Every finding on record at MyMichigan Medical Center Sault

Based on observation, interview and record review, the facility failed to effectively monitor for progression of a Stage IV pressure injury (full-thickness tissue loss with exposed muscle, bone, tendon or cartilage exposed) for one Resident (#21) of two residents reviewed for pressure injuries. This deficient practice resulted in unidentified worsening of the wound with infection requiring debridement and intravenous (IV) drug therapy.Findings include:Resident #21 (R21)An observation on 1/12/2026 at 12:49 p.m. revealed R21 seated in bed, reading. A wound vac (vacuum-assisted wound closure device) was observed with tubing leading from the device toward the resident, disappearing under the Resident's blanket near the area of her buttocks. When asked about her wound, R21 stated, it's been there for some time, and could offer no further details. Further observation revealed an IV access line in R21's right upper arm.On 1/14/2026 at 1:30 p.m. an observation of R21's wound care was completed as conducted by Registered Nurse (RN) H. The observation revealed a large, stage IV pressure injury covering R21's sacral region (base of the spine) and extending down toward the Resident's coccyx (tailbone) and into her gluteal cleft. The wound appeared to be approximately 16.5 centimeters (cm) wide by 10.5 cm long and 4 cm deep. The edges of the wound were irregularly shaped with scattered areas of dark purple and black tissue. Further observation revealed a small area of exposed bone near the center of the wound and an area of brown eschar (dead tissue) just superior and to the left of the exposed bone. Undermining was observed to be present at approximately the 1:00 o'clock and 5:00 o'clock positions of the wound.Review of R21's, Skin & Wound Evaluation(s), for 11/01/ 2025 through 12/15/2025, provided by the Director of Nursing (DON), revealed the following:11/05/2025, 4:38 p.m. Stage 4 Pressure. Sacrum, medial, middle . Area: 49.3 cm2 (centimeters squared). Length: 5.8 cm. Width: 11.4 cm. Depth: Not Applicable. Undermining: Not Applicable. Tunneling: Not Applicable. It was noted in review there was no documentation of the areas for evaluation and description of the wound bed, signs/symptoms of infection, exudate, peri wound, wound pain, and treatment provided. The only other area of documentation was the area to document Progress, which was marked as deteriorating.11/11/2025 4:46 p.m. Stage 4 Pressure. Sacrum, medial, middle . Area: 44.1 cm2. Length 6.2 cm. Width 11.0 cm. Depth: Not Applicable. Undermining: 3.0 cm. Tunneling: Not Applicable. It was noted the evaluation did not include a description of the wound bed, where the tunneling was in the wound, signs/symptoms of infection, exudate, peri wound, wound pain or treatment provided. The area for evaluation of wound progress was marked as, deteriorating.11/17/2025 2:15 p.m. Stage 4 Pressure. Sacrum, medial, middle . Area: 63.8 cm2. Length 6.3 cm. Width: 13.9 cm. Depth: Not Applicable. Undermining: Not Applicable. Tunneling: Not Applicable. Wound Bed: Granulation . 80% of wound filled. Slough [dead tissue] . 10% of wound filled. Eschar [dead tissue] . 10% of wound filled. Bleeding. Pink or red. Exudate: Heavy . sanguineous/bloody . Odor noted after cleansing: Moderate . Peri wound: Rolled edge. Surrounding tissue: Denuded - loss of epidermis . Fragile . Macerated. Induration 2-4 cm extending [greater than] 50% around wound . Progress: Deteriorating .11/25/2025 3:08 p.m. Stage 4 Pressure. Sacrum, medial, middle . Area: 51.2 cm2. Length: 5.8 cm. Width 12.5 cm. Depth: Not Applicable. Undermining: Not Applicable. Tunneling: Not Applicable. It was noted; all other assessment areas were left blank. There was no further data included in the evaluation, including assessment of the wound bed, signs/symptoms of infection, exudate, peri wound, wound pain or treatment provided.There were no further nursing skin and wound evaluations for R21's stage IV pressure wound, including measurements, description, signs and symptoms of infection, exudate, peri wound, or wound pain found in the EMR from 11/25/2026 through 1/12/2026. It was noted during wound care observation on 1/14/2026 at 1:30 p.m., R21's pressure injury appeared significantly larger that the last wound evaluation on 11/25/2026 The approximate surface area was calculated at 173.25 cm2 which was a significant increase from the last known surface area measurement at 51.2 cm2 on 11/25/25.Review of the Minimum Data Set (MDS) assessment, dated 1/08/2026, revealed R21 was initially admitted to the facility on [DATE] and had diagnoses including heart failure, dementia, osteomyelitis, and Stage 4 pressure ulcer of the sacral region. Further review revealed R21 required substantial/maximal staff assistance for toileting and bed mobility, was dependent on staff for transfers and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating mild cognitive impairment.Review of R21's, Wound Care Physician Note, dated and signed on 1/12/2026 at 6:39 p.m., revealed the following: Upon evaluation patient is found to have a stage IV sacral pressure injury. There was a negative pressure wound therapy dressing on the patient upon arrival at today's visit. Upon remove of the dressing, patient's noted to have some dark and gangrenous [decaying] tissue withing the borders of the ulcer. There is significant amount of odor associated with the ulcer . recommend a surgical consult to determine if it is appropriate for the patient to have a surgical debridement in the OR [operating room].Review of R21's, Skin & Wound Evaluation(s), for 11/01/ 2025 through 12/15/2025, provided by the Director of Nursing (DON), revealed the following:11/05/2025, 4:38 p.m. Stage 4 Pressure. Sacrum, medial, middle . Area: 49.3 cm2 (centimeters squared). Length: 5.8 cm. Width: 11.4 cm. Depth: Not Applicable. Undermining: Not Applicable. Tunneling: Not Applicable. It was noted in review there was no documentation of the areas for evaluation and description of the wound bed, signs/symptoms of infection, exudate, peri wound, wound pain, and treatment provided. The only other area of documentation was the area to document Progress, which was marked as deteriorating.11/11/2025 4:46 p.m. Stage 4 Pressure. Sacrum, medial, middle . Area: 44.1 cm2. Length 6.2 cm. Width 11.0 cm. Depth: Not Applicable. Undermining: 3.0 cm. Tunneling: Not Applicable. It was noted the evaluation did not include a description of the wound bed, where the tunneling was in the wound, signs/symptoms of infection, exudate, peri wound, wound pain or treatment provided. The area for evaluation of wound progress was marked as, deteriorating.11/17/2025 2:15 p.m. Stage 4 Pressure. Sacrum, medial, middle . Area: 63.8 cm2. Length 6.3 cm. Width: 13.9 cm. Depth: Not Applicable. Undermining: Not Applicable. Tunneling: Not Applicable. Wound Bed: Granulation . 80% of wound filled. Slough [dead tissue] . 10% of wound filled. Eschar [dead tissue] . 10% of wound filled. Bleeding. Pink or red. Exudate: Heavy . sanguineous/bloody . Odor noted after cleansing: Moderate . Peri wound: Rolled edge. Surrounding tissue: Denuded - loss of epidermis . Fragile . Macerated. Induration 2-4 cm extending [greater than] 50% around wound . Progress: Deteriorating .11/25/2025 3:08 p.m. Stage 4 Pressure. Sacrum, medial, middle . Area: 51.2 cm2. Length: 5.8 cm. Width 12.5 cm. Depth: Not Applicable. Undermining: Not Applicable. Tunneling: Not Applicable. It was noted; all other assessment areas were left blank. There was no further data included in the evaluation, including assessment of the wound bed, signs/symptoms of infection, exudate, peri wound, wound pain or treatment provided.There were no further nursing skin and wound evaluations for R21's stage IV pressure wound, including measurements, description, signs and symptoms of infection, exudate, peri wound, or wound pain found in the EMR from 11/25/2026 through 1/12/2026. It was noted during wound care observation on 1/14/2026 at 1:30 p.m., R21's pressure injury appeared significantly larger that the last wound evaluation on 11/25/2026.A review of R21's electronic medical record (EMR) from 11/01/2025 through 12/15/2025 revealed the following progress notes:11/01/2025 2:30 a.m. Skin/Wounds Note. When changing and dressing coccyx wound RN noted small pink area on skin to lower left buttock. RN applied foam dressing at this time.11/03/2025 10:43 a.m. N Adv - Long Term Care Evaluation . Skin Issue #001: Location: Coccyx. Pressure Ulcer/Injury - full thickness skin and tissue loss . Signs and Symptoms of Infection: None. Painful: Yes . measurement not documented as part of this assessment . refer to wound assessment in EMAR. Undermining: Yes . 5 or more instances of undermining. Tunneling: Yes . 5 or more. Dressing appearance: Intact. Dressing saturation: heavy [greater than] 75% .11/09/2025 3:48 p.m. Skin/Wounds Note. Wound care completed as directed by wound care clinic . resident continue with increased pain during and after wound care completion .11/16/2025 12:59 a.m. Health Status Note. Wound care done per treatment order. Dressing was saturated with purulent [thick, yellow-white, indicative of infection] mixed with serosanguinous drainage. Foul odor present .11/17/2025 2:52 p.m. Pharmacy Note [sic]. Daily dressing change completed today as ordered. Wound bed continues to deteriorate. Resident is not tolerating wound care, she is crying and moaning out in pain . resident has follow-up at wound care clinic on 11/18/25 .It was noted in review of the EMR, there was no documentation of physician notification of the deterioration of R21's wound as noted in the Skin & Wound Evaluation(s) dated 11/05/2025, 11/11/2025 or 11/17/2025. It was also noted in review of R21's progress notes, there was no indication of physician notification of the worsening of R21's wound as noted by increased pain on 11/09/2025, odor and purulent discharge on [DATE] or continued deterioration on 11/17/2025.Review of R21's Wound Care Physician Note(s), revealed the following:10/28/2025 9:00 a.m. The sore is larger with considerable undermining .11/18/2025 8:00 a.m. The ulcer is considerable worse . I did a moderate debridement of necrotic [dead] tissue today.12/15/2025 1:00 p.m. Excisional debridement was performed at today's encounter utilizing scissors and forceps. The deepest level of tissue removed was viable muscle. There was odor associated with the wound at today's encounter .12/22/2025 1:45 p.m. There is bone exposed at today's encounter . Order recommendations sent to DON at the long-term care facility for the IV antibiotics and the negative pressure wound therapy dressing [wound vac dressing] .Review of R21's MRI pelvis with and without contrast, result dated 12/18/2025, revealed the following: Impression: Osteomyelitis [infection of the bone] in the sacrum (underlying the large decubitus ulcer in the central lower back) .Review of R21's physician orders revealed the following: Ceftriaxone Sodium Solution (IV antibiotic medication) Reconstituted 1 GM [gram]. Use 1 gram intravenously one time a day for infection/osteomyelitis for 42 days. Start Date: 12/23/2025.On 1/14/2026 at 1:12 p.m., the DON was asked to provide all nursing wound evaluations completed from 12/01/2025 through 1/12/2026. The DON reported there were no wound evaluations for R21's stage IV sacral pressure injury for the requested period. The DON reported the wound clinic documentation was housed in another EMR system, which she had already provided, therefore there was no further wound documentation available.Further review of R21's Wound Care Physician Note(s), provided by the DON, revealed the following:12/24/2025 (no time provided) Sacrum (Active) . Stage 4 . With patient in side lying position, removed existed dressing. Visual inspection revealed ongoing red tissue with undermining present . non-selective debridement with saline and 4x4 gauze . Pre-Debridement Wound Bed Appearance: 90% beefy red, 10% yellow slough. Post-Debridement Wound Bed Appearance: 100% granulation . Applied black granufoam into the wound bed. Secured with Tegaderm and applied bridge system. Set wound vac to 125 mmHG [millimeters of mercury, measurement of pressure] .In review, it was noted there were no wound evaluations documented from the date of the placement of the wound vac on 12/24/2025 through the removal of the wound vac and noted deterioration on 1/12/2026.Review of R21's Treatment Administration Records (TARs) for December 2025 and January 2026 revealed the following order: Place wound vac/negative pressure dressing to coccyx, place contact layer such as adaptic or mepitel over exposed bone, use the bridging dressing to reduce pressure over the ulcer, run at 125 mmHg, one time a day every Mon, Wed, Fri. Start Date: 12/26/2025 . D/C Date: 1/13/2026 .During an interview and record review on 1/14/2026 at 1:46 p.m., the DON confirmed wound care evaluations were not documented by the facility from 11/25/2025 through 1/12/2026 and the wound care evaluations were incomplete as reviewed for 11/05/2025, 11/11/2025 and 11/25/2025. The DON was asked the importance of complete wound evaluations in the assessment of wound progression to which she reported she was aware complete assessments were necessary to identify worsening of wounds and the need to alter treatment. The DON reported that it seems everyone has a different piece of R21's care and there was a need for a cohesive system of documentation to ensure changes in wound status were quicky identified.Review of the facility policy titled, LTC Pressure Ulcer Protocol, effective 1/2026, revealed the following: Assessments/care to be completed: . Evaluate and initiate changes as needed by the interdisciplinary team. Document wound assessment findings by wound care clinician or designee weekly .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by:Failing to ensure labeling of food.Failing to ensure expired food was discarded.Failing to ensure proper hand sanitization when preparing food.This deficient practice had the potential to result in food borne illness among any or all 35 residents in the facility who receive meals.Findings include:During an observation of the kitchen on 1/12/26 at 11:54 a.m., Dietary Staff C and Dietary Staff D were not wearing beard restraints while they were preparing food.During an interview on 1/12/26 at 11:55 a.m., Registered Dietitian B reported the Dietary Staff that have long facial hair are to wear beard restraints when working in the kitchen.During an interview on 1/12/26 at 11:56 a.m., Dietary Staff C reported that He does not normally wear a beard restraint while working in the kitchen.Review of policy titled Food Safety Management System last revised 5/31/25, read in part .Food employees must wear hair restraints such as hats, hair coverings or nets beard restraints.During an observation on 1/12/26 at 11:58 a.m., an open rack with 4 trays of muffins and 4 trays of cookies were observed directly adjacent to an open garbage can.During an observation on 1/12/26 at 12:00 p.m., the #9 refrigerator contained a small pan of sliced tomatoes which were unmarked and undated.During an observation on 1/12/26 at 12:04 p.m., the #12 freezer contained a small, prepackaged container of mini cupcakes out of the original box with no date the item was taken out of the original box or a use by date.During an observation on 1/12/26 at approximately 12:15 p.m., the #1 refrigerator contained the following: half of a bag of opened Monterey jack cheese with an open date of 1/2/26 and a use by date of 1/11/26. a quarter of a bag of opened Asiago cheese with no open date or use by date on the bag.a small box of yellow squash dated 12/19/25 that appeared shriveled with brown spots covering the squash.During an interview on 1/12/26 at 12:16 p.m., RD B acknowledged the items found in the refrigerators were incorrectly stored per the facility policy and must be discarded.During an observation on 1/12/26 at 12:21 p.m., the large sugar bin contained an open bag of sugar with no open date or use by date and a separate flour bin with an open bag of flour with no open date or use by date.During an interview on 1/12/26 at 12:21 p.m., RD B reported the sugar bag and flour bags should have been marked with an open date and use by date and acknowledged the bags of flour and sugar were opened an undated.Review of policy titled Food Safety Management System last revised 5/31/25, read in part Refrigerated, ready to eat, [Time/Temperature Control for Safety] TCS food prepared and held in a food establishment.must be clearly marked with a use by/discard date .food that is required to be date marked must be discarded if it.is in a contained or package that does not bear a date or day mark.During an observation on 1/12/26 at 12:29 a.m., Dietary Staff D recorded a temperature in the temperature logbook. He bumped into an eraser that was located near the logbook. The eraser fell onto the floor. Dietary Staff D leaned over and picked the eraser off the floor. He placed the eraser next to the logbook and did not remove the gloves he was wearing or wash his hands. Dietary Staff D then walked over to the prep area and grabbed a pan and started to spray the pan with a non-stick spray.During an interview on 1/12/26 at 12:30 a.m., RD B acknowledged Dietary Staff D did not practice hand hygiene after picking up the eraser off the floor and considered the pan sprayed and the can of non-stick spray contaminated.Review of policy titled Food Safety Management System last revised 5/31/25, read in part Handwashing policy.Hands must be washed frequently and correctly including at the following times.after handling soiled equipment to utensils, During food preparation as often as necessary to remove soil and contaminations when changing tasks.after engaging in other activities that contaminate hands.Review of policy titled Hand Hygiene on [Long Term Care] LTC last revised 1/26, read in part .Hand Hygiene.To remove transient microorganisms.good hand hygiene is the single most effective means of interaction prevention and control.Hand hygiene should be performed, in accordance with the [World Health Organization] WHO five moments of hand hygiene.after contact with inanimate objects.before preparing and serving food.

Based on interview and record review, the facility failed to ensure COVID 19 vaccinations were offered to five Residents (#1, #3, #7, #21, & #25) of five residents reviewed for COVID 19 vaccinations resulting in the potential for serious respiratory illness.Resident #1 (R1)Review of the Minimum Data Set (MDS) assessment, dated 12/10/2025, revealed R1 was admitted to the facility on [DATE]. Review of R1's electronic medical record (EMR) revealed no documentation indicating the Resident was offered and/or received/declined the current 2025-26 Covid-19 vaccination. Further review of the EMR revealed the most recent documentation was a signed declination for the 2024-25 Covid-19 vaccination, dated 10/10/2024.Resident #3 (R3)Review of the MDS assessment, dated 12/02/2025, revealed R3 was admitted to the facility on [DATE]. Review of R3's EMR revealed no documentation regarding the Resident's Covid-19 immunization status. Further review revealed no documentation R3 was offered and/or received/declined the current 2025-26 Covid-19 vaccination.Resident #7 (R7)Review of the MDS assessment, dated 11/04/2025, revealed R7 was admitted to the facility on [DATE]. Review of R7's EMR revealed no documentation of screening for Covid-19 immunization upon admission or anytime thereafter. Further review of the EMR revealed no documentation R7 was offered and/or received/declined the current 2025-26 Covid-19 vaccination.Resident #21 (R21)Review of the MDS assessment, dated 1/07/2026, revealed R21 was admitted to the facility on [DATE]. Review of R21's EMR revealed no documentation R21 was offered and/or received/declined the current 2025-26 Covid-19 vaccination. R21's most recent Covid-19 vaccination was documented as 7/17/2024.Resident #25 (R25)Review of the MDS assessment, dated 11/11/2025, revealed R25 was admitted to the facility on [DATE]. Review of R25's EMR revealed no documentation R25 was offered and/or received/declined the current 2025-26 Covid-19 vaccination. R25's most recent Covid-19 vaccination was documented as 2/19/2024. Review of the Centers for Disease Control and Prevention (CDC) guidance titled, Staying Up to Date with Covid-19 Vaccines, dated 11/19/2025, revealed the following: CDC recommends a 2025-2026 Covid-19 vaccine for people ages 6 months and older . Getting the 2025-2026 Covid-19 vaccine is especially important if you . Are ages 65 years and older . Are living in a long-term care facility . Available vaccines: 2025-2026 Moderna Covid-19 Vaccine Spikevax. 2025-2026 Moderna Covid-19 Vaccine mNexspike. 2025-2026 Pfizer-BioNTech Covid -19 Vaccine Comirnaty. 2025-2026 Novavax Covid-19 Vaccine . 2025-2026 Novavax Covid=19 Vaccine Nuvaxovid .During an interview on 11/14/2025 at 3:00 p.m., the Director of Nursing (DON) reported to be the facility's Infection Preventionist. The DON was queried regarding the facility's process for screening residents for Covid-19 immunization status and offering eligible residents the current Covid-19 vaccination. The DON reported she was new to the role and recently found there was no formal process in place for ensuring residents were screened for Covid-19 immunization or for offering of the current vaccine to eligible residents. The DON reported the 2025-26 Covid-19 vaccine should have been offered as soon as it was available to ensure coverage for the current season. The DON began screening residents upon recognition of the oversight and reported she began asking residents and calling resident representatives last week to offer the 2025-26 Covid-19 vaccination, but no vaccines had been administered as of the time of the interview. The DON reported all documentation of immunization history should be documented in the EMR. When asked for the facility Covid-19 Immunization policy, the DON reported there was no working policy at the time of the interview, but the Covid-19 immunization screening was incorporated into the admission policy and was to be reviewed at the next Quality Assurance/Performance Improvement (QAPI) meeting. A request for the policy was requested at the time of the interview.Review of the undated facility policy titled, admission Process/Pre-Screening, revealed the following: Immunizations: MCIR [Michigan Care Improvement Registry] and any provided medical records will be reviewed prior to admission care conference. Any vaccinations which are not up to date will be offered to the resident or their guardian at this time, using CDC guidance and recommended timelines. Consents or declinations will be obtained and documented in the resident chart. MCIR will be updated after vaccination is administered. Covid-19 immunizations will be offered residents annually.

Based on observation, interview, and record review, the facility failed to perform an assessment for self-administration of medication for one Resident (#5) of one resident reviewed for self-administration of medication.Findings include:Resident #5 (R5)A review of R5's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses including: anxiety disorder, depression, and diabetes mellitus. R5 scored 12 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of moderate cognitive impairment.During an observation on 1/12/26 at 2:15 p.m., R5 had a tube of antibiotic ointment and a small bottle of [name brand] advanced eye relief drops on her bedside table.During an interview on 1/12/26 at 2:16 p.m., R5 explained she used eye drops to moisten her dry eyes during the day. R5 was queried about the antibiotic ointment, and she pointed to a scratch on her forearm and explained she had the ointment to treat a scratch.Review of R5's Electronic Medical Record (EMR) did not reveal a doctor's order for R5 to self-administer any medication, and an assessment had not been completed for R5 to self-administer medication.During an interview on 1/14/26 at 3:40 p.m., Director of Nursing (DON) reported R5 did not have a self-administration of medication assessment completed. The DON stated, she would agree residents should be evaluated for medication safety before being able self-administer them and acknowledged R5 would not be safe to self-administer medication. The DON reported she was unaware R5 had medications at her bedside and was concerned as people can become sick if they ingest medications not meant for them.Review of policy titled LTC Medication Administration last revised 1/2026, read in part .resident self-administration.a resident who states a preference to self-administer their medications must first pass a capacity assessment or decision making capacity assessment.a self-administration assessment must also be completed with a staff nurse and the resident must pass the assessment.the provider [physician] must write an order stating the resident may self-administer their medications.

Based on interview and record review, the facility failed to ensure residents or resident's representatives were provided with written notification of transfer and/or the facility's bed hold policy at the time of transfer out of the facility or anytime thereafter for two Residents (#1 and #3) of three residents reviewed for hospitalization.Findings include:Resident #1 (R1)Review of the Minimum Data Set (MDS) assessment, dated 11/19/2025, revealed R1 was initially admitted to the facility on [DATE] and was transferred to a short-term general hospital on [DATE].Review of R1's census data in the electronic medical record (EMR) revealed a hospitalization on 11/17/2025 and R1 returned to the facility on [DATE].The EMR for R1 revealed the following progress note:11/17/2025 at 7:00 a.m. CNA this morning had this writer come into resident's room to have a listen to her. Upon entering the room this writer could hear resident gargling and a wet cough. Vital signs taken BP-104/51, P-113, O2-84%, T-100.4, R-22. Resident was visibly shaking in bed. Resident then continued to have an emesis after coughing. O2 applied to resident at 2 liters . Resident taken to emergency room via stretcher .Review of R1's EMR revealed no evidence the facility provided R1 or their representative with written notification of the reason for transfer or information regarding the facility's policy for bed holds to correspond with the transfer and subsequent hospitalization on 11/17/2025. Resident #3 (R3)Review of the MDS assessment, dated 12/30/2025, revealed R3 was initially admitted to the facility on [DATE] and was transferred to a short-term general hospital on [DATE].Review of R3's census data in the EMR revealed a transfer to the hospital on [DATE] and R3 returned to the facility on [DATE].The EMR revealed the following progress note:11/28/2025 4:30 p.m. [physician] gives order to send to ER [emergency room], spoke with resident and she is agreeable to go to the ER .Review of R3's EMR revealed no evidence the facility provided R3 or their representative with written notification of the reason for transfer or information regarding the facility's policy for bed holds to correspond with the transfer and subsequent hospitalization on 11/28/2025.During an interview on 1/14/2026 at 11:13 a.m. the Director of Nursing (DON) was queried regarding the process of written notification of discharge and the facility bed hold policy upon transfer to the ER. The DON reported the Quality Nurses (charge nurses) on duty at the time of the transfer complete the written notifications and provide the forms to the resident or resident's representatives, along with a copy of the facility's bed hold policy.During an interview on 1/14/2026 at 12:15 p.m., Quality Registered Nurse (RN) E explained the process of written notification of transfer and discharge and the facility bed hold policy. RN E reported upon obtaining an order for transfer to the ER, the Quality Nurse or the nurse assigned to the resident's care, if the Quality Nurse was not available, completed the written notification of transfer or discharge form. RN E reported one copy of the notification was sent with the resident at the time of transfer and one copy was sent to medical records for inclusion in the medical record. During a record review at the time of the interview, RN E confirmed no written notification of transfer or evidence of receipt of the facility's bed hold policy could be located for R1's transfer on 11/17/2025 or R3's transfer on 11/28/2025. RN E reported the forms were generally scanned into the EMR within one to two days after the transfer.Review of the facility policy titled, Notice of Transfer-Discharge, effective 3/2025, revealed the following: The facility will permit each resident to remain in the facility and not transfer or discharge the resident from the facility; unless . 1. The facility notifies the resident and the resident's representative in writing and in a language and manner they understand with the reasons for the move at least 30 days prior to the transfer or discharge; and . 7. An immediate transfer or discharge is required by the resident's urgent medical needs . Note: If a resident is discharged based on any, or a combination of elements 4-8 above . the same notification in element 1 will be given as soon as practicable before transfer or discharge.

Based on observation, interview, and record review, the facility failed to meet the needs of a resident coping with verbal and physical abuse, provide emotional support from social services, obtain outside referral services, and develop and implement a comprehensive care plan for one Resident #5 (R5) of one resident reviewed for social services and referral services. This deficient practice resulted in harm which affected R5's psychosocial wellbeing with statements of physical and verbal abuse from her son and a verbalization of feeling scared.Based on observation, interview, and record review, the facility failed to meet the needs of a resident coping with verbal and physical abuse, provide emotional support from social services, obtain outside referral services, and develop and implement a comprehensive care plan for one Resident #5 (R5) of one resident reviewed for social services and referral services. This deficient practice resulted in harm which affected R5's psychosocial wellbeing with statements of physical and verbal abuse from her son and a verbalization of feeling scared.Findings include:Resident #5 (R5)A review of R5's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: anxiety disorder and depression. R5 scored 12 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of moderate cognitive impairment.During an interview and observation on 1/12/26 at 2:03 p.m., R5 reported My son hurt me when I lived with him in Tennessee.he punched my where my pacemaker is and it hurt (she pointed to her heart and flinched when she described how it hurt).he also stole $9,000 from me and he had to go to court because of it.he had to pay me back and he said if he every sees me again he is going to shoot me in my head (and pointed to the center of her forehead and used a facial tissue to wipe the tears from her eyes and blew her nose ).I can't believe my own son wants to kill me (resident wiped tears from her eyes and said I am sorry for crying).I am not lying to you, I have told the people here and nobody wants to listen to me or believes me (resident used a facial tissue to wipe her eyes and blew her nose).I just want to talk with someone.I hope I will be ok I am scared (she curled up and sat on the edge of her bed, it appeared she was trying to hide).During an interview on 1/13/26 at 3:19 p.m., Social Services A reported R5's son did punch her in her pacemaker near her heart. I did talk with her and her son did threaten to kill her if he ever saw her again.he was in town last week for his court date, but he didn't try to come in here.we do have a picture of him but we haven't put it out in the nurses station so staff know what he looks like.the Durable Power of Attorney (DPOA)/Legal Guardian does not want him to see her and we did not inform the staff or add that to the care plan.She has been pretty upset and I should have addressed it in her care plan and send a referral to psych services for emotional/behavioral assistance.she is on medication for anxiety and depression and I should have been monitoring her depression and anxiety.I should have monitored R5 more closely and put something in her plan of care but I was on vacation at the time R5 was admitted to the facility and didn't follow up.During an interview on 1/13/26 at 3:55 p.m., Quality Registered Nurse RN F reported that she completed the admission for R5 and remembered being told about the son hitting her and stealing form her.she also told me that she witnessed an accident and lost her favorite son traumatically.Review of Progress Notes dated 11/9/25 at 4:30 p.m., read in part Resident reported to Certified Nurse Aide (CNA) hat her son had stolen $9,000 from her and if he sees her again that he will put a bullet in her head.Review of Progress note dated 12/21/26 at 4:47 p.m., read I part . Res [Resident] comes out to listen to Christmas singers, no further reports of not feeling well, apologizes for what happen earlier and then starts talking about how her son wants to kill her. talking about how her son wants to kill her.Review of document titled Social Service Initial Assessment dated 11/14/25, read in part .Initial Care Conference Discussion Information: Mood/Behavior Concerns: [Resident name] has a diagnosis of depression and anxiety.5. Consult with Psych Nurse Practitioner (NP) yes [checked in box].Review of Social Services Notes did not address R5's statements of her son wanting to kill her or any referral for outside services.Review of document titled Job Description read in part .Position title: social worker.essential duties and responsibilities: Evaluates the patients [residents] social, emotional, spiritual, financial and environmental factors related to their illness response to treatment, and adjustment to care. Develops a social work treatment plan based on assessment and input from patient, family, and other disciplines involved in care. Collaborates with physician and other team members regarding significant social and emotional factors that affect the medical plan of care. Advocates and negotiates with healthcare team and community agencies for patient/family to receive needed care. Provides social work interventions to patient [resident] and family including counseling, education, crisis management patient centered decision making, advance directive, care planning.other duties and responsibilities.consults with agencies regarding patient needs and makes referrals as appropriate.assess patient.psychosocial status.identifying where additional counseling or specialized services or therapy is needed.Review of policy titled LTC Resident Care Planning last revised 9/25, read in part .A comprehensive plan of care (POC) shall be developed based on interdisciplinary team assessments, identifying the resident's needs, goals, and interventions. The POC shall include identified concerns/problems/needs, goals and objective of care, approach methods for care.The POC shall be reviewed and updated periodically.a comprehensive care plan shall be completed within 21 days of admission.care plans will be reviewed and updated quarterly and as needed.

Based on interview and record review, the facility failed to ensure timely review and follow-up for pharmacy recommendations for two Residents (#1 and #2) of five residents reviewed for unnecessary medications.Findings include:Resident #1 (R1)Review of the Minimum Data Set (MDS) assessment, dated 12/10/2025, revealed R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease, depression and adjustment disorder. Further review of the MDS assessment revealed R1 scored five out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident had severe cognitive impairment.Review of the June through December 2025 medication regimen reviews (MRRs) completed by the facility's consultant pharmacist and gleaned from the electronic medical record (EMR), revealed a pharmacist's Consultation Report, with a recommendation date of 6/06/2025. Further review of the Consultation Report, revealed the following: [R1] receives Abilify [antipsychotic medication] 15 mg [milligram] daily since Nov [November] 2022. There is only 1 behavior noted in progress notes over the past month. She is also taking Remeron [antidepressant medication] 15 mg nightly (increased in the hospital), Zoloft [antidepressant medication] 125 mg and Ingrezza [medication used to treat adverse effects of certain psychotropic medications] 40 mg for TD [tardive dyskinesia; adverse effects of antipsychotic medications including involuntary repetitive movements of the face and limbs]. Recommendation: Please attempt a gradual dose reduction (GDR) of Abilify to 12.5 mg daily .Further review of the pharmacist's Consultation Report, dated 6/06/2025, revealed the report contained a handwritten note, signed by Licensed Bachelor of Social Work (LBSW) A and dated 6/18/2025. Review of note made by LBSW A revealed the following: BMC [Behavior Management Committee] recommendation: Seven [sic] history of CNA [Certified Nursing Assistant] reported behaviors GDR is not recommended at this time.Continued review of the pharmacist's Consultation Report, revealed the physician addressed the pharmacist's recommendation as following: I decline the recommendation(s) . Pt. [patient] has continued with behaviors noted by CNA staff.It was noted during review, the physician signed and dated the recommendation as addressed on 9/18/2025, three months after the consultant pharmacist's and LBSW A made their recommendations.Resident #2 (R2)Review of the MDS assessment, dated 12/10/2025, revealed R2 was admitted to the facility on [DATE] and had diagnoses including renal insufficiency, diabetes, Alzheimer's Disease, anxiety, depression and bipolar disorder. Further review of the MDS assessment revealed R2 scored 9 out of 15 on the BIMS, indicating the Resident had moderate cognitive impairment.Review of the June through December 2025 MRRs completed by the facility's consultant pharmacist and gleaned from the EMR, revealed the following pharmacist's recommendations: [R2] started on Risperdal (risperidone; an antipsychotic medication) 0.5 mg daily on 2/5/2025. There are no behaviors noted and the behavior management committee states no mood or behaviors were observed . Recommendation: Please attempt his first gradual dose reduction (GDR) of risperidone to 0.25 mg daily.Further review of the pharmacist's Consultation Report, dated 6/06/2025, revealed the report contained a handwritten note, signed by LBSW A and dated 6/18/2025. Review of note made by LBSW A revealed the following: BMC recommendations: Previous GDRs resulted in suicidal ideation and actions . no GDR recommended at this time.Continued review of the pharmacist's Consultation Report, revealed the physician addressed the pharmacist's recommendation as following: I decline the recommendation(s) . pt [patient] stable at amt [amount].It was noted during review, the physician signed and dated the recommendation as addressed on 9/19/2025, three months after the consultant pharmacist's and LBSW A made their recommendations. A duplicate pharmacy Consultation Report was found in the EMR, dated 8/11/2025 with noted physician documentation declining the recommendation dated 9/02/2025.Further review of R2's MRRs revealed the following pharmacist's recommendations:9/04/2025: [R2] frequently requires Humalog [rapid-acting insulin] per sliding scale three times daily. He also takes Humalog 9 units with breakfast, 16 units with lunch and 14 units with supper and Jardiance [an oral medication to lower blood glucose] daily and Rybelsus [an oral medication used to lower blood glucose] and Lantus [long-acting insulin] 25 units daily. He uses 4 units or higher when he does receive sliding scale. Sliding scale insulin is on the BEERs list [list of medication potentially harmful to adults over [AGE] years of age] and should be avoided. Recommendation: Please re-evaluate his blood sugars and consider to increase his scheduled Humalog such as 11 units with breakfast, 18 units with lunch and 16 units with supper . Rationale for Recommendation: Prolonged use of sliding scale insulin is not recommended as it often results in wide variations in blood glucose, including prolonged periods of hyperglycemia [abnormally high glucose levels] or hypoglycemia [abnormally low glucose levels].It was noted the reviewing physician signed and dated the recommendation on 9/09/2025 as Declined with a rationale provided of Deferred to [Physician G]. The Consultation Report included no indication the recommendation was forwarded to Physician G or notated any type of follow-up to whether the recommendation was accepted or declined as deferred to Physician G.11/06/2025: Recommendation: Please re-evaluate his blood sugars and consider to increase his scheduled Humalog such as 13 units with breakfast, 20 units with lunch, and 16 units with supper . Rationale for Recommendation: Prolonged use of sliding scale insulin is not recommended as it often results in wide variations in blood glucose, including prolonged periods of hyperglycemia or hypoglycemia.It was noted the reviewing physician signed and dated the recommendation on 11/10/2025 as Declined with a rationale provided of please defer to [Physician G]. The Consultation Report included no indication the recommendation was forwarded to Physician G or notated any type of follow-up to whether the recommendation was accepted or declined as deferred to Physician G.Review of R2's active medication orders revealed the following:Humalog KwikPen 100 Unit/ML [milliliter], inject as per sliding scale before meals.Humalog KwikPen 100 Unit/ML, inject 11 units one time per day [breakfast], and inject 18 units one time per day [lunch] and inject 14 units one time per day [supper].During an interview on 1/14/2026 at 12:20 p.m., the DON was queried regarding the process for review of the pharmacist's monthly MRRs and follow-up to the consultant pharmacist's recommendations. The DON reported she receives the recommendations via email and distributes the Consultation Reports among the interdisciplinary team for follow-up. The DON reported recommendations related to psychotropic medications were given to LBSW A for inclusion of the behavior committee recommendation and LBSW A then forwards the Report to the attending physician for review and acceptance or declination of the recommendation. The DON confirmed LBSW A's written recommendation was only a note to the physician to guide in decision-making and did not replace the need for physician review. The DON stated she expected a one-week turnaround time for receipt of the physician's review to allow for the implementation of required changes or implementation of new orders, when indicated. The DON stated she was currently working on a new process to ensure tracking of the Consultation Reports to ensure timely review. During a record review at the time of the interview, the DON reported she was unsure if Physician G had received R2's pharmacy recommendations for changes to insulin therapy dated 9/04/2025 and 11/06/2025 but would investigate the matter and report back to the survey team.On 1/14/2025 at 3:15 p.m., the DON provided R2's progress notes from a visit with Physician G on 10/01/2025. The DON reported the note was found in the physician's office medical record and not in the facility EMR for R2. Review of the note revealed no indication Physician G had reviewed the pharmacist's recommendation issued prior to the visit on 9/04/2025, nor was documentation provided to indicate the pharmacist's recommendation dated 11/06/2025 had been forwarded to Physician G for review.On 1/14/2026 at 3:30 p.m. the Nursing Home Administrator (NHA) was asked to provide the facility policy for completion of the consultant pharmacist's MRRs and resulting recommendations. The NHA reported he did not believe the facility had a specific policy for completion of the MRRs.Review of the Pharmacy Products, Services and Consultant Agreement, provided by the NHA and dated 11/01/2024, revealed no language as to the facility's process or responsibility for review and follow-up to the consultant pharmacist's MRRs or resulting recommendations.

Based on interview and record review, the facility failed to implement an effective antibiotic stewardship program affecting one Resident (#29) of one resident reviewed for antibiotic use. This deficient practice resulted in the potential for the administration of unnecessary medication and antibiotic resistance.Findings include:Resident #29 (R29)Review of the Minimum Data Set (MDS) assessment, dated 11/11/2025, revealed R29 was admitted to the facility on [DATE] and had diagnoses including dementia and urinary tract infection (UTI).Review of R29's electronic medical record (EMR), accessed 1/12/2026, revealed the following active physician order:Bactrim (sulfamethoxazole-trimethoprim) Oral Tablet 400-80 MG [milligram]. Give one tablet by mouth in the morning for chronic UTI. Starte date: 2/08/2025.Review of R29's pharmacist Consultation Report, dated 7/03/2025, revealed the following: [R29] has received Bactrim 1 tablet daily for UTI prevention since 2-8-25. The order has a stop date of 1-14-26. She recently had a UTI and the sensitivity report showed that it was resistant to Bactrim, so she was started on Macrobid 100 mg bid [twice daily] x 5 days. If she is continuing to have UTIs and they are resistant, then is the Bactrim helping??? Recommendation: Please re-evaluate continued use of Bactrim daily and consider to discontinue or please state benefits if you wish to continue.Further review of the Consultation Report, dated 7/03/2025, revealed the attending physician checked the following: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below.It was noted the attending physician had written, Continue current dosing Bactrim [one daily], then signed and dated the recommendation on 7/16/2025. No further reason for continuing the Bactrim 400-80 mg daily was included in the rationale.It was also noted, a duplicate pharmacist Consultation Report, dated 7/03/2025, was found scanned into the EMR. The attending physician signed the recommendation as declined on 7/18/2025 with the following rationale provided: Continue daily Bactrim. No further reason for continuing the Bactrim 400-80 mg daily was included in the rationale.Review of laboratory results of R29's urine culture and sensitivity (C&S, test used to determine the identified organism's susceptibility to types of antibiotics), provided by the Director of Nursing (DON) and dated 6/30/2025, revealed the following: Culture: 100,000 COL/ML Escherichia Coli [e. coli] Abnormal. Susceptibility . Trimethoprim-Sulfamethoxazole [Bactrim] - Resistant.It was noted in review of R29's urine C&S revealed out of 14 types of antibiotics listed on the susceptibility chart, Bactrim was the only medication listed as resistant.During review of the facility's Antibiotic Stewardship program on 1/14/2025 at 3:00 p.m., the DON reported she was also the facility's current Infection Preventionist. The DON was asked if she could provide a rationale for the continued us of prophylactic Bactrim for R29. The DON reported she could not provide a rationale because she had not been provided with a reason by the physician. The DON was queried as to the risks associated with overuse of antibiotic medications and reported the major concern to be the growth of organisms resistant to the antibiotic being used. The DON was asked to provide the facility's Antibiotic Stewardship policy at the time of the interview. The DON reported that the Antibiotic Stewardship policy was included as part of the new draft of the Infection Prevention policy.Review of the facility policy titled, LTC Infection Prevention Committee, origination date 9/2023, revealed the following: Antimicrobial Stewardship: The goal of Antimicrobial Stewardship is to improve appropriate antimicrobial utilization in order to improve patient outcomes, minimize toxicity and the emergence of antimicrobial resistance .

Based on observation, interview and record review, the facility failed to ensure the residents right to be free from abuse for two Residents (R10 and R11) of four residents reviewed for sexual abuse, resulting in the potential for psychosocial harm including feelings of humiliation and fear based on a reasonable person standard. Findings include: Review of a facility five-day investigation summary, submitted to the State Agency (SA) on 2/23/2025 at 6:04 p.m., revealed the following: On 2/23/25, [R10] was sitting in the dining room across the table from [R11] when [CNA C] heard [R10] ask [R11] 'come here and come on, you want to touch it. [CNA C] witnessed [R10] with his penis pulled through the bottom of the left leg of his shorts in his hand. Review of the Minimum Data Set (MDS) assessment, dated 3/6/2025, revealed R10 was admitted to the facility on [DATE] and had diagnoses including anxiety, sleep disorder and dementia. Further review of the MDS assessment revealed R10 was independent for transfers and ambulation and scored 11 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he was cognitively intact. Review of the MDS assessment, dated 2/12/2025, revealed R11 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety and depression. Further review of the MDS assessment revealed R11 required partial/moderate assistance (helper does less than half the effort) with sit to stand and chair/bed to chair transfers and was independent with wheelchair mobility. R11 scored 00 out of 15 on the BIMS, indicating she had severe cognitive impairment. On 3/12/2025 at 10:15 a.m. R11 was observed lying in her bed, awake and holding a small stuffed animal. When greeted, R11 smiled. An interview at the time of the observation revealed R11 had no recollection of the reported event that occurred on 2/23/2025. On 3/12/2025 at 10:20 a.m., R10 was observed lying in his bed with his eyes closed. R10 was wearing black pants, a t-shirt and black athletic-type shoes. R10 did not respond to this Surveyor's knock on the door or verbal greeting. During a telephone interview on 3/12/2025 at 12:19 p.m., R10's legal guardian reported he did not want R10 to be interviewed again related to the alleged incident on 2/23/2025. R10's guardian reported R10 had a long-standing history of depression and he did not want to exacerbate the condition. R10's guardian reported asking the Resident if he exposed himself to R11 and asking her to touch his penis. R10's guarding stated R10 reply was I don't remember. and I won't do it again. During an interview on 3/12/2025 at 2:20 p.m., Certified Nursing Assistant (CNA) C reported witnessing R10 ask R11 to touch his exposed penis on 2/23/2025. CNA C reported R10 was seated across the table from R11 in the dining room. Upon turning around to retrieve a product from the refrigerator, CNA C stated, I heard [R10] say 'Hey come over here, you want to touch it?' CNA C reported upon turning back around to face the dining room, she witnessed R10 talking to R11 with his penis pulled through the leg of his shorts. CNA C reported R10 had his penis in his hand and was shaking it and R11 appeared confused and responded to R10 by stating huh? CNA C reported upon approaching R10, he ceased the activity, placed his penis back inside the leg of his shorts without any redirection like he knew it was wrong. CNA C was queried as to whether R10 had exhibited sexual behaviors toward others in the past. CNA C reported she was aware R10 had a past incident with another resident in the facility which the State Agency had been in to investigate. CNA C was unaware of the prior incident involving R11 on 1/19/2025. CNA C stated, I should have known something was up. When asked what she meant, CNA C reported R10 was out of his usual routine on 2/23/2025 and stated, I noticed [R10] at a table he normally does not sit at. When asked to clarify, CNA C reported on 2/23/2025 R10 entered the dining room at a time out of his normal routine and sat at a table of female residents, which he never did, and was acting sneaky. CNA C stated staff recognized the risk and removed some of the ladies from the dining area. According to CNA C, R10 had a history of watching pornography and masturbating in public areas of the facility. When asked why R10 was not redirected from the dining room if his behavior was suspicious, CNA C reported she thought R10's prior behaviors were only directed toward a specific resident, who had already been removed from the dining area and away from R10. Review of an incident report, provided by the Director of Nursing (DON) and dated 1/19/2025 at 11:55 p.m., revealed the following: This nurse went to check where [R10] was as he had recently been sitting in the dining room . went around the hallway towards the large bathroom. [R10's) one hand was on a female resident's shoulder and what appeared to be pulling down his shorts. This nurse immediately asked what he was doing, and he quickly adjusted his shorts and went to his bedroom . Further review of the incident report revealed R10 to be in the large bathroom with R11. During an interview on 3/13/2025 at 9:33 a.m., Registered Nurse (RN) D recalled working on 2/23/2025 and being informed by staff of R10's presence in the dining room. RN D reported she was aware R10 had a history of inappropriate sexual behavior but understood the behavior to be directed toward a specific resident, whom staff had removed from the dining room upon R10's entry. When asked if she was aware R10 had a history of sexual behaviors directed toward other residents, RN D reported she was aware of R10's prior behavior of exposing himself in public areas within the facility but was unaware of any incident involving R11 until after the incident on 2/23/2025. Review of a physician encounter note, dated 11/20/2024 at 2:08 p.m., revealed the following: GDR [gradual dose reduction] paxil [anti-depressant medication] from 30 mg [milligrams] to 20 mg for depression/anxiety and associated symptoms with intent to continue monitoring symptoms . Continue non-pharm [pharmacological] interventions might also include: Avoiding over stimulation of TV or radio programs, radios, magazines; involve crafts that occupy his hands to help prevent inappropriate touching or public masturbation, providing stuffed animal such as replica of the pink [NAME] where he is able to fondle the puppet rather than others; provide clothing that lacks zippers . scheduled times for providing privacy in satisfying patient's own sexual drive. During an interview on 3/13/2025 at 10:50 a.m., Social Worker (SW) F reported she had worked with R10 since his admission to the facility. When asked when R10's inappropriate sexual behaviors began, SW F reported R10's behaviors had been present since admission but seemed to worsen at times when R10 was depressed or bored. SW F reported R10 had a dose reduction of his antidepressant medication in December 2024 which she believed contributed to R10's increase in inappropriate sexual behaviors. When asked if R10 was provided with non-pharmacological interventions to deter inappropriate sexual behaviors, SW F reported R10 was provided with pornographic materials to view in the privacy of his own room. SW F stated R10 would not engage in the viewing of the materials in his room but proceeded to view the materials and masturbate in public areas of the facility including the dining room in view of other residents, which was inappropriate. SW F reported R11 did not recall the incident on 2/23/25 and showed no change in her behavior since the incident. Review of R10's Psychiatric Outpatient Evaluation, dated 2/25/2025, revealed the following: The patient's recent concerning behaviors are discussed with him. He reports he has been told by staff that he exposed himself to another female peer on the unit. He does not recall the event. When asked if he felt this was appropriate or inappropriate, he states that it was inappropriate. During an interview on 3/13/2025 at 11:45 a.m., the Nursing Home Administrator (NHA) confirmed R10 was known to have exhibited sexually inappropriate behaviors, including coercion and public sexual acts in the facility prior to the event involving R11 on 2/23/2025. When asked if staff should have anticipated the incident on 2/23/2025 due to the prior incident in which R10 was found in the large bathroom with R11 on 1/19/2025, the NHA did not offer a response and stated, it seems the dining room is a trigger for his behavior. Review of R10's care plan revealed the following: [R10] is at risk and/or has behaviors . making sexually inappropriate statements to staff . engaging in sexual actions in public area of facility [with] other residents . increased social/behavioral disinhibitions because of cognitive loss . [R10] lacks the capacity to make choices regarding sexual activity due to appointment of guardianship. Date initiated, 4/01/2024. Interventions: Provide intervention and redirection when [R10] is attempting or engaging residents where he is displaying inappropriate actions for public areas. Date initiated, 4/01/2024. The care plan had nothing to address preventing the behaviors from occurring in the first place. The focus was on a previous resident R10 had an inappropriate interaction with, and failed to address other potential victims in prevention of further sexual abuse potential. Review of R11's care plan revealed the following: [R11] has a behavior problem of invading others personal space, not easily redirected/physical aggression [with] staff . and other residents during incidental contact . Date initiated, 4/01/2024. It was noted in review of R11's care plan, there were no foci, goals or interventions developed and implemented to reduce the likelihood of R11 being exposed to R10's sexually inappropriate behaviors or to alert staff of the incidents that occurred between R10 and R11 on 1/19/2025 and 3/23/2025. Review of the undated facility policy titled, [Facility Name] Abuse Prevention, revealed the following: Purpose: To protect the resident's right to be free from verbal, sexual, physical and psychological abuse . Prevention: The facility will provide supervision of staff and residents to the fullest extent possible . Protect: Responding immediately to protect the alleged victim .

This citation pertains to intake MI00150095. Based on observation, interview and record review, the facility failed to follow care planned interventions to ensure staff performed safe transfers for two Residents (#1 and #3) of four residents reviewed. This deficient practice resulted in actual harm when Resident #1 experienced a fall resulting in a right femur fracture and subsequently required surgical intervention and pain. Findings include: Resident #1 (R1) Review of a Witnessed Fall, report, provided by the Director of Nursing (DON) and dated 1/29/2025 at 5:41 p.m., revealed the following: Resident [R1] was ambulating x 1 CNA [Certified Nursing Assistant] assist to toilet when legs became weak, and the resident was lowered to the ground with a gait-belt . Immediately post lowering the resident complained of right leg pain. RLE [right lower extremity] appeared to be shortened and foot inverted . did [complain of] right leg/thigh pain .The resident was assisted with a transfer sheet onto a stretcher and immediately transferred to the ED [emergency department]. Review of R1's Emergency Department Evaluation Note, dated 1/29/2025 at 5:00 p.m., revealed the following: Patient [R1] . from our long-term care facility that presents following a fall from standing . Reports landing and hitting her right hip on the ground . Reporting pain 10 out of 10. Patient was noted to have shortening and internal right rotation of her right lower extremity . preliminary bedside read of right knee x-ray revealed a distal femur spiral fracture [fracture of the distal thigh bone resulting from a twisting motion] . Review of R1's x-ray report, dated 1/29/2025 at 8:11 p.m., revealed R1 had a comminuted [broken in at least two places], displaced fracture of the distal femur. Review of R1's hospital Procedure Note, provided by the DON, dated 1/30/2025, revealed R1 underwent right distal femur open reduction internal fixation (surgical procedure to place an implant to stabilize broken bones) on 1/30/2025 at 3:12 p.m. Review of the facility incident investigation summary submitted to the State Agency (SA) on 2/6/2025 at 4:43 p.m., revealed the following: The facility investigation concludes that [CNA C] . transferred [R1] as a one-assist while [R1] was care planned as a two-assist transfer . Review of the most recent quarterly Minimum Data Set (MDS) assessment, dated 1/9/2025, revealed R1 was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease (COPD) and dementia. Further review of the MDS revealed R1 had severe cognitive impairment and required substantial/maximal assistance (helper does more than half the effort) for sit to stand, chair/bed-to-chair and toilet transfers (the ability to get on and off a toilet or commode). On 2/19/2025 at 11:15 a.m., R1 was observed seated in a wheelchair at a table in the dining room. R1's right leg was elevated and resting on a leg rest while her left leg was in a dependent position with her left foot resting on the left foot pedal. During a telephone interview on 2/19/2025 at 2:20 p.m., CNA C recalled R1's fall on 1/29/2025. CNA C stated she was assisting R1 to the bathroom by positioning R1, seated in a wheelchair, between the entrance to R1's room and the bathroom doorway. CNA C stated she placed a gait belt around R1's upper abdomen and assisted the R1 to take a couple steps into bathroom from the chair and then assisted R1 to pivot into position in front of the toilet. While turning to position R1 in front of the toilet, R1 began calling out I'm falling. CNA C stated R1 was facing the doorway, with the toilet to R1's right side, when R1 began to fall. CNA C reported she was standing in front of R1 at that time and using one hand to grip the gait belt and her other hand to grasp the waistband of R1's pants, and lowered R1 to the ground at which time R1 reported pain in her right leg. When asked what position R1's right leg was in after the fall, CNA C stated she [R1] was sitting on it. CNAC stated no other staff were present to assist her in transferring R1 to the toilet. When asked what R1's transfer was in accordance with R1's comprehensive care plan, CNA C reported the care planned interventions were posted on the inside of R1's closet but she did not check R1's care plan prior to the attempt to transfer R1 to the toilet on 1/29/2025. CNA C stated, I had seen the resident transferred a million times with only one-person assistance, so I thought it [R1's transfer status] hadn't changed. Review of R1's care plan revealed the following, in part: [R1] has an ADL [activities of daily living] self-care performance deficit [related to] dementia, limited mobility, pain to her lower back . Interventions: Two assist with gait belt and wheeled walker, able to bear full weight but uses two people to enable the standing position, Date Initiated: 9/24/2025, Resolved: 2/05/2025 . Toilet Use: [R1] requires assistance by 2 staff for toileting, Date Initiated: 5/02/2024. Further review of R1's care plan revealed: [R1] is at risk for falls related to unsteady gait, weakness, poly-pharmacy and evidenced by unable to walk or transfers without assistance, Date Initiated: 4/01/2024 . During an interview on 2/19/2025 at 4:00 p.m., the DON confirmed the facility investigation determined the root cause of R1's fall on 1/29/2025 was staff failure to follow R1's comprehensive care plan related to R1's transfer status. The DON reported CNA C attempted to transfer R1 alone when R1 was care planned for two-person assistance for toileting. The DON reported staff should follow the resident-specific interventions related to transfer status to ensure resident safety. When asked how staff know what each resident's transfer status was, the DON stated individual care plan reports are posted inside each resident's closet for easy reference by staff. Resident #3 (R3) Review of the MDS assessment, dated 2/19/2025, revealed R3 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety and a history of repeated falls. Further review of the assessment revealed R3 had severe cognitive impairment and required substantial/maximal assistance (helper does more than half the effort) for sit to stand, chair/bed-to-chair and toilet transfers (the ability to get on and off a toilet or commode). Review of R3's care plan on 2/19/2025 at 10:58 a.m. revealed the following: [R3] has an ADL self-care performance deficit [related to] cognitive, loss, weakness, history of pelvic fracture . Date Initiated: 5/03/2024 . Transfers: [R3] requires assistance by 2 staff to transfer with the [sit-to-stand] lift (yellow sling). Date Initiated. 5/23/2024. Revision on 2/12/2025. On 2/19/2025 at 1:24 p.m., R3 was observed being transferred from a wheelchair to the toilet by CNA D and Registered Nurse (RN) A using a sit-to-stand mechanical lift. CNA D fastened a green trimmed lift sling around R3's torso and attached the sling to the lift. RN A instructed R3 to hold the hand grips as CNA D began to lift the resident from the wheelchair. R3 was observed unable to place her feet flat on the base of the lift to allow her to stabilize her position on the lift. CNA D lowered R3 back down to a seated position in the wheelchair and reported R3 was not appropriate to use the sit-to-stand mechanical lift due to R3's inability to place her feet flat on the base of the lift for stability. CNA D stated R3 would be transferred to the bed for care delivery. RN A was observed securing a gait belt around R3's upper abdomen. Seated in the wheelchair, R3 was positioned next to her bed and RN A stood on R3's left side while CNA D stood in front of R3 as they pulled R3 to standing and pivoted the Resident to a seated position on the bed. Immediately following the observation, the care plan report attached inside of the door of R3's closet was reviewed with CNA D and RN A. Upon review of the care plan, CNA D reported R3 was care planned for two-person assist with the [NAME]-lift [sit-to-stand lift] using a yellow sling. CNA D reported the yellow sling was broken therefore they had to use green because there were no other slings available for use. The care plan revealed no intervention indicating R3 could be transferred with a gait belt and two-person assist if R3 was unable to use sit-to-stand lift to transfer. CNA D stated R3 was hit and miss with her transfer ability and because she knew R3, she felt the R3t was appropriate to transfer with a gait belt and two-person assistance. When asked if facility policy allowed for staff to use a lesser means of transfer when Resident's failed at the care planned transfer status, RN A stated she was unsure of what was acceptable according to facility policy. CNA D reported R3's transfer status changed, and staff are not alerted when changes to care plans were made. CNA D stated staff must check for changes by checking the care plans daily. During an interview on 2/19/2025 at 2:38 p.m., Physical Therapist (PT) G reported R3 was recently referred for evaluation due to staff concerns R3 could not always transfer safely with just the use of a gait belt and staff assistance. PT G confirmed R3's transfer status was changed to a two-person assist with the sit-to-stand mechanical lift. When asked if it was appropriate for staff to utilize a lesser means of assistance without further evaluation, PT G stated staff should obtain a therapy evaluation to ensure residents are safe to use less assistance. During an interview on 2/19/2024 at 4:00 p.m., the Director of Nursing (DON) reported the facility did not have a policy related to safe, staff-assisted transfers. The DON stated the facility was in the process of reviewing policies for relevance to the long-term care setting and would be considering a policy related to staff-assisted transfers. A review of the National Institute of Health (NIH) National Library of Medicine guidelines located at https://www.ncbi.nlm.nih.gov/books/NBK564305/, accessed on 3/3/25, regarding patient/resident safety for transfer from a bed to a wheelchair read as follows: Transferring patients from a bed to a wheelchair requires understanding the patient's needs. Always communicate with the person being transferred so that assistance is given at the appropriate time, allowing for coordination between the assistant and the patient. A one-person assist may be performed if the patient can bear weight on both lower extremities and predictably take small steps. If these criteria are not met, a 2-person transfer or a mechanical lift may be necessary to transfer the patient safely . This would indicate a more supportive transfer assistance would be more appropriate in the above observation of R3 and not a less supportive transfer.

This citation pertains to MI00149861 Based on interview and record review, the facility failed to notify the state agency of a resident-to-resident sexual abuse allegation to the state agency for two Residents (#1 and #3) of four Residents reviewed for abuse. This deficient practice resulted in the potential for sexual abuse abuse. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: dementia and depression. R1 scored a 9 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of moderate cognitive impairment. Resident #3 (R3) Review of R3's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: dementia, anxiety disorder, and depression. R3 scored a 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Review of R1's behavior note dated 1/18/25 at 15:45 revealed R1 was sitting next to R3 in the dining room, and R3 was holding onto R1's exposed penis. During an interview on 1/30/25 at 3:27 p.m., Registered Nurse (RN) C confirmed that Certified Nurse Aide (CNA) D reported that R1 was holding R3's penis in the dining room and that the incident was documented by RN C and reported to the Director of Nursing (DON). During a phone interview on 1/30/25 at 3:45 p.m., CNA D stated, I saw R1 and R3 sitting close to one another in the dining room and when I walked by I saw R3 holding onto R1's penis .R1 asked R3 to grip onto it harder .I took R3 away from the dining room and reported it to RN C right away and she called the DON . During an interview on 1/30/25 at 12:19 p.m., the Nursing Home Administrator (NHA) acknowledged the incident was not reported to the State Agency (SA). During an interview on 1/31/25 at 7:37 a.m., the DON stated the incident on the 18th was not investigated and the incident was not reported to the SA. Review of Facility policy titled LTC (Long Term Care) Resident Abuse, Neglect or Mistreatment last reviewed 1/25, read in part .The Administrator or designee will report to the state officials, as designate by law and investigate all allegations .the Administrator or designee ill contact state and law enforcement within .24 hours of all allegations and will complete the investigation within 5 days .The results of the investigation shall be reported to official (State and Federal agencies) in accordance with State and Federal law and within five working days .

This citation pertains to MI00149861 Based on interview and record review, the facility failed to ensure care plans were updated promptly and revised appropriately for two Residents (#1 and #3) of four residents reviewed for care plans. This deficient practice resulted in care plans which did not reflect resident needs. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: dementia and depression. R1 scored a 9 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of moderate cognitive impairment. Resident #3 (R3) Review of R3's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: dementia, anxiety disorder, and depression. R3 scored a 3 of 15 on the BIMS assessment reflective of severe cognitive impairment. Review of R1's behavior note dated 1/18/25 at 15:45 revealed R1 was sitting next to R3 in the dining room, and R3 was holding onto R1's exposed penis. Review of the care plan's for R1 and R3 did not reveal an updated revision or intervention to mitigate the resident-to-resident altercation in the dining room. During an interview on 1/31/25 at 9:11 a.m., The Director of Nursing (DON) was asked about updating the residents care plan to mitigate the resident-to-resident altercation and the DON said the care plans were not updated, reviewed, or revised after the incident and indicated the facility normally revises the care plan after each incident. Review of facility policy titled LTC (Long Term Care) Resident Care Planning last revised 9/23, read in part, .The care plan shall be implements with documentation in the resident's clinical record. Evaluation of the results of the planned care or intervention shall be documents in the residents clinical record. The care plan shall be reviewed and elements of care evaluated periodically as necessary to reflect the resident's condition .a resident care conference shall be held periodically .to evaluate the residents needs and to provide for the appropriate revision of the resident care plan .

This Citation Pertains to Intake Number MI00149462. Based on interview and record review the facility failed to ensure a complete and thorough investigation was completed on an incident of potential abuse involving two Residents (#30 and #31) out of three Residents reviewed for abuse. This deficient practice resulted in the potential for undetected abuse. Findings include: Resident #30 (R30)/Resident #31 (R31) A Facility Reported Incident (FRI) was received on 1/1/25 at 7:45 PM, which read in part: Incident Summary Registered Nurse (RN E) reported to NHA (Nursing Home Administrator) . witness and Resident Assistant (RA D) reported . she heard (R31) ask (R30) to touch him on the groin. (R30) subsequently placed her hand on (R31's) groin. Residents were immediately separated . On 1/16/25 at 1:25 PM, the NHA and this surveyor viewed the dining room video of the incident between R30 and R31. The residents involved in the FRI were present in the video but were seated at a far distance from the camera. No sound was recorded. R30 does lean in and is visibly closer to R31 several times but her hand is not visible nor is the lap of R30. She does not wheel away or appear to take offense. At least three other residents were seated in the dining room closer to the camera and several people move in and out of the camera view during the timeframe of the FRI from 2:43 PM until 3:06 PM on 1/1/25. The witness, RA D, was seen in the video entering the dining room and working serving beverages at 2:51 PM. At 3:06 PM, RN E came into the dining room and wheeled R30 out of the room. During an interview on 1/16/25 at 1:35 PM, the NHA was asked about the investigation into the FRI. The investigation folder was reviewed and did not contain any witness statements from RA D or RN E who separated R30 and R31 and did not contain an incident report with details of the event. The other residents and those seated or walking through the dining room during the 23 minutes R30 and R31 were seated together were not interviewed. Other staff working that shift who may have had observations were not interviewed and no statements were obtained. When asked why the hospitality aide had not separated R30 and R31 but instead left the dining room to get a nurse, the NHA did not know. When asked if there had been an incident report completed as part of the electronic medical record the answer was no. When asked if any witness statements had been taken the answer was no. The facility policy titled LTC (Long Term Care) Abuse, Neglect or Mistreatment, last reviewed 01/2025 read in part: .Resident's care and treatments shall be monitored by all staff, on an ongoing basis, to assure residents are free from abuse, neglect or mistreatment. It is the responsibility of the staff to provide a safe environment for the residents. Allegations of resident abuse, neglect, or misappropriation of property or mistreatment will be reported to the LTC Administrator at which time the LTC Administrator can delegate to the Director of Nursing or designee. The delegated person will thoroughly investigate . 6. An incident report will be completed .9. Results of the investigation shall be reported to officials . The report shall include: i. Witness statements; j. A list of people in the area at the time of the incident:

Based on interview and record review, the facility failed to ensure that a Quality Assurance and Performance Improvement (QAPI) program committee was composed of the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues placing all 35 residents of the facility at risk for quality care concerns. Findings include: During an interview on 12/4/24 at 3:10 PM, the Nursing Home Administrator (NHA) stated the QAPI committee previously met quarterly and now met monthly. The NHA reviewed the Long Term Care (LTC) QAPI Sign In or meeting attendance records for the required members and identified the following: - On 2/15/24 the QAPI meeting included the NHA, the Director of Nursing (DON), the Medical Director, the Infection Preventionist (IP), plus 3 other members. - The next record of a QAPI meeting was not until 6/20/24 which included the NHA, the DON, the IP, plus 5 other members. The Medical Director was not in attendance. - On 7/18/24 the QAPI meeting was held and included, the DON, the IP, plus 4 other members. The Medical Director and the NHA were not in attendance. - On 8/15/24 the QAPI meeting was held and included the required members. - On 9/19/24 the QAPI meeting was held and included the NHA, the DON/IP, plus 3 other members. The Medical Director was not in attendance. - On 10/17/24 the QAPI meeting was held and included the NHA, the DON/IP, plus 3 other members. The Medical Director was not in attendance. - On 11/14/24 the QAPI meeting was held and included the required members. The facility policy Quality Assurance Performance Improvement Program - LTC was dated as last revised 9/2023 and read in part, QAPI members required at each meeting include: LTC Medical Director, Director of Nursing, Member of Management, three other employees, minimum. The policy did not include the requirement of the infection preventionist attending the QAPI meetings.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to ensure that food items were kept free from contamination due to improper storage or due to potential thawing and refreezing. B. Failing to properly clean and sanitize dishes and utensils. C. Failing to ensure food preparation surfaces in the dietary department were properly sanitized. D. Failing to ensure that food items were dated and discarded on or before the expiration date. This deficient practice had the potential to result in food borne illness among any or all 35 residents in the facility. Findings include: During a tour of the kitchen with Registered Dietitian (RD) A on [DATE] at 10:00 AM, a walk-in freezer (#2) had no internal thermometer and large chunks of ice had formed on the floor of the freezer under the condenser. RD A stated there was a work order to look at this problem. There was evidence of ice cascades on food product under the condenser. RD A stated this condition was not optimum and said, The (food) product is not protected. The temperature log for freezer #2 was reviewed for the month of November and was found to have 8 days with no temperatures recorded. The tour continued and the back walk-in freezer (#5) also had no internal thermometer and had a large chunk of ice formed on the ceiling and ice on the floor. A steam table pan of uncovered cooked rice was on a cart directly under the condenser. The cart had a frozen puddle of clear liquid on the top shelf next to the open rice pan. Another cart was observed in this freezer (#5) with 6 small, uncovered steam table pans of marinara sauce and 6 small, uncovered steam table pans of chili on its top shelf. The temperature log for freezer #5 was reviewed for the month of November and was found to have 9 days with incomplete documentation and 8 days with no temperatures recorded . With the presence of ice cascades and freezer temperatures not being consistently monitored for safety, it could not be concluded the food had not had periods of thawing. The tour continued and observations were made of the three-compartment sink which was operational with all three sinks filled and being used to wash, rinse and sanitize food contact surfaces of utensils, pans, and lids. An interview to determine the procedure for testing the sanitizing chemicals was conducted at this time with dietary Staff B. A demonstration by Staff B using a QT40 (sanitizer level) test strip held in the sanitizing solution for 10 seconds took place. The strip was compared to the dispenser and had a color corresponding to 0 ppm (parts per million) signifying no sanitizer was present in the sink. Staff B indicated the test strip should be 200 ppm. RD A was also present. Staff B tested the solution twice and then opened a spool of new test strips, but all test strips registered zero ppm. The sanitizing bucket used to sanitize food preparation surfaces was observed on the counter with cleansing cloths floating in the solution. This bucket was tested and registered 0 ppm indicating sanitizer was not present. During a tour of the Long Term Care satellite kitchen on [DATE] at 10:23 AM, the service area reach-in freezer was observed to contain: - Unlabeled, open to air, meat patties without a date of preparation or a use by date - An unsealed plastic bag labeled beef hot dogs dated ,d+[DATE], open to air - Omelets with unreadable marking on the plastic bag without a use by date - Unlabeled potato patties with unreadable marking on the plastic bag. On [DATE] at 11:08 AM, the Director of Nursing (DON) observed the above food items in the freezer and said Yes I can't tell the dates. I will alert dietary. On [DATE] at 10:42 AM, the dietary walk-in freezer #5 continued to have ice remaining on the floor and on food packaging. Items under the condenser had evidence of ice on the outer packaging including pita bread with a hole ripped in the top of the package. Walk-in freezer #2 also continued to have ice remaining on the floor and contained a foil steam table pan labeled chopped steak ,d+[DATE] which was observed open to air and was located under the condenser unprotected. The facility policy titled Floor Supplies/Nursing Pantries/Food from an Outside Source Policy dated as last revised ,d+[DATE] read in part: .All perishable and nonperishable items .delivered to the floor are labeled and have an expiration date, after which the item is to be removed and discarded .Expired, out-of-date, opened or uncovered, unlabeled and improperly stored items are discarded .Temperatures of patient refrigerators are recorded daily by food service staff on a refrigerator log . The FDA Food Code 2017 States: - ,d+[DATE].11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; - ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO_EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C [Celsius] (41 F [Fahrenheit]) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 - ,d+[DATE].11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts ,d+[DATE] - ,d+[DATE].14 Wiping Cloths, Use Limitation. (A) Cloths in-use for wiping FOOD spills from TABLEWARE and carry-out containers that occur as FOOD is being served shall be: (1) Maintained dry; and (2) Used for no other purpose. (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under S ,d+[DATE].114; - ,d+[DATE].114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness. A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under ,d+[DATE].11(C) shall meet the criteria specified under S,d+[DATE].11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, P and shall be used as follows: .C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24 C (75 F), P (2) Have a concentration as specified under S ,d+[DATE].11 and as indicated by the manufacturer's use directions included in the labeling, P and (3) Be used only in water with 500 MG [milligrams]/L ([liter] hardness or less or in water having a hardness no greater than specified by the EPA-registered label use instructions; - ,d+[DATE].11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.

Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for four Residents (#26, #23, #3, and #24) of 6 residents reviewed for dining assistive devices. This deficient practice resulted in increased difficulty with food consumption and independent eating, as well as the potential for decreased food/fluid intake and risk for weight loss. Findings include: Resident #26 (R26) On 12/2/24 at 12:21 PM, R26 was eating lunch in the facility dining room and was observed with regular utensils including a knife, fork, and spoon. R26's meal tray card included Adaptive Equip: No Knives/cut food as needed for resident. Certified Nurse Aide (CNA) K approached the resident and removed the knife without explanation. When questioned CNA K was not sure why the resident could not have knives. A review of the electronic medical record (EMR) for R26 revealed a care plan including a focus of: The resident has potential nutritional problem r/t (related to): Medical/Physical conditions -Dementia dx (diagnosis); has confusion/memory deficits. May have decreased interest in food, appetite changes, and/or changes in food preferences. May struggle to recognize food/beverages, and/or be unsure how to feed self. Care Plan approaches included:*Adaptive equipment/modifications: -No knives; all food in bite-size pieces.*Assist needed for meals/snacks: Usually independent; may need set-up assist & supervision at times .Date Initiated: 04/01/2024 Revision on: 11/25/2024 Resident #23 (R23) On 12/3/24 at 8:40 AM, R23 was observed eating breakfast on a regular plate and was eating unassisted with her fingers. R23's meal tray card included instructions for: Adaptive Equip: . Divided plate . CNA D stated R23 did well attempting to feed herself and said a divided plate helped her. The care plan for R23 included a focus of: The resident has potential nutritional problem r/t: *Medical conditions -Dementia; has frequent confusion and memory deficits; may have decreased interest in food, appetite changes, and/or changes in food preferences. May be unsure how to feed self .*Diet:-Poor appetite at times. *Weight:-Hx (history) of significant weight loss .Date Initiated: 04/01/2024 Revision on: 11/18/2024. The care plan approaches included: Offer to make meal into a sandwich; resident prefers finger food . Date Initiated: 04/01/2024 Revision on: 11/18/2024 Resident #3 (R3) On 12/4/24 at 12:41 PM, R3 was eating her lunch in the dining room. Her meal included two coffee cups and water in a Styrofoam cup. All beverages were uncovered. There was a lid sitting on the table. The meal tray card for R3 included instructions of: Adaptive Equip: Cup w (with)/lid (with lid) . CNA D said the tray card has instructions that lids were needed and they should have been on the beverages. The care plan for R3 included a focus of: The resident has potential nutritional problem r/t: Medical/Physical conditions -Dementia and hx of traumatic brain injury; has confusion & memory deficits .Intake: -Hx of poor frequent poor appetite . Date Initiated: 04/01/2024 Revision on: 10/15/2024 The care plan approaches included: .Adaptive Equipment/Modifications: -All beverages in cup w/lid . Date Initiated: 04/01/2024 Revision on: 10/15/2024 Resident #24 (R24) On 12/4/24 at approximately 1:00 PM, R24 was observed eating lunch in her room. R24 had a small plastic fork as her only utensil. R24 stated, I can't eat that well with a plastic fork and I really need a spoon for my dessert. The meal tray card did not indicate plastic utensils were needed for R24. During an interview in the serving area on 12/4/24 at approximately 1:10 PM, Dietary Staff E and CNA D were asked about R24's utensils and stated, We ran out of forks. They only could find a soup spoon left to deliver to R24. The staff members stated they gave out plastic forks to approximately 6-8 of the last trays served.

Based on observation, interview and record review, the facility failed to ensure appropriate feeding assistance for one Resident (#20) of one resident reviewed for nutrition, resulting in the potential for decreased intake and weight loss. Findings include: Resident #20 (R20) A review of R20's Minimum Data Set (MDS) assessment, dated 11/6/2024 revealed R20 was admitted to the facility on [DATE] and had diagnoses including dementia and arthritis. Further review of the MDS assessment revealed R20 had severe cognitive impairment. Review of R20's, Medical Nutrition Therapy Assessment, completed by Certified Dietary Manager (CDM) C on 11/11/2024 at 2:49 p.m. revealed R20 had a history of weight loss/underweight BMI [body mass index]. Further review of the Assessment reviewed the following: . verbal reports from CNA [certified nursing assistant] and NSG [nursing] indicate signs resident may need increased cueing and assistance [related to] gradual cognitive decline and increased dexterity/pain [related to] rheumatoid arthritis . Staff advised to encourage resident to dine in MDR [main dining room] for increased monitoring, cueing, and assistance when needed. Review of R20's care plan revealed the following: The resident has potential nutritional problem [related to]: cachexia [weight and muscle loss] . chronic poor intake . [history] of weight loss . Interventions: Assist needed for meals/snacks: At minimum needs set up assist + [plus] supervision [due to] food hoarding tendencies and/or disposing of food in inappropriate places. Due to progressing arthritis and cognitive decline, may need cuing and limited assist at times . encourage resident to dine in MDR to better monitor for increase assistance needs . Encourage intake and all nutritional interventions in place. On 12/2/2024 at 12:57 p.m., an unidentified staff person was observed delivering R20's noon meal tray to the Resident's room. R20 was observed in the room, sleeping in her wheelchair. Upon setting the meal tray down, two foam cups with lids and two unopened straws atop the over bed table were positioned approximately three feet from where R20 was sleeping, the unidentified assistant left the room and R20 remained sleeping. Further observation at 1:08 p.m. revealed R20 still asleep in her wheelchair and her meal untouched with the unopened straws resting on the over bed table near the two foam cups filled with liquids. An observation of the tray card on R20s meal tray revealed the following: Alerts: encourage eating in MDR for [greater] assistance. Needs cueing [and] assist during meals. On 12/2/2024 at 1:23 p.m., R20 was observed awake, still seated in her wheelchair approximately three feet from the over bed table and meal tray. R20 was pleasantly confused and when asked if she was going to eat her meal she stated, I'm going to try. Upon exiting R20's room, two unidentified staff members were observed approaching R20's doorway, and from the hallway, asked R20 if she was finished with her meal to which R20 was heard replying, I haven't even started yet. The two staff members told R20 they would check back later and then left R20s doorway and continued down the hall. Further observation on 12/2/2024 at 1:50 p.m. revealed R20 seated in a wheelchair in her room with the meal tray still atop her over bed table with all food remaining untouched and the drinks still covered and without the straws inserted. The two straws remained unopened and sitting on the table next to the drinks. At that time, CNA H and CNA I entered R20's doorway and asked R20 if she was finished with her meal. R20 responded I haven't even started. Neither CNA H or CNA I entered R20's room to provide cueing or assist with her meal before leaving the doorway and continuing down the hall. On 12/4/24 at 9:03 a.m., R20 was observed sitting in her bed. A plate with one-half slice of toast, a full bowl of sausage pieces and a full bowl of scrambled eggs were positioned in front of R20 on an over bed table. Both the sausage and the eggs appeared untouched. When asked if she was going eat her meal, R20 responded, oh, I don't know. There were no staff present in R20's room at the time of the observation. During an interview on 12/4/24 at 2:02 p.m., CDM C reported R20's progressive dementia puts her at risk of decreased dietary intake and weight loss. CDM C confirmed R20 required cueing and assistance with meals and stated she was unaware R20 was not receiving assistance with meals when the Resident was served in her room. CDM C reported R20's dietary intake improved greatly with assistance and cueing. CDM C stated R20 had cognitive decline and difficulty with arthritis in her hands which made eating difficult at times. Review of the facility policy titled, Feeding the Resident on Long Term Care, last revised 9/2023, revealed the following: Purpose: To assist the patient/resident who is physically, medically or cognitively unable to feed themselves. Further review of the policy revealed no language or instruction related to feeding assistance provided per the CDM recommendations or the resident's person-centered care plan.

Based on observation, interview and record review, the facility failed to physically assess an acute change in condition and failed to timely identify and treat constipation for one Resident (#18) of one resident reviewed for change in condition, resulting in abdominal discomfort, nausea, and the potential for worsening of medical condition and complications of constipation. Findings include: Resident #18 (R18) Review of R18's Minimum Data Set (MDS) assessment, dated 10/23/2024, revealed admission to the facility on [DATE] with diagnoses including peripheral vascular disease, Type 2 diabetes mellitus with hyperglycemia, left above the knee amputation and gangrene (tissue death from infection or lack of blood flow) of the right foot. Further review of the MDS assessment revealed R18 was cognitively intact and required extensive/maximal assistance with transfers and toileting. On 12/2/2024 at 10:13 a.m., R18 was observed seated in bed, holding a tissue to her mouth. Further observation revealed a green emesis bag on top of the over bed table positioned in front of R18 in bed. R18 was observed, diaphoretic (sweating) with a pale color. R18 reported she was nauseous and had been vomiting that morning. R18 was unable to continue the interview and requested privacy. During an interview on 12/2/2024 at 12:40 p.m., Licensed Practical Nurse (LPN) G reported being aware R18 was nauseous and had been vomiting that morning. LPN G reported she was unsure why R18 was not feeling well. A review of R18's electronic medical record (EMR) conducted on 12/2/2024 at 11:20 a.m. and 12/4/2024 at 10:15 a.m. No documented physical assessment of R18 was observed, including checking the resident for fever, bowel sounds and assessment of the abdomen or blood glucose evaluation on 12/2/2024 to correspond with the Resident's condition. Further review of the EMR revealed no documentation of physician notification related to R18's condition or nausea and vomiting on 12/2/2024. During an interview on 12/4/2024 at 10:55 a.m., the Director of Nursing (DON) reported nursing staff informed her they believed R18's nausea and vomiting on 12/2/2024 was related to constipation, and therefore the physician was not notified because the facility had standing orders for bowel care. The DON stated nursing staff should have conducted a physical assessment and blood glucose check in response to R18's condition on 12/2/2024. The DON reviewed R18's record at the time of the interview and confirmed no physical assessment or blood glucose check was documented for R18 for the timeframe of 12/2/2024 through the date and time of this interview. The DON confirmed nursing assessment is a standard of practice and should be conducted to promptly identify potential complications related to illness and change in condition. Review of the facility's, Admission Standing Orders, for bowel care, presented by the DON, revealed the following: A) Colace 200 mg [milligram], by mouth every PM; B) Milk of Magnesia 30 ml [milliliter] by mouth at bedtime on day 2, without BM [bowel movement] or as needed; C) Bisacodyl suppository in AM on day 3 without BM; D) Fleet enema if no BM 1 hour after suppository; E) Soap suds enema day 4, without BM. Review of R18's EMR including point of care documentation titled, B&B - Bowel Elimination, for November and December 2024 revealed documentation R18 had no bowel movements from 11/18/2024 at 2:54 a.m. until 11/24/2024 at 5:59 a.m. (approximately 6 days). Review of R18's November 2024 Medication Administration Record (MAR) revealed the bowel care standing orders were not implemented until 11/23/2024 at 8:34 a.m. with administration of a dose of Milk of Magnesia 30 ml., more that five days after R18's last bowel movement. It was noted there were no documented refusals of bowel care for R18 from 11/18/2023 through 11/24/2024 in the EMR or included on the November 2024 MAR. It was also noted there was no documentation of physician notification of the Resident's condition during the referenced timeframe. Review of R18's progress notes revealed the following: 11/23/2024, 18:33 [6:33 p.m.], Resident complaining of stomach pain [related to] constipation. MOM [Milk of Magnesia] administered as directed with noted results. Further review of R18's point of care documentation for B&B -Bowel Elimination, revealed the Resident did not have a bowel movement recorded from 11/30/2024 at 2:00 p.m. until 12/03/2024 at 3:41 p.m., a timeframe of more than three full days with no bowel movement. Review of R18's December 2024 MAR revealed no initiation of bowel protocol or documented refusals during the three-day period R18 did not have a bowel movement.

Based on interview and record review, the facility failed to provide written notification of the bed-hold policy to residents or their representatives prior to a hospital transfer for two Residents (#16 and #1) of two residents reviewed for hospital transfers. Findings include: Resident #16 (R16) A review of the electronic medical record (EMR) revealed on 9/13/24, R16 was transferred to the hospital and returned 9/16/24. The EMR revealed no documentation indicating R16 or their representative was provided information on the facility bed hold policy or agreement at the time of transfer or after hospitalization . During an interview on 12/4/24 at 11:20 AM, the Nursing Home Administrator (NHA) stated the bed hold policy was not reviewed with the resident or the responsible party at the time of transfer. 41978 Resident #1 (R1) Review of R1's EMR progress notes revealed R1 was transferred to the emergency department on 7/29/2024 and admitted to the hospital with discharge back to the facility on [DATE]. Further review of R1's EMR revealed no documentation indicating R1 or their representative was provided information on the facility bed hold policy or agreement at the time of transfer or after hospitalization . Review of the facility policy titled, Transfer (Internal and External) and Discharge, last revised 9/2023, revealed the policy did not include any language or instruction related to the provision of bed hold agreement before or upon transfer out of the facility.

Based on interview and record review, the facility failed to notify, in writing, the resident, resident's representative and a representative of the Office of the State Long-Term Care Ombudsman of the transfer to the hospital for two Residents (#16 and #1) for two residents reviewed for transfers out of the facility. Findings include: Resident #16 (R16) A review of the electronic medical record (EMR) revealed on 9/13/24, R16 was transferred to the hospital and returned 9/16/24. The notification of transfer or discharge to be provided to R16 or their representative, and the notification to the Ombudsman was unable to be located in the EMR. During an interview on 12/4/24 at 11:20 AM, the Nursing Home Administrator (NHA) presented the September Ombudsman transfer log. This log did not list R16. The NHA stated after the change in leadership the notices of transfer had not been done. The NHA also stated the ombudsman log might not be complete and may not include all the discharges. 41978 Resident #1 (R1) Review of R1's EMR progress notes revealed R1 was transferred to the emergency department on 7/29/2024 and admitted to the hospital with discharge back to the facility on [DATE]. Further review of R1's EMR revealed no documentation of notification of transfer or discharge was provided to R1 or their representative. Review of the July 2024 transfer and discharge list provided to the Long-Term Care Ombudsman revealed R1's transfer and hospitalization was not included on the list. Review of the facility policy titled, Transfer (Internal and External) and Discharge, last revised 9/2023, revealed the following: Purpose: To ensure residents are appropriately transferred or discharged from the LTC [Long Term Care] . During review of the policy, it was noted the policy included no language or instruction on the provision of notification of transfer or discharge to the resident, the resident's representative or the facility's assigned Long-Term Care Ombudsman.

This citation pertains to intake MI00136508. Based on interview and record review, the facility failed to ensure freedom from significant medication errors for one Resident (R20) of three residents reviewed for medication administration. This deficient practice resulted in actual harm when R20 was administered another Resident's (R35) narcotic medication, resulting in R20 becoming unresponsive, requiring resuscitation and hospitalization . Findings include: A review of R20's Emergency Department Note, dated 4/22/2023, revealed the following: (R20) presents the (sic) emergency department sent over from long-term care for acute altered mental status change. In emergency department . unresponsive to voice . has shallow and slow repirations . When she was initially evaluated in the emergency department she is found to be hypoxic (absence of enough oxygen to sustain bodily functions) to the low 80s (normal range 95-100) . placed on nonrebreather (mask used to deliver high concentrations of oxygen) oxygen . 2 mg (milligrams) of Narcan (opioid reversal medication), within 30 seconds, the patient became much more alert, somewhat agitated with staff, speaking clearly but clearly somewhat confused . Urinalysis was positive for oxycodone (intermediate-acting narcotic medication). This is not on her medication list so unclear how she would have ingested this however clinically she did appear to have an acute opioid overdose given her brisk response to Narcan. This was repeated in the emergency department after the initial 2 mg dose. She did seem to have return of her encephalopathy (altered brain function), so she was given another 0.4 mg IV (intravenous) dose . standing order was placed for repeat doses as needed . admission to ICU (Intensive Care Unit) for observation, Narcan administration as needed . hypoxia presumed at this time to be due to acute opioid intoxication. A review of R20's hospital History and Physical Report, dated 4/22/2023, revealed the following: Assessment & Plan: 1. Opioid Intoxication. Toxic metabolic encephalopathy secondary to opioid ingestion. Opioid ingestion with unintentional overdose . patient required multiple doses of Narcan . will be admitted to the ICU in case that she needs a Narcan drip . Right lower lobe pneumonia . patient has new right lower lobe infiltrate. Could represent aspiration . R20 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, hypertension, anxiety, and depression. A review of R20's annual Minimum Data Set (MDS) assessment, dated 2/1/2023, revealed R20 had severe cognitive impairment. A review of R20's electronic medical record (EMR) revealed the following: 4/22/2023 15:16 (3:16 p.m.) - Nurse Note . (R20) sleeps in this shift . eyes look hazy and pinpoint . sitting up in dining room but does not eat . had not taken any morning medication at this point due to sleeping in this a.m. Cena (CNA) attempts to feed (R20) for lunch but (R20) not chewing or swallowing . 1430: writing checks on (R20) . laying awake in bed and does look at this writer when being spoken to . holding breath on and off .not taken medications or taken (sic) in food or fluid . ER (emergency room ) called . (R20) will be taken down to (emergency room ). A review of R20's April 2023 Medication Administration Record (MAR), provided by the Nursing Home Administrator (NHA), revealed the Resident was not prescribed oxycodone or any narcotic pain medications. A review of the facility Incident Investigation report, signed by the Nursing Home Administrator (NHA) and dated 4/28/2023, revealed the following: . spoke with both nurses . who worked night shift on Friday night . (Registered Nurse [RN] B) said that she had a good shift . did talk about another resident (R35), had been up all night vomiting . I went and spoke to (R35) to see how she was feeling . (R35) reported . I just kept throwing up . (R35) reported she usually takes her oxycodone around midnight. She thought she might try another nausea pill around that time . and if she kept it down and was still okay by (1:30 a.m.) she would try and take it. When (R35) decided she would try and take the pain medicine (oxycodone), she stated (RN B) didn't bring the right oxy (oxycodone) . I then asked (RN B) if the wrong medication could have possibly been given, and what happened with (R35's) oxycodone . (RN B) indicated (R35) had vomited her pills up into her washcloth. I went back and asked (R35) if she had vomited any medication up and (R35) denied that she did . After thorough review of the chart, interviewing witnesses, and compiling information, it is suspected that (R20) received (R35's) oxycodone on the evening of 4/21/2023. (R35's) room is right next door to (R20's) and the location of their medications in the medication cart are right next to each other. It is suspected that the proper way of identifying resident to administer medications, utilizing the photos provided both in the chart and in the medication care, was not followed, causing the medication error. A review of R35's most recent, complete MDS assessment, dated 6/21/2023, revealed she scored 15 out of 15 on the Brief Interview for mental Status, indicating she was cognitively intact. A review of R35's April MAR revealed the following order: Oxycodone 80 mg tab, ER (extended release), q8h (every eight hours) 0800, 1600, 0000 (8:00 a.m., 4:00 p.m., 12:00 a.m.). It was noted the MAR provided by the NHA did not include the actual dates and times the medication was administered. A review of R35's Controlled Substance proof-of-Use Record, for the prescribed oxycodone 80 mg tablets, revealed a dose signed out by RN 'B on 4/21/2023 at 12:00 a.m. Attempts to contact RN B were made on 7/27/2023 at 10:15 a.m. and 11:45 a.m. No return call was received from RN B prior to the end of the survey on 7/27/2023 at 5:30 p.m. or anytime thereafter. During an interview on 7/27/2023 at 10:00 a.m., the DON reported she was unsure of how the medication error occurred. The DON confirmed R20 was not prescribed oxycodone and there was no suspicion of family or anyone outside the facility providing the medication to the Resident. The DON stated RN B's contract was not renewed, and she would no longer be working for the facility. When asked what immediate actions were taken to ensure this type of medication error would not occur again, the DON reported recent nursing education on medication administration was conducted and RN B was observed for competency prior to her departure from employment. A review of the facility policy titled LTC (Long Term Care) Medication Administration, last reviewed 5/25/2023, revealed the following: Purpose: To ensure nursing staff are following the proper rights of medication administration. All medications are to be administered by licensed medical or nursing personnel in accordance with the Medicine and Nurse Practice Acts of the State of Michigan. Medications prescribed for one resident may not be administered to another resident. Medication errors and drug reactions are immediately reported to the Director of Nursing or Administrator on call and the attending physician and recorded in the resident's clinical record as well as on an incident report. Included with the facility investigation documents was a form titled Long Term Care Staff Meeting, dated 6/15/2023. A review of the form revealed the purpose of the meeting included Education: Med Errors . and Policy review. Also included with the investigation documents was the Observation of (RN B), completed by the DON and dated 5/4/2023. It was noted the documentation did not include audits of medication administration, other than the observation of RN B on 5/4/2023, to ensure compliance with the facility policy and professional standards of practice.

This citation pertains to intake MI00138227. Based on observation, interview and record review, the facility failed to safely transfer one Resident (R35) of three residents reviewed for accidents. This deficient practice resulted in actual harm when R35 fell to the floor and sustained a left femur (thigh bone) fracture and left tibia (shin bone) dislocation with subsequent hospitalization , surgical intervention and pain. Findings include: On 7/26/2023 at 10:20 a.m., R35 was observed in her room, sitting in bed. R35 was observed wearing an immobilizing leg brace on her left leg. R35's left lower extremity could not be visualized due to being covered by the brace from her mid-thigh to ankle. R35's left ankle appeared deformed and contracted up toward midline and to the lateral (left) side of her body so that her ankle appeared to be where her heel would normally rest. R35's right lower extremity appeared to have been surgically removed above her right knee. During an interview at the time of the observation, R35 reported she had her right leg surgically removed a few years ago. R35 stated she no longer walked after her right leg amputation. When asked if she could stand on her left leg, R35 reported due to her chronic left ankle deformity she was unable to bear weight on her left leg. R35 reported she always transferred with the assistance of two people and the use of a full body mechanical lift. R35 stated she recently fell during a transfer from her wheelchair to her bed. R35 stated her left leg was broken in three places from the fall and her left knee was dislocated. R35 stated she underwent a surgical intervention to repair her left knee but opted out of repair for the thigh frature. R35 reported she had a surgical incision from left knee up to left hip and was required to keep the immobilizer brace on at all times. When asked about pain, R35 winced and stated her current pain level in her left lower extremity was consistently seven on a scale of 10 (highest severity). R35 was queried regarding the circumstances leading to the fall resluting in her left femur fracture and knee injury. She stated Certified Nurse Aide (CNA) A and CNA D picked her up and carried her to her wheelchair so she could visit with family. When she wanted to return to bed, CNA A was the only aide available and he attempted to place a sling for the total (full body), mechanical lift underneath her as she sat in the wheelchair. R35 stated CNA A instructed her to place her arms around his neck and hold on as he attempted to lift the Resident, at which time she attempted to place weight on her deformed, left foot and started to fall. R35 reported CNA A tried to catch her but CNA A fell and then she fell on her left knee and left hip with her upper body coming to rest on top of CNA A. R35 was admitted to the facility on [DATE] and had diagnoses including rheumatoid arthritis, right AKA (above the knee amputation), chronic pain syndrome, and osteoarthritis deformans (misshaping of joints due to wearing down of cartilage between bones). A review of R35's Minimum Data Set (MDS) assessment, dated 6/21/2023, revealed she required extensive, one-person physical assistance with bed mobility and R35's transfer status was not assessed due to the activity not occurring during the five-day lookback period for the assessment. Further review revealed R35 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. A review of R35's MDS assessment prior to the 6/21/2023 assessment, dated 4/5/2023, revealed she required extensive, two-person assistance with transfers (how the resident moves between surfaces including: to or from bed, chair, wheelchair or standing position). A review of R35's electronic medical record (EMR) revealed the following: 6/29/2023 15:51 (3:51 p.m.) - Nurse Note . Fall during transfer with lift from chair - while cena (CNA) was attempting to place sling under resident's leg for transfer, she slipped forward sliding out of wheelchair seat . cena tried to hold her up but she was unable to hold on to him and she landed on top of cena and both went to the floor. Resident gently slid to her buttocks by cena . Resident c/o (complained of) left hip area pain and left knee pain, small bruise developing to left knee . xrays ordered left hip, knee, tib/fib (lower leg). 6/30/2023 09:00 (9:00 a.m.) - Nurse Note . States pain is 9/10 to left leg. Baseline pain is usually 8/10. Small bruise noted to left knee with some swelling . 6/30/2023 13:40 (1:40 p.m.) - Nurse Note . Resident was sent to ED . A review of R35's Diagnostic Imaging Report, dated 6/29/2023, revealed the following result: 1. Posterior dislocation of the left tibia (shinbone). 2. Comminuted fracture (broken in more than two places) distal left femur. A review of R35's Emergency Department (ED) Note, dated 6/30/2023at 1:46 p.m., revealed the following: Fall yesterday/Left leg pain . she developed pain in the left leg immediately. The pain has been constant, persistent and there is (sic) been swelling and some deformity down to the left leg or knee . ultimately showed a distal comminuted femur fracture, and dislocated tibia she has had previous knee replacement on that side . we do not have orthopedic coverage at this time, and it is anticipated that she will need to be transferred to facility with orthopedic coverage . A review of R35's hospital History and Physical Report, dated 7/1/2023 at 12:52 a.m., revealed the following: (R35) . transfer from (ED) for a left femur (fracture) . was being transferred to her bed from wheelchair without the (name brand full body mechanical lift) and was dropped on the floor . presented . as trauma transfer . admitted to medical surgical unit with an orthopedic surgery consultation . A review of R35's Orthopedic Progress Note, dated 7/1/2023 at 2:21 a.m., revealed R35 underwent an attempted close reduction in OR (operating room) under general anesthesia on 7/1/2023. Per the EMR, R35 returned to the facility on [DATE] at 3:53 p.m. Further review of R35's EMR revealed the following: 7/09/2023 05:27 (5:27 a.m.) - Nurse Note . Resident reports 9/10 continuous pain to left leg with 10/10 intermittent (frequent) spasms and 9/10 burning pain to left leg. 7/09/2023 10:59 (10:59 a.m.) - Nurse Note . (R35) brought down to (ED) this morning for her (complaint of) pain 10/10 for the past 2 days . she is still having spasms and uncontrollable pain . A review of R35's Emergency Department (ED) Note, dated 7/09/2023, revealed the following: She was seen here . after falling on June 29 (2023) . was found to have a distal left femur fracture with an associated posterior dislocation of the left knee joint . Records indicate that there (was) an attempt at closed reduction under general anesthesia what was unsuccessful, and she returned to (facility) . will plan whatever operative procedure may be necessary to achieve reduction of her dislocated knee . A review of R35's hospital History and Physical Report, dated 7/09/2023, revealed the following: Plan: A total knee arthroplasty (joint replacement). I talked to patient about fixating her (left) distal femur to get her out of pain . She is not interested on a further operation . R35 returned to the facility on [DATE]. During an interview on 7/27/2023 at 2:00 p.m., CNA A reported R35 fell on [DATE] when he attempted to transfer the Resident unassisted. CNA A stated R35 requested to be transferred back to bed and CNA D was busy assisting another resident. CNA A then stated he decided to use the full body mechanical lift, unassisted, to transfer R35. CNA A reported he had difficulty positioning the lift sling under R35 while she was seated in the wheelchair. CNA A stated R35 began to slip out of the wheelchair, at which time he went to the hallway to see if any staff were available but no staff were visible. CNA A was asked if R35 was falling out of the wheelchair to which he answered no, but he was worried she would. CNA A reported he went back to assist R35 and made another attempt to place the sling under R35, but was unsuccessful. CNA A stated he then asked R35 if she wanted him to physically pick her up. CNA A stated R35 then placed her arms around his shoulders, and he attempted to pick R35 up and carry her to bed. CNA A reported his knees buckled and both he and R35 fell to the ground. A query was made as to what R35's transfer status was prior to the fall. CNA A stated R35's care guide listed her as a two-person, physical assist. CNA A was remorseful and stated he regretted not waiting for assistance to transfer R35. A review of R35's Care Guide, dated 6/27/2023 at 5:46 p.m., revealed the following: Transfer: Used to transfer - Maxi Lift (full body mechanical lift), 2 person assist. Comment: maxi lift and 2 person or able to use bath trolley. During an interview on 7/27/2023 at 2:35 p.m., the Director of Nursing (DON) stated she was aware of R35's fall on 6/29/2023 but unaware CNA A attempted to carry R35 from her wheelchair to the bed, resulting in the fall. The DON confirmed R35 was care planned to be transferred using two-person assistance, both prior to and after the fall. The DON reported staff should never physically carry a resident. The facility policy related to safely transferring a resident was requested at this time. A review of the facility policy titled LTC Transfer belt/Gait belt, reviewed 7/13/2023 and provided by the DON, revealed the following: To ensure physical safety of resident and staff during transfer and/or ambulation a gait belt will be used on all resident for transfers and ambulation . Note to the Staff Member: In order to prevent a potentially serious injury to yourself or the resident, you must be aware of you own physical strength and capabilities before lifting a resident. If unsure of your or the resident's ability to perform the transfer, get help before attempting the transfer. It was noted the policy did not mention referring to a resident's care guide to determine transfer status prior to transferring a resident.

Based on observation, interview, and record review, the facility failed to maintain adequate Infection Control procedures due to failure to: 1. Properly isolate a Resident (#36) who had an exposure to a COVID-19 positive Resident (#16). 2. Ensure a Resident (#18) who was not under investigation for COVID-19 exposure was not placed with a Resident (#36) who was under investigation for COVID-19 exposure. 3. Implement and/or maintain isolation measures for Residents (#14, #15, #17, #27, #29, #34, #36, #142) under investigation for COVID-19 exposure or symptoms consistent with COVID-19. 4. Properly dispose of waste from a Resident (#36) room under investigation for COVID-19 exposure. 5. Perform hand hygiene when necessary to prevent spread of infections. 6. Have an effective soiled linen and refuse policy to effectively address prevention of spread of transmission based organisms. 7. Have infection surveillance data present for May 2021. 8. Ensure staff were properly trained on when to change gloves and perform hand hygiene in between tasks and how to avoid contaminating uniform unnecessarily. 9. Ensure infection control policies were reviewed at least annually. This deficient practice resulted in an immediate jeopardy concern with the likelihood of widespread COVID-19 exposure to the entire facility population and the potential for serious complications and/or death related to COVID-19 disease. On 7/27/21 at 8:30 AM the SA (State Agency) survey team met with the Administrator, the Director of Nursing (DON), and the Infection Control Officer/ Staff P to notify the facility of an immediate jeopardy concern at F 880 related to improper isolation and PPE (Personal Protective Equipment) use for residents with suspected exposure to COVID-19. An abatement plan for removal of the immediacy was requested. The immediate jeopardy began on 7/18/21 when Resident #18 was moved from 1173 to room [ROOM NUMBER] when the facility implemented their COVID-19 unit and was exposed to Resident (#36) who was under investigation for exposure to a COVID-19 positive Resident #16. Resident #18 subsequently tested positive for COVID-19 on 7/25/21. During the initial tour of the facility, room [ROOM NUMBER] was observed with a zippered door barrier, but the door barrier was unzipped. room [ROOM NUMBER] and room [ROOM NUMBER] had no door barrier and no PPE accessible at the room door. room [ROOM NUMBER] had a zippered barrier affixed to the door, but the two zippers were unzipped and near the top of the doorway and the center section of the barrier was rolled up and being held by a metal hook. All 8 Residents who were under investigation for exposure or symptoms consistent with COVID-19 had their room environments open to the facility, contributing to the likely spread of COVID-19. The immediate Jeopardy was removed on 7/27/21 at 12:00 PM when the facility placed barriers over the doors of the resident rooms who were under investigation due to exposure or symptoms consistent with COVID-19, assured staff adquate access of PPE, and staff education had begun for isolation guidance. Findings include: On 7/26/21 at 12:30 PM, entrance to the facility was made by the SA survey team. The entrance screening was performed by an acute care hospital staff person. The entrance screening person did not advise SA survey team and visitors to the hospital (who were screened just before and after the survey team) on what PPE was supposed to be worn, social distancing to be maintained, any hand hygiene instructions, and did not advise on what to do if a visitor develops symptoms consistent with COVID-19. 7/26/21 1:42 PM, during a simultaneous interview and observation of rooms under investigation, the Administrator stated room [ROOM NUMBER] had one Resident (#36) who was under investigation due to her roommate testing positive, and there were three Residents (#14, #15, and #142) in 1164 under investigation due to one Resident (#142) with symptoms consistent with COVID-19. The Administrator stated the Residents (#29 & #34) in room [ROOM NUMBER] were placed under investigation due to exposure to a positive Resident (#16- tested Positive 7/17/21) who shared dining space with those under investigation. The Administrator stated #29 and #34 were being tested as part of the their protocol. The Administrator stated Resident # 29 was under investigation and had upper respiratory symptoms and a fever consistent with COVID-19 and was also in and out of the hospital for CHF (congestive heart failure) was under infection precautions. Residents #14, #15, were also under quarantine as a result of sharing a room with Resident #142. Residents #17 and #27 in room [ROOM NUMBER] were under precautions as a result of two positive room mates ( Resident #25 and Resident #21). There was no signage present at room [ROOM NUMBER] to alert staff Residents #14, #15, and #142 were under investigation as a result of Resident #142 having symptoms consistent with COVID-19. There was also no PPE requirements posted, no zippered barrier, and no PPE available at the door of room [ROOM NUMBER]. A fell ow Surveyor had already gone in to screen Residents #14, #15, and #142 and was unaware of those residents being under investigation for COVID-19. The Administrator stated the entire resident population had been tested and the facility was waiting for the results. On 7/26/21 at 2:05 PM, Certified Nurse Aide (CNA) L and CNA M were observed exiting room [ROOM NUMBER]. CNA L and CNA M did not have any protective eyewear, or gown on or gloves. When asked if they were wearing PPE for the residents in 1164, CNA L and CNA M stated they were not. CNA L and CNA M also stated they were not aware the residents in 1164 were under investigation as a result of Resident #142 having symptoms consistent with COVID-19 and recent hospitalization s. Registered Nurse (RN) N stated Residents #14, #15, and #142 were being watched closely because of one of the residents (#142) having (COVID-19) symptoms. On 7/26/21 at 2:14 PM, during an interview, CNA O was asked why the zippered barrier was rolled up toward the top of the door and secured by a hook. CNA O stated he was under the impression room [ROOM NUMBER] was no longer under precautions. Resident #17 and Resident #27 were exposed to room mates, Resident #21 who tested positive on 7/20/21, and Resident #25 who tested positive on 7/18/21. On 7/26/21 at 2:19 PM, during a follow-up interview, the Administrator stated Resident #25 tested positive for COVID-19 on 7/18/21 and was transferred from 1173 to the quarantine unit the same day. The Administrator then stated on 7/20/21 Resident #21 tested positive for COVID-19 and was transferred from 1173 to the quarantine unit. The Director of Nursing (DON) stated the most recent COVID-19 exposure to Resident #17 and Resident #27 was on 7/20/21. When asked how many residents had been vaccinated, the Administrator and DON stated 100% of the residents had been vaccinated. When asked what precautions were supposed to be in place for those residents who were under investigation, the Administrator stated the first couple of days they were using full PPE, and then they kept a barrier up to make staff aware the residents in those rooms were being watched. When asked about the rationale for this, the Administrator stated she spoke to her infection preventionist, Staff P from the hospital and he said that the test used by the facility would be good for five days. When asked what the test being good for five days meant, the Administrator stated the test is accurate five days out on whether or not a resident will test positive or not. On 7/26/21 at 5:15 PM, during a follow-up interview, the Administrator stated the facility staff vaccination rate was approximately 62%. On 7/27/21 at 07:36 AM, room [ROOM NUMBER] where Resident #36 resided had her most recent exposure to a COVID-19 positive Resident (#18) who tested positive on 7/25/21. Resident #18 was moved to room [ROOM NUMBER] on 7/18/21 for the facility to create a COVID-19 unit. Resident #16 tested positive for COVID-19 on 7/17/21 after going to the hospital and had been in room [ROOM NUMBER] with Resident #36. Resident #36 should have been still under quarantine when Resident #18 was moved into room [ROOM NUMBER]. The room door to 1161 had a barrier that was hanging but not well secured to the door frame and the barrier was not zipped shut. room [ROOM NUMBER] continued to be without signage or PPE available at the room door at the time of this entry. On 7/27/21 at 7:50 AM, during an interview, the DON stated Resident #16 went to the emergency roiagnom on [DATE] for symptoms unrelated to COVID-19 which needed to be acutely addressed. The DON stated Resident #16 tested positive on admission to the hospital and this was the first identified case for the facility outbreak. On 7/27/21 at 7:52 AM, during an interview, Staff P stated he was notified the day the first COVID-19 positive case was identified on 7/17/21. Staff P stated he instructed the staff to perform a COVID-19 test on all the residents and on 7/18/21 another COVID-19 positive Resident (#25) was identified. Staff P stated testing was again performed on all the residents on 7/20/21 and this was when Resident #21 and CNA Q tested COVID-19 positive. Staff P stated nasopharyngeal COVID-19 testing was done on 7/21/21 for Resident #17 and #27 because of being under investigation due to exposure by room mates (Resident #21 and #25) who tested positive for COVID-19 7/18/21 and 7/20/21. When asked about what required PPE needed to be used to enter the rooms under investigation, Staff P stated, It's basically their choice to wear PPE or not. When they first began full PPE was mandated. Staff P stated full PPE was stopped on 7/21/21 after (brand name) testing came back negative for Resident #17 and #27, they were negative for symptoms, and had been fully vaccinated. Staff P stated Resident #142 and the two room mates (#14 & #15) in 1164 were tested due to Resident #142's symptoms. On 7/27/21 at 8:49 AM, the Administrator came to the SA survey team to clarify a concern, and stated no one got moved into a room under investigation for COVID-19 Exposure. The SA survey team sat down with the Administrator and clarified and confirmed findings which determined Resident #18 was moved from the area where the facility implemented the use of a designated COVID-19 unit on 7/18/21. Resident #18 was moved into room [ROOM NUMBER] where Resident #36 was under investigation for exposure to a COVID-19 positive Resident (#16) who tested positive for COVID-19 on 7/17/21. On 7/27/21 at 9:56 AM, CNA R was observed placing a disposable meal container used by Resident # 36 who was under investigation for COVID-19 exposure in an open trash barrel as it passed by the room. The trash barrel was being pushed by an unidentified staff member down the hallway with no lid. On 7/27/21 at 12:09 PM CNA R was observed exiting room [ROOM NUMBER] where Residents (#14, #15, & #142) were under investigation due to symptoms Consistent with COVID-19 displayed by Resident #142. CNA R removed her gloves and then removed a mask covering a mask on her face by touching the exterior surface without performing hand hygiene. CNA R then disposed of the mask and placed a new mask over the one which remained on her face without performing hand hygiene. CNA R finally performed hand hygiene after contaminating her face with soiled hands after she removed and touched the exterior of a soiled face mask. On 7/27/21 at 2:17 PM, CNA L was observed taking clear plain unmarked bags of linen and trash from a suspected COVID-19 exposure isolation room (1173). When asked how refuse and linen was supposed to be bagged for an isolation room, CNA L stated the facility does not place these items in specific color coded or specially marked bags. On 7/27/21 at 2:20 PM, the DON was asked for a policy to describe how the facility handles linen and refuse from an isolation room. On 7/28/21 at 10:38 AM, during an interview, the DON stated Resident #16 had gone to a wedding on July 2nd, 2021, and then to a casino on or around July 5th or 6th and again on July 10th or 11th. The DON stated Resident #16 tested positive on July 17th, 2021 after a visit to the emergency room unrelated to COVID-19 for a [CONDITION(S)]. CNA Q was the only staff member to test positive on July 20th, 2021 and she was negative on Sunday July 18th, 2021. The DON stated she gets tested weekly due to her decision to be unvaccinated and this was the facility protocol. The DON stated CNA Q had also taken care of both residents in room [ROOM NUMBER] who tested positive for COVID-19 (Resident #21 & #25). The DON stated the facility could not determine if the point source was the unvaccinated staff member CNA Q, or if Resident #16 picked up COVID-19 from her outings. On 7/18/21 Resident # 25 tested for symptoms and was positive for COVID-19 and then on 7/20/21 Resident #21 tested positive for COVID-19. Then Resident # 18 tested positive on 7/25/21 after being tested for related symptoms of a cough and a temp. The DON stated Resident #16, #18 and #21 did have a history of eating meals in proximity of each other as well, but at appropriate social distancing. Resident #25 did have contact with her son and husband prior to testing positive on 7/18/21 as well. A copy of the outbreak mapping, line listing and investigation summary were requested from the DON. A review of Infection control surveillance book revealed no surveillance data for May 2021. The DON was asked to provide evidence of May 2021 surveillance being completed. The DON stated it was probably somewhere on her desk. When asked if a staff member should be expected to change gloves and perform hand hygiene after performing perineal care to a resident and prior to performing a Foley catheter bag emptying procedure, the DON stated Absolutely. Resident #22 On 7/28/21 at 8:25 AM, CNA S was observed performing perineal and urinary catheter care. After performing catheter and perineal catheter care, CNA S used the same gloves to retrieve an alcohol prep pad from her left front scrub top pocket contaminating the inside of her pocket. CNA S then used the same soiled gloves to perform the catheter emptying procedure. A review of the facility policy Long Term Care Antimicrobial Stewardship Policy and Procedure with an approved date of 12/5/19 revealed the policy had not been reviewed or updated annually. A review of the facility policy Employee Testing and Reopening with a revised date of 5/10/21 read in part: Testing for Low Risk Region per MI Safe Start Map .1. Employees or residents who have any of the following symptoms will be tested and isolated: New onset persistent cough, fever, shortness of breath, sore throat, loss of taste or smell, new headache, muscle pain or chills . .Testing for Medium or High Risk Region per MI Safe Start Map 3. Employees or residents who have any of the following symptoms will be tested and isolated: New onset persistent cough, fever, shortness of breath, sore throat, loss of taste or smell, new headache, muscle pain or chills . .Refusal of Testing or Missing Test . .3 For any resident who refuses to be tested , all efforts will be made to obtain the test. Residents who cannot be tested will remain under strict isolation, and full PPE will be used, or they will be transferred to a regional hub or other nursing facility who has a Covid unit and is capable of caring for a potential Covid positive resident . .Other Testing and Reopening Considerations . .2. New admits will be tested within 72 hours prior to admittance to LTC (Long Term Care). They will be quarantined in LTC for 14-days, if they have not completed their vaccination series . A review of the facility policy Universal Precautions with a revised date of 7/2018 revealed the policy was not reviewed at least annually. The policy read in part: .4. MASK OR RESPIRATOR Front of mask/respirator is contaminated DO NOT TOUCH!! Grasp bottom, then top ties or elastics and remove discard in waste container. PERFORM HAND HYGIENE IMMEDIATELY AFTER REMOVAL OF ALL (PPE) . .3. BIOHAZARD TAGS The biological hazard tag shall be used to signify the actual or potential presence of a hazard, to identify equipment, containers, rooms, materials, experimental animals or combination thereof, which contain or are contaminated with viable hazardous agents. a. Bags or other receptacles containing articles contaminated with potentially infectious material, including contaminated disposable items, must be tagged or otherwise identified. The tag shall have the signal work BIOHAZARD or the biological hazard symbol. The tag shall indicate that the bag could contain infectious wastes an given any additional instructions: e.g. if the outside of the bag is contaminated with body fluids, a second outer bag should be used . A review of the facility policy Routine Hand Hygiene with a revised date of 6/2020 read in part: .J. Decontaminate hands after removing gloves . A review of the facility policy Regulated Medical Waste Removal and Transportation with a revised date of February 2016 read in part: .2. All containers for RMW (Regulated Medical Waste) used for temporary storage shall be lined with bag that is at a minimum labeled and/or color-coded per Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard. Labeling includes the word BIOHAZARD with the accompanying universal biohazard symbol. Color coding includes using red bags or containers. Additional labeling with Infectious Waste may be used at some facilities. Depending on the geographic location of each unit, these bags may need to be printed in English and Spanish . A review of the facility policy Isolation Precautions with a revised date of 2/2020 revealed the policy was not reviewed at least annually. The policy read in part: .b. Bags or other receptacles containing articles contaminated with potentially infectious loose material,(e.g. bottles, suctions, dripping materials) containers including contaminated disposable items with visual dripping, must be tagged or otherwise identified. The tag shall have the signal word BIOHAZARD or the biological hazard symbol. The tag shall indicate that the bag could contain infectious wastes and given any additional instructions: e.g. if the outside of the bag is contaminated with body fluids, a second outer bag should be used. c. Employees shall be informed of the meaning of tags. With respect to tagged material, they shall also be instructed to use double bagging where puncture or outside contamination of the bag is likely . There was no specific guidance in the facility policy with regard to COVID-19 Isolation guidelines. A review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (COVID-19) Spread in Nursing Homes. Nursing Homes & Long-Term Care Facilities. Updated Mar. 29, 2021 accessed on 8/3/21 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read in part: .Summary of Recent Changes . .Added management of residents who had close contact with someone with [CONDITION(S)]-CoV-2 infection which includes a description of quarantine recommendations including resident placement, recommended PPE, and duration of quarantine. Added addressing circumstances when quarantine is recommended for residents who leave the facility. Added responding to a newly identified [CONDITION(S)]-CoV-2-infected HCP or resident. Added addressing quarantine and work exclusion considerations for asymptomatic residents and HCP who are within 90 days of resolved infection. Key Points Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2. A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Even as nursing homes resume normal practices and begin relaxing restrictions, nursing homes must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. These recommendations supplement CDC ' s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic and are specific for nursing homes, including skilled nursing facilities, but may also apply to other long-term care and residential settings . .Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection Residents with suspected [CONDITION(S)]-CoV-2 infection should be prioritized for testing. Residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection do not need to be placed into an airborne infection isolation room (AIIR) but should be cared for HCP using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown . .Ideally a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit . .If limited single rooms are available or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should shelter-in-place at their current location pending return of test results . .Roommates of residents with [CONDITION(S)]-CoV-2 infection should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents while they are in quarantine (i.e., for the 14 days following the date their roommate was moved to the COVID-19 care unit) . Managing Residents with Close Contact Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection Residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure. Residents in quarantine should be placed in a single-person room. If limited single rooms are available or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposures or symptoms concerning for COVID-19, residents should shelter-in-place at their current location while being monitored for evidence of [CONDITION(S)]-CoV-2 infection . .HCP should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents . .Residents can be transferred out of quarantine if they remain with no fever and without symptoms for 14 days . .Healthcare facilities should understand that shortening the duration of quarantine might pose additional transmission risk . A review of the CDC, Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination. Updated Apr. 27, 2021 accessed on 8/3/21 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html, read in part: .Fully vaccinated inpatients and residents in healthcare settings should continue to quarantine following prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with [CONDITION(S)]-CoV-2 infection . The immediacy was removed when the facility initiated the following abatement plan: July 27, 2021 Immediate Jeopardy Abatement Plan Please see the attached summary of the incident signed by the Administrator provided as part of the facility reported incident process. Below is a summary of the immediate actions taken to ensure no other residents were at risk as required for the Immediate Jeopardy Abatement. * Immediate action taken upon identification of Infection Control concerns related to Covid-19: * Residents in rooms [ROOM NUMBERS] were put on Droplet Precautions due to exposure to Covid (19) positive residents on 7/26/2021 at 2000 (8:00 PM). Staff education of expectations for PPE use, and reinforcement of education given to staff on current shift, and oncoming staff for night shift on 7/27/21 at 1745 (5:45 PM) and 1845 (6:45 PM). Done by both Administrator and DON. * Residents in rooms [ROOM NUMBERS] were put on Droplet Precautions on 7/27/2021 at 1000 (10:00 AM) due to symptoms for Covid. Staff education of expectations for PPE use, and reinforcement of education given to staff on current shift, and oncoming staff for night shift on 7/27/21 at 1745 (5:45 PM) and 1845 (6:45 PM). Done by Administrator. Staff education of expectations for PPE use given to oncoming staff on 7/28/21 at 0545 (5:45 AM) and 0645 (6:45 AM) by Administrator. * DON Educated staff on requirements for Droplet Precautions for residents in rooms 1161, 1163, 1164 and 1173. Education begins today, 7/27/2021 and will be completed and shared with all staff by 7/28/2021. * Zip Walls installed in the doorways to rooms [ROOM NUMBERS]. rooms [ROOM NUMBERS] already had Zip Wall up. This was completed by Administrator and PES (Maintenance) employee on 7/27/21 by 1200 (12:00 PM). * DON notified [CONDITION(S)] staff of resident on Droplet Precautions on 7/27/2021. Notified via email at 12:12 (PM) on 7/27/21 by DON. * Care plans will be updated for the residents in rooms 1161, 1163, 1164 and 1173 on 7/27/2021, to indicate the residents are on Droplet Precautions. DON and MDS (Minimum Data Set [assessment]) Coordinators updated on 7/27/21 completed by 2000 (8:00 PM). * Continued observation for symptoms of all residents and staff. Ongoing. * Continued testing for Covid-19 per guidelines. Ongoing. * DON to send email to all staff that work on LTC and [CONDITION(S)] department on requirements on 7/27/2021. Email sent by DON on 7/27/21 at 12:47 (PM).

Based on interview and record review, the facility failed to assess a resident's change in condition according to professional standards of practice and notify a physician of a change in condition for one Resident (#1) of three residents reviewed for quality of care. This deficient practice resulted in worsening of Resident #1's condition, subsequent hospitalization on the intensive care unit (ICU) and undergoing a life-altering surgical procedure. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a hospital Discharge Summary, dated and signed 7/17/20 at 12:13 p.m. by Physician A, revealed the following, in part: (Resident #1) admitted to the intensive care unit with critical care consultation and IV pressor therapy (medication to raise blood pressure) to maintain blood pressures which ultimately resulted from hypovolemic shock . secondary to profound diarrhea and fluid volume losses from her ileitis/[MEDICAL CONDITION] . she was placed on corticosteroid therapy [MEDICATION]), this was helpful . her diarrhea was improving and her symptoms were resolving and then as per our plan (corticosteroid) was withdrawn. This unfortunately resulted in a return of her abdominal symptoms of diarrhea, discomfort and distention along with [MEDICAL CONDITION] and weakness and her (corticosteroid) was resumed at a lower dose which resulted in improvement of her symptoms once again . to be admitted to long-term care unit for a period of strengthening and conditioning prior to return home. A review of the New Admission email sent to all nursing staff and certified nurse aides (CNAs) on 7/17/20 at 2:02 p.m., revealed the following, in part: (Resident #1) to LTC (long-term care) for short-term rehab . admitted to (hospital) on 7/1/20 with abdominal pain, vomiting and diarrhea . still has occasional loose stools . usually continent . appetite has been poor. A review of the, Bladder/Bowel Movement Assessment(s), for Resident #1 revealed the following, in part: Sat [DATE]:40 (CNA B) . Stool Size: Large, Stool Color: Brown Black, Stool Consistency: Liquid, Bowel Continence: Continent & Incontinent . Sun [DATE]:00 (CNA B) . Stool Size: Large, Stool Color: Black, Stool Consistency: Loose. Bowel Continence: Incontinent . Fri [DATE]:46 (CNA C) . Stool Size: Large, Stool Color: Brown, Blood Tinged, Stool Consistency: Loose, Mucous, Bowel Continence: Incontinent. Further review of the electronic health record (EHR) for Resident#1 revealed no nursing assessment to correspond with the Bladder/Bowel Movement Assessment(s), entered by CNA B and CNA C. The EHR for Resident #1 revealed no documentation that a licensed nurse or Resident #1's physician had been notified of the occurrences when Resident #1 had experienced black and blood-tinged stool. The EHR revealed Resident #1 had episodes of diarrhea recorded every day from admission on 7/17/20 to discharge on 8/4/20. On 7/24/20, the consistency of Resident #1's stool changed from, loose, to loose, watery. On 7/25/20, Resident #1 had, large, watery, loose, bowel movements recorded at 5:46 (a.m.) and 23:32 (11:32 p.m.). A review of the, Meals/Nourishment Record, revealed no recorded oral fluid intake for Resident #1 on 7/25/20. On 7/28/20, Resident #1's record revealed, large, loose, watery, bowel movements recorded at 8:00 a.m., 9:00 a.m. and 12:00 p.m. A review of the, Meals/Nourishment Record, revealed Resident #1 had no recorded oral intake for 7/28/20. On 7/31/20, large, watery, loose, bowel movements were recorded for Resident #1 at 1:12 a.m., and 9:45 a.m. Further review revealed Resident #1 had a recorded total oral, fluid intake of 60 milliliters (amount in two - standard, graduated, medicine cups). Resident #1's daily average of oral fluid intake, based on recorded intake, was 377 milliliters per day. Review of the Nurse Note, dated 7/20/20 at 4:03 a.m., signed by Licensed Practical Nurse (LPN) D revealed the following: Resident had greenish/black loose stools times 2 tonight. CNA stated she has had those since she came. Will monitor. An interview with LPN D, on 8/18/20 at 11:11 a.m., revealed LPN D did not call Resident #1's physician to report the black stool. When asked what black stool indicated, LPN D reported black stool indicated (Resident #1) was bleeding or taking an iron supplement. LPN D could not remember if Resident #1 had been taking an iron supplement at that time. When asked what the protocol was for reporting a suspected gastrointestinal (GI) bleed, LPN D reported she would pass on the information during shift report for the next shift nurse to monitor as staff did not phone physician's on the night shift, unless it is an emergency. A review of Resident #1's Medication Administration Record, [REDACTED]. An interview with Registered Nurse (RN) E, on 8/13/20 at 10:20 a.m., revealed the process for notifying the attending physician of concerns regarding a resident's condition was for the nurse caring for the resident to alert the, desk nurse, of the concern. RN E reported the desk nurse would then use an order request form to report the concern by fax to the physician, who would then respond by fax or phone call. RN E reported the faxed notifications were kept in a file for reference. RN E showed this Surveyor the file where the faxed notifications were kept at the nurses' station. The faxed notifications regarding Resident #1 were requested at this time. A review of the Order Request from (Hospital) - Long Term Care Unit, forms provided by the Director of Nursing (DON) , revealed no form had been faxed regarding a concern for blood in Resident #1's stool on 7/18/20, 7/19/20, 7/20/20 or 7/24/20. Further review revealed no notification had been faxed regarding a change in the consistency of Resident #1's stool from loose to watery on 7/24/20 or of Resident #1's continued incontinence. A review of a nurse note, dated 8/3/20 at 7:08 p.m., revealed the following, in part: Resident complaining of feeling nauseous after lunch . Resident stated . I just feel so weak. I wish I had an appetite. Is there a pill they can give me? Desk nurse sent note to doctor. Waiting response. Further review of the nurse note revealed, (Resident #1 family member) wanted to know what was going on . family was getting voicemails of (Resident #1) stating, I don't feel good. I want to go home. I can't breathe . Upon assessment . Resident stated I just feel so sick to my stomach . Resident had small emesis at supper complaining of feeling nauseous. Will continue to monitor. A review of the Medicare Nurse Assessment - LTC, dated 8/3/20 at 9:15 p.m., signed by RN F, revealed the following, in part: Gastrointestinal: Description: Round. Distended. Nausea. Diarrhea. Incontinence. Further review of all prior assessments revealed Resident #1's abdomen had not been distended prior to the assessment on 8/3/20. A review of the Order Request from (Hospital) - Long Term Care Unit, forms provided by the DON, revealed no form documenting the physician had been notified by fax of the Resident's change in condition on 8/3/20 at 9:15 p.m. A review of the EHR for Resident #1 revealed no documentation indicating the physician had been notified by any other means of communication. A review of a nurse note, dated 8/4/20 at 10:18 a.m., revealed the following, in part: Resident blood pressure low this morning. BP - 104/37 (normal range 120's/80's) on left arm, 81/45 on right arm . Resident continues to have poor fluid and food intake. Resident's (family) called this morning with concerns . requesting (Resident #1) be seen in ER (emergency room ) . (Resident #1) agreed to be seen in ER. On 8/14/20 at 9:50 a.m., a review of Resident #1's EHR with the DON, revealed no documentation the physician had been notified, by any means of communication, regarding a concern of the frequency and consistency of Resident #1's stool or a concern of blood in the Resident's stool. There was no documentation the physician had been notified of Resident #1's condition on 8/3/20. In an interview at the time of the review, the DON confirmed staff had failed to recognize the concern for blood in the Resident's stool and the change in the consistency of the Resident's stool, along with limited oral fluid intake, as a change in Resident #1's condition, therefore did not notify the physician. The DON also confirmed the physician should have been notified on 8/3/20 when the nursing assessment revealed Resident #1's abdomen had become distended in addition to the Resident's nausea, vomiting and continued diarrhea. The DON reported Resident #1 did not complain to nursing staff which caused staff to make, assumptions, regarding the Resident's condition. The DON agreed that the Resident's lack of reporting how they felt, to nursing did not absolve nurses from conducting accurate nursing assessments and notifying the physician of concerns in order to allow the physician to change the course of treatment, if needed. A review of the Emergency Department Note, dated 8/4/20 at 9:43 a.m., revealed the following, in part: .presents to emergency department from long-term care with complaints of persistent diarrhea up to 3-4 times daily . replacing fluid losses with oral intake . nausea and occasional vomiting . will admit to ICU . plans to obtain a CT scan of the abdomen and pelvis while admitted . A review of the Internal Med History & Physical, dated 8/4/20 at 7:44 p.m., revealed the following, in part: Assessment and Plan. [MEDICAL CONDITION] . secondary to dehydration from diarrhea . Fecal occult blood test positive (positive for blood in stool). A review of the Diagnostic Imaging Report, CT Abdomen Pelvis wo con, dated 8/5/20 and signed 8/6/20 at 8:27 a.m., revealed the following, in part: Impression/Summary. 1. There has been interval development of a ventral wall hernia . The appearance suggests incarceration/strangulation. Bowel ischemia (inadequate blood supply causing tissue death) is suspected. A review of the General Surgery Consult Note, dated 8/5/20 at 7:08 p.m., revealed the following, in part: Location: ICU. Assessment and Plan . recommend urgent exploration . A review of the Operative Report, dated 8/5/20 and signed 8/6/20 at 6:13 a.m., revealed the following, in part: Post-procedure Diagnosis: [REDACTED]. Procedure: Exploratory laparotomy, resection of contaminate mesh, [MEDICATION NAME] colectomy (removal of a portion of the colon) with end-[MEDICAL CONDITION] formation (diversion of the colon through the abdominal wall for elimination of stool). A review of the General Surgery Progress Note, dated 8/6/20 at 6:38 a.m., revealed the following, in part: Location: ICU . Assessment and Plan: s/p (following) lap [MEDICATION NAME] colon resection for ischemic [MEDICAL CONDITION] with multiple areas of necrosis/perf (holes). A review of the General Surgery Progress Note, dated 8/14/20 at 6:38 a.m., revealed the following, in part: Location: ICU. Assessment and Plan: pt (patient/Resident #1) developing atelectasis (collapse) rt base (right lung), pt (patient/Resident #1) depressed. The progress note revealed Resident #1 remained hospitalized in the ICU as of 8/14/20.

Based on observation, interview and record review, the facility failed to ensure appropriate assessment, interventions and supervision were in place to prevent hot liquid spills [MEDICAL CONDITION] one Resident (#302) out of 3 residents reviewed for supervision. This deficient practice resulted in Resident #302 receiving a second degree burn to his left anterior thigh after spilling hot soup on himself, and the potential for [MEDICAL CONDITION] further assessments, interventions and supervision in place. Findings include: Resident #302 had a current admission date of [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #302 had a functional status which required extensive assistance for, toileting, transfers, dressing, and personal hygiene with two-person physical assistance, and that Resident #302 required supervision with set up for eating. This MDS assessment also revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. On 1/21/20 at 12:25 PM, Resident #302 was observed in the main dining room eating his meal unassisted and unsupervised. He was wearing a terrycloth permeable clothing protector and had two uncovered mugs of coffee and one of tea. He was noted to be spilling some food off his fork as his hands were feeble and a bit shaky. He sat with three other residents, and no staff were observed to be supervising. His meal tray card was at his place setting and read: Adaptive Equipment: SUPERVISION. A review of the facility reported incident report for Resident #302 revealed on 1/7/20 at approximately 5:30 PM while moving his soup to the edge of the table he moved it too far and it spilled on his lap. Resident #302 reported pain during initial spill of soup to be a 6 on the pain scale of 1 to10. A Certified Nursing Assistant (CNA) C and Licensed Practical Nurse (LPN) D assisted Resident #302 to the bathroom and changed his clothing, assessed his skin, and noted a red non-blistered area to the left thigh. LPN D requested a wound care consult. Two days later 1/9/20, the wound care nurse LPN H assessed the wound and documented at 11:03AM there was a ruptured blister (approximately 1cm x 1cm x 0.05cm) to the left thigh of Resident #302 with serous drainage. On 1/21/20 at 2:27PM, LPN H was interviewed regarding the burn from the hot liquid spill. LPN H stated that the spill happened during the evening meal and she got a consult two days afterward due to a printer error, about 2 days after the fact. LPN H stated, It looked like a ruptured blister and had a bit of redness around it like a burn would. On 1/21/20 at 216PM, the dietary clerk/ Staff I presented the kitchen temperature log. There were no hot beverage temperatures recorded on the sheet. Staff I stated, We do not take temperatures of the beverages. Staff I believed that the CNAs did that. Staff I said, I have no idea where they (CNAs) put them. On 1/21/20 at 2:40, CNA C was interviewed and stated that at dinner an activity aide called CNA C on the walkie (the walkie talkie) and said that Resident #302 needed his pants changed because he spilled his beef vegetable soup on himself. CNA C said his leg looked pink and the area turned into a blister burn later. CNA C stated that Resident #302 knocked his bowl onto himself . he was holding it. CNA C said that the CNAs do not take the temperatures and thought the kitchen did that, but CNA C said, It had to be boiling hot. CNA C went on to say, I got him another bowl, but I said let this one cool down before you eat it. On 1/21/20 at 4:09PM, the Administrator in Training/ Staff F explained that the temps are taken in the kitchen and then spot checked up on the floor (after going into the steam table). Staff F said, I would have to imagine that the soup was just too hot. Staff F said she spoke with the Dietary Director and the temperatures from the steam table are not recorded or logged anywhere. Staff F went on to say, Today, I went and had the cook check the temperatures . I think they need to check them on a regular basis and take temps on any items warmed up in the microwave as well . We are not doing this now. That is something we need to put in place . We want to make sure the soup does not burn anyone. On 1/21/20 at 12:16PM, the Certified Dietary Manager (CDM) A was observed in the dining room assisting with the lunch tray set up. When asked if there was an assessment completed to determine if residents were at risk for injury from hot liquids, CDM A stated there was not a hot liquid assessment that I know of, unless speech therapy or occupational therapy does one. On 1/21/20 at 1:25PM, the Certified Occupational Therapy Aide (COTA) J stated that Occupational Therapy staff screens residents after a screen request is sent through by nursing staff. COTA J said, If there was a spill with a burn there should be a screen. I do not recall a screen. On 1/21/20 at 1:36PM, the Speech Language Pathologist (SLP) B was interviewed concerning the burn that resulted from the soup spill by Resident #302. SLP B said that hot liquids would be a concern, but she had never been alerted if there was a spill. SLP B stated, I would hope the person who served the food would be sure it is not too hot to eat. If it burned his leg it would be too hot to eat . I was not called in this case. In fact, I did not hear about the burn until today. A review of the facility's LTC (Long Term Care) Hot Beverages policy reviewed last on 5/25/18 read in part, Serve hot beverages between 140 F and 160 F . If a burn occurs, cool the area as quickly as possible by flushing the affected area with cold water . On 1/22/20 at 12:02PM, Cook G stated that she had been serving the evening meal on 1/7/20 and she heard Resident #302 cry out for help and she saw the soup on the floor. Cook G did not see how the incident happened. On 1/22/20 at 12/10PM, CNA C stated that nothing had been done prior to her taking Resident #302 to the bathroom to be changed. No cold water had been flushed onto the affected area that she had known of. On 1/22/20 at 10:40AM, the Director of Nursing (DON) stated that she had investigated the incident. When asked if there was an assessment for hot liquids or if interventions had been put in place to prevent further burns, the DON stated that they had not yet implemented assessments or additional interventions.

Based on interview and record review, the facility failed to provide adequate supervision and a safety device intervention to prevent a fall for one (Resident #102) of three residents reviewed for falls from a facility population of 47 residents. This deficient practice resulted in Resident #102 falling face forward from his wheelchair, landing on the floor with subsequent harmful injuries that included intraventricular hemorrhage, multiple facial fractures, and traumatic brain injury. Findings include: A Facility Investigation Report dated 10/7/13, showed on 10/01/13 at approximately 7:40 p.m., "(Resident #102) had fallen forward out of his wheelchair and was sent to the emergency room (ER) due to his condition, unresponsiveness and bleeding from his face." The report showed Certified Nurse Aide (CNA) "B" was getting Resident #102 ready for bed and had removed Resident #102's lap tray (safety device) off his wheelchair and left the room. She returned to the room to find Resident #102 "on the floor...with blood around his head". CNA "B" immediately called for help, the resident was examined, taken to ER and transported to a regional hospital. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #102 is an [AGE] year old man admitted to the facility on [DATE], with the primary [DIAGNOSES REDACTED]. This MDS assessment revealed Resident #102 had a Brief Interview for Mental Status (BIMS) score of 3/15, which indicated Resident #102 had severe cognitive impairment. This MDS assessment also revealed Resident #102 needed total physical assist of two individuals for transfers, was incontinent of bowel and bladder and required extensive assistance for all activities of daily living. A review of indicators of nutritional status dated 8/19/13, reflects Resident #102 did not have any chewing or swallowing problems and required total assistance at meals to eat. The Falls Risk Care Plan for Resident #102 was "revised/rewritten" on 12/10/12 and last updated on 10/01/13. This care plan showed the resident had an extensive history of falls (16 falls since admission) with multiple interventions including a "lap tray on wheelchair" that was initiated on 1/09/13. Resident #102's history and physical (H&P) from the acute care hospital dated 10/02/13 revealed, "Final Report Clinical Indication: This is an [AGE] year old with traumatic brain injury... He was admitted directly to the ICU (intensive care unit) setting... Lab and Diagnostic imaging: CT (computed tomography) scan of his (Resident #102) head performed today does show evidence of some trace diffuse subarachnoid blood...left subdural hematoma... There is also evidence of intraventricular hemorrhage...there is also evidence again of multiple extensive facial fractures." A review of a hospital consultation report dated 10/2/13, reflects the following, "...patient (Resident #102) has extensive bruising of the face and patient is unable to give us any history. He does respond to painful stimuli with moaning. He resists eye opening but pupils are reactive. There is marked edema and swelling of the face noted. He has nasal packing in place and a bandage at the nares... lungs: display scatter bibasilar crackles... impression: significant facial trauma secondary to fall..." A review of a hospital consultation report dated 10/5/13, reflects the following, "...the family reports that the patient (Resident #102) has had a progressive decline in oral intake and they request gastrostomy tube place to aid in nutritional support, hydration, and delivering of medications. The patient has been evaluated by Neurosurgery and ENT (ears, nose, throat). He is felt to have suffered acute brain trauma and multiple nondisplaced anterior and lateral maxillary sinus wall fractures, as well as a minimally angulated nasal bone fracture on the left with acute maxillary sinusitis.... ENT has further evaluated the patient for safety and stability regarding endoscopically-guided percutaneous gastrostomy tube placement as this will involve place a bite block...and passage of the endoscope with some pressure on the anterior face. ENT judges that this will not be an issue..." A telephone interview was conducted with CNA "B" on 10/8/13 at 1:19 p.m. When asked about Resident #102, CNA "B" stated, "I was going to get him ready for bed, I removed his lap tray and heard a bang outside. I walked out of the room, and when I came back (Resident #102) was face down on the floor." An interview with the Director of Nursing (DON) was conducted on 10/9/13 at 10:30 a.m. When asked about Resident #102's fall and hospitalization , the DON stated, "Yes, I know, she (CNA "B") should have never have left him (Resident #102)." The Facility Investigation Report Conclusion for Resident #102 dated 10/07/13 reads, "After investigating this incident it does appear that this fall could have been prevented and the certified nurse aide removed a safety device, a lap tray that was care planned to prevent (Resident #102) from falling." ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO FOLLOW CLEAN TECHNIQUE DURING WOUND TREATMENT AND FAILED TO APPLY A PHYSICIAN ORDERED DEBRIDEMENT AGENT TO A STAGE 4 PRESSURE ULCER IN ONE (#103) OF FOUR RESIDENTS REVIEWED FOR PRESSURE ULCERS OF 11 SAMPLED RESIDENTS, FROM A TOTAL FACILITY POPULATION OF 48 RESIDENTS. THIS DEFICIENT PRACTICE HAS THE POTENTIAL TO RESULT IN THE DEVELOPMENT OF AN INFECTION AND DELAYED HEALING OF A PRESSURE ULCER. FINDINGS INCLUDE: THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED RESIDENT #103 IS A [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THIS MDS REVEALED RESIDENT #103 HAD ONE STAGE 4 (FULL THICKNESS TISSUE LOSS-MUSCLE/BONE VISIBLE) PRESSURE ULCER MEASURING 6.0 CM (CENTIMETERS) X 6.0 CM WITH A DEPTH OF 0.5 CM. A FACILITY DOCUMENT FOR RESIDENT #103 TITLED, "PHYSICIAN ORDERS" DATED 3/1/13 THRU 3/31/13 READ, "RT (RIGHT) HEEL: APPLY TOPICALLY [MEDICATION NAME] (A SODIUM [MEDICATION NAME] DRESSING) AND BULKY DRSG (DRESSING) QD (EVERY DAY)." AN ADDITIONAL ORDER READ, "TO NECROTIC TISSUE: APPLY TOPICALLY SANTYL (A DEBRIDEMENT AGENT) WITH DRESSING CHANGE". DURING A DRESSING CHANGE OBSERVATION OF RESIDENT #103 ON 3/20/13 AT 11:00 A.M., LICENSED PRACTICAL NURSE (LPN) "A" HAD WASHED HER HANDS AND DONNED A PAIR OF NONSTERILE GLOVES. LPN "A" PROCEEDED TO SET UP SUPPLIES FOR THE DRESSING CHANGE. THE BEDSIDE TABLE WAS NOT CLEANED IN ANY MANNER AND NO CLEAN BARRIER WAS PLACED ON THE TABLE. SHE PLACED ALL DRESSING SUPPLIES ON THE RESIDENT'S BED. SHE HAD A PAIR OF SCISSORS (WHICH SHE STATED SHE CLEANED WITH ALCOHOL PRIOR) AND PLACED THEM ON THE [MEDICATION NAME] AG DRESSING. LPN "A" THEN TOOK THE SCISSORS AND CUT THE OLD CONTAMINATED DRESSING OFF THE RIGHT HEEL OF RESIDENT #103 AND WITH HER GLOVED HANDS, SHE REMOVED THE DRESSING. LPN "A" TOOK THE SATURATED GAUZE 4X4'S (WITH CONTAMINATED GLOVED HANDS), WENT INTO THE BATHROOM AND WHEN SHE RETURNED, BEGAN INDISCRIMINANTLY BLOTTING RESIDENT #103'S INFECTED RIGHT HEEL PRESSURE ULCER WITH ADDITIONAL 4X4'S . LPN "A" DISCARDED THESE 4X4'S, REMOVED HER GLOVES, WASHED HER HANDS AND PUT ON A NEW PAIR OF NONSTERILE GLOVES. LPN "A" THEN USED THE CONTAMINATED SCISSORS TO CUT THE [MEDICATION NAME] AG DRESSING AND PLACED THIS DRESSING ON RESIDENT #103'S RIGHT HEEL ULCER. LPN "A" WRAPPED THE WOUND WITH A BULKY DRESSING. NO [MEDICATION NAME] AGENT (SANTYL) WAS OBSERVED IN USE DURING THE WOUND TREATMENT. DURING AN INTERVIEW ON 3/20/13 AT 4:00 P.M. WITH LPN "A", THIS SURVEYOR ASKED WHY SHE DIDN'T ESTABLISH A CLEAN FIELD FOR THE DRESSING SUPPLIES AND PLACED DRESSING SUPPLIES ON RESIDENT #103'S BED. LPN "A" STATED, "...BUT THIS IS HOW SHE (RESIDENT #103) IS USED TO HAVING IT DONE, SO I DIDN'T WANT TO CHANGE THE ROUTINE." WHEN ADDRESSING THE FACT THAT SHE DID NOT CHANGE GLOVES ONCE THEY WERE CONTAMINATED AND THAT SHE USED CONTAMINATED SCISSORS, SHE STATED, "I HAVE NO EXCUSE... I SHOULD HAVE USED BETTER TECHNIQUE...". LPN "A" STATED, "YES, I DID NOT CLEAN THE SCISSORS AFTER I CUT THE OLD DRESSING... I SHOULD HAVE CLEANED THEM WITH ALCOHOL... YEAH, I GUESS I NEED TO BRUSH UP ON MY TECHNIQUE." IN AN INTERVIEW WITH LPN "A" ON 3/21/13 AT 11:05 A.M., AFTER REVIEWING THE PHYSICIan order for [REDACTED]. I DIDN'T SEE IT ON THE TREATMENT SHEET... IT'S MY FAULT... I DIDN'T SEE IT (THE ORDER) AND THEREFORE, DIDN'T PUT IT ON." DOCUMENTATION OF RESIDENT #103'S PRESSURE ULCER FROM THE DATE OF HER ADMISSION ON 1/22/13 TO THE MOST RECENT MEASUREMENTS ON 3/21/13 SHOW NO SUBSTANTIAL REDUCTION IN THE SIZE OF THE WOUND. A REVIEW OF THE FACILITY DOCUMENT TITLED, "SKIN CONDITION REPORT FOR SELECTED CONDITIONS" (FOR RESIDENT #103) DATED 3/14/13 READ, "COMMENTS: ...STAGE 4 LENGTH IN CM = 6.5 WIDTH IN CM = 5.2, DEPTH IN CM = 0.4. ...ESCHAR (A SCAB OR CRUST (DEAD TISSUE) THAT RESULTS FROM... INFECTION) TISSUE TYPE = 10%...". A FOLLOW UP ENTRY DATED 3/21/13 READ, "COMMENTS: ...STAGE 4 PRESSURE ULCER EVEN THOUGH TRUE DEPTH OF WOUND IS UNKNOWN DUE TO 25% OF WOUND BED COVERED WITH BROWN TO BLACK ESCHAR... STAGE 4, LENGTH IN CM = 6.8, WIDTH IN CM = 6.8... ESCHAR TISSUE TYPE = 25%... DETERIORATION NOTED IN SITE...". THE FACILITY DOCUMENT TITLED, "SUBJECT - SKIN CARE - PRESSURE ULCER TREATMENT AND ALL NON-PRESSURE ULCER SKIN CONDITIONS" DATED REVISED 2/12/13 READ, "4. ...TREATMENT IS TO BE GIVEN IN ACCORDANCE WITH PHYSICIAN DIRECTION...". THE FACILITY'S POLICY TITLED, "NON-STERILE DRESSING CHANGE" DATED 9/30/09 READ: "PURPOSE: NON-STERILE DRESSINGS PROTECT OPEN WOUNDS FROM CONTAMINATION AND ABSORB DRAINAGE." THE DETAILED PROCEDURE READ, "STEPS: ...3. PREPARE A CLEAN, DRY WORK AREA AT BEDSIDE. USE DISINFECTANT SOLUTION TO PREPARE WORK SURFACE. OPTIONAL: COVER WORK SURFACE WITH CLEAN DRY PAPER OR CLOTH TOWEL, TO PREVENT CONTAMINATION OF SUPPLIES.... 5. WASH HANDS, APPLY GLOVES. 6. PREPARE/OPEN DRESSING ITEMS ON TABLE. IF DRESSINGS NEED TO BE CUT TO SIZE, USE CLEAN OR STERILE SCISSORS. OPEN PACKAGES AND CUT TAPE... WHEN SCISSORS ARE USED, CLEAN WITH ALCOHOL WIPE PRIOR TO AND AFTER USE.... 9. REMOVE SOILED DRESSING... 10. REMOVE GLOVES, WASH HANDS, APPLY NEW GLOVES... 12. CLEAN WOUND WITH NORMAL SALINE... 15. ...IF SCISSORS ARE USED, CLEAN WITH ALCOHOL AFTER USE.... 17. APPLY PRESCRIBED TOPICAL AGENT TO WOUND....". ( ) --

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THE CORRECT APPLICATION OF A PROTECTIVE DEVICE FOR A FOOT WITH IMPAIRED CIRCULATION, FAILED TO ASSESS THE EFFECTS OF THIS DEVICE ON THE IMPAIRED FOOT AFTER APPLICATION IN ONE (RESIDENT #2) RESIDENT AND FAILED TO IDENTIFY AND IMPLEMENT ADEQUATE PRESSURE REDISTRIBUTION INTERVENTIONS IN ONE (RESIDENT #6) OF EIGHT RESIDENTS REVIEWED FOR PRESSURE ULCERS IN THE TOTAL SAMPLE OF 13 RESIDENTS OUT OF A FACILITY POPULATION OF 49. THIS DEFICIENT PRACTICE RESULTED IN RESIDENT #2 DEVELOPING A FACILITY ACQUIRED PAINFUL SUSPECTED DEEP TISSUE INJURY TO HER LEFT FOOT AND RESIDENT #6 DEVELOPING A REOCCURRING FACILITY ACQUIRED PRESSURE ULCER TO HER BUTTOCK THAT DETERIORATED TO A PAINFUL STAGE III PRESSURE ULCER. FINDINGS INCLUDE: THE MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #2 IS AN [AGE] year OLD WOMAN. THIS MDS REVEALED THE RESIDENT WAS KNOWN TO BE AT HIGH RISK FOR PRESSURE ULCER DEVELOPMENT. HER [DIAGNOSES REDACTED]. THIS MDS ALSO REVEALED RESIDENT #2 HAD 2 STAGE IV PRESSURE ULCERS. A REVIEW OF PHYSICIAN ORDERS [REDACTED].#2 REFLECTED A "CAST BOOT LEFT LEG". DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN)/WOUND CERTIFIED NURSE (WCN) "G" ON 1/24/13 AT 9:15 A.M., IT WAS LEARNED THAT THE PHYSICIAN ORDERED "CAST BOOT" WAS ALSO REFERRED TO AS A "BRACE". WCN "G" VERIFIED THE "BRACE" WAS REMOVABLE. THE "PROGRESS NOTES BY RESIDENT" FOR RESIDENT #2 DATED 3/22/12 AUTHENTICATED BY LPN/WCN "G", READ, "BOOT IN PLACE ON (LEFT) FOOT." THERE WAS NO EVIDENCE IN THE PROGRESS NOTES REFLECTING RESIDENT #2'S LEFT FOOT WAS REASSESSED AFTER APPLICATION OF THE "BOOT" OR THAT THE "CAST BOOT/BRACE" WAS MONITORED FOR THIS HIGH RISK RESIDENT THROUGHOUT ITS' USE. THE "PROGRESS NOTES BY RESIDENT" FOR RESIDENT #2 DATED 3/23/12 READ, "...NEW DARKENED AREA OF SKIN ON (LEFT) FOOT. INNER EDGE NEAR BALL OF FOOT. REPORTED TO (LPN/WCN "G")". A FACILITY REPORT TITLED, "SKIN CONDITION/WOUND PROGRESSION" FOR RESIDENT #2 DATED 3/23/12 REVEALED, "NEW (1ST RECORDING)... PRESENT ON THE LEFT TOP GREAT TOE IS A PRESSURE ULCER". THE FOLLOWING FINDINGS WERE DOCUMENTED, GENERAL COMMENTS: "MEDIAL SIDE OF BALL OF GREAT TOE HAS A NEW PRESSURE ULCER CAUSED FROM LEG BRACE (BOOT) BEING ON FOR ONE DAY, RECTANGULAR WOUND (THAT) IS BLACK WITH SKIN INTACT, UNABLE TO ACCURATELY STAGE - SUSPECTED DEEP TISSUE INJURY... LENGTH IN CM (CENTIMETERS) = 2.7, WIDTH IN CM = 1.1, DEPTH IN CM = 0, SKIN IS NOT BLANCHABLE, NO ODOR IS APPARENT, NO DRAINAGE IS APPARENT. THIS WOUND WAS NOT PRESENT ON ADMISSION...ACUTE PAIN LEVEL IS 4/10...". A "SKIN CONDITION/WOUND PROGRESSION" NOTE DATED 1/18/13 REFLECTED RESIDENT #2'S FACILITY ACQUIRED PRESSURE ULCER TO HER LEFT GREAT TOE AREA DETERIORATED. THE DOCUMENTATION READS, "PRESENT ON THE LEFT TOP GREAT TOE IS A PRESSURE ULCER... LATERAL BALL OF GREAT TOE... DRY BLACK 80%, FOUL (PURULENT) DRAINAGE ON DRESSING, SCANT SEROUS DRAINAGE, MINIMAL (PURULENT) DRAINAGE, FOUL ODOR NOTED... LENGTH IN CM = 3.7, WIDTH IN CM = 3.3, SKIN IS NOT BLANCHABLE, A FOUL ODOR IS APPARENT... SURROUNDING SKIN IS MACERATED, SURROUNDING TISSUE IS [MEDICAL CONDITION] AREA IS PALE... PITTING [MEDICAL CONDITION] 1+... PAIN LEVEL IS 8/10." ON 1/23/13 AT 2:50 P.M., LPN/WCN "G" WAS OBSERVED PROVIDING WOUND CARE TO RESIDENT #2'S LEFT FOOT WHILE SHE SAT IN HER WHEELCHAIR IN HER ROOM. THE DRESSING ON HER LEFT FOOT WAS REMOVED. THERE WAS A STRONG, FOUL ODOR WHICH PERMEATED THE ROOM WHEN THE DRESSING WAS REMOVED. THE DRESSING WAS SATURATED WITH SEROUS SANGUINEOUS DRAINAGE ALONG WITH SOME GREEN-TAN DRAINAGE. RESIDENT #2 HAD MULTIPLE PRESSURE ULCERS ON TOP AND BOTTOM OF FOOT. LPN/WCN "G" CLEANED THE WOUNDS AND MEASURED EACH AREA. LPN/WCN "G" APPLIED A WET TO DRY DRESSING. THE SIDE OF THE (L) GREAT TOE AREA WAS CLEANED AND RESIDENT #2 GRIMACED, PULLED BACK HER HEAD, GRABBING THE ARMS OF THE WHEELCHAIR AND CALLED OUT IN PAIN SAYING, "IT HURTS!" THE SIDE OF THE LEFT GREAT TOE MEASURED 4.0 CM X 3.1 CM AND QUESTIONABLE DEPTH. THE AREA WAS DESCRIBED BY LPN/WCN "G" AS "SURROUNDING SKIN IS MACERATED, SWOLLEN WITH FOUL PURULENT DRAINAGE." WHEN LPN/WCN "G" PROBED THE AREA, RESIDENT #2 WRENCHED BACK IN HER WHEELCHAIR AND CRIED OUT, "IT HURTS!" DURING RESIDENT #2'S PRESSURE ULCER DRESSING PROCEDURE ON 1/23/13 AT 3:30 P.M., LPN/WCN "G" WAS ASKED ABOUT EACH WOUND AND HOW RESIDENT #2'S PRESSURE ULCERS DEVELOPED AND THE PROGRESSION OF EACH ULCER TO CURRENT STATUS. LPN/WCN "G" STATED, THE PRESSURE ULCER TO GREAT TOE WAS FROM AN IMPROPERLY APPLIED BRACE TO THE LEFT FOOT. LPN/WCN "G" STATED, "...THEY WERE PUTTING (THE BRACE TO LEFT FOOT) ON... TO PREVENT THIS... AND THEN THIS DEVELOPED IN 24 HOURS AND NOW WE ARE STILL DEALING WITH IT... THE AREA HAS NECROTIC TISSUE BUT IT IS WET BENEATH IT AND THE DRAINAGE IS PURULENT AND THE SURROUNDING AREA IS MACERATED ...SWOLLEN. THIS IS NOT GOOD. YES, I BELIEVE THIS COULD HAVE BEEN PREVENTED... HER FOOT SHOULD HAVE BEEN CHECKED... IT'S PART OF CARE WHEN SOMETHING LIKE THAT IS APPLIED... THE BRACE WAS TOO TIGHT... IT WAS IMPROPERLY APPLIED TO THE FOOT... WITHOUT BEING CHECKED AND HER POOR CIRCULATION AND ALL HER CO-MORBIDITIES... THIS OCCURRED IN 24 HOURS." A REVIEW OF RESIDENT #2'S CARE PLAN TITLED "PRESSURE ULCER CARE PLAN" DATED 3/7/12 REVEALED THIS CARE WAS NOT UPDATED UNTIL 5/17/12. THE FACILITY FAILED TO PROVIDE DIRECTION AS TO THE CORRECT APPLICATION OF THE "BOOT/BRACE" TO RESIDENT #2'S LEFT FOOT THAT WAS ORDERED BY THE PHYSICIAN ON 3/21/12 AND FAILED TO IDENTIFY THE PARAMETERS FOR ASSESSING HOW IT WAS AFFECTING RESIDENT #2'S LEFT FOOT. ON 1/24/13 AT 9:00 A.M., AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) AND REGISTERED NURSE (RN)/CHARGE NURSE "H". THE DON AND RN "H" WERE ASKED TO PROVIDE EVIDENCE THAT THE FACILITY MONITORED/ EVALUATED RESIDENT #2'S LEFT FOOT WHILE THE "CAST BOOT/BRACE" WAS APPLIED (3/22/12) TO ENSURE NO ADVERSE EVENT OCCURRED DUE TO THE RESIDENT'S HIGH RISK FOR PRESSURE ULCER DEVELOPMENT. THE FACILITY DID NOT PROVIDE ANY DOCUMENTATION TO DEMONSTRATE THAT RESIDENT #2'S LEFT FOOT WAS RE-ASSESSED OR MONITORED WHEN THE BOOT/BRACE WAS APPLIED. THE FACILITY'S PROTOCOL TITLED, "PRESSURE ULCER PROTOCOL" DATED 1/21/09, READ, "APPROACHES/ INTERVENTIONS: 6. RELIEVE PRESSURE ON HEELS USING POSITIONING DEVICES... 22. EVALUATE AND INITIATE CHANGES AS NEEDED." ( ) ACCORDING TO THE FACE SHEET, DATED 11/08/12, RESIDENT #6 IS AN [AGE] year OLD WOMAN readmitted to the facility on THE SAME DATE. HER [DIAGNOSES REDACTED]. ACCORDING TO THE ADMISSION MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE], RESIDENT #6 NEEDS EXTENSIVE ASSIST OF ONE PERSON FOR TRANSFERS, AMBULATION, AND EATING. RESIDENT #6 REQUIRES TOTAL ASSIST FROM ONE PERSON FOR BATHING AND HYGIENE NEEDS. RESIDENT #6 IS FREQUENTLY INCONTINENT OF BOWEL AND BLADDER. RESIDENT #6 WAS DEEMED TO BE "AT RISK" FOR PRESSURE ULCER DEVELOPMENT AND "NO OPEN AREAS" WERE IDENTIFIED UPON READMISSION, ACCORDING TO THE MDS. A REVIEW OF THE CARE PLAN FOUND IN RESIDENT #6'S MEDICAL RECORD TITLED "SKIN BREAKDOWN POTENTIAL FOR" DATED 11/21/12 LISTED THE FOLLOWING INTERVENTIONS: - ASSIST RESIDENT TO TURN EVERY TWO HOURS AND AS NEEDED - POSITION PILLOWS TO PREVENT PRESSURE, IF NEEDED - INCREASE OUT OF BED ACTIVITY AS TOLERATED A FACILITY "SKIN CONDITION REPORT" FOR RESIDENT #6 DATED 1/18/13 REFLECTS, "3RD RECORDING... STAGE II TO LEFT LOWER BUTTOCKS, MEASURES 0.7 CENTIMETERS (CM) IN LENGTH BY 0.5 CM IN WIDTH BY 0.1 CM IN DEPTH... SCANT CLEAR DRAINAGE... SURROUNDING TISSUE IS RED, SURROUNDING TISSUE IS SCARS..." DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN)/WOUND CERTIFIED NURSE (WCN) "G" ON 1/24/13 AT 11:15 A.M., IT WAS LEARNED THIS REPORT INDICATED THE PRESSURE ULCER TO RESIDENT #6'S LEFT LOWER BUTTOCKS HAD REOCCURRED FOR THE THIRD TIME. A REVIEW OF RESIDENT #6'S CARE PLAN FOR SKIN BREAKDOWN AND A FACILITY DOCUMENT TITLED "PATIENT KARDEX" (CNA CARE PLAN) DATED 1/10/13 REVEALED THE FACILITY FAILED TO IDENTIFY ANY ADDITIONAL PRESSURE REDUCING INTERVENTIONS TO ADDRESS HER PRESSURE ULCER PRODUCING RISK FACTORS AFTER THE PRESSURE ULCER TO RESIDENT #6'S LEFT LOWER BUTTOCK REOCCURRED FOR THE THIRD TIME. ON 1/22/13 AT 3:25 P.M., RESIDENT #6 WAS OBSERVED SLEEPING IN HER RECLINER (STANDARD HOUSEHOLD CHAIR). THE FOOT REST WAS ELEVATED, PLACING DIRECT PRESSURE ONTO HER BUTTOCKS. SHE WAS LEANING ONTO HER LEFT HIP/BUTTOCKS (AREA OF PRESSURE ULCER). NO PILLOWS WERE SEEN IN THE RECLINER AS DIRECTED BY HER CARE PLAN. ON 1/23/13 AT 9:20 A.M., RESIDENT #6 WAS OBSERVED BEING TRANSFERRED FROM HER WHEELCHAIR TO THE TOILET. EXAMINATION OF RESIDENT #6'S BUTTOCKS REVEALED A STAGE II PRESSURE ULCER TO THE LEFT BUTTOCK WITH RED/RUDDY COLORED SKIN SURROUNDING THE ULCER (REPRESENTING SCAR TISSUE AND PREVIOUS TISSUE DAMAGE). CERTIFIED NURSE AIDE (CNA) "J" APPLIED "STOMA ADHESIVE POWDER" AND "[MEDICATION NAME] OINTMENT" TO BOTH AREAS. ON 1/23/13 AT 2:30 P.M., RESIDENT #6 WAS OBSERVED SITTING IN HER RECLINER, PULLING AT HER BLANKETS, LIFTING HER LEGS UP & DOWN, POTENTIALLY CAUSING FRICTION AND SHEARING TO HER BUTTOCKS. NO PILLOW WAS VISUALIZED IN THE RECLINER TO OFFER PRESSURE REDISTRIBUTION. ON 1/23/13 AT 3:45 P.M., RESIDENT #6 WAS AGAIN OBSERVED SITTING IN HER RECLINER, LIFTING HER LEGS UP & DOWN, PULLING AT HER BLANKETS. THERE WERE NO PILLOWS OBSERVED UNDER RESIDENT #6'S BUTTOCKS. ON 1/24/13 AT 8:45 A.M., 10:30 A.M., AND AGAIN AT 1:50 P.M., RESIDENT #6 WAS OBSERVED SLEEPING IN HER RECLINER. THE FOOT REST WAS ELEVATED, CAUSING DIRECT PRESSURE TO HER BUTTOCKS. THERE WERE NO PILLOWS OBSERVED IN THE SEAT OF THE RECLINER TO AFFORD PRESSURE REDUCTION AND/OR REDISTRIBUTION. A WOUND CARE OBSERVATION WAS MADE WITH LPN/WCN "G" ON 1/24/13 AT 11:15 A.M. LPN/WCN "G" CLEANSED THE AREA WITH A WASHCLOTH AND SOAP AND WATER. LPN/WCN "G" WAS OBSERVED SCRUBBING THE ULCER AREA TO REMOVE THE [MEDICATION NAME] OINTMENT, POTENTIALLY CAUSING DAMAGE TO THE NEW TISSUE DEVELOPMENT. MEASUREMENTS WERE OBTAINED AND THE LEFT LOWER BUTTOCK PRESSURE ULCER MEASURED 1 CM (CENTIMETER) WIDE BY 1.4 CM LONG AND 0.1 CM DEEP. LPN "G" STATED, "THE MEASUREMENTS ARE WORSE." A REVIEW OF RESIDENT #6'S COMPUTER GENERATED SKIN CONDITION REPORT NOTES DATED FROM 4/27/12 THROUGH 1/18/13, SHOWED RESIDENT #6 DEVELOPED MULTIPLE STAGE II AND ONE STAGE III PRESSURE ULCERS THAT WOULD HEAL AND RE-DEVELOP. THESE ULCERS HAD BEEN ON HER RIGHT AND LEFT BUTTOCKS. DETAILS INCLUDED: -ON 4/27/12, LEFT LOWER BUTTOCKS STAGE II PRESSURE ULCER MEASURED 1.0 CM IN LENGTH BY 1.0 CM IN WIDTH BY 0.0 CM IN DEPTH. -ON 5/17/12, LEFT LOWER BUTTOCKS, STAGE II PRESSURE ULCER MEASURED 0.2 CM BY 0.3 CM BY 0.1 CM... STOMA POWDER AND [MEDICATION NAME] OINTMENT APPLIED... NEW PROXIMAL TO ANUS, OVAL IN SHAPE, STAGE II 5 CM BY 2 CM BY 0.1... MODERATE DRAINAGE... ACUTE PAIN LEVEL 4/10 (0-10 SCALE). -ON 5/25/12, LEFT LOWER BUTTOCKS, STAGE II PRESSURE ULCER IS HEALED (1ST RECORDED ULCER)... RAISED PERIWOUND SKIN WITH SCAB COVERING WOUND 100%, DEPTH UNKNOWN DUE TO WOUND BEING COVERED WITH DRY BROWN SCAB. -ON 5/31/12, NEW LEFT LOWER BUTTOCKS (PROXIMAL TO BUTTOCKS) STAGE III 1 CM BY 1.5 CM BY 0.2 CM, REPORTS PAIN AS "OUCH" CANNOT RATE PAIN AT THIS TIME, STOMA POWDER AND [MEDICATION NAME] OINTMENT APPLIED... -ON 6/22/12, LEFT LOWER BUTTOCKS (ANAL AREA), RAISED SCARRED SKIN AT BASE OF SCAB COVERED WOUND, [MEDICATION NAME] APPLIED..., RESIDENT VERBALIZED "OUCH" BUT UNABLE TO RATE PAIN ON 0-10 SCALE, LEFT BUTTOCK IS ALSO AT RISK FOR BREAKDOWN, STAGE III 1.0 CM BY 1.0 CM... -ON 6/29/12, LEFT LOWER BUTTOCKS (ANAL AREA) HEALED. TO DATE, THE FACILITY ACQUIRED PRESSURE ULCER TO RESIDENT #6'S LEFT LOWER BUTTOCKS HAS HEALED TWICE. AT THE TIME OF THE SURVEY, IT HAD REOPENED FOR THE THIRD TIME - STAGE II PRESSURE ULCER. AN INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) "N" AND LPN "O" ON 1/24/13 AT APPROXIMATELY 3:50 P.M. BOTH NURSES WERE ASKED HOW THEY REMOVE [MEDICATION NAME] OINTMENT FROM PRESSURE ULCER AREAS. LPN "O" STATED "I USE MINERAL OIL, THAT'S WHY WE HAVE IT HERE. WE APPLY IT (MINERAL OIL) TO A PAD OR WASHCLOTH AND WIPE THE AREA AND IT ([MEDICATION NAME] OINTMENT) COMES RIGHT OFF... NO SCRUBBING." LPN "N" AGREED, "OTHERWISE YOU COULD BE HURTING GOOD TISSUE." DURING AN INTERVIEW WITH LPN/WCN "G" ON 01/23/13 AT 11:15 A.M., LPN/WCN "G" WAS ASKED IF HE WAS FAMILIAR WITH THE P.U.P. (PRESSURE ULCER PROTOCOL). LPN/WCN "G" REPLIED, "YES, I HELPED DEVELOP IT." LPN/WCN "G" WAS THEN ASKED TO EVALUATE THE MATTRESS ON RESIDENT #6'S BED, CUSHION IN HER WHEELCHAIR AND THE SEAT OF THE RECLINER RESIDENT #6 SITS IN. LPN/WCN "G" STATED, "THIS MATTRESS IS HARD, THIS ISN'T THE RIGHT MATTRESS... WE HAVE AIR MATTRESSES AVAILABLE TO USE FOR THIS (RESIDENTS' WITH P.U.P.)... I THINK THE WHEELCHAIR CUSHION IS A FOAM ONE... AND I SEE SHE SITS IN HER RECLINER ON TOP OF AN INCONTINENT PAD AND THE FALL ALARM... THIS MAY BE CAUSING THE PROBLEM WITH HER BUTTOCKS BREAKING DOWN. I'LL WRITE AN ORDER TO HAVE PHYSICAL/OCCUPATIONAL THERAPY EVALUATE HER FOR A WHEELCHAIR AND RECLINER CUSHION... SHE (RESIDENT #6) SPENDS MOST OF HER TIME IN HER RECLINER." A REVIEW OF THE P.U.P., DATED 1/21/09, READS: "APPROACHES/INTERVENTIONS:... 1. A PUP PLACARD WILL BE PLACED ON THE OVERBED LIGHT AND A CNA CARE PLAN COMPLETED AND PLACED IN THE RESIDENT'S CLOSET, (CARE PLANS MUST INDICATE WHICH TREATMENT PROTOCOL HAD BEEN IMPLEMENTED)... 4. WHEN SITTING IN A WHEELCHAIR, REPOSITIONING SHOULD OCCUR EVERY 1 HOUR... 5. USE POSITIONING DEVICES (PILLOW, FOAM WEDGES) TO MAINTAIN 30 DEGREE LATERAL POSITION AND SEPARATION OF BONY PROMINENCES. AVOID SKIN TO SKIN CONTACT... 22. EVALUATE AND INITIATE CHANGES AS NEEDED. PUP-2 STAGE 2 PRESSURE ULCER... 1. ALTERNATING AIR MATTRESS OVERLAY APPLIED TO BED... 3. IF WOUND IS OPEN, APPLY [MEDICATION NAME] (FOAM TYPE DRESSING) AND OPSITE DRESSING (OCCLUSIVE BARRIER TO PREVENT CONTAMINATION)..." ON 1/24/13 AT 4:15 P.M., AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) AND REGISTERED NURSE (RN) "H". WHEN ASKED WHY A PRESSURE REDUCING CUSHION WAS NOT IN RESIDENT #6'S RECLINER, RN "H" REPLIED, "WE'VE NEVER TRIED A PRESSURE ULCER CUSHION IN HER RECLINER... WE FEEL THE RECLINER SEAT IS SUFFICIENT FOR PRESSURE REDUCTION... SHE LIKES BEING UP IN HER RECLINER, AND BECAUSE SHE IS A FALL RISK, IT'S EASIER FOR US TO SEE HER FROM THE HALLWAY." ( ) --