN stated I do not take pictures, assess, monitor or document anything on surgical wounds, they (management) told me not too; I did not look at it.During an interview done on 8/12/25 at 12:55 p.m., the facility Administrator stated, The evidence does support we did not follow the care plan.Review of the facility Wound Treatment Management policy dated 10/26/23, stated Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.

This Citation Pertains to Intake Number MI00149747. Based on observation, interview and record review, the facility failed to ensure comprehensive assessment and timely implementation of a plan of care and interventions for one resident (Resident #703) of three residents reviewed, resulting in the lack of facility and staff knowledge of the resident's situation, history of inappropriate sexual behaviors, and the potential for unmet care needs and Resident #703 and other facility Residents to experience psychosocial injury. Findings include: Review of intake documentation, dated as received on 1/21/25, revealed staff were not notified a Resident admitted to the facility had a history of sexually deviant behavior with a law enforcement ordered tether monitoring device. The intake indicated the facility did not comprehensively assess the Resident to ensure their needs were identified and met upon admission and did not notify staff to ensure interventions and monitoring were in place for safety. Resident #703: On 1/29/25, Resident #703 was sitting on the edge of their bed in their room. The Resident was listening to music. A black colored device was observed on the Resident's ankle. An interview was completed at this time. When queried how long they had been at the facility, Resident #703 was slow to respond and revealed they had been there a few weeks. Record review revealed Resident #703 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, dementia with mood disturbance, heart disease, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and needed partial-to-total assistance to complete Activities of Daily Living (ADL). The MDS detailed the Resident displayed no behaviors and had no hallucinations and/or delusions. Review of Resident #703's Electronic Medical Record (EMR) revealed the following care plans and interventions upon admission to the facility: Care plan: Resident takes psychotropic/mood stabilizer medication as evidenced by use of antipsychotic, antidepressant and antianxiety medications (Initiated: 1/9/25; Revised: 1/13/25). This care plan included the interventions: - Administer medications as ordered (Initiated: 1/9/25) - Refer to psychologist/psychiatrist as needed (Initiated: 1/9/25) - Observe for and report to Physician/NP/PA adverse effects of antidepressant medication use . (Initiated: 1/9/25) - Observe for and report to Physician/NP/PA adverse effects of antipsychotic/mood stabilizer medication use . (Initiated: 1/9/25) Care plan: Resident is at risk for impaired skin integrity related to incontinence, decreased mobility, tether to right ankle (Initiated: 1/9/25; Revised: 1/13/25). The care plan did not include any specific information pertaining to the tether. On 1/13/25, a care plan entitled, Resident has an impaired mood/psychiatric status related to visual and auditory hallucinations r/t (related to) Parkinson's Disease, Dementia with anxiety/depression/moods/behaviors (Initiated and Revised: 1/13/25). The care plan included the interventions: - Administer medications and treatments as ordered (Initiated: 1/13/25) - Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.) (Initiated: 1/13/25) - Encourage on-going involvement with family and friend(s) (Initiated: 1/13/25) (Initiated: 1/13/25) A care plan entitled, Resident has behavior(s) related to hx (history) of sexual deviant behavior as evidenced by: Sexually inappropriate conversations with staff was initiated on 1/20/25. This care plan included the interventions: - Give non-judgmental support (Initiated: 1/20/25) - Observe and document episodes of inappropriate behaviors . (Initiated: 1/20/25) - Observe behavior episodes and attempt to determine underlying cause . (Initiated: 1/20/25) - Behavior: Sexually inappropriate conversations with staff. Intervention: Redirect conversation to socially appropriate content (Initiated and Revised: 1/20/25) - Male caregivers only for showers (Initiated and Revised: 1/20/25) Review of Resident #703's EMR revealed the following: - 1/9/25 at 3:31 PM: Nursing Evaluation Summary . verbal report from (hospital) . RLE (Right Lower Extremity) 'tether'; do NOT remove per law enforcement . Speech deficit: stutters, slow to respond. HOH . No s/s (signs/symptoms) anxiety/depression. 3 MAX assist transfer. w/c (wheelchair) primary locomotion . - 1/10/25 at 12:40 PM: Initial Social Service History . Admission . Does the resident have a spouse or significant other? Yes . Ended in divorce, now won't speak to him .Recollection of relationship with children: 1 son doesn't consider him his dad at all . Behavior, Medical, and Psychiatric History . No major health occurrences or behavioral concerns . admitted on a psychoactive medication(s)? Yes . behaviors or mood disorders: Anxiety, depression, dementia . Things that make you become anxious/agitated: Ex-wife won't talk to him . Anticipated length of stay: Long Term Stay . The Trauma assessment within the admission assessment indicated the Resident did not have a diagnosis of Post-Traumatic Stress Disorder (PTSD) and/or a history of trauma. - 1/19/25: Progress Notes . seen for pain in low back and left side . Reports has chronic back pain and was on Norco (narcotic pain medication), MS (Morphine Sulfate- narcotic pain medication) continue in past. Unsure why med was discontinued. May have stopped when in prison . There was no documentation of completion of a criminal background check completed in the EMR. Review of the Michigan Sex Offender Registry and the Offender Tracking Information System ([NAME]) revealed Resident #703 was convicted of two separate counts of Criminal Sexual Conduct (CSC) in the second degree on 10/20/16. The Resident was sent to prison and discharged on [DATE]. Record review revealed Resident #703 was seen by a Behavioral Health Care Provider on 1/16/25. The Behavioral Health Care Provider note detailed, Initial evaluation: depression/ anxiety/ psychosis/ dementia; medication review . (Resident #703) admits to a long history of psychiatric illness . managed on multiple psychotropic medication . unsure of actual diagnosis' . (Resident #703) admits to being unhappy with situation . admits to hallucinations . Psych Exam . Judgement: Marginal . Insight: Marginal . Thought Process: Organized . Thought content: + auditory and visual hallucinations . Review of Point of Care (POC) task documentation in Resident #703's EMR revealed documentation of Sexually inappropriate conversations on 1/20/25 at 10:13 PM. An interview was conducted with Certified Nursing Assistant (CNA) A on 1/29/25 at 1:35 PM. When queried regarding Resident #703's behaviors, CNA A stated, (Resident #703 said) they raped their daughters. When queried regarding the context in which that was said, CNA A responded that the Resident had been telling the staff why they were in prison. CNA A verbalized staff were unaware that Resident #703 had been incarcerated and/or that they had a tether. When queried if the Resident had displayed any inappropriate behaviors at the facility, CNA A revealed the Resident called them pet names such as love and sweetheart and made them feel uncomfortable. CNA A revealed they looked the Resident up on the State Sex Offender website and were concerned that the information had not been passed on to staff. With further inquiry, CNA A verbalized they were concerned because there are children that visit the facility, and the Resident did not have a care plan in place to ensure increased supervision. An interview was conducted with the facility Administrator and Director of Nursing (DON) on 1/29/25. When queried regarding the facility admission process, including background check completion, the Administrator indicated admissions are screened in a central location for multiple facilities within the organization prior to the referral information being received at the facility. The Administrator verbalized that background checks are completed for residents prior to admission. When queried regarding Resident #703, the Administrator revealed they were aware the Resident had a history of CSC. When queried if other staff were aware, the Administrator responded that it had been discussed during the facilities morning meeting. The Administrator was asked who is included in the morning meeting and replied, Leadership. When queried why the care plan related to Resident #703 having sexual deviant behaviors was implemented on 1/20/25, the Administrator and DON relayed the Resident had verbalized inappropriate sexual comments to staff. The Administrator and DON were then asked why Resident #703 had a tether from law enforcement in place and what the conditions of the tether were, and both verbalized they did not know. With further inquiry, the Administrator and DON relayed that Resident #703 told staff they were in prison because they had sex with their stepdaughters, but they did any other information. When queried if they asked Resident #703 why they had a tether and/or the condition in place for the tether, both the DON and Administrator stated they had not. When asked how they comprehensively assessed and created a meaningful care plan for the Resident without knowing the Resident's history and current situation/needs, the DON confirmed they could not. When queried if children entered the facility, the Administrator confirmed school age children come to the facility as part of the Activities program. When asked if the facility had assessed and implemented interventions to ensure adequate supervision and monitoring of Resident #703 during times when children were in the facility, the Administrator and DON indicated the Resident had required significant assistance when they first arrived at the facility and had not attended activities. When asked about the Resident's current mobility and level of assistance required, the Administrator and DON revealed the Resident had made great improvements in therapy and were able to move around more independently now. When asked how the facility was ensuring adequate supervision of Resident #703 to ensure safety for staff, other residents, and visitors, the Administrator indicated they would need to reevaluate. No further explanation was provided. An interview was conducted with Resident #703 and the DON on 1/29/25. Resident #703 was asked why they had a tether in place and responded they were not sure. The Resident revealed the tether was put on when they got out of prison and their Probation Officer (PO) had replaced it several times. When asked, Resident #703 was unable to recall the full name of their PO. Resident #703 was asked if they were still on probation and did not provide a clear response. When queried regarding the conditions and reason for the tether, the Resident said they liked to bounce their granddaughters on their lap and indicated that was the reason had the tether. The Resident then expressed denial of any wrongdoing and blamed others for their conviction and imprisonment. Resident #703 became very sexually focused and began making statements regarding their daughter in laws sexual life and behaviors. The interview was concluded at this time. After exiting the Resident's room, a follow up interview was conducted with the DON. When queried, the DON confirmed Resident #703 made inappropriate sexual comments and was hyper sexually focused during the interview. When queried regarding Resident #703's behavioral history including what they stated during the interview and what they had told staff, the DON revealed they did not know what the crime and/or the Resident's behavioral history was. When queried if the mental health provider was aware of the Resident's history and tether when they evaluated Resident #703, the DON revealed the mental health provider seen the Resident for a medication evaluation. When queried how staff were able to meet Resident #703's needs and ensure safety of staff and visitors, when they did not know and had not comprehensively assessed the Resident, the DON verbalized agreement. Review of facility policy/procedure entitled, Behavior Management Program (Revised 10/27/23) did not address comprehensive assessment and care planning. Review of facility policy/procedure entitled, Baseline Care Plan (Reviewed/Revised: 12/28/23) revealed. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . The facility may develop a comprehensive care plan in place of the baseline care plan during the first 48 hours of admission .

Based on observation, interview and record review, the facility failed to provide palatable meals for four residents (Resident #7, Resident #9, Resident #36, Resident #57) of 30 residents reviewed for the dining task, resulting in complaints of dried food items and soggy bread with the likelihood of decreased food consumption. Findings include. On 9/03/24, at 12:58 PM, Resident #36 complained they had to cut the top off the sweet potato because it was too dry to eat and was only able to eat the inside. On 9/03/24, at 1:16 PM, Resident #57 was in their room with their lunch meal which consisted of ham, bread, cauliflower and half of a yam potato. Resident #57 complained they had to cut off the dried top of the yam that was dried and crusted. Resident #57 picked up their bread which was soggy from the ham juice. On 9/03/24, at 1:38 PM, Certified Dietary Manager (CDM) A was interviewed regarding the provided lunch meal. CDM A was asked to explain how the yam was cooked and CDM A offered they cut in half and baked it. CDM A was asked if they used any butter or oil to keep it moist and CDM A no, we just cut it in half and put it in the oven. CDM A was asked how they serve bread and butter and CDM A stated, they put it on the plate. On 9/03/24, at 2:05 PM, Resident #9 complained the yam provided at lunch was too dry to eat. On 9/03/24, at 2:15 PM, Resident # 7 complained the potato served for lunch was too dry. On 9/4/24, at 12:45 PM, Resident #36 was eating in their lunch. They complained they could only eat 1 half of buttered bread as the other half was soggy from the baked beans the bread was sitting on.

This Citation pertains to Intake Numbers MI00146271 and MI00146574. Based on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) care (showers, nail care, hair care, general hygiene) in a timely manner for six residents (#6, #25, #27, #29, #31, and #178) of 19 residents reviewed, resulting in a lack of hygiene with showers, nail care, hair washing, and general hygiene of six residents to have unmet needs, anger/frustration, embarrassment, and complaints. Findings include: Record review of the facility 'Activity of Daily Living (ADL)' policy dated 12/28/2023 revealed the facility takes measures to minimize the loss of resident's functional abilities, including Activities of Daily Living (ADL). Activities of Daily Living include the ability to: (1) Bathe, dress and groom . A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .The facility, maintains individual objectives of the care plan through periodic review and evaluation. Resident #29: Record review of Resident #29's progress note dated 9/9/2024 at 3:37 PM noted: Resident is long term. Resident has long and short-term memory loss, he is legally blind, has some of his own teeth. Resident depends on staff for locomotion and is not an elopement risk. Resident needs assistance with his ADL (Activities of Daily Living). Resident uses a mechanical lift for transfers and a wheelchair for locomotion and mobility . Observation and interview on 09/03/24 at 01:21 PM with Resident #29 stated that he gets a shower or bath every couple of days or weeks he gets a shower. Observed of Resident #29 to be seated in a high back Broda chair in the library area of the facility with his hair to be sticking up at odd angles. Observation on 09/05/24 at 08:22 AM of Resident #29 to be seated up in high back Broda chair in the dining room seated at the assist dining table. The resident was assisted with the meal. Observation on 09/05/24 at 08:58 AM of Resident #29 to be seated in Broda chair in the library area with 9 other residents to watch funny videos on TV with no volume and then the Rise and Shine group activity was to begin. Resident noted to have his hair sticking up and appeared unkept. Clothing was changed from the previous days' clothes. in an interview on 09/10/24 at 09:22 AM with Resident #29 stated that they don't do anything with him. No, he did not get his shower yesterday. He could not state why he did not get the shower. Record review of Resident #29's Task: Bathe/Showers 30 day look back revealed: 8/15/2024 Response not required. 8/15/2024 bed bath 8/19/2024 Bed bath 8/22/2024 Bed bath 8/26/2025 shower 8/29/2024 Response not required. 9/2/2024 Response not required. 9/5/2024 Response not required. 9/9/2024 Response not required. Resident #178: Record review of Resident #178's electronic medical record revealed that the resident was admitted on [DATE] as a respite care admission for 10 to 16 days. Medical diagnosis included Chronic Obstructive Pulmonary Disease (COPD), dementia and Post Traumatic Stress Disorder (PTSD). In an interview on 09/03/24 at 12:37 PM with Resident #178 revealed that he did not get a shower for over a week and that the showers are not at regular times. Record review on 09/04/24 at 12:19 PM Resident #178's Care plans pages 1 through 17 revealed that intervention for bathing initiated 8/27/2024 consisted of one person assist, twice weekly and as needed. There were no set days for showers in the care plan. Record review of Resident #178's Tasks: Showers/bathing Wednesday morning and Sunday evening. 30 days look back revealed resident was admitted on [DATE] and did not receive any bathing until 8/28/2024 consisting of a bed bath. 22347 Resident #27: Review of Resident #27's electronic record including the Activity of Daily Living/ADL care plan, revealed diagnosis that included dementia and post traumatic stress. The resident required 24-hour supervision and assistance with all ADL's. Observation of Resident #27 was made on 9/4/24 at 10:50 a.m. The resident was sitting at the dining table on A-Hall having her nails done. The resident's hair was matted on the back and sides. It looked like it had not been combed at all. There were staff, activity aide and other residents in the room at the time. The resident was talking appropriately and showing no behavioral signs at the time. 39059 Resident #6: On 9/03/24, at 11:38 AM, Resident #6 was propelling in their wheelchair. Their face was unshaven. On 9/04/24, at 9:00 AM, a record review of Resident #6's electronic medical record revealed an admission on 06/22/2024 with diagnoses that included cognitive impairment, weakness and visual impairment. Resident #6 required assistance with all Activities of Daily Living (ADL's) and had impaired cognition. A review of the . ADL self-care performance deficit care plan . revealed . BATHING: 1 assist. Twice weekly and as needed. Date Initiated: 09/01/2023 . PERSONAL HYGIENE/ORAL CARE: Requires set up assist Date Initiated: 09/01/2023 . A review of the 30 day look back task list . Type of bath provided Shower . revealed the resident did not receive the twice weekly showers that were care planned and revealed the following: 8/9/2024 The Shower column was check marked. 8/16/2024 Response Not Required 8/17/2024 The Shower column was check marked. On 9/04/24, at 9:58 AM, Resident #6 was up in their wheelchair and remained unshaven. Resident #25: On 9/03/24, at 10:17 AM, Resident #25 was in their room in their wheelchair. Their nails were long, unclipped and slightly jagged. Resident #25 was unshaven and offered, they shower themselves and cut their own nails. On 9/04/2024, at 9:30 AM, a record review of Resident #25's electronic medical record revealed an admission on 05/11/2023 with diagnoses that included Dementia, impaired vision and Parkinson's disease. Resident #25 required assistance with all ADL's and had impaired cognition. A review of the . ADL self-care performance deficit . care plan revealed . BATHING: 1 assist. Twice a week and as needed. Date Initiated: 06/11/2024 . PERSONAL HYGIENE/ORAL CARE: 1 person assist Date Initiated: 09/01/2023 . A review of the 30 day look back task list . Type of bath provided Shower . revealed the resident did not receive the twice weekly showers that were care planned and revealed the following: 8/23/2024 Shower was check marked. 8/30/2024 Response Not Required 8/31/2024 Shower was check marked. On 9/04/24, at 10:00 AM, Resident #25 was sitting in their wheelchair and their nails remained unclipped. Resident #31: On 9/03/24, at 12:56 PM, Resident #31 was sitting in their room. Resident #31 was unshaven. On 9/03/24, at 3:20 PM, a record review of Resident #31's electronic medical record revealed and admission on 11/11/2022 with diagnoses that included Schizophrenia, weakness and failure to thrive. Resident #31 required assistance with ADL's and had intact cognition. A review of the ADL self-care performance deficit revealed . PERSONAL HYGIENE: 1 assist Date Initiated: 09/29/2023 . On 9/04/24, at 10:08 AM, Resident #31 was in their room. Family member was present and complained that the resident can't use their left hand. Family member further complained that hygiene is very important. Family member complained they are supposed to make sure he has his splint on but the use the excuse, he refuses.

Based on observation, interview and record review, the facility failed to ensure a clean and sanitary kitchen, serve food sanitarily and discard expired foods for a census of 71 residents who consume food from the kitchen, resulting in the likelihood for food borne illness with possible hospitalization . Findings Include: Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law, effective [DATE], revealed all potentially hazardous foods must have an open and use-by date. The food items must be disposed of on or after the use-by date. During the initial kitchen walk through done on [DATE] at 10:30 a.m., accompanied by Registered Dietitian A, the following concerns were observed: Kitchen initial tour: On [DATE] starting at 10:15 a.m., the initial tour of the kitchen accompanied by Registered Dietitian/RD A the following observations were made: -At 10:16 a.m., in the middle refrigerator was found sliced ham with the open date of [DATE], and the use-by date of [DATE]; it was past it's use-by date (unsafe). -At 10:17 a.m., in the middle refrigerator was found lettuce dated ,d+[DATE], with a use-by of ,d+[DATE]. -At 10:18 a.m., 3 clean and ready for use small plastic bowels with dried food particles inside were found. During an interview done on [DATE] at 10:18 a.m., RD A stated we will wash them. -At 10:27 a.m., 1 clean and ready for use plastic coffee cup was found with dried on food particles inside. -At 10:30 a.m., 4 white plates were found on the plate warmer, clean and ready for use with dried food particles on them. During an interview done on [DATE] at 10:32 a.m., RD A informed this surveyor that they did not have enough staff, they were short. 39059 On [DATE], at 12:13 PM, During dining task, Dietary [NAME] O was observed with gloved hands which were resting on their bilateral hips. Dietary [NAME] O walked to the serving line and began to serve the lunch meal with no hand hygiene performed. Dietary [NAME] O picked up butter bread with their gloved hands and placed the bread directly on the plate. On [DATE], at 12:30 PM, Infection Control (IC) Nurse P was alerted of the observation of the Dietary [NAME] P not performing hand hygiene and serving lunch with dirty gloves. IC Nurse P planned to provide education.

This Citation pertains to Intake Number MI00146574. Based on observation, interview and record review, the facility failed to ensure that the A-Hall (the Memory Care/Dementia/Behavioral secured unit) eliminated lingering odors, resulting in unsanitary environment, lingering foul odors, angry staff, with the likelihood of embarrassment from residents and staff. Findings Include: Observation of A-Hall locked unit was done on 9/3/24 at 10:53 a.m. The carpet starting at the door down to the main dining/activity room had a very strong odor of urine. During an interview done on 9/4/24 at 10:10 a.m., Staff K stated You have to use hot water and disinfectant and it will deactivate the glue, it will be deactivated (carpet will come up). It was stained on the first day it was put down with (BM). During an interview done on 9/4/24 at 10:11 a.m., Housekeeper J said when they have to keep cleaning the carpet daily, it would take time away from their other housekeeping duties. During an interview done on 9/4/24 at 10:12 a.m., CNA L stated It makes no sense; it gets dirty daily. We have one resident who (BM's) on it and two that pee on it. We told them not to put carpet down before they did it. During an interview done on 9/4/24 at 10:50 a.m., the Director of Nursing stated, I don't agree with it (carpet down on a A-Hall, Memory Care/Dementia/Behavioral secured unit). During an interview done on 9/3/24 at 11:00 a.m., Nursing Assistant/CNA B stated It's the carpet that smell, they (resident's) pee on it. During an interview done on 9/10/24 at 11:45 a.m., Director of Housekeeping M stated It was a bad idea (putting carpet on A-Hall); I am going to have to use my carpet machine every morning. Review of the facility Safe and Homelike Policy dated 7/28/20, said the facility would minimize odors, and report lingering odors., and maintain a sanitary, and comfortable environment.

Based on observation, interview and record review, the facility failed to ensure that three medication carts and one treatment cart were clean and sanitary of 5 medication carts and 2 treatment carts, resulting in the unsanitary condition of medication carts, cross contamination, and the unaccounted for loss of 1 medication. Findings Include: Observation of medication cart C and cart D was done on 9/3/24 at 9:48 a.m. and at 9:55 a.m., accompanied by Nurse, LPN J. During observation of medication cart C, drawers second and third were noted to have crushed medications and papers in the back of the drawers. During observation of medication cart D, the second drawer had white crushed medications and papers in the back of the drawer. During an interview done on 9/3/24 at 9:55 a.m., Nurse J stated Night's cleans it (6:00 p.m. to 6:00 a.m., cleans medication carts). During observation of the treatment cart for C and D hall done on 9/3/24 at 10:03 a.m., accompanied by Nurse J, a large container of ketoconazole shampoo was found to have an excessive amount of dried shampoo drippings on the sides and top. Observation of medication cart A back done on 9/3/24 at 10:48 a.m., and cart A front was done on 9/3/24 at approximately 11:40 a.m., accompanied by Nurse, LPN I. During observation of medication cart A back done on 9/3/24 at 10:48 a.m., revealed In the second and third drawers, crushed medications, papers and white sprinkles (medication) on the bottom of the drawers. During observation of medication cart A front done on 9/3/24 at approximately 11:40 a.m., revealed the second drawer had an orange-colored loose pill in the back of the drawer. During an interview done on 9/3/24 at 10:48 a.m., Nurse I revealed the night shift was supposed to clean the medication carts. Review of the facility Medication Storage policy dated 10/30/2020, stated It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.

This Citation pertains to Intake Number MI00146574. Based on observation, interview and record review, the facility failed to order and ensure the administration of oxygen at bedtime for one resident (Resident #178) out of 2 residents reviewed, resulting in the likelihood for oxygen desaturation at nighttime, confusion, and shortness of breath/hypoxia. Findings include: Record review of the facility 'Oxygen Safety' policy dated 1/1/2022, revealed the facility is to provide a safe environment for residents, staff and public. licensed staff using oxygen equipment will be trained in its operation. Record review of the facility 'Oxygen Administration' policy dated 10/26/2023 revealed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with intent of treating or preventing the symptoms and manifestations of hypoxia. Compliance guidelines: Oxygen is administered under the orders of a physician . Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy . The resident's care plan shall identify the interventions for oxygen therapy. Resident #178: Record review of Resident #178's referral packet paperwork dated 8/20/2024 (prior to admission) identified that the resident used home oxygen. Record review of the referral medical diagnosis included: Chronic Obstructive Pulmonary Disease (COPD) with home oxygen at 3 liters for nighttime use. In an interview on 09/03/24 at 10:19 AM with Resident #178 stated the use of Oxygen at times and use's 3 liters. Resident #178 stated using (oxygen) it all the time at night, because oxygen level drops off at night. Resident #178 stated was in the hospital when they found that (resident) dropped oxygen levels, they shook him and shook him till he woke-up. When I first came to the home (facility), I told them I needed oxygen at night. Observation on 09/03/24 at 10:19 AM while in Resident #178's room revealed a concentrator to the head of the bed on the right-hand side with oxygen tubing dated and set at 3 liters of oxygen. Record review of Resident #178's physician order dated 8/27/2024 revealed Oxygen via nasal cannula at HS (bedtime) at 2 liters was ordered four days after admitted [DATE]. Record review of Resident #178's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of August 2024 revealed on 8/27/2024 at 8:00 AM Oxygen via nasal cannula was administered. Record review on 9/3/2024 of Resident #178's care plans pages 1 through 17 revealed there was no oxygen therapy care plan or interventions for monitoring of nighttime oxygen saturation levels noted. In an interview on 09/05/24 at 11:09 AM with Licensed Practical Nurse (LPN) I the A-hall Unit manager, revealed that the floor nurse input the referral orders into the computer. the referral process is being updated; I review all the admission orders. Referrals are reviewed by the Director of Nursing (DON), and she accepts or declines the referrals. Resident #178 has oxygen in his room, and he will tell you that he uses it when he needs it usually at night. Record review of Resident #178's medical record revealed admitted on [DATE] and had no oxygen to use until 8/27/2024, (4 days and nights) without oxygen. In an interview on 09/05/24 at 11:47 AM with the Director of Nursing (DON) revealed admission referral paperwork are reviewed by central intake office and then sent to the facility, were she looks at the referral and decides what room is appropriate for the resident. Resident #178's home oxygen was missed. The daughter brought him in here, he walked using his cane with no oxygen. His room was not dirty, it had just been cleaned, we had 2 residents that were discharged from that room and the room was cleaned. He was the only person originally until the roommate came. There was nothing said about a private room by resident or family. Air conditioning- comes from the ceiling in the hallways. Oxygen was administered on 8/27/2024 evening per order.

This Citation pertains to Intake Number MI00146574. Based on observation, interview and record review, the facility failed to develop a comprehensive and individualized care plan related to Resident #178 required oxygen therapy at bedtime and Activities of Daily Living (showers) of 19 residents reviewed, resulting in Resident #178 to have the likelihood of unmet needs. Findings include: Record review of the facility 'Admission to Facility' policy dated 1/1/2022 revealed that the primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. Prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident . Care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan. Record review of the facility 'Oxygen Administration' policy dated 10/26/2023 revealed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Compliance guidelines: Oxygen is administered under the orders of a physician . Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy . The resident's care plan shall identify the interventions for oxygen therapy. Record review of the facility 'Activity of Daily Living (ADL)' policy dated 12/28/2023 revealed the facility takes measures to minimize the loss of residents functional abilities, including activities of daily living (ADL). Activities of daily living include the ability to: (1,) Bathe, dress and groom . A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .The facility ,maintains individual objectives of the care plan through periodic review and evaluation. Resident #178: Record review of Resident #178's electronic medical record revealed that the resident was admitted on [DATE] as a respite care admission for 10 to 16 days. Medical diagnosis included Chronic Obstructive Pulmonary Disease (COPD), dementia and Post Traumatic Stress Disorder (PTSD). In an interview on 09/03/24 at 12:37 PM with Resident #178 revealed that he did not get a shower for over a week and that the showers are not at regular times. Record review on 09/04/24 at 12:19 PM Resident #178's Care plans pages 1 through 17 revealed that intervention for bathing initiated 8/27/2024 consisted of one person assist, twice weekly and as needed. There were no set days for showers in the care plan. Record review of Resident #178's Tasks: Showers/bathing Wednesday morning and Sunday evening. 30 days look back revealed resident was admitted on [DATE] and did not receive any bathing until 8/28/2024 consisting of a bed bath. Record review of Resident #178's referral packet paperwork dated 8/20/2024 (prior to admission) identified that the resident used home oxygen. Record review of the referral medical diagnosis included: Chronic Obstructive Pulmonary Disease (COPD) with home oxygen at 3 liters for nighttime use. Observation on 09/03/24 at 10:19 AM while in Resident #178's room revealed a concentrator to the head of the bed on the right-hand side with oxygen tubing dated and set at 3 liters of oxygen. Record review of Resident #178's physician order dated 8/27/2024 revealed Oxygen via nasal cannula at HS (bedtime) at 2 liters was ordered four days after admitted [DATE]. Record review of Resident #178's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of August 2024 revealed on 8/27/2024 at 8:00 AM Oxygen via nasal cannula was administered. Record review on 9/3/2024 of Resident #178's care plans pages 1 through 17 revealed there was no oxygen therapy care plan or interventions for monitoring of nighttime oxygen saturation levels noted.

Based on observation, interview and record review, the facility failed to include a Post Traumatic Stress Disorder (PTSD) diagnosis in the comprehensive admission assessment noted on the CMS 802 form, dated 9/3/2024 and on 9/5/2024, for one resident (Resident #178) out of 19 residents reviewed for assessments, resulting in the likelihood for an inaccurate assessment of the resident's abilities, treatments and unmet needs. Findings include: Record review of the facility 'MDS (Minimum Data Set) 3.0 Policy' dated 1/24/2024 revealed it is the policy of the facility to utilize the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual as the source document for any/all MDS scheduling, encoding, completion, submission, correction, and retention requirements as outlined in chapters 2 through 6 of the RAI manuals. Chapter 4: provides guidance on Care Area Assessment (CAA) triggers, completion requirements, and care plan development. Resident #178: Record review of Resident #178's referral packet paperwork dated 8/20/2024 (prior to admission) identified that the resident used home oxygen. Record review of the referral medical diagnosis included: Post Traumatic Stress Disorder (PTSD). Record review of Resident #178's electronic medical record revealed that the resident was admitted on [DATE] as a respite care admission for 10 to 16 days. Medical diagnosis included Chronic Obstructive Pulmonary Disease (COPD), dementia and Post Traumatic Stress Disorder (PTSD). Observation on 9/3/2024 at the beginning of the annual recertification survey revealed that Resident #178 was in a semi-private room and resided closest to the room door. Resident #178 was able to sit up on the edge of the bed and talk with the surveyor about his care. Record review on 09/04/24 at 02:10 PM of facility provided the CMS 802 form dated 9/3/2024 at 11:22 AM revealed for Resident #178 diagnosis of Post Traumatic Stress Disorder (PTSD) was not identified on the CMS 802 form. In an interview on 09/05/24 at 09:47 AM with Registered Nurse N the Minimum Data Set (MDS) assessment nurse stated that the MDS assessment starts with resident entry/upon arrival, and an admission within 19 days we do a 5 day. It captures the first 5 days of stay. Respite is the same way, His 5 day is due today 9/5/2024, when I finish it today, I'll bring it to you. Record review on 9/5/2024 at 10:29 AM of the newly provided CMS 802 form revealed that Resident #178 was identified for PTSD/trauma on the revised form.

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure that indwelling urinary catheter care was conducted according to professional standards of practice, for one resident (Resident #21) of four residents reviewed, resulting in Resident #21's catheter being maintained in an unsanitary matter, a lack of documentation of care and monitoring per the Health Care Provider's (HCP) order, repeated Urinary Tract Infections ([CONDITION(S)]), hospitalization for a [CONDITION(S)] with [CONDITION(S)] (infection throughout the body), and the likelihood for a decline in the resident's overall health status. Findings include: Resident #21: On 6/21/22 at 12:01 PM, Resident # 21 was observed in their room in bed. The Resident made eye contact but did respond verbally when spoke to. Resident #21's mouth was slightly open, and their mucous membranes and tongue were markedly dry. There were no beverages present within the Resident's reach. An indwelling urinary catheter drainage bag was noted on the right side of the Resident's bed. The drainage bag was not contained, nor covered in a dignity bag, and positioned directly on the floor. The urine in the tubing and drainage bag was dark in color with significant amounts of sediment noted. A thick, off white colored coating was present on the inside of the drainage tubing. Record review revealed Resident #21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive assistance to perform all ADLs. Review of Resident #21's care plans revealed a care plan entitled, The resident has (indwelling) catheter . r/t (related to) retention (Initiated: 2/1/22; Revised: 4/5/22). The care plan included the interventions: - Change per order (see TAR [Treatment Administration Record]) and PRN (as needed) (Initiated: 2/1/22; Revised: 4/5/22) - Monitor and document output as per facility policy (Initiated: 2/1/22; Revised: 4/5/22) - Monitor/document for pain/discomfort due to catheter (Initiated: 2/1/22; Revised: 4/5/22) - Monitor/record/report to MD for s/sx (signs/symptoms) [CONDITION(S)]: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns (Initiated: 2/1/22; Revised: 4/5/22) - Position catheter bag and tubing below the level of the bladder and away from entrance room door (Initiated: 2/1/22; Revised: 4/5/22) - Provide for gravity drainage (Initiated: 2/1/22; Revised: 4/5/22) At 3:20 PM on 6/21/22, another observation occurred of Resident # 21. The Resident was in their room, in the same position in bed. Their indwelling urinary catheter drainage bag remained not covered and/or contained and positioned on the right side of the bed directly on the floor. Resident #21's urine within the tubing and drainage bag remained dark in color with visible sediment. The off-white-colored sediment build-up remained within the tubing. An interview was completed with Licensed Practical Nurse (LPN) D on 6/22/22 at 1:44 PM. When queried regarding the rationale for Resident #21's indwelling urinary catheter, LPN D specified the Resident's catheter was due to urinary retention. LPN D was then queried regarding Resident #21's catheter drainage bag being observed directly on the floor. LPN D revealed catheter drainage bags should always have a barrier and should not touch the floor. When asked about the color and sediment of Resident #21's urine including the cloudy, off white colored coating in the drainage tubing, LPN D did not provide further explanation. When queried regarding nursing care and management of the Resident's catheter, LPN D revealed they would need to review the Resident's orders. An observation of incontinence/daily ADL care for Resident #21 was completed with Certified Nursing Assistant (CNA) R and CNA S on 6/22/22 at 2:12 PM. During daily care, the Resident was noted to not have a urinary catheter securement device in place. When asked, both CNAs indicated Resident #21 pulls at their catheter when they have a securement device. With further inquiry regarding the type of securement devices used by the facility, the staff revealed the facility utilizes the securement devices which attach (stick) to the skin. CNA R continued that Resident #21 has sensitive skin and they were unsure if the device caused skin irritation. The staff were then asked if the wrap around, non-adhesive, Velcro style catheter securement device had been tried and both indicated it had not. Review of Resident #21's Medication Administration Record (MAR) for May 2022 revealed the Resident was started on [MEDICATION(S)] ([MEDICATION(S)]- antibiotic) 500 mg (milligram) three times a day for seven days due to a [CONDITION(S)] on 5/28/22. Review of Resident #21's Treatment Administration Record (TAR) for May 2022 revealed the following: - Change catheter drainage bag monthly and as needed. Label with date in the morning every 28 day(s) (Start Date: 4/6/22). The TAR indicated the catheter drainage bag was due to be changed on 5/4/22. There was no documentation of completion. - Change indwelling catheter as needed one time a day every 28 day(s) (Start Date: 4/6/22). The TAR indicated the catheter was due to be changed on 5/4/22. There was no documentation of completion on 5/4/22. - Change indwelling catheter as needed as needed (Start Date: 4/5/22). Documented as completed on 5/12/22 at 2:42 AM. - Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any changes every shift (Start Date 3/8/22). The TAR included documentation sections for completion three times per day. There was no documentation of completion on: 5/4/22 Day, 5/5/22 Day, 5/9/22 Day, 5/16/22 Night, 5/23/22 Evening, 5/25/22 Day, and 5/29/22 Night. Review of progress note documentation in Resident #21's medical record revealed the following: - 2/21/22 at 4:15 AM: Nurses' Notes . On call notified: Upon admit resident did have a Foley for urinary retention, was discontinued over a week ago. Has milky discharge from penis frequent urination without being able to empty bladder fully. After moderate urine inct (incontinent) episode did bladder scan still has 500 cc + of urine. - 2/21/22 at 4:32 AM: Nurses' Notes . Order received: Obtained 650 cc of cloudy urine with foul odor. Resident had visual relief and tolerated well. UA sent . - 2/27/22 at 6:43 AM: Nurses' Notes . HX (History) of urinary retention had a Foley upon admission, after removed over a week ago had retention and is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Today Resident was a no void for 8 hrs. Procedure done straight cath'ed obtained 1000 cc of clear dark yellow urine, tolerated well and showed signs of relief. Due to this resident has a cogitative deficit is unable to verbalize urge to void and has difficulty alerting staff of discomfort . - 5/12/22 at 3:00 AM: Nurses' Notes . Resident was showing s/s (signs/symptoms) of discomfort, reaching for genitals. This writer attempted to flush Foley catheter but was unsuccessful. A standing order for Foley catheter change PRN (as needed) is for a 14 F (French) 10 mL (milliliter). This was unavailable. On call (provider) approved a 16 F . 10 mL of sterile water was used to inflate the balloon. New collection bag was attached . 250 mL of clear amber colored urine return noted in bag . - 5/14/22 at 3:55 AM: Nurses' Notes . Noted that resident has indwelling cath 16 fr was [incontinent] of large amount of urine around the cath [insertion] site. (Registered Nurse [RN] Q) in to assess resident. Deflated cath balloon only had 5 cc (cubic centimeters) in, replaced with 10 cc. draining to gravity urine in tubing. Noted this resident has had issues like this in the past and replacing entire cath is very difficult . - 5/14/22 at 10:54 PM: Nurses' Notes . Resident has had continuous issues with Foley not draining well even after being replaced earlier today with 16 french. Urine is coming out both penis and Foley tubing and resident is experiencing lower abd (abdomen) discomfort and retention. Bladder scanner not working correctly get inconsistent numbers each time scanned consecutively. - 5/14/22 at 11:27 PM: Nurses' Notes . Notified on call said that a different size Foley may be used. Also noted has moderate amount of discharge from tip of penis and urine cloudy. - 5/14/22 at 11:31 PM: Nurses' Notes . Inserted 20 fr (French) Foley per ok from on call. Resident tolerated well and it is draining well to gravity. Drank 350 at dinner and had out so far after change 250 cc. - 5/22/22 at 4:04 AM: Nurses' Notes . No urine in tubing after 8 hrs. Inserted 20 fr Foley per ok from on call. Resident tolerated well and it is draining well to gravity. - 5/23/22 at 4:54 AM: Nurses' Notes . For the last 24 hrs have been encouraging fluids and output for 8 hrs has been consistently low in Foley around 300 cc each 8 hr period. Discharge from penis and urine dark with foul odor. Remains afebrile. HX (history) of recurrent [CONDITION(S)]'s. Notified on call. - 5/24/22 at 5:28 PM: Nurses' Notes . resident spiked a temperature, administered Tylenol and cold compress applied to forehead, tested for Covid results = neg, np (Nurse Practitioner)/dr (Doctor) notified Note: A Health Care Provider order and/or Urinalysis (UA) laboratory testing was not ordered and/or completed at the facility. - 5/31/22: Health Care Progress Note: Visit Type: Acute . Chief Complaint [CONDITION(S)] (low blood pressure) /[CONDITION(S)]/fever . seen for [CONDITION(S)], [CONDITION(S)], fever. Nursing reports this patient has had decreased oral intake of food & fluids and problems with Foley cath 3 days ago . was sent to the ED to have Foley reinserted r/t (related to) urinary retention . was dx (diagnosed ) with a [CONDITION(S)] and returned on an antibiotic . Patient does better at meals when assisted. Nursing reports appears to be doing better today than yesterday . is more alert & interactive . Review of Resident #21's MAR and TAR for June 2022 revealed documentation of the Resident's catheter and drainage bag was changed on 6/1/22, twenty days after it was last changed. Resident #21's May 2022 TAR further revealed the task, Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any changes every shift (Start Date: 3/8/22) was not completed on during the Evening on 6/2/22 and 6/11/22, the Day on 6/21/11, and the Day, Evening, and/or Night shifts on 6/22/22, 6/23/22, 6/24/22, 6/25/22, 6/26/22, 6/27/22, 6/28/22, 6/29/22, and 6/30/22. Further review of Resident #21's medical record revealed the Resident was transferred to the hospital on 7/3/22 due to a change in condition. Review of hospital record documentation for Resident #21 detailed the Resident was diagnosed with [CONDITION(S)] (infection throughout the body) secondary to pneumonia and a Urinary Tract Infection ([CONDITION(S)]) at the hospital on 7/3/22. A review of Resident #21's hospital ED (Emergency Department) Provider Note dated 7/3/22 at 6:40 AM, specified, (Resident #21) is nonverbal and unable to communicate . present to the emergency room by EMS after nursing home called believing that (the Resident) was getting ready to die. Apparently (Resident #21) was diaphoretic (sweating) and had a decreased level of responsiveness. EMS arrived to find the patient alert and looking around and in no obvious distress . presented to the emergency room awake and alert but [CONDITION(S)] (rapid heart rate) with a heart rate in the 120's (elevated) . General . somewhat pale and malnourished appearing . lips are dry and cracked and oral mucosa is dry . [CONDITION(S)] . ED Clinical Course . does appear . septic and the source is most likely urine. (Resident #21's) Foley (indwelling) catheter was changed out and had a significant amount of pus noted in urine . Problem/Assessment/Plan . [CONDITION(S)] . HAP (Healthcare Acquired Pneumonia) . [CONDITION(S)] . Review further revealed Resident #21 was readmitted to the facility on [DATE]. Review of facility medical record documentation following their readmission revealed: - 7/5/22 at 2:29 PM: Nursing Evaluation Summary . Note Text: resident readmit . lethargic (Resident) baseline, new abx (antibiotic) orders for [CONDITION(S)] (Urinary Tract Infection), notified NP/MD/on call provider NP . - 7/5/22 at 7:13 PM: Nurses' Notes . Resident came back from brief stay at hospital, all prior orders to resume, new orders for severe [CONDITION(S)] [MEDICATION(S)] (antibiotic) 875/125 mg (milligram) bid (twice a day) x 10 days, [MEDICATION(S)] 800-160 mg (antibiotic) bid x 10 days, resident is lethargic . baseline, (hospital) reinserted Foley . was low on magnesium and potassium (treatment provided at hospital) . Review of Resident #21's MAR and TAR for July 2022 revealed no documentation of the Resident's indwelling catheter and/or drainage bag being changed. The MAR/TAR further revealed no documentation during the day of completion for the task, Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any changes every shift (Start Date: 3/8/22) on 7/3/22, 7/5/22, 7/8/22, and 7/9/22. On 7/11/22 at 2:47 PM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #21's recent discharge the DON stated, (Resident #21) was sent out for a [CONDITION(S)] and came back. When asked if catheter drainage bags should be positioned directly on the floor, the DON revealed drainage bags should be off the floor and contained/covered. When queried regarding observations of Resident #21's urine, catheter tubing and drainage bag, the DON stated they were not pleased. With further inquiry, the DON implied they were unable to refute observations and would address with staff. A review of the Resident's medical record was completed with the DON at this time. When queried regarding the lack of documentation of completion of monitoring, assessment, observation, and timely care in response to symptoms, the DON was unable to provide an explanation. When asked if there was a correlation between the lack of documentation of monitoring, assessment of the Resident's catheter care/urine, surveyor observations of the catheter, transfer to the ED and subsequent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON then stated that Resident #21's health status had been declining and was recently transferred to Hospice. When asked the correlation between Hospice and a [CONDITION(S)], the DON did not provide further explanation. Review of facility provided policy/procedure entitled, Catheter Care Procedure - Urinary (Implemented: 1/1/21) revealed, Policy: It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. Catheter care will be provided by the nursing assistant and/or nurse. Details: 1. Residents who have indwelling urinary catheters will be provided catheter care in accordance with current clinical standards. This may include a. Every shift b. With each bowel movement (incontinence or continence) c. As needed and per request 2. Catheters should be maintained to provide gravity drainage, without kinks or loops 3. Catheters should be secured to prevent pulling and damage to the urethral meatus. This may be accomplished by: a. Utilizing the appropriate drainage device (leg bag or catheter bag) b. Leg strap c. Velcro strap d. Linen/clothing clamp e. Adhesive securing device 4. Catheters should be emptied every shift or as needed 5. Urinary output should be recorded per facility protocol. 00

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure comprehensive pressure ulcer assessment, care and management per professional standards of practice including documentation, diligent infection control practices, implementation of personalized interventions and monitoring of interventions to prevent the development of pressure ulcers for one resident (Resident #21) of four residents reviewed. This deficient practice resulted in a lack of pressure ulcer identification, assessment, and documentation. Resident #21 developing five pressure ulcers including four unstageable, Deep Tissue Injuries (DTI) [dark colored, non-blanchable area over a bony prominence due to a pressure-related injury to underlying tissue with unknown depth] and one Stage Three pressure ulcer (full thickness tissue loss), unnecessary pain, and the likelihood of infection, and an accelerated deterioration in overall health status. Findings include: Resident #21: On 6/21/22 at 12:01 PM, Resident # 21 was observed in their room in bed, positioned on their back. Resident #21 made eye contact when spoke to but did not respond verbally. The Resident's lower legs were bent at the knees and positioned outward, in a crisscrossed fashion, with the lateral (outside) aspect of their legs positioned directly against the mattress. The Resident was receiving oxygen therapy via nasal cannula. The nasal cannula tubing was visibly tight and appeared to be digging into the skin on the left side of Resident #21's face and ear. An alternating air mattress was in place on the Resident's bed. The mattress controller was set at 3. The mattress was hard when touched. Record review revealed Resident #21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive assistance to perform all ADLs. The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. Review of Resident #21's Admission MDS assessment dated [DATE] revealed the Resident did not have any pressure ulcers. On 6/21/22 at 3:20 PM, Resident #21 was observed in their room in the same position in bed. Resident #21's eyes were closed, and their lateral lower legs remained positioned directly on the mattress. The oxygen tubing remained visibly tight and pressing into the skin on the left side of their face and ear. Review of Resident #21's care plans revealed an active care plan entitled, The resident has [potential or actual] impairment to skin integrity of the following location coccyx and left elbow (Initiated and Revised: 1/28/22). The care plan included the interventions: - Check and change every 2 hours; float heels off bed; turn every 2 hours as resident allows (Initiated: 2/1/22; Revised: 6/3/22) - Encourage good nutrition and hydration in order to promote healthier skin (Initiated: 2/1/22) - Identify/document potential causative factors and eliminate/resolve where possible (Initiated: 2/1/22) - Keep skin clean and dry. Use lotion on dry skin. Do not apply on skin impairment area(s) (Initiated: 2/1/22) - Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician/provider (Initiated: 2/1/22) - The resident uses the following devices to relieve/prevent friction/sheer/pressure; alternating low air loss mattress; cushion in chair (Initiated and Revised: 2/1/22) - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface (Initiated: 2/1/22) - Use lifting device to move resident (Initiated and Revised: 2/1/22) - Weekly skin assessment (Initiated: 2/1/22) - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (Initiated: 2/1/22) Review of the facility provided CMS-802 Resident Matrix form, dated 6/21/22, indicated Resident #21 did not have any pressure ulcers. Review of Resident #21's Health Care Provider Orders and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Cleanse bilateral heels with wound cleanser, apply skin prep to heels twice daily (Ordered: 4/14/22) - Cleanse coccyx with wound cleanser, apply Dermafilm lite ([MEDICATION(S)] wound dressing for management of partial and full-thickness pressure ulcers and wounds) in the morning every 3 day (s) for skin healing (Start: 6/1/22; Discontinued: 6/7/22). The treatment was not documented as completed on 6/7/22. - Cleanse coccyx with wound cleanser, apply Dermafilm lite in the morning every 3 day (s) for skin healing (Ordered: 6/7/22; Start: 6/9/22). The initial treatment was completed on 6/9/11. The treatment was not documented as completed on 6/21/22. - Cleanse bilateral buttocks with soap and water; dry well; apply Dermaseptin (non-prescription cream to treat skin irritations) TID (three times a day) every shift for skin healing (Start: 2/16/22). The treatment was not documented as completed on 6/2/22 Evening, 6/11/22 Evening, 6/13/22 Day, and 6/21/22 Day. Review of discontinued orders revealed Resident #21 had prior orders for wound care treatments on their coccyx, left elbow, left heel DTI, right buttocks, and bilateral heels. Review of documentation in Resident #21's Electronic Medical Record (EMR) revealed the following progress notes: - 2/8/22: Wound Care (Provider) . Chief Complaint Wound care . resident is seen for wound care . open areas on left elbow and coccyx. We had these areas documented as an abrasion to the left elbow and moisture damage to his coccyx, while the hospital had these areas as pressure area. Resident is a functioning quadriplegic with a history of down syndrome who lived at home with (family) . Resident is dependent on staff for cares and is unable to reposition self frequently. Residents Foley was discontinued one week ago, and these areas have since resolved. Resident skin is intact at this time but frail and easily damaged. It is unsure at this time if the resident will be able to discharge back home . - 3/16/22 at 8:25 AM: SOC-Skin . New DTI left lateral heel; measures 1.5 cm (centimeters) x 1.5 cm . History . Pressure injury left buttock; Pressure injury left elbow . Contributing deficits: Limited mobility; dependent on staff for ADL's; changes position slightly; incontinent of bowel; chairbound/bedbound; dependent on staff for fluids/nutrition . Contributing lab results: None . Care plan (current/revised/new) interventions: New . Comments: Monitor weekly . Cleanse with wound cleanser, apply skin prep BID (twice a day) - 3/24/22 at 11:21 AM: SOC-Skin . Existing; DTI left heel; measures 1.5 cm x 1.5 cm . History: Falls; Pressure injury left buttock; Pressure injury left elbow . Contributing deficits: Limited mobility; dependent on staff for ADL's; changes position slightly; incontinent of bowel; chairbound/bedbound; dependent on staff for fluids/nutrition . Contributing lab results: None . Care plan (current/revised/new) interventions: Current . Comments: Monitor/measure weekly . Cleanse with wound cleanser, apply skin prep BID - 4/1/22 at 3:16 PM: SOC-Skin . Existing; DTI left heel; measures 0.7 cm x 0.6 cm . Background . Pressure injury left buttock; Pressure injury left elbow . Contributing deficits: Limited mobility; dependent on staff for ADL's; changes position slightly; incontinent of bowel; chairbound/bedbound; dependent on staff for fluids/nutrition . Contributing lab results: None . Stable . Cleanse with wound cleanser, apply skin prep BID - 4/7/22 at 12:22 PM: SOC-Skin . Existing; DTI left heel; measures 0.8 cm x 0.6 cm . Comments: Continue to monitor x 2 weeks . Skin prep to heels BID - 4/14/22 at 11:24 AM: SOC- Skin . Existing; DTI left heel; measures 0.7 cm x 0.6 cm . Comments: Stable; heel firm . Skin prep to heels BID; preventative - 5/2/22: Health Care Provider Progress Notes . Visit Type: Acute . resident is seen for [CONDITION(S)] (decreased blood pressure) . Skin: no itching or burning . Skin: warm and dry . - 5/5/22: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . General: Patient for routine 30 day follow up . in sub-acute rehab for falls, sacral pressure injury . staff relates no concerns regarding patient . dependent in 5/6 ADL . no issues with intake . Skin: warm and dry. noted with continued L (left) heel deep pressure injury that is > 90% resolved . - 5/26/22 at 1:43 PM: SOC-Nutrition/Hydration . Resident is being reviewed in SOC r/t (related to) nutritional risks. Mitigating factors . Wound care nurse is following skin status . Recommendations- Increase med plus 2.0 (nutritional supplement) 120 mL (milliliters) BID . and Prostat (nutritional supplement) 30 mL QD (every day) . - 5/31/22 at 1:35 PM: Skin & Wound Evaluation . Type (Blank) . Location (Blank) . Acquired (Blank) . How long has the wound been present? (Blank) . Wound Measurements . Length: 1.9 cm . Width: 0.8 cm . Edges . Attached . Cleanse with wound cleanser, apply Dermafilm thin . - 6/2/22 at 11:17 AM: SOC-Nutrition/Hydration . Resident is being reviewed in SOC r/t nutrition risk. CBW (Current Body Weight) is 107.4 (on) 6/2/22 . Mild weight loss noted. BMI class is WNL (Within Normal Limits) . pureed textures diet is provided with fortified foods QD, med plus 2.0 120 mL BID and Prostat 30 mL QD. Supplements were increased on 5/26/22 per recommendations to aid in weight loss prevention . Impaired skin integrity noted. Tx (treatments) are in place. Supplements are in place which may aid in healing . - 6/14/22 at 3:26 PM: Skin Assessment . Are there any new abnormal skin areas? No . site(s) of any existing abnormal skin areas . Tip of penis red from chronic foley . Buttocks excoriation . - 6/20/22: (Provider) Progress Notes . Chief Complaint: Increased secretions/altered Skin Integrity . recently signed onto hospice services . multiple areas of altered skin integrity, these areas come & go continuously . Skin: multiple areas of redness, some blanchable and some are not . - 6/21/22 at 7:17 AM . Skin & Wound Evaluation . Type: Moisture Associated Skin Damage (MASD) . Location: Left Buttocks . In- house acquired . New . Length: 0 cm . Width: 0 cm . On 6/22/22 at 10:40 AM, an observation occurred of Resident #21 in their room. The Resident was in bed, positioned on their back. The Resident made eye contact and smiled when spoke to. Resident #21's legs were in the crisscross position with the lateral aspect of their legs directly against the mattress. Resident #21's oxygen tubing remained visibly tight on the left side of their face and ear as observed on 6/21/22. An observation of Resident #21 occurred on 6/22/22 at 1:16 PM in their room in bed The Resident was positioned on their back with both of their lower extremities in a crisscrossed position and the lateral aspect of their lower extremities directly against the mattress. The oxygen tubing remained visibly tight and pressing into the skin on the left side of the Resident's face and ear. When spoke to, Resident #21 would smile but did not provide meaningful responses when asked questions. On 6/22/22 at 1:44 PM, an interview was completed with Licensed Practical Nurse (LPN) D. When queried how frequently facility nursing staff monitor residents' oxygen tubing to ensure it is positioned properly, LPN D implied staff should check the tubing when they are in a Residents room. LPN D was then asked if Resident #21 had any wounds and/or pressure ulcers and indicated they were not aware and would need to review the Resident's medical record. When queried if floor nursing staff complete wound care treatments, LPN D specified the facility has a wound care nurse who is primarily responsible for wound care and the majority of treatments are completed on night shift. Upon request, an observation of Resident #21 was completed with LPN D at this time. Upon entering the room, Resident #21 was observed on their back in bed, in the same position as previously observed, with their legs bent and lower extremities directly against the mattress. The oxygen tubing remained noticeably tight on the left side of their face and ear. LPN D was queried regarding the position of Resident #21's oxygen tubing. LPN D did not respond verbally but began to adjust and reposition the tubing. When LPN D loosened the adjuster under the Resident's chin and lifted the oxygen tubing, a dark colored, significantly indented line was present along on the left side of the Resident's face from their chin to their ear where the tubing had been pressing into their skin. When LPN D went to remove the tubing from around Resident #21's left ear, they indicated it was stuck at the top. Closer inspection revealed the tubing was dug into the skin on the top portion of the Resident's left ear. A thick yellow/off-white colored drainage was present on the tubing and the gray colored foam wrap in place on the section of the tubing wrapped around the ear. LPN D proceeded to remove the tubing and an open, draining pressure ulcer was observed on the top of the fold between the helix (top part of the external ear) and the skin on the head. The wound bed was white/gray in color, slightly smaller than a dime with a distinct foul odor present. The Resident's hair was visibly dirty with observable wet and dried drainage present near the wound on their ear and multiple chunks of unknown substances present throughout their hair and on their scalp. LPN D was asked if the wound was caused by pressure and replied, Yes. LPN D revealed they were going to have Wound Care Nurse P come to Resident #21's room to evaluate and treat the wound. LPN D was then asked if they remove Resident #21's oxygen tubing routinely to monitor skin integrity as part of the nursing skin assessment and revealed they did not. When queried if they observe all areas of the skin when completing skin assessments, including all bony prominence's, LPN D indicated facility CNA staff typically notify nursing staff if there are any skin concerns. With further inquiry, LPN D revealed they did not comprehensively observe and assess areas of the skin for potential breakdown, including all bony prominence's, when completing skin assessments. At 2:12 PM on 6/22/22, Certified Nursing Assistant (CNA) R and CNA S entered Resident #21's room to provide ADL care and Wound Care Registered Nurse (RN) P entered the room to evaluate the pressure ulcer on the Resident's left ear. An observation of Resident #21's skin was requested to be completed at this time. A dark colored area, approximately the size of a quarter was observed on Resident #21's right lateral (outside) heel. The area was directly over a bony area of their heel, where their lower extremity had been positioned directly against the mattress. Wound Care RN P was asked if the area was blanchable. RN P proceeded to press on the wound and the tissue was observed to not blanch (no color change indicating lack of blood flow and underlying tissue damage). RN P stated, Non-blanchable. Wound Care RN P was then asked if the wound was caused by pressure and replied that it was. Another area, approximately the size of a dime and dark in color was observed on Resident #21's left lateral heel. The area was noted to be where the Resident's lower extremity had been positioned directly on the mattress and over a bony prominence. When queried, RN P pressed on the wound bed and the area was observed to be non-blanchable. When asked, RN P stated the wound was non-blanchable. CNA R and CNA S then repositioned Resident #21 on their side. Observation of the Resident's buttocks/coccyx revealed a dark colored discolored area, circular in shape, and approximately the size of a golf ball. There was no dressing in place over the coccyx wound. Blanching was not observed when RN P assessed the wound. When asked, RN P stated the wound was non-blanchable and caused by pressure. RN P was queried regarding the stage of the pressure ulcers on the Resident's right and left lateral heels and coccyx and stated, All DTI so unstageable. Wound Care RN P exited the room at this time to obtain supplies. Upon returning, RN P was asked to assess the condition of the skin on the bony prominence of Resident #21's left elbow. A dark area, approximately the size of a nickel was observed on the bony prominence over the Resident's elbow. When queried, RN P indicated it was non-blanchable. RN P revealed the wound was also an unstageable, DTI pressure ulcer. RN P donned gloves at this time, without washing their hands, and proceeded to complete wound care treatment on Resident #21's coccyx pressure ulcer. When asked to measure the wound, RN P stated, The Internet is down and revealed the facility utilizes an electronic wound measurement system for pressure ulcers and do not complete manual measurements. When asked if the pressure ulcer was approximately the size of a golf ball, RN P replied, I agree, golf ball size. RN P indicated they had forgot to bring an Allevyn (wound care dressing) and proceeded to doff their gloves and exit the room. RN P returned with the dressing, donned new gloves without performing hand hygiene, and applied to the dressing to the Resident's coccyx. Without doffing/donning new gloves and/or performing hand hygiene, RN P proceeded to clean the pressure ulcer on Resident #21's left ear. When queried regarding the wound, RN P indicated it was caused from pressure and stated, It's a stage two (partial thickness tissue loss without slough). When asked if slough (dead tissue that is white or yellow in color) was present on the wound bed, RN P revealed there was. RN P was queried why the pressure ulcer was not a stage three due to the presence of slough but did not provide an explanation. RN P applied calcium alginate (wound care treatment) and covered with a dressing. RN P did not perform hand hygiene after cleansing the draining wound bed and applying the dressing. RN P then applied skin prep the Resident #21's left elbow and left heel using the same skin prep pad. When CNA R and CNA S lifted the Resident's left lower extremity for RN P to apply the skin prep, another pressure wound was noted on the Resident's left mid lateral foot area. The area was approximately the size of a nickel and directly over the bony area on the lateral side of the foot. When asked about the area, RN P assessed and stated, non-blanchable. RN P revealed the area was a DTI pressure ulcer and applied skin prep to the area. During wound care evaluation, treatment, and repositioning, Resident #21 made moaning sounds and cried out while displaying facial grimacing and non-verbal signs and symptoms of pain. CNA staff were observed attempting to verbally calm and comfort the Resident. RN P did not assess the Resident's pain at any time prior, during, and/or after wound assessment and treatment. After completing skin assessment and treatment application, RN P exited the Resident's room. An interview was completed with CNA R and CNA S at this time. When queried how frequently Resident #21 is turned and repositioned in bed, both CNAs indicated they do their best. With further inquiry, CNA R revealed the Resident did not get out of bed anymore and was receiving Hospice services. The staff were then asked about the settings on Resident #21's alternating air mattress and both revealed they were unaware of what the settings are supposed to be and do not monitor the mattress. When queried regarding observations of Resident #21's lower extremities being positioned directly on the mattress and if the Resident had pressure reduction devices, both CNA R and CNA S revealed Resident #21 did not have any repositioning devices for pressure reduction/prevention. An interview was completed with CNA U and CNA V on 6/22/22 at 2:45 PM. When queried regarding the frequency in which Resident #21 is supposed to be turned and repositioned, both CNAs indicated the Resident is supposed to be repositioned every two hours. CNA U then stated, We try but we cannot. With further inquiry, CNA U and CNA V revealed they were unable to turn Resident #21 and other residents every two hours due to the needs of the residents in the facility and staffing levels. The staff explained that there are multiple residents who require two-person assistance, need assistance to eat, and have multiple, time-consuming care needs. Both CNA's indicated they provide the care they are able to provide but are not able to turn residents every two hours, especially when the resident requires two assist, as the residents need to be. When asked if they had discussed this with facility leadership, the staff indicated leadership told them the staffing numbers were adequate. An interview was conducted with Wound Care RN P on 6/22/22 at 2:54 PM. When asked what interventions were in place to prevent pressure ulcer development for Resident #21, RN P replied, Alternating air mattress. RN P was then questioned regarding the alternating air mattress settings including what the mattress controller settings are supposed to be set at and who monitors the mattress. RN P revealed they were unsure of what the settings were supposed to be and/or if it is monitored by staff. When queried who initially installs the mattress on the bed and sets up the controller, RN P stated, Maintenance. When queried regarding Resident #21's alternating air mattress feeling very hard when touched, RN P stated, I bet it is. RN P was asked how they knew the mattress was providing effective pressure reduction and fluctuation of pressure when they were not aware of what the settings needed to be and when the mattress function was not being monitoring by facility staff, RN P was unable to provide an explanation. When asked about observations of Resident #21's lower extremity position, identification of new pressure ulcers, and interventions in place to prevent pressure, RN P indicated staff were supposed to keep the Residents heels elevated. When asked why their heels had not been elevated, RN P was unable to provide an explanation. When queried if any alternative interventions had been attempted such as heel boots, RN P replied, I was instructed to not use heel boots. When queried who had instructed them to not use heel boots, RN P replied the DON (Director of Nursing). With further inquiry, RN P revealed the reason they were instructed to not use heel boots was because there was an issue with a (heel) boot causing a pressure ulcer because the staff did not remove it and check (skin under boot). RN P continued, They (heel boots) all got thrown away. When queried regarding staff stating they were unable to turn and reposition Resident #21 every two hours due to staffing and the Resident not getting out of bed, RN P indicated they believed the Resident was not repositioned as frequently as they should be. RN P was then asked how Resident #21's pressure ulcers could have been prevented. RN P indicated the Resident's nutritional status had changed and stated, As far as turning and repositioning, there is nothing I can say. RN P was queried regarding dietary documentation in Resident #21's medical record indicating the Resident's BMI remained within normal limits on 6/2/22 and 6/9/22, RN P did not provide a response. When asked if turning/repositioning and elevation of their lower extremities would have prevented the pressure ulcers from developing, RN P replied that it would have helped to prevent development. When queried what interventions were in place to prevent pressure ulcer development on Resident #21's elbow, especially considering their history of a pressure ulcer on their elbow, RN P reviewed the Resident's EMR and revealed there were no specific interventions in place to prevent development of pressure ulcers on the Resident's elbow. RN P was queried regarding the drainage from the pressure ulcer identified on Resident #21's left ear and replied, I think it (oxygen tubing) dug right in there (skin). When queried regarding the size of the pressure ulcer on Resident #21's left ear, RN P stated, Estimate 2 centimeters (cm) by 2 cm. When asked about the chunks of substance on the Resident's head and hair, RN P replied, It is some sort of buildup but did not elaborate further. RN P was then queried why they did not perform hand/hygiene and/or change gloves during wound care including following cleansing and application of a dressing to the open, draining wound on Resident #21's ear. RN P stated, You are correct, I did not. When asked why they did not, RN P replied, I should have. No further explanation was provided. RN P was questioned regarding Resident #21's pressure ulcer risk and revealed the Resident had prior pressure ulcers and was at risk for pressure ulcer development. When asked why other interventions and more resident specific interventions had not been attempted and implemented such as more frequent turning and repositioning and positioning devices, RN P was unable to provide justification. A follow-up interview was completed with Wound Care RN P on 6/22/22 at 3:46 PM. RN P revealed they had information regarding Resident #21's alternating air mattress. RN P stated, Per maintenance, it is set to (the Resident's) comfort level. RN P was asked how facility staff were able to ask/determine Resident #21's comfort level when they are non-verbal and replied, You can't. When queried regarding wound documentation on 5/31/22 being incomplete and not including the wound site and/or type, RN P reviewed the documentation and revealed they had authored the documentation but did not complete it (wound assessment). When asked where the wound was located, RN P was unable to provide documentation of the wound. When queried regarding facility policy/procedure related to wound treatment completion and assessment documentation, RN P stated, Weekly wound evaluation is (completed) by me. RN P further revealed that staff nurses document in the daily skilled assessment, progress notes, and/or TAR. When queried regarding why weekly wound assessments were not noted in Resident #21's medical record, RN P indicated the assessments should have been completed. The Residents medical record was reviewed by RN P at this time. After review, RN P confirmed the assessments had not been completed weekly and stated, They should have been. Resident #21's TAR was reviewed with RN P at this time. When queried regarding the blank areas on the TAR, RN P confirmed that meant the treatment was not completed. RN P was asked why the treatments were not completed but did not provide an explanation. When asked if the treatments should have been completed, RN R indicated they should have been. RN P was then queried regarding the different treatments in place for Resident #21's coccyx/buttocks wound and replied, Use Dermaseptin when it (skin) is pink or looks red depending on the person. When asked, RN P revealed Dermafilm dressings are used for open pressure wounds. RN P was then asked about the Skin & Wound Evaluation they completed and documented on 6/21/22. When asked if they had removed the Resident #21's oxygen tubing and assessed their ears, RN P replied, No. When asked if they had assessed all of Resident #21's skin and areas of potential pressure, RN P revealed they did not. When asked why they did not, RN P indicated the CNA staff will let the nursing staff know if there are any issues related to skin integrity. RN P was then queried regarding the lack of consistent and comprehensive weekly wound assessment documentation in Resident #21's EMR, RN P revealed that was an area which could be improved but did not provide further explanation. When queried regarding documentation of Resident #21's pressure ulcers and treatments completed today, RN P stated they would do their best to document the assessment but revealed they were retiring and today was their last day of work. An interview was conducted with the facility Administrator on 6/22/22 at 4:30 PM. When queried regarding Resident #21 including identification of multiple pressure ulcers, lack of comprehensive assessment and documentation by nursing staff, lack of treatment completion as ordered, and lack of implementation of interventions to prevent pressure ulcer development, the Administrator did not provide further explanation. Review of facility provided Incident and Accident Reports for Resident #21 revealed the Resident developed a facility acquired DTI pressure injury in March 2022. The report detailed, 3/15/22 . 1:30 PM . Brief Description: Purple area lateral L (left) heel. Low loss mattress noted . tx (treatment) ordered. Care plan in . Injury Type . DTI left heel . An interview was completed with the Director of Nursing (DON) on 7/11/22 at 2:46 PM. When asked if they were aware of Resident #21's pressure ulcers and surveyor observations, the DON indicated they were made somewhat aware by facility staff. When queried regarding Resident #21 including identification of multiple pressure ulcers, lack of comprehensive assessment/documentation by nursing staff, lack of treatment completion as ordered, and lack of implementation of interventions to prevent pressure ulcer development, the DON stated, Oh wow, okay. The DON revealed they were not made aware of the number and/or severity of the concerns regarding Resident #21's pressure ulcers. When queried regarding the lack of documentation of wounds, including consistent assessment, the DON revealed they can't argue with the documentation or lack of documentation. No further explanation was provided. When queried regarding the facility provided incident and accident report for Resident #21, dated 3/15/22, indicating the Resident had developed a facility acquired pressure ulcer, the DON indicated the area had developed then resolved/healed. When queried regarding RN P not completing an assessment and/or note in the EMR related to the Residents wounds and/or treatments following observations on 6/22/22, the DON was unable to explain the reason RN P did not document their assessment but stated they were no longer employed at the facility. When asked, the DON confirmed the assessment and care provided should have been documented. The DON acknowledged multiple areas of concern related to Resident #21's pressure ulcers and stated, All we can do is fix it. Review of facility policy/procedure entitled, Pressure Injury Prevention and Management (Revised: 1/1/22) revealed, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate . 4. Interventions fo [TRUNCATED]

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure interventions were implemented and in place to prevent the development of a pressure ulcer (wound caused by pressure) for one resident (Resident #35) of four residents reviewed, resulting in the development of a Stage III pressure ulcer (full thickness tissue loss) with significant tunneling which necessitated surgical intervention, pain, and the likelihood for decline and medical complications. Findings include: Resident #35: On 6/8/21 at 10:07 AM, Resident #35 was observed in their room in bed, partially covered by a sheet with their bare legs and chest exposed. An alternating air mattress was present on the Resident's bed. The alternating air mattress was set at two marks above the soft setting. The Resident's heels were positioned directly on the mattress. An interview was attempted to be completed with the Resident at this time. When spoke to, the Resident responded with one-word answers with a disproportionately loud voice. When queried if they had any wounds or sores on their skin, Resident #35 replied, Yes but did not elaborate. When asked if they were in pain, Resident #35 indicated they were but did not provide details regarding the location and/or severity of their pain when asked. Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive two-person assistance with bed mobility, transferring, dressing, personal hygiene, and dressing. The MDS further revealed Resident #35 was at risk for pressure ulcers, had a current stage three pressure ulcer as well as a surgical wound, and did not ambulate nor locomotion on the unit. Review of Resident #35's admission MDS assessment dated [DATE] revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers at that time. Review of the facility provided MDS Resident Matrix, CMS 802 Form indicated Resident #35 did not have a pressure ulcer. An interview was conducted with the Director of Nursing (DON) on 6/8/21 at 4:42 PM. When queried regarding the discrepancy noted between the documentation on the facility provided MDS Resident Matrix, CMS 802 Form and the Resident's MDS documentation, the DON stated, (Resident #35) had surgery. It was a track with debridement. Resident #35's Gentell wound documentation was reviewed with the DON at this time. After review, the DON revealed the pressure ulcer developed at the facility and stated, Oh, I guess it would be a facility acquired pressure ulcer then. Facility policy/procedure pertaining to pressure ulcer prevention and care was requested from the DON at this time. At 7:45 AM on 6/9/21, Resident #35 was observed in their room in bed covered with a sheet. The Resident was positioned on their back with their heels directly on the bed and their eyes closed. On 6/9/21 at 7:50 AM, an interview was completed with Licensed Practical Nurse (LPN) I. When queried regarding communication with Resident #35, LPN I revealed the Resident speaks loudly and will yell out. With further inquiry regarding the Resident yelling out, LPN I stated, (Resident #35) doesn't like to be bothered. When asked about ADL care, LPN I replied, (Resident #35) will let the aides (Certified Nursing Assistants - CNAs) do care. LPN I was then queried if the Resident had a pressure ulcer and replied, Yes, on their left buttocks. When queried regarding the origin of the pressure ulcer, LPN I revealed they were not familiar with the wound details prior to Resident #35 having surgical debridement. Unit Manager/Wound Care Registered Nurse (RN) L joined the interview at this time. When queried regarding Resident #27's pressure ulcer, RN L replied, It was acquired, I think it was a pressure ulcer. RN L continued, I started irrigating it because the hole got bigger. It had purulent drainage. When queried regarding progression of the pressure ulcer, RN L stated, I could see a tract. I worked on a surgical consult. With further inquiry regarding the wound, RN L revealed Resident #35 had surgery and was no longer receiving wound care treatments. When asked what interventions where in place to prevent pressure ulcer development at the time the pressure ulcer was identified, RN L indicated they wound need to review the Resident's medical record. Review of Resident #35's Treatment Administration Record (TAR) for June 2021 revealed the most recent treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . All of Resident #35's Gentell wound documentation was requested. Review of documentation revealed the following: -1/11/21: Location: Left buttock (open) . Date First Observed: 12/29/20 . Length/Width/Depth: 0.2 (centimeter- cm)/0.2/0.2 . Acquired . Tunneling: Yes - depth 9.0 cm location three 0' Clock . Stage: 2 . Type of Wound: Pressure . Exudate Type: Serosanguinous . Exudate Amount: Light . Wound Edges: Unattached . -1/13/21: Wound: Left buttocks . Acquired . Pressure . Stage: 3 . Length: 0.1 cm, Width: 0.1 cm, Depth: UTD (Unable To Determine) . Tunneling: Yes . Depth: 9 cm three O'clock . Exudate Amount: Light; Exudate Type: Purulent; Exudate Color: White . Wound Edges: Attached . Pain: Yes . -1/18/21: Wound: Left buttocks . Acquired . Pressure . Stage: 3 . Length: 0.2 cm, Width: 0.2 cm, Depth: UTD . Tunneling: Yes . Depth: 9 cm three O'clock . Exudate Amount: Light; Exudate Type: Serous . Wound Edges: Attached . -2/1/21: Wound: Left buttocks . Acquired . Pressure . Stage: 3 . Length: 0.2 cm, Width: 0.2 cm, Depth: UTD . Tunneling: Yes . Depth: 9 cm three O'clock . Exudate Amount: Moderate; Exudate Type: Purulent; Exudate Color: Cream . Wound Edges: Attached . The wound treatment was changed from wound cleanser and border foam application to wound cleanser, calcium alginate (topical treatment to promote wound healing), and cover with border foam dressing following the dressing change on 2/1/21. -2/10/21: Wound: Left buttocks . Acquired . Pressure . Stage: 3 . Length: 0.3 cm, Width: 0.3 cm, Depth: UTD . Tunneling: Yes . Depth: 9 cm three O'clock . Exudate Amount: Moderate; Exudate Type: Purulent; Exudate Color: Cream . Wound Edges: Attached . -2/16/21: Wound: Left buttocks . Acquired . Pressure . Stage: 3 . Length: 0.2 cm, Width: 0.2 cm, Depth: UTD . Tunneling: Yes . Depth: 9.3 cm three O'clock . Exudate Amount: Moderate; Exudate Type: Purulent; Exudate Color: Cream . Wound Edges: Attached . Following the dressing change on 2/16/21, the wound treatment was changed from wound cleanser, calcium alginate (topical treatment to promote wound healing) and a border foam dressing to irrigation with normal saline and cover with a border foam dressing. -2/22/21: Wound: Left buttocks . Acquired . Pressure . Stage: 3 . Length: 0.2 cm, Width: 0.2 cm, Depth: UTD . Tunneling: Yes . Depth: 9.2 cm three O'clock . Exudate Amount: Moderate; Exudate Type: Purulent; Exudate Color: Cream . Wound Edges: Attached . -3/1/21: Wound: Left buttocks . Acquired . Pressure . Stage: 3 . Length: 0.2 cm, Width: 0.2 cm, Depth: UTD . Tunneling: Yes . Depth: 9.5 cm three O'clock . Exudate Amount: Moderate; Exudate Type: Serosanguinous; Exudate Color: Reddish/cream . Wound Edges: Attached . -3/12/21: Wound: Left buttocks . Date Evaluated: 3/7/21 . Acquired . Pressure . Stage: 3 . Depth: 0.2 cm . Tunneling: Yes . Depth: 9.5 cm three O'clock . Exudate Amount: Light; Exudate Type: Purulent; Exudate Color: Reddish/cream . Wound Edges: Attached . -3/16/21: Wound: Left buttocks . Date Evaluated: 3/15/21 . Acquired . Pressure . Stage: 3 . Length: 1.5 cm, Width: 1.2 cm, Depth: 1.8 cm . Tunneling: Yes . Depth: 9.5 cm three O'clock . Exudate: Light . Purulent . Reddish/cream . Depth of wound tract is 2.3 cm . -3/23/21: Wound: Left buttocks . Date Evaluated: 3/22/21 . Pressure . Stage: 3 . Length: 0.2 cm, Width: 0.2 cm, Depth: 2 cm . Tunneling: Yes . Depth: 9.5 cm three O'clock . Exudate: Light . Purulent . Reddish/cream . Width of wound tract is 2.3 cm . Resident is scheduled for surgical intervention 3/23/21 . -3/25/21: Wound: Left buttocks . Date Evaluated: 3/22/21 . Surgical . Stage: 3 . Length: 8 cm, Width: 4 cm, Depth: 1.5 cm . Tunneling: Yes . Depth: 9 cm three O'clock . Exudate: Light . Serosanguinous . Red . -3/30/21: Wound: Left buttocks . Date Evaluated: 3/22/21 . Surgical . Stage/thickness: Full . Length: 11.5 cm, Width: 1 cm, Depth: 0. cm . Tunneling: No . Exudate: Light . Serosanguinous . Red . The treatment was changed following the dressing on 3/30/21 to wound cleanser, rinse with normal saline, pack with moist 4 X 4 gauze, and cover with bordered foam dressing. -4/21/21: Wound: Left buttocks . Date Evaluated: 4/19/21 . Surgical . Pressure . Stage/thickness: Full . Length: 11.5 cm, Width: 1 cm, Depth: 0. cm . Tunneling: No . Exudate: Light . Serosanguinous . Red . No Gentell wound notes after 4/21/21 were provided by the facility. Review of Resident #35's Electronic Medical Record (EMR) revealed the most recent wound documentation was dated 6/3/21 and detailed, SOC Skin . Surgical incision left buttock; measures 0.4 cm x 0.2 cm x 0.3 cm . [MEDICATION(S)] tract left buttock . Record review of Resident #35's care plans revealed a care plan entitled, (Resident #35) is at risk for impairment to skin integrity R/T (related to): Weakness, decreased mobility, incontinence of bowel and bladder (Initiated: 10/30/20; Revised: 6/9/21). The care plan included the following active and discontinued interventions: - CNA'S to assess skin with cares and during showers, and report findings to nurse (Initiated: 3/18/21). - Educate resident/family/caregivers of causative factors and measures to prevent skin injury (Initiated: 10/30/20) - Encourage good nutrition and hydration in order to promote healthier skin (Initiated: 10/30/20) - Identify/document potential causative factors and eliminate/resolve where possible (Initiated: 10/30/20) - Maintain low air loss mattress (Initiated: 4/30/21) - Turn and reposition according to the yellow dot program (Initiated: 3/31/21) - Weekly skin assessment by licensed nurse and document results (Initiated: 2/25/21) - Yellow dot program; float heels off bed; turn every 2 hours (Initiated and Revised: 4/6/21) - CANCELLED: Irrigate left buttock wound tract with NS (Normal Saline); apply foam bordered 4x4 dressing; daily (Initiated: 1/13/21; Revised and Cancelled: 3/30/21) An interview was conducted with the DON on 6/10/21 at 8:44 AM. When queried what interventions were in place to prevent pressure ulcer development due to the Resident #34's limited mobility, compromised nutritional status, and identified risk of pressure ulcer development, the DON indicated they would need to review the Resident's care plan. Resident #34's care plans were reviewed with the DON at this time. After review, the DON stated, I don't see anything when asked what interventions were in place prior to pressure ulcer development. When queried if Resident #34 should have had interventions in place to prevent pressure ulcer development, the DON replied, Absolutely. Facility policy/procedure related to pressure ulcer prevention and care was requested from the DON on 6/8/21 at 4:42 PM but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure adequate supervision and monitoring to prevent falls for two residents (Resident #41 and Resident #158) of three residents reviewed for falls, resulting in lack of staff supervision, lack of implementation of basic care and interventions including appropriately sized clothing, and Resident #41 experiencing a fall with segmental fracture to their ulna bone fracture (fracture composed of at least two fracture lines isolate a segment of bone frequently associated with a high energy mechanism injury, devascularization of the segmental fracture fragments, and are linked to increased morbidity and long-term complications including delayed bone union, non-union of the bone, and/or infection), delayed treatment, unnecessary pain, and the likelihood for decline in overall health status. Findings include: Resident #41: On 6/8/21 at 11:38 AM, Resident #41 was observed sitting in a wheelchair in the central area of the unit. The Resident had a full cast in place on their right arm which extended from their hand to their mid bicep. Resident #41 was pleasantly confused but unable to provide meaningful responses to questions when asked. An interview was completed with Certified Nursing Assistant (CNA) FF on 6/8/21 at 11:46 AM. When queried regarding Resident #41's arm cast, CNA FF stated, They fell . CNA FF was asked how they had fell and revealed they were not working when the Resident fell . CNA FF stated, We were told (Resident #41) got their feet caught in the blanket (on the bed) and hit their elbow on the bedside table. With further inquiry, CNA FF revealed the Resident hit their elbow on the metal, vertical part of the table. When asked how the Resident hit their elbow on the up and down part of the table, CNA FF replied, It doesn't make sense to us either. When queried, CNA FF revealed the Resident had a history of falls. Review of Resident #41's medical record revealed the Resident was most recently admitted to the facility on [DATE] with diagnoses which included dementia, [CONDITION(S)], and repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required limited assistance of one staff member for bed mobility, transfers, locomotion, dressing, and personal hygiene. Review of Resident #41's care plans revealed a care plan entitled, The resident is at risk for falls related to: Confusion, History of falls, hearing loss, and poor to no safety awareness . (Initiated: 1/27/20; Revised: 2/24/20). The care plan included the interventions: - Anticipate and meet the resident's needs based on nursing assessments (Initiated: 1/27/20; Revised: 1/29/20) - Assist resident with toileting after meals (Initiated: 3/11/20) - Check frequently to monitor for resident ambulating independently in room, intervene and assist if observed (Initiated: 5/20/20) - Ill-fitting clothing/pants removed resident's room (Initiated: 5/4/21) - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Initiated: 1/27/20; Revised: 1/29/20) - Encourage resident to toilet every 2 hours as resident allows (Initiated: 3/2/20) - Resident should wear shoes when up to ambulate and grippy socks when in bed (Initiated: 1/27/20; Revised: 1/31/20) - Review information on past falls and attempt to determine cause of falls. Record possible root causes. Remove any potential causes if possible. Educate resident/family/caregivers as to causes (Initiated: 1/27/20; Revised: 1/29/20) - Staff to assure clear path when resident is attempting to ambulate independently (Initiated: 2/4/20; Revised: 2/16/21) - Staff to intervene (assist) pt (patient) when attempting to ambulate (Initiated: 2/8/20) - Staff education to keep pathways clear (Initiated: 2/4/21; Revised: 2/26/21) Resident #41's Electronic Medical Record (EMR) assessment documentation revealed Resident #41 had a history of falls within the facility. Fall assessment documentation indicated since May 2020 the Resident fell on [DATE] (two falls), 5/30/20, 12/23/20, 1/19/21, 2/4/21, and 5/2/21. Review of Resident #41's documentation in the Electronic Medical Record (EMR) revealed the following: - 5/2/21 at 8:30 PM: Pertinent Charting-Falls . Situation Details: Resident witnessed to be crossing the hall from room. CNA was not quite in reach of resident when pants fell down and resident tripped. Assessment: Hit right elbow area on bedside table. C/O (complain of) pain to right elbow, no other apparent injury noted. Mitigating Factors: Pants were large on resident and (Resident) had knotted the tie strings. These were removed from resident's belongings . All other clothing will be assorted per size . -5/3/21: Nurse Practitioner (NP) Encounter . Visit Type: Acute. Transition of Care: No transition occurred . Chief Complaint . Right arm pain . seen today after having a fall earlier this morning. Resident was ambulating in the hallway when their pants fell down. (Resident #41) went to pick them up and they tripped and fell . landed on right side. Since the fall has complained of right elbow pain. It is swollen and very tender. (Resident #41) has reduced range of motion. Resident has a history of dementia and it makes it difficult to assess as (the Resident) will become agitated when they are experiencing pain .resides in the memory care unit due to history of dementia . Only communicate that they had pain on the right elbow . Musculoskeletal . swelling and palpable tenderness of the right elbow . patient does keep (right elbow) flexed and guarded . Musculoskeletal: + right elbow swelling, tenderness, firm and reduced ROM (Range of motion) . -5/3/21 at 2:15 AM: Nurses' Notes . Resident noted to have 1+ [CONDITION(S)], bruising and continued c/o pain to right arm. On call physician notified with new orders for X-rays to forearm and elbow. -5/3/21 at 4:09 PM: Pertinent Charting-Falls . C/O of pain right elbow. Mobile x-ray coming to do x-ray today . -5/4/21: Physician Encounter . Visit Type: Acute. Transition of Care: No transition occurred . Patient seen today for routine 60-day follow-up. History . Patient also had a recent fall . fell on right elbow and had elbow pain afterwards . some swollen swelling and tenderness . X-Ray was reported as having a nondisplaced fracture of the ulna (bone in lower arm) . does keep it (right arm) flexed and guarded . doubtful that the patient would require casting, however, it needs to be evaluated by an orthopedist . - 5/4/21 at 00:09 AM: Pertinent Charting-Fall . Date of Fall: 5/3/21 . X-ray completed right arm, results received and faxed to on call NP. Ace wrap applied. area remains bruised . - 5/4/21 at 5:19 AM: Orders - Administration . Ace wrap to right elbow. Check circulation Q (every) 4 hr. ok to remove for showers/bathing every 4 hours for Right elbow contusion for 7 Days. -5/4/21 at 8:09 AM: Pertinent Charting-Falls . Date of Fall: 5/4/21 . cont (continue) to monitor and access-awaiting ortho consult. -5/5/21: Nurse Practitioner (NP) Encounter . Visit Type: Acute. Transition of Care: No transition occurred. Chief Complaint . Right arm pain . seen today after having a fall early Monday morning. Resident was ambulating in the hallway when their pants fell down. (Resident #41) went to pick them up and tripped and fell . (The Resident) landed on their right side. Since the fall has complained of right elbow pain. It has been swollen and very tender . reduced range of motion. Resident has a history of dementia and it makes it difficult to assess as (Resident) will become agitated when experiencing pain. X-ray was ordered and results were available yesterday. Orders were given to place a splint and consult ortho for further instruction. Specific splint required is not available and resident needs prior authorization before going to orthopedic appointment. Resident continues to have pain and would benefit most from transfer to the hospital. Imaging: 5/3/21: Right forearm: segmental fractures of the proximal (upper) and distal (lower) shaft of the ulna . Unable to obtain/place splint. Cannot get into ortho until VA approval of consult. Further delay likely to lead to further compromise or increased pain. Send to ED for treatment . - 5/5/21 at 1:44 PM: Nurses' Notes . Nurse Practitioner in and review X-ray again . decided to send resident to ER for eval and treat-resident transferred via ambulance . -5/5/21 at 3:00 PM: Pertinent Charting-Falls . (Resident #41) returned from hosp. ER has brace and sling in place . -5/6/21 at 11:16 AM: Nurses' Notes . Appt. with (external Orthopedic Provider) today. Right arm splint cast applied . -5/12/21 at 12:47 PM: SOC-Falls . Resident continues to follow up with orthopedic surgeon, cast intact to right arm Comments: cast remains intact to Right arm, resident to follow up with orthopedic surgeon . -5/25/21 at 12:05 PM: SOC-Pain New onset/Unrelieved pain: Fractured Right ulna .Pain characteristics: stabbing and aching. Precipitating factors: movement . Review of Resident #41's weight documentation in the EMR revealed Resident #41 had gained weight since January 2021. On 1/7/21, Resident #41 weighed 165.2 pounds (lbs) and on 6/3/21, they weighed 171.4 lbs. Review of diagnostic imaging results revealed, Performed: 5/3/21; Reported Date/Time: 5/3/21 at 10:01 PM . Findings Right Forearm: Examination reveals segmental [MEDICATION(S)] and slightly oblique fractures involving the proximal and distal shafts of the ulna with no significant displacement . On 6/9/21 at 5:28 PM, all of Resident #41's Incident and Accident reports for the previous year were requested from the facility Director of Nursing (DON) and Administrator. Incident and Accident Reports for the Resident's falls on 2/4/21 and 5/2/21 were provided. Review of the Incident and Accident Report for Resident #41's most recent fall on 5/2/21 detailed, Observed . Fall . Brief Description: Resident walked from their room across hall . witnessed Resident's pants dropped, and Resident dropped and fell . Hit right elbow on bedside table . Injury Type: No apparent injury . c/o pain .Ice Applied . Pants removed . The included Fall RCA Investigation Tool included a hand drawn image of the Resident laying on the floor with their head near a bed and table near their feet. Another table, further away, was on the Resident's right side and a door was on the Resident's left side. The Tool included a description authored by Nurse GG revealed, Resident was in bed sleeping in clothes . self-transferred and ambulate across the hall. CNA witnessed this and before they could get to (Resident 41), pants dropped and they tripped . The Fall RCA Investigation Tool further detailed, What appears to be the initial root cause of the fall? Resident clothing to big . Was Resident incontinent when incident occurred: Yes . Level of Assistance Resident requires . Assist of 2, gait belt . List staff/witnesses that were present at time of incident: Fall unwitnessed . Resident #158: On 6/08/21 at 1:14 PM, from the hallway of the facility, Resident # 158 was observed sitting on their bed wearing only a brief and one non-slip sock. The room was dimly lit with the lights off and the window shades closed. Upon entering the room, Resident #158 was observed to have a disheveled and unkept appearance. The call light was not visible nor within reach of the Resident. The Resident had a raised edge mattress in place. The raised edge aspect of the mattress was toward the foot of the Resident's bed (raised edge should be at the head of the bed). An interview was attempted to be completed at this time but did not provide meaningful responses to questions. Resident #158 attempted to stand up from their bed multiple times and fall backwards on the bed while this Surveyor was in the room. No staff were observed in the hallway outside of the Resident's room prior to and/or during the time in Resident #158's room. No staff were present in the hall after exiting the Resident's room. Record review revealed Resident #158 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included end stage [CONDITION(S)] with [CONDITION(S)] dependence, [CONDITION(S)], unspecified signs and symptoms involving cognitive functions and awareness, and history of falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was rarely/never understood, required extensive, two-person assistance for bed mobility, transferring, dressing, and toileting and total assistance for bathing. Review of Resident #158's care plans revealed a care plan entitled, The resident is at risk for falls related to: Recent acute metabolic [CONDITION(S)] due to end stage renal disease requiring [CONDITION(S)], side effects from medications (Had 3 falls in one week at home prior to admit) (Initiated: 5/13/21; Revised: 5/25/21). Care plan interventions included: - Anticipate and meet the resident's needs based on nursing assessments (Revised: 5/25/21) - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed (Revised: 5/25/21) - Floor mat at side of bed, bed to wall (Initiated: 6/4/21; Revised: 6/7/21) - Resident should wear clothing that is easy to remove for toileting (Revised: 5/25/21) - Staff encourage to resident to wear grip socks while in bed, and to re-apply if resident observed removing grip socks (Initiated: 6/2/21; Revised: 6/3/21) Review of Incident and Accident reports for Resident #158 detailed the following falls: -5/27/21 at 11:50 AM: Resident Room . Unobserved . Fall . Brief Description: Pt (patient) roommate put call light on and yelled out that (Resident #158) was on the floor . Injury . Hematoma/Bruise . Stated they were trying to go to the bathroom . -5/31/21 at 2:45 AM: Resident Room . Fall (Not witnessed) . Brief Description: Resident noted to be lying on floor by bed, had pulled Foley (urinary catheter) out . Provided Fall RCA Investigation Tool detailed, What appears to be the initial root cause of the fall? Resident has poor safety awareness r/t (related to) cognitive status . Care Plan/ Nurse Aide Assignment Updates: Bed against wall with mat on floor next to bed . Witness Statement by CNA HH revealed, (Two Staff) and I were talking with the nurses at the nurse station when we heard a crash down hall . Upon arrival to (Resident #158's) room, we found (Resident) on the ground next to their bed . stated their head hurt . -6/3/21 at 4:30 AM: Resident Room . Observed on Floor . (Not witnessed) . Brief Description: Entered Res. Room . (Resident #158) was behind the door laying on left side in fetal position. No injury noted. Knees were not red so might have ambulated to door, lost balance, and then to floor . Included Quality Assessment and Assurance Investigation Report included, Results of Investigation: Root cause of incident . Resident attempted to ambulate independently and removed grip socks . lost balance and fell . Staff to toilet Resident frequently at night and reapply gripper socks if observed not wearing . On 6/10/21 at 7:38 AM, Resident #158's room door was open, and the Resident was visible from the hallway. Resident #158 was on their bed, wearing only a brief. The Resident did not have non-slip socks in place, and none were observed in the room. The Resident's call light was not within reach of the Resident and the cord of the call light was visibly stuck between the bed and wall. The Resident had a raised edge mattress in place. The raised edge aspect of the mattress was toward the foot of the Resident's bed and a pillow had been placed under the mattress sheet towards the head of the bed. Upon seeing this Surveyor in Resident #158's room and upon request, Unit Manager Registered Nurse (RN) L entered the room. When queried regarding Resident #158's call light location, RN L stated, I don't see one. RN L then located the call light stuck under the bed frame on the side of the bed positioned directly against the wall. When queried regarding Resident #158's call light not being in reach, RN L stated, This is all wrong. RN L was queried regarding Resident #158 not having non-slip footwear in place. RN L revealed Resident #158 should have non-slip socks in place and began looking through the Resident's room, including drawers and closet for socks. RN L was unable to locate non-slip socks and indicated they would have to obtain them. When asked why the Resident's mattress was positioned with the raised edge portion being at the foot of the bed, RN L revealed the someone must have put the head of the mattress on the wrong side. RN L was then queried why the Resident had a pillow under the fitted sheet of their mattress and stated, To keep (Resident #158) in bed. When asked if that was acceptable, per facility policy/procedure, RN L did not provide a response. At 7:47 AM on 6/10/21, an interview was completed with Certified Nursing Assistant (CNA) CC. When queried regarding Resident #158's call light not being within reach and why the Resident did not have non-slip socks in their room, CNA CC did not provide an explanation. On 6/10/21 at 12:20 PM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #41's fall with fracture, the DON revealed the Resident's pants were too big and they fell down. With further inquiry regarding the Resident's pants being big, the DON stated, Maybe they lost weight. The Resident's weights were reviewed with the DON at this time. After review demonstrating the Resident had not lost weight, the DON stated, I don't know. When queried if the Resident dressed themselves, the DON revealed the Resident required assistance from staff for dressing. The DON was then asked why staff would dress the Resident in pants that were large enough to fall off, especially given the Resident's history of falls and self-transferring. The DON was unable to provide an explanation and revealed staff should have not dressed the Resident in pants that were large enough to fall off. The DON was then asked about Resident #41's interventions to prevent falls and how the fall on 5/2/21 occurred and indicated that ensuring Residents are dressed in properly fitting clothing is a basic aspect of care. When asked why Resident #41 was not sent to the hospital sooner for treatment after the X-ray results revealed the fracture and the facility did not have the medical equipment and supplies to provide appropriate treatment and splinting to prevent further injury, the DON indicated the facility was waiting for approval for the Resident to go to an orthopedic specialist from the VA. No further explanation was provided. The DON was then queried regarding observations of Resident #158 including observations of the Resident attempting to stand, lack of non-slip socks, the mattress being placed incorrectly, lack of staff monitoring, and the call light not being available. The DON was unable to provide an explanation regarding the mattress placement and indicated the call light should be in reach. Review of facility provided policy/procedure entitled, Fall Prevention Program (Implemented 1/1/21) revealed, Each resident will be assessed for the risks of falling and will receive care and services in accordance . 5. Each resident's risk factors and environmental hazards will be evaluated with developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed .

Based on observation, interview and record review, the facility failed to prevent and treat pressure ulcers for 1 of 1 (#25), resulting in stage II pressure ulcer to the left buttocks with no treatment or wound measurements or physician notification. Findings include: Record review of facility 'Pressure Ulcer/Skin Breakdown-Clinical Protocol' policy dated 11/28/2017, revealed that on the resident's assessment, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individuals clinical condition demonstrates that they were unavoidable, and a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. Assessments include weekly skin assessments by a nurse. Record review of a hand out located in the multi-disciplinary office stuck pin to a bulletin board, 'Staging Pressure Ulcers' undated, revealed Stage II- characterized by partial-thickness loss of the dermis, presenting as a shallow, open ulcer with a red-pink wound bed without slough. It may present as an intact or open serum-filled blister. This stage should not be used to describe skin tears, burns, excoriation or maceration. Resident #25: Record review of Resident #25's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year-old resident with severely impaired cognitive abilities. Medical [DIAGNOSES REDACTED]. Section H of the MDS- Bladder/Bowel assessments revealed an indwelling catheter. Record review of Resident #25's Certified Nurse Assistant task charting from 2/21/19 through 3/6/19, of skin observation identified on 2/23/19 a red area. The report did not indicate the location of the red area. Documented on 2/26/19 'Open area'. The report did not indicate the location of the open area. Record review of Resident #25's 'Order Summary Report' dated 3/6/19 at 3:43 PM, with the Director of Nursing, revealed Cleanse left buttocks with normal saline, pat dry, apply bordered foam dressing, change every day and as needed start date 10/22/18. There was no end dated noted for the order. The DON stated that the dressing had not been being used or applied for while. Record review of Resident #25's Medication Administration Record [REDACTED]. Record review on 3/6/19 of resident #25's Care Plans page 1 through 23, revealed a skin care plan at risk for pressure ulcers related to immobility, last updated on 4/6/2018. There was no new intervention related to the stage II pressure ulcer located on the left buttocks. Record review of Resident #25's urinary infection care plan last revision date 9/26/18 revealed that at risk for urinary tract infection related to urology procedure. No were in the care plan pages 1-23 was there a mention that the resident had a Foley catheter or how to care for the catheter and leg strap, or of the tear at the penis meatus to be monitored. Observation on 03/06/19 at 01:47 PM Registered Nurse K unit manager, Of Resident #25's Foley catheter and observations of buttocks area with Certified Nurse Assistant (CNA) C revealed observed of a 16 French Foley catheter in place with a tear/cleaved penis of approximately 1 inch, located at the meatus opening where the Foley catheter was inserted and an open wound on the left upper buttocks. There was no cream or dressing treatment to the area. RN K stated that she was not aware of the open area and did not know about it. The state surveyor had RN K measure the open left buttocks area, 2 cm X 1 cm stage II pressure ulcer. The right buttocks reddened area measuring 0.5 x 0.5 cm stage I was not open. applied cream to area. Cleaved penis area approximately 1 inch to 1 1/12 inches- no skin assessments related to the penis that she was aware of. In an interview on 03/06/19 at 02:16 PM with the Director of Nursing (DON) regarding Resident #25's left buttocks wound revealed that the skin area started as a shear area a couple of weeks ago. The DON stated that he thought that he had put a treatment in place. Record review of Resident #25's medical record with the DON revealed there were no orders for treatment or cream, no wound measurement and no skin assessment documentation on sheared area. The state surveyor requested the last skin assessments for Resident #25 that was located in the medical record dated 2/26/19 revealed a left arm scab. There was no mention of a left buttocks skin shear or reddened area or of the penis meatus tear from the Foley catheter.

This citation pertains to MI 078. Based on interview and record review, the facility failed to implement abuse procedures to ensure staff was trained to implement an investigation of abuse allegations, and to immediately implement an investigation of an allegation of physical abuse, to screen employees through information from past employers and current licensure verification, for one resident (#20) out of one resident reviewed for an abuse allegation resulting in a delay of the investigation into an abuse allegation that resulted in a fall, laceration, and bruising with the potential for further abuse due to the employee working after the incident of abuse. Findings include: The undated facility Abuse Prevention Program, stated that the facility was committed to protecting their residents from abuse by anyone. According to the undated facility Abuse Prevention Program, the definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful means that the individual acted deliberately, not that the individual must have intended to inflict injury or harm. The video footage of camera 7 did show that on [DATE] Registered Nurse (RN) E had stomped on Resident #20's feet, hit her in the face with his head, and twisted her arm and pushed so hard that it caused Resident #20 to fall on the floor. The video also revealed there were verbal exchanges between Resident #20 and RN E with RN E making gestures with his arms and at one time pointing his finger into the face of Resident #20. Right after this incident, Resident #20 went to another nurse to request a Band-Aid for a skin tear. One and a half days later, bruising was noted on Resident #20's face. There was no incident report about the fall. The incident report regarding the skin tear was dated [DATE] and was completed by the DON B. There was no nurses note about the skin tear that had occurred on [DATE]. The undated facility Abuse Prevention Program directed that employees must immediately report any suspected abuse or incidents of abuse to the Administrator. In the absence of the Administrator, such reports may be made to his/her designee. Instructions were given that an examination of the resident was to be performed and the findings recorded in the resident's medical record. An incident report was to be completed and a statement from the person reporting the incident was to be obtained. Any employee who had been accused of resident abuse was to be suspended from duty immediately. Employee witness statements were to be signed and dated. On [DATE] at 2:10 pm, RN Unit Manager F was interviewed. RN F stated that when a nurse suspects abuse, the first responsibility is to remove the resident from harm. If the suspected abuser was a staff member, he/she would be sent home and excused from work until the investigation had an outcome. The nurse would document in the nurses' notes and notify the Administrator and Director of Nursing (DON) of the allegation immediately. An incident report was to be filled out, the physician and family member would be notified and the nurse would ask other staff if they had seen anything. On [DATE] at 4:15 pm, RN Staff Educator Staff G was asked what a nurse was to do if the Administrator could not be contacted to report an allegation of abuse. RN G said that she has told staff, in orientation, that if the Administrator cannot be reached they were to keep going. RN G said that she had told them to call the corporate office or Adult Protective Services. RN G said that new staff are given those phone numbers during orientation. On [DATE] at 12:15 pm, LPN C was interviewed regarding an incident on the evening of [DATE]. LPN C stated that Resident #20 had come to her at about 8:40 pm to request a Band-Aid. When LPN C saw the huge skin tear on Resident #20's left forearm, she asked Resident #20 what had happened and Resident #20 had pointed to RN E, who was on another hallway and said, He did it. LPN C said that she had been very upset and believed abuse had occurred because He (RN E) put his hands on her and caused an injury. LPN C said that she had called the Administrator and the Director of Nursing and had left messages for both of them but neither one called her back before the end of her shift at 10:30 pm. LPN C said she did not complete an incident report, nurses notes, did not ask other staff if they had witnessed anything, and did not notify the responsible party or physician of Resident #20 about her concern of abuse. LPN C said she wasn't sure how to word the incident report or nurses notes and that in training she had learned that the Administrator or Director of Nursing would guide us through the process. LPN C said that she could not have sent him home because he was the only other nurse on duty with her at the time. LPN C said she had told the oncoming nurse, RN I at 9:45 pm when she came in to start her shift. LPN C said she had asked RN I if she had thought it was ok to not have sent RN E home. LPN C said she had also told RN I that she had left messages for the Administrator and Director of Nursing but had not heard back from either of them. According to the State Agency's facility reported incident (FRI) database, there was no abuse allegation incident reported to the State Agency until [DATE] at 9:00 am. Additionally, the facility failed to immediately and thoroughly investigate the injury of unknown origin, Resident #20's skin tear, even after LPN C reported it to both NHA A and DON B. RN E, who physically abused Resident #20 on [DATE], was allowed to continue to work, placing Resident #20 and all other residents at risk of being abused. On [DATE] at 11:05 am, DON B said she had RN E do additional training on managing behavior of residents with dementia and allowed him to work his next shift on [DATE]. RN I was contacted by telephone on [DATE] and a message left at 4:10 pm and did not return the phone call. During an interview on [DATE] at 12:45 pm, Nursing Home Administrator (NHA), A stated that he had returned the phone call to the facility on [DATE] just after LPN C had left and he had spoken with RN I. NHA A said the term abuse did not come up during the conversation and he had thought that RN E had tried to defuse a physical situation and Resident #20 had gotten hurt. During an interview with the Director of Nursing (DON) B on [DATE] at 11:05 am, she stated that she had learned about Resident #20 receiving a skin tear on her left arm on [DATE] when she came on duty. DON B said that LPN C had returned to duty at 6:00 am on [DATE]. DON B said that LPN C had been quite upset but calmed as they spoke. DON B said that LPN C did not give an indication to her that she thought abuse had occurred. According to the undated facility Abuse Prevention Program, employee witnesses will be required to sign and date any witness report they make. RN E had written in a statement dated [DATE] that he had grabbed the snack bowl from Resident #20 when she was trying to give a snack to her former room mate and had told her that the aides would give out the snacks. RN E had also written that he had grabbed the arms of Resident #20 to stop her from hitting him, not that he had held his arms up to deflect the blows or that he had backed away from Resident #20 when she began hitting. RN E did not write in his statement that he and Resident #20 had raised their voices or had loud verbal exchanges. In the article Dealing with Assaultive Behavior: An Overview for CNAs, published ,[DATE] by RN.com, the learner is instructed to maintain self-control, stay in a relaxed pose and not to argue. Physical aggression is to be defended by deflecting blows or staying out of the way. Review of the facility's FRI (Facility Reported Incident) Summary Report, under the date of [DATE], it was noted that RN E had said to the DON that he had not meant to step on Resident #20's foot. The statement written by RN E did not include that he had stepped on Resident #20's foot and was not investigated further as to how or when RN E had stepped on the foot of Resident #20. In an undated Statement of Witness for an incident that had occurred on [DATE], Certified Nursing Assistant (CNA) J had written that she had heard yelling between (RN E) and (Resident #20) on B Hall. It wasn't uncommon for (Resident #20) to get upset over other people in her hallway, it was something the two argued over often, so I didn't really think much of it. In an undated Statement of Witness for an incident that had occurred on [DATE], CNA K had written that I saw (Resident #20) and (RN E) down C hall exchanging words. Not being able to hear the conversation I assumed it was a discussion on wandering in the hall which occurs on a fairly regular basis. Resident #20 had written an account of the incident with Friday written at the top. The writing was shaky and difficult to read in places. Resident #20's account included notations about the university and did not mention verbal exchanges between herself and RN E. Resident #20 wrote that he grabbed my arm & twisted it strongly so it moved my whole body forward. He didn't say anything, neither did I, but it jerked me forward strongly. That was all. Resident #20 did have a Behavior care plan in place, initiated on [DATE], with a focus The resident has a behavior problem related to wanting to help peers with their cares. she used to be the Dean of Women at U of M. her history has her in control of 600 + women in the dormatories. she tends to revert back to the behavior of being the hall monitor. she does not like it when peers come down her hall that don't live there. she sometimes becomes angry with peers and she does struggle with her memory. The approach for when Resident #20 became agitated, initiated on [DATE] and revised on [DATE], was to Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later/have another staff member try to calm and redirect resident. The undated Abuse Prevention Program identified that the education program for employees was to include Training staff to understand and manage a resident's verbal or physical aggression .monitoring staff on all shifts to identify inappropriate behaviors toward residents and helping staff to deal appropriately with stress and emotions. On [DATE] at 11:05, DON B stated she had spoken with RN E on [DATE] who said he had been trying to keep Resident #20 from hitting him and he had grabbed her by the arms. DON B said that RN E had told her that he had felt he could have handled the situation better. DON B said that she had also spoken with Resident #20, who was confused, but that Resident #20 had also told her that a man had grabbed her arms and that Resident #20 gave no indication that there was any more to the story. DON B recalled that RN E had failed a licensure exam for massage therapy that he had taken a course to prepare for, and had been planning to pursue a business opportunity with his wife in the field of massage therapy. DON B said that RN E had been reeled both by the failure of the exam and the incident with Resident #20. DON B stated that she had received a couple of complaints from staff that RN E had been short with them but at the time she had felt that the complaints were related to RN E's supervisory role. DON B said she had received one resident complaint regarding RN E. The complaint was that RN E had not administered the resident's medications as she preferred and had gotten pudding from the spoon up her nose. The resident had told DON B that she had felt as if she was being rushed. DON B had not received reports that RN E argued with or yelled at Resident #20 even though CNA J had written in her witness statement that it had happened often. DON B said she had spoken with RN E and the concern had been resolved. DON B said that there had been one time that RN E had been short with her and that was in regards to his workload. According to Dictionary.com, the word grab means to seize suddenly or quickly, snatch, clutch, to take illegal possession of or to seize forcibly or unscrupulously. Even though RN E had used the word grabbed twice in his written statement and once in conversation with the DON, even though DON B was aware of the stressor that RN E faced, RN E had told DON B he had stepped on Resident #20's foot without writing that fact in his statement, and that RN E had a resident complaint, complaints from fell ow staff, and DON B had witnessed RN E being short, she did not formulate any suspicion of abuse related to how Resident #20's skin tear had materialized and did not initiate an investigation of the incident. During an interview with the DON B on [DATE] at 3:30 pm, she stated that no staff competencies related to dementia or behavior management were evaluated and that there were no performance evaluations of employees during the first three months of employment. According to an incident report dated [DATE], at 8:30 am, Resident #20 had been noted to have bruising that extends from bridge of nose to under bilateral eyes. During an interview with NHA A on [DATE] at 12:45 pm, he stated that when the bruising was noted on Resident #20's face on [DATE], the DON B had begun an investigation and when the two of them spoke about the injury of unknown origin on [DATE], it was then that they had discussed viewing the video tapes from the cameras in the hallways of the building. NHA A stated that the video footage was not routinely used as a tool for investigations. NHA A stated that viewing the video tapes was not a part of the facility Abuse Prevention Program that was a program written at the corporate level. NHA A said that the facility could implement the video tapes as a part of a facility specific procedure. The undated facility Abuse Prevention Program, stated that comprehensive policies and procedures that govern, at a minimum, protocols for conducting employment background checks. According to the facility policy Checking References on New Hires, dated [DATE], individual references were to be checked on each employment candidate. Documentation was to include all of the information provided during the check, any refusals to provide information, and all attempts to obtain information. During an interview on [DATE] at 3:15 pm, Nursing Home Administrator (NHA) A said that the company had changed ownership in (MONTH) (YEAR) but that it was policy to try to get two reference checks; although more often than not, a previous employer would not provide information. During a review of the personnel file for Registered Nurse (RN) E, who had been hired by the facility on [DATE], it was noted that the two Telephone Reference Check forms were not completed. There was a Facsimile Cover Sheet for the previous employer, dated [DATE], but no indication of the date or time it had been faxed. It was also noted that the copy of the RN license from the state of Michigan for RN E had expired on [DATE]. RN E had no performance evaluations or competency evaluations in the personnel file. During a review of the personnel file for Licensed Practical Nurse (LPN) C, who had been hired by the facility on [DATE], it was noted that the two Professional Reference Check forms were blank. During an interview with the Payroll Benefits Coordinator, Staff D on [DATE] at 11:55 am, she stated that before (MONTH) of (YEAR), it had been the responsibility of the Department Heads to perform reference checks but since (MONTH) of (YEAR), that responsibility had been given back to the Human Resources Department. Staff D also said that she verifies licensure or registry for new staff initially and that Registered Nurse (RN) G, the RN Education Director, would verify the licenses annually. On [DATE] at 1:45 pm, Unit Manager, RN F reviewed the book with nurse's licenses that was kept by RN G who was not in the building. RN F stated that the company that had owned the facility up until (MONTH) (YEAR) had a policy in place to verify active employees had a current license or registry certificate but that the current company did not have such a policy. RN F was unable to locate a current RN license for RN E. On [DATE] at 2:10 pm, RN F said he has spoken with RN G by phone. RN F reported that RN G said she did not print out license verifications for staff, that she just wrote them down. In the book for licenses kept in RN G's office was a sheet of untitled, undated paper with four names followed by dates written in pencil. Behind the name of RN E was the penciled date [DATE] with no indication of what the date meant or when it had been penciled in. In a book with information related to a facility reported allegation of abuse incident that occurred on [DATE], was a printout from the Michigan Department of Licensing and Regulatory Affairs that revealed RN E's RN license had been checked with the agency on [DATE].

This citation pertains to MI 078. Based on observation, interview, and record review, the facility failed to provide an environment free from staff to resident physical abuse for one resident (#20) out of one resident reviewed for abuse resulting in a fall, a 65 millimeter (2.5 inches) long laceration/skin tear of the left forearm and facial bruising. Findings include: According to the Admission Record, dated [DATE], Resident #20 was an [AGE] year old female who was admitted to the facility on [DATE]. The Admission Record, dated [DATE], listed [DIAGNOSES REDACTED]. Resident #20's most recent Minimum Data Set (MDS) Resident Assessment, dated [DATE], indicated she was cognitively impaired as she scored 8 out of 15 on the brief interview for mental status (BIMS). The MDS, dated [DATE], reported no physical or verbal behaviors or wandering for Resident #20. The MDS, dated [DATE], revealed that Resident #20 was able to walk independently using a walker for support. On [DATE] at 12:40 p.m., Resident #20 was observed walking with her walker leaving the main dining room. Faded yellowish colored bruising was observed on her face around her eyes and an intact dressing was observed on her left forearm. Resident #20 was alert and responsive and readily engaged in conversation. Resident #20 shared her work and family history and her countries of past residence. Resident #20 did not identify or indicate any concerns with her stay in the facility. Review of the facility's 5-day investigation dated [DATE], revealed that video footage showed that Registered Nurse E, is seen stepping on both of residents feet one at a time. He is see (sic) stepping forward and hitting resident in the face with his head .Nurse pushes at resident and she falls against wall landing on her buttocks on the floor . On [DATE] at 9:15 am, the Nursing Home Administrator, Staff A, advised that a video recording of the physical contact between Registered Nurse (RN) Staff E and Resident #20 was available. The video footage was from camera 7 on the C Wing hall. Camera 7 was mounted high on the wall of C Wing at the end of the hall closest to the central nurses station and pointed down toward the other end of the hallway. No audio was present on the tape. The following was viewed on the video tape. The video tape was date stamped [DATE] and the beginning time stamp was 19:00:00 (7:00:00 p.m.). At 19:00:00 (7:00:00 p.m.) Resident #20 was seen walking with a walker at the far end of the hall. RN E was standing at a medication cart about half way down the hall. AT 19:00:52 (7:00:52 p.m.), RN E was seen to walk down the hall and enter a room on the left. Resident #20 was seen standing in the hall outside of the same room. At 19:02:00 (7:02:00 p.m.), Resident #20 was seen to turn toward the camera and had a silver bowl in her left hand. At 19:02:,[DATE]:02:40 (7:02:,[DATE]:02:40 p.m.), RN E came out of the room, walked past Resident #20, then turned back and grabbed the bowl out of Resident #20's hand so forcefully that it caused her to lurch forward. RN E then gestured with his hand toward the camera. RN E then walked toward the camera holding the bowl. At 19:02:53 to 19:02:58 (7:02:53 to 7:02:58 p.m.), RN E was out of the camera frame and then walked back down to the hall to the medication cart. At 19:03:10 (7:03:10 p.m.), Resident #20 was observed to walk by RN E. It appeared that RN E and Resident #20 exchanged words. At 19:03:15 (7:03:15 p.m.), Resident #20 had walked past RN E and he approached her. Resident #20 turned to face RN E with her walker behind her, closer to the camera. Resident #20 reached out and put her hands on RN E's shoulders. They then took a few steps to her left with her still having a hold of his shoulders. Her back was to the camera and RN E was facing her. At 19:03:23 (7:03:23 p.m.), Resident #20 was moving her right arm and her hands were about at his chest. At 19:03:25 (19:03:25 p.m.) Resident #20 let go of RN E and pushed at his chest. RN E moved Resident #20's walker further away from her and gestured. They had moved toward the left side of the hall and Resident #20 was holding the hand rail with her left hand. At 19:03:33 (7:03:33 p.m.) RN E stomped on Resident #20's left foot and continued to gesture pointing in the direction of the camera. RN E then stomped on the same foot again at 19:03:36 (7:03:36 p.m.). At 19:03:39 (7:03:39 p.m.) Resident #20 tried and missed a stomp on RN E's foot as they moved back down the hall a few steps away from the camera and her walker. At 19:03:43 (7:03:43 p.m.), RN E gestured again pointing toward the camera and Resident #20 put her hands on her hips. RN E pointed his finger in Resident #20's face and at 19:03:44 (7:03:44 p.m.), Resident #20 moved her hands forward and slapped RN E on his sides. At 19:03:53 (7:03:53 p.m.), RN E moved in closer to Resident #20 and forcefully slammed his head into her head as he head butted her. Resident #20's head jerked backwards and her arms went up into the air, bent at the elbows, and then she grabbed the side of his head with her left hand. RN E grabbed Resident #20's left arm and twisted and pushed causing her to fall into the wall and her right shoe to come off. Resident #20 lost her balance and fell hard to the floor landing on her right side with her right arm under her. At 19:04:01 (7:04:01 p.m.), RN E approached Resident #20, kicked her shoe toward her, then leaned over as she righted herself to a sitting position and he grabbed her under her arms and quickly lifted her to her feet. RN E steadied her and put her right shoe back on her foot. At 19:04:14 (7:04:14 p.m.) RN E rolled the walker to Resident #20 and went back to the medication cart turning his back on her. At 19:04:30 (7:04:30 p.m.), Resident #20 lifted her left arm and examined it, then, using her walker, she walked under the camera and out of view. RN E continued to work at the medication cart. No other people were in view of the camera during the incident. On [DATE] at 12:15 p.m., Licensed Practical Nurse (LPN) Staff C was interviewed. LPN C stated she had been on duty on [DATE] and had been approached by Resident #20 who had requested a Band-Aid at about 8:40 p.m LPN C said that when she asked Resident #20 how she had hurt her arm, Resident #20 had pointed at RN E, and said he did it. On [DATE] at 4:25 p.m., a police officer from the local law enforcement agency, Officer H , said he would refer the case to the county prosecutor as an assault charge against RN E. No explanation was provided as to the difference between the time stamps on the video and the accounts of witnesses time lines. After viewing the video, no doubt was left that RN E was physically aggressive and made physical contact with Resident #20.

Based on observation, interview and record review, the facility failed to prevent development of facility acquired pressure sores for 3 (#3, 5, and 14) of 4 sampled residents from 17 total sampled residents, resulting in harm for Resident #3 sustaining multiple 7 new preventable pressure sores/area, Resident # 5 developed bilateral buttocks pressure areas and left heel deep tissue injury of dark purple to black colored tissue damage and Resident #14 developing right iliac crest hip pressure sore stage II. Findings include: Record review of facility 'Pressure Ulcer Prevention/Treatment' policy dated April 2009 revealed all residents will be assessed on admission and weekly for four weeks, quarterly, and with significant change of condition.......Pressure Ulcer Prevention/Treatment interventions may include, but are not limited to: Mange pressure- use support surfaces on bed or wheelchair. Use turning and repositioning. Off-loading heel pressure. Record review of Resident #3's 'Nursing Comprehensive Admission Data Collection and Assessment' dated 1/27/15 at 8:00 PM revealed a skin assessment of a 2 cm X 1 cm reddened area to coccyx region. Record review of Resident #3's Minimum Data Set ((MDS) dated [DATE] revealed a bed mobility of 3 extensive assist with two people. Skin was noted at risk with no Pressure sores noted on MDS. On the MDS dated [DATE] revealed a bed mobility of 3 extensive assist with stage I pressure sore noted. Record review of Resident #3's 'Skin Grid- Pressure/[MEDICAL CONDITION] Ulcer/other' forms for the month of February, 2015 for multiple areas of Resident #3's body noted the following: 1. On 2/3/15 abrasion to left shin area of 6cm X 2.5 cm not staged, noted not being present upon admission. 2. On 2/3/15 left heel 3 cm X 3 cm dry/intact purple not staged, area noted not being present upon admission. 3. On 2/1/15 coccyx left buttocks 7 cm X 5 cm not staged, noted not being present upon admission. 4. On 2/1/15 right buttocks 4 cm X 3 cm not staged, noted not being present upon admission. 5. On 2/18/15 left knee 0.8 cm X 0.7 cm not staged, noted not being present upon admission. 6. On 2/17/15 right side of spine 2 cm X 2 cm not staged, noted not being present upon admission. 7. 2/17/15 left back 0.5 cm X 2 cm X 2 cm staged II, noted not being present upon admission. Observation on 2/19/15 at 10:45 AM of Resident #3 while in his room for isolation for [MEDICAL CONDITION], revealed multiple skin pressure areas to the resident's body. An abdominal binder was noted to the mid-section which was opened to observe feeding tube and biliary tube and collection pouch. Observation on Resident #3's back side revealed bilateral pressure areas to the upper hip areas which aligned with the abdominal binder edges. Dressing changes were observed and wound measurements were obtained. A large left buttocks pressure sore measured 13.5 cm X 13.5 cm with 5 smaller areas within the wound bed. An interview on 2/20/15 at 8:00 AM with the Director of Nursing (DON)/wound care nurse "B" revealed that she was aware of the pressure ulcers to Resident #3 and that they were acquired in the facility. DON/wound care nurse "B" stated that she had changed the abdominal binder to a less wider/smaller binder since the previous binder rubbed the skin that caused the upper hip pressure areas. The DON and state surveyor went to Resident #3's room to review the pressure areas; the DON "B" stated that she last observed the pressure sores on 2/17/15 and that they had changed (worsened) since then and that they were now a stage III in appearance and had depth. However, the staging to a III level was not documented in the facility's Skin Grid- Pressure/[MEDICAL CONDITION] Ulcer form. Record review of Resident #5's 'Nursing Comprehensive Admission Data Collection and Assessment' dated 1/14/15 at (untimed) revealed a skin assessment of a reddened area to coccyx region not measured and a left heel with redness that was noted as blanchable and dry/intact. Record review of Resident #5's Minimum Data Set ((MDS) dated [DATE] revealed a transfer and ambulation of 3/3 extensive assist with two people. Resident #5 was admitted for a left hip surgical repair rehabilitation. Record review of Resident #5's 'Skin Grid- Pressure/[MEDICAL CONDITION] Ulcer/other' forms for the months of January and February, 2015 for multiple areas of Resident #5's body noted the following: 1. On 1/21/15 left heel 2.5 cm X 2.75 cm unstaged. 2. On 1/25/15 left buttocks 2 cm X 2 cm reddened. On 2/3/15 2.5 cm X 3 cm opened with serosanguineous drainage noted. Area not noted upon admission 3. On 1/25/15 Right buttocks 1 cm X 0.5 cm un-staged, and on 1/27/15 right buttocks stage II 1 cm X 0.5 cm open with serosanguineous drainage noted. Area not noted upon admission An interview and observation on 2/18/15 at 9:30 AM with Licensed Practical Nurse (LPN) "E" stated that physical therapy notified her of the left heel being purple on 1/21/15. LPN "E" performed pressure sore dressing changes on Resident #5. Measurements were obtained during the dressing change of 2.5 cm X 3.5 cm left heel, 1.5 cm X 1.75 cm left buttocks, 1 cm X 1 cm right buttocks. In an interview on 2/18/15 at 9:30 AM during dressing changes, Resident #5 stated that the heel was purple because the heel would rest on the end wood foot board. Resident #5 confirmed her left hip was a fracture repair and described that since she was so tall laying her in bed ended with her heel resting on the wood board . She also added , " I do not know why my butt was sore". Record review of Resident #14's skin assessment form the 'Nursing Comprehensive Admission Data Collection and Assessment' dated 12/24/14 at 7:00 PM identified a 1.5 cm yellow open area. Record review of Resident #14's Minimum Data Set ((MDS) dated [DATE] scored a bed mobility of 3/3 extensive assist with two people. Record review of Resident #5's 'Skin Grid- Pressure/[MEDICAL CONDITION] Ulcer/other' form dated 2/12/15 revealed a right iliac crest pressure sore stage II measuring 2 cm X 2 cm. Measurements on 2/18/15 during the annual survey revealed right buttocks 0.3 cm X 0.5 cm and the left buttocks 1 cm X 1 cm. Nurse noted area with healing in the middle with pink tissue. Two open areas open with small drainage noted. In an interview on 2/20/15 at 8:00 AM with the Director of Nursing (DON)/wound care nurse "B" revealed that she was aware of the pressure ulcers to Resident #14 and that the right iliac crest pressure ulcer occurred at the facility. (# )