Every finding on record at Novi Lakes Health Campus

This citation pertains to intake: 3073158.Based on interviews and record reviews the facility failed to timely implement appropriate treatment and interventions for pressure wounds and failed to identify and timely respond to the worsening of the wound for one (R201) of one resident reviewed for wounds. This resulted in the prompting of the family to insist on the transfer of the resident to a higher level of care and subsequently required multiple debridements and multiple Intravenous antibiotics therapy to treat the infected decubitus ulcer with an associated abscess and fat necrosis of the buttock wound and pain.Findings include:A review of a complaint submitted to the State Agency (SA) reported concerns of the facility failure to promptly treat a wound infection and transferring to a higher level of care timely.A review of the medical record revealed R201 was admitted to the facility on [DATE] and transferred to the hospital two weeks later on 5/30/26. R201 was admitted with diagnoses that included: rhabdomyolysis (condition where damaged muscle tissue breaks down rapidly, releasing proteins and electrolytes into the blood) and acute kidney failure. R201 required staff assistance for Activities of Daily Living (ADLs).A review of the transferring hospital documentation provided to the facility upon R201's admission documented in part, . Wound Care Consultation. May 13, 2026. Wound Care Consult: Coccyx DTI (Deep Tissue Injury- intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue)- Bilateral knee- unstageable (Full-thickness and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar)- left ankle- Unstageable. Coccyx- DTI: 11x12 cm (centimeters), slight evolvement in center with superficial pink moist tissue, dark purple non blanching skin. left knee- unstageable: 1 scab ( 2 x 2 cm) surrounding tissue is dark purple and non blanching. right knee- unstageable: 1 scab ( 2 x 2 cm) surrounding tissue is dark purple and non blanching. left ankle- unstageable: 1 scab ( 2 x 2 cm) surrounding tissue is dark purple and non blanching. Treatment and Dressing Plan: 1. Cleanse all wounds with wound cleanser and gently pat dry with each dressing change, 2. Apply thin layer of Medihoney to coccyx open skin and cover with large Allevyn q (every) 48 hrs, 3. Add date and time to dressing, monitor q shift, 4. Continue to offload and turn q 2 hours, place turn wedge between hip and shoulder to ensure off-loading, 5. Keep HOB (head of bed) at 30 degrees or less and slightly elevate lower extremities (if patient can tolerate), when resting, to help relieve pressure, 6. Keep knees clean and dry, if the scabs open, cover with Telfa and Kerlix. Wound Care spoke with patient about the etiology, treatment, and preventative methods for wound type, and the importance of follow up care and treatment with PCP (primary care physician) upon discharge.A review of a Nursing note dated 5/15/26 at 6:47 PM, documented in part . arrived to facility via EMS (emergency medical services). Resident has an open are to coccyx and bilateral bruising to both knees.A review of the Physician orders and Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2026 documented the following:5/15/26 Incontinence Care- cleanse skin with personal cleanser and apply protective ointment/cream as needed after each incontinence episode. Three Times A Day.There were no orders initially implemented for the left ankle or knees.Further review of the progress notes revealed the following:On 5/18/26 at 11:18 AM, a Nursing note documented in part . IDT (interdisciplinary team) Review: Resident admitted to facility after fall. Upon admission to facility resident has a diagnosis of UTI (Urinary Tract Infection) and is being treated with cephalexin (antibiotic) 500mg (milligram) BID (twice a day) from 5/15-5/16/26.On 5/18/26 at 4:26 PM, a Nursing note documented in part . IDT Review- Resident skin assessed noted multiple ulcers to bilateral knees, sacrum and left lateral ankle. Resident daughter (name) notified of wound per permission of resident and . options discussed. Right knee measures 6.5x1.0 with multiple ulcers noted. Left knee measures 6.5x1.5 with multiple ulcers noted. Both areas stable with edges intact with no erythema (redness of the skin) or maceration (breakdown of skin). No drainage or signs of infection noted. Surround skin clean and dry. Left lateral ankle measures 1.0x1.5 with 100% eschar noted. Edges are intact and free of maceration and erythema. No drainage or signs of infection noted. Surrounding skin clean and dry. Sacral wound measures 9.0x12.0 with 90% slough (non-viable yellow, tan, gray, green or brown tissue) tissue with intact edges. Small amount of seropurulent (cloudy, thin yellow or tan fluid) drainage with green tinge. Slight fruity odor noted. Surrounding skin clean and dry. Treatments in place and appropriate. This was documented by the facility's Wound Nurse (WN) A.Further review of May 2026 Physician orders and MAR and TAR documented the following orders implemented on 5/18/26-Apply skin prep to bilateral knees and leave open to air qd (every day) and prn (as needed).Iodosorb (cadexomer iodine) gel; 0.9% topical. Cleanse sacral wound with wound cleanser or normal saline, pat dry, apply skin prep to peri-wound, apply Iodosorb gel to Xeroform (cut to fit) apply to wound bed and cover with 4x4 then apply 6x6 Island dressing qd. A PRN order was implemented for the same treatment if dressing was found dislodged or soiled.Left lateral ankle- Cleanse wound with wound cleanser or normal saline, pat dry, apply skin prep to peri-wound, and cover with Allevyn 4x4 dressing PRN if dislodged or soiled. A once a day order was also implemented for the same treatment.Observe left lateral ankle dressing to open area(s) every shift for draining on dressing and dislodgement.Observe sacrum dressing to open area(s) every shift for draining on dressing and dislodgement.Monitor scabs to bilateral knees for s/sx (signs & symptoms) of infection. Notify provider of any changes- three times a day.Bilateral heel protectors WIB (while in bed) three times a day.Pressure reducing cushion to w/c (wheelchair) three times a day.Dietary Supplement: Ensure. Twice a day for protein calorie malnutrition.Dietary Supplement: LiquaCel, 30 ml (milliters)A review of the complaint submitted to the SA noted the following in part . was not observed by a nurse until 5/18/26. Complainant states that she got a call from the director of nursing on 5/18/26. Complainant states that she said that she observed the ulcer, and it seemed infected because there was a smell coming from it. was in the facility for two weeks and his family continued to see him decline. Complainant states that she was concerned that (R201 name) had a UTI again, so she requested for them to check his urine. (R201 name) could not go to an assisted living facility because the pressure ulcer was so bad. the family found a group home and the owner said that they needed to observe (R201) first. Complainant stated that the owner of the facility went and told her that she would contact the doctor right away. (R201 name) was sent to the emergency room, and he was diagnosed with a soft tissue infection. Complainant states that when the staff determined that (R201 name) had an infection, he should have received immediate medical attention. Complainant states that if it was not for the group homeowner suggesting that (R201 name) go to the hospital, (R201 name) could have been dead by now.Further review of the progress notes revealed the following:On 5/22/26 at 1:59 AM, a Nursing note documented in part . RN (registered nurse) spoke with resident's daughter. via phone call. states her family is concerned that the resident has another UTI (urinary tract infection) based off of some of the conversations that they had with him on 5/21. She feels he is saying things that do not make sense and states these are the same symptoms he had when he was hospitalized for a UTI previously. RN obtained a clean catch from the resident and performed a urine dipstick. At this time the dipstick was negative. Upon assessment resident was alert and oriented x3 and understood the plan of care.On 5/22/26 at 9:52 AM, a Nursing note documented in part IDT Review: Residents family feels resident has increased confusion, RN dipped urine- dipstick negative. Preventative order implemented to encourage water x3/day. Provider notified of family concern.On 5/22/26 at 8:21 PM, a Nurse Practitioner (NP) note documented in part . CHIEF COMPLAINT confusion. The patient was seen today for a follow-up and evaluation of confusion. Nursing reported family concerns that the patient might have another UTI. During my assessment, the patient was alert and oriented to person, place, and time. He denied any issues with urination, did not report any pain or dysuria (pain while urinating), and denied abdominal pain or suprapubic pain. Nursing performed a urine dip last night to check for a UTI, which was negative. The plan is to continue monitoring the patient's mental status. A urinalysis can be sent out to rule out a UTI if the patient experiences further confusion. notify the provider of any changes in the patient's condition.On 5/25/26 at 4:40 AM, a NP note documented the following in part . DATE OF SERVICE: May 19, 2026. CHIEF COMPLAINT- Wound care nurse assessing pt (patient) wound and changing unstageable sacral wound dressing with heavy exudate, requesting NP eval (evaluation) and documentation of wound findings. Pt admitted to facility with multiple PU's (pressure ulcers). NP observed wounds to Lt (left) Lateral ankle, scattered x 2 PU on each knee bilaterally. Circumference line drawn around knee and still visible from hospital concerns for cellulitis. Bilateral knee wounds are OTA (open to air), they are clean and dry with no swelling, redness or heat to site and are inside circumference line. PU (pressure ulcer) to sacrum unstageable with the presence of slough, epibole from approx. (approximately) 1-4 o clock. Core at approx 9-11 o clock sanguineous and appears to be starting to possible separate from wound edge. Heavy exudate yellow (serous)/light brown and serosanguineous saturated primary and secondary dressing. No foul odor noted. RN treated with wound cleanser, covered with iodosorb and secondary dressing. Team to continue to monitor for wound degradation, s/sx of infection.On 5/30/26 at 1:07 PM, a Physician Assistant (PA) note documented in part . exhibited a buttock wound. Daughter refused any further treatment for his wound at the facility and insisted the resident to be sent to ER (emergency room). Order was given to send the resident to ER.On 5/30/26 at 1:53 PM, a Nursing note documented in part . Writer was approached by resident daughter, who stated that the resident is being evaluated by a facility he plans to transfer to after discharge. Daughter reported that the nurse evaluating the resident stated he needed immediate transfer to the hospital due to infected wound on his buttocks. Resident daughter stated that if the resident was not transferred out ,she would put him in her car and take him herself. Resident wound was changed by writer at 0800. No signs or symptoms noted at that time. Vital signs WNL (within normal limits). NP (name) gave order to send resident to the hospital for further evaluation. Resident transferred to hospital with daughter at bedside at the time of transfer.A Late Entry Nursing note created on 6/2/26 at 5:57 AM and back dated to 5/29/26 at 1:55 PM, documented . Daughter (name) in wound care reviewed and treatment completed with all questions answered. No erythema surrounding. Odor improving. Will continue to monitor. This note was documented by WN AA review of the hospital records revealed the following:An Emergency Medicine consultation dated 5/30/26 at 3:05 PM, documented in part . CHIEF COMPLAINT WOUND CHECK. presents to emergency department via EMS from (facility name) for evaluation of a sacral wound. Independent historian is EMS who states patient was currently on cefazolin however staff reports the infection is not getting any better. The patient reports increased pain with movement. The patient also notes a wound on his left ankle. The patient denies fever, chills. History of present illness is somewhat limited due to patient's mental status. Imaging: CT (computed tomography scan) Abdomen and Pelvis. Final Result 1. Innumerable (too many to count) foci of air within the sacral region extending to the left gluteal soft tissues that is concerning for necrotizing fasciitis. There is also a 6.8 x 2.8 cm left gluteus maximus intramuscular abscess. There is subtle nearby erosion of the cortex of the sacral tubercles which could be either chronic in nature or secondary to osteomyelitis. Differential diagnosis includes but not limited to sacral wound, necrotizing fasciitis, abscess, cellulitis, osteomyelitis, other. Will obtain labs and imaging for further evaluation of his wound. Will start Rocephin and vancomycin. 1936 (7:36 PM) General surgery came down and evaluated the patient and debrided the wound. I independently interpreted the patient's CT which showed evidence of necrotizing fasciitis with a gluteal abscess. The patient antibiotics were changed to add Zosyn and clindamycin. accepts admission. The patient's hemoglobin was low, gave a unit of blood. The patient is otherwise stable, vital signs stable. Culture were obtained. Diagnosis at time of disposition: 1. Gluteal abscess, 2. Necrotizing fasciitis, 3. Anemia, 4. Lactic acidosis. ED (Emergency Department) Disposition: hospitalized .A review of a Operative Procedure Summary dated 5/30/26 at 7:43 PM, documented in part . Post-Operative Diagnosis: Decubitus Ulcer/Abscess. After evaluating the wound(s), it was determined that excisional debridement was necessary to remove nonviable and viable tissue to stimulate healing. I debrided the wound area down to the muscle. The wound area debrided was 60 sq (square) cm.A review of a General Surgery consult dated 5/30/26 at 8:06 PM, documented in part . no evidence of necrotizing fasciitis. I&D (incision and drainage) performed. Lengthy discussion with family-Agree surgery would be painful and result in no improved outcome. They do not want surgery. Supportive care. May warrant palliative consult.A General Surgery progress note dated 5/30/26, documented in part . Patient seen and evaluated at bedside. Pt forgetful but oriented to self. Decubitus Ulcer with Fat Necrosis Stage 4. Plan for bedside re-packing of wound today.A General Surgery consult dated 6/1/26 at 6:11 PM, documented in part . Procedure Performed: buttock Wound Debridement. Indications: Indication for treatment: devitalized skin and purulent drainage. Debridement of the buttock. Debridement performed down to and including faschia level. Hyperkeratotic tissue removed with scissors and scalpel. Necrotic/fibrotic tissue removed with scissors and scalpel. This was repeated until the majority of necrotic/fibrotic tissue was cleared. A total area of 80 cm2 (centimeters squared) was debrided. Silver nitrate used and multiple figure of 8 vicryl sutures. Additional necrotic tissue was not removed as severe bleeding, patient discomfort and poor visualization precluded further debridement. IV (intravenous) abx (antibiotic). Agree with continued treatment.A review of an Infectious Disease consultation dated 6/2/26 at 10:19 AM, documented in part . Reason for Consult: infected decubitus ulcer. Infected decubitus ulcer/abscess with fat necrosis. 5/30 cultures: GPC (gram-positive cocci), GNB (gram-negative bacilli/rods), GPR (gram-positive rods/bacilli). Continue IV vancomycin and stop IV zosyn: start IV Unasyn. Medical Decision Making: This is considered a severe infection and without appropriate treatment the progression of this infection may have significant risk of morbidity and may require escalation in level of care.A review of the hospital Discharge Summary dated 6/5/26 at 11:51 AM, documented in part . Principle Problem: Gluteal abscess. Procedures Performed: Debridement of wound. Hospital Course. seen and evaluated originally admitted to the hospital treated for infected decubitus seen by Medicine Infectious Disease debridement of the wound patient's otherwise stable discharge to a different group home with instructions to follow up outpatient.A review of the medical record revealed no documentation of the resident to have been on cefazolin therapy at the facility as reported to the EMS personnel and ER physician.On 7/29/26 at 11:29 AM, the Wound Nurse (WN) A was requested from the Administrator and Director of Nursing (DON) for an interview. Shortly after the DON stated WN A was off duty.On 7/29/26 at 11:49 AM, the DON was interviewed and asked the name of the facility's wound doctor and if they examined the residents with wounds weekly. The DON replied the facility had WN A who oversees the wounds and reports the findings to the facility's Medical Director. The DON explained WN A performs weekly wound measurement rounds, obtain treatment orders from the physician, and ensures preventive care is in place and if the wound needs to be assessed by the Physician they would contact the Medical Director. The DON was asked about the three day delay in the implementation of appropriate treatment for R201 wounds and the failure of the staff to promptly identify the sign and symptoms of R201's wound infection. The DON stated they would review the record and follow back up. At 12:20 PM, the DON returned and stated they felt as if the wound was improving and that . the size even improved. The DON went on to say the resident's family was disgruntled and the facility assessment showed . the smell was getting better and the wound was getting smaller. The DON stated regarding no appropriate treatment to have been in place for the three days after admission, that an aide had documented that a patch was in place when they provided care. The DON went on to say . he must have had the same treatment from the hospital on and that should technically last a week. The DON was informed that they are welcome to submit any additional documentation or explanation for review before the end of the survey. No additional information or documentation was provided.

This citation pertains to intake: 3072746.Based on interview and record reviews the facility failed to follow current standards of practice for obtaining weights for one (R202) of one resident reviewed for Nutritional concerns. Findings include:A review of a complaint submitted to the State Agency (SA) noted concerns of the resident's enteral pump malfunctioning, enteral feeding to have not been provided as ordered and staff failing to promptly correct the issue.A review of the medical record revealed R202 was admitted to the facility on [DATE] and discharged on 7/20/26, with diagnoses that included: cerebral infarction (stroke), dysphagia (swallowing difficulties) and severe protein-calorie malnutrition. R202 required staff assistance for Activities of Daily Living (ADLs).A review of the weights obtained for R202 revealed one documented weight dated 7/5/26 AT 12:59 pm at 167 lbs. (pounds).There were no other weights obtained nor documented in the medical record.A review of a Nurse Practitioner (NP) note dated 7/6/26 at 9:54 PM, documented in part . Due to ongoing dysphagia PEG (percutaneous endoscopic gastrostomy) tube was placed.On 7/16/26 at 9:51 AM, a Nutritional assessment completed almost two weeks after admission documented in part . NPO r/t (related to) dysphagia. Current enteral order adequate to meet nutritional needs. Nursing reports tolerating feedings via pump currently. Suggest + bolus feedings. Monitor weights weekly.On 7/29/26 at 1:09 PM, the weight protocol policy for new admissions was requested from the Administrator and Director of Nursing (DON).A review of the facility policy titled Guidelines for Weight Tracking with a review date of 7/1/26 also failed to provide guidance on the current standards of practice for obtaining weights for newly admitted residents.On 7/29/26 at 2:19 PM, the Administrator and DON was asked to have the Dietician come to the conference room for an interview. At 2:35 PM, the Administrator responded that the Dietician was on personal leave.At 3:13 PM, the DON was asked about the one weight obtained for R202 and asked to provide all weights obtained for R202. The DON stated they would look into it and follow back up. The DON returned at 3:29 PM and acknowledged that no other weights were obtained for R202. The DON stated the Dietician seen the resident on 7/16/26 and the resident discharged shortly after on 7/20/26, before the facility could start the weekly weights on the resident.Review of the Centers for Medicare & Medicaid Services guidance documented in part . Current professional standards of practice recommend weighing the resident on admission or readmission (to establish a baseline weight), weekly for the first 4 weeks after admission and at least monthly thereafter to help identify and document trends.

Based on interview and record review, the facility failed to implement key elements of an effective water management plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility . Findings include:On 7/7/2026 at 9:45 AM reviewed Water Management Program (WMP) documents with the Director of Plant Operations (DPO) N. Review of the document titled Legionella Water Management Plan (undated, 6 pages) identified the Water Management Team (WMT) as: Executive Director, Director of Plant Operations, Director of Health Services, and Director of Environmental Services. When asked about how the WMT functions, DPO N indicated that they do not meet regularly and have not met in the past year. The current WMP has not been reviewed/updated annually by the WMT.The WMP documents did not include a facility risk assessment to identify areas where Legionella and other opportunistic waterborne pathogens could grow and spread. The WMP did not include procedures for communication of WMP activities to the WMT, including annual legionella testing results and follow up activities.Though not indicated in the Legionella Water Management Plan (undated) document, the facility conducts annual legionella testing, and 2026 annual legionella testing results were reviewed. When asked about communication with the WMT about the testing results, DPO N indicated consulting with the corporate maintenance support person and following instructions to apply engineering controls (cleaning, disinfecting, changing faucet aerators and shower heads) when needed. DPO N indicated the WMT was not informed of the annual legionella test results, and no retesting had taken place. On 7/7/2026 at 11:25 AM interviewed the Director of Health Services (DHS). When asked about WMT involvement, she indicated the WMT doesn't meet regularly and DPO N would share concerns as needed. When asked if she was aware of annual legionella sampling results from 2025 or 2026, she was not. When asked if there had been any legionella cases in the past year, she indicated there were not.On 7/7/2026 at 11:45 AM interviewed the Executive Director (ED). When asked about WMT involvement, he indicated the WMT doesn't meet regularly. When asked if he was aware of annual legionella sampling results from 2025 or 2026 before today, he was not. He indicated that going forward the facility would include the WMP in their Quality Assessment and Performance Improvement (QAPI) program.On 7/7/2026 at 2:10 PM asked ED and DHS for any additional policies or procedures for their WMP. Corporate Clinical (CC) staff member A provided a corporate standard operating procedure (SOP) document titled Annual Legionella Testing dated 4/3/2019. This document was not currently part of the facility WMP documents. Record review of this document indicated that: Facilities Management Support will collaborate with the campus and [the vendor lab] to create the action plan for positive results. All results, retests, and steps taken must be uploaded into [electronic maintenance logs] and a copy kept in the Water Management Binder. The SOP did not include procedures for communication of testing results with the facility WMT.On 7/8/2026 at 1:45 PM An additional WMP related document was provided by DPO N for review, it was located within the facility Emergency Operations Plan and titled Legionella and Other Opportunistic Pathogens (undated). Record review of this document found the following:A risk assessment of water system components will be conducted to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems.The risk assessment will be completed by facility leadership and the Infection Preventionist with collaboration from other facility team members such as maintenance employees, safety officers, risk and quality management staff, and Director of Nursing.The facility will conduct an annual review of the water management program as part of the annual review of the infection prevention and control program.

Based on observation, interview and record review, the facility failed to determine self-administration of medications was safe and appropriate for three (R5, R46, R30) of four observed with medications at the bedside. Findings Include. R46 On 7/6/26 at 10:11AM, R46's bedside table was observed revealing two tubes of Vitamin A&D ointment (moisture barrier topical medication) and one tube of Calmoseptine (zinc and menthol topical medication). Record review of R46's Medication Administration Record (MAR) did not indicate Vitamin A&D and Calmospetine was ordered and no prescriber's order to self-administer. On 7/7/2026 at 8:11AM, During medication administration for R11, one tube of Vitamin A&D ointment was observed on the bedside table. Record review of R11's MAR did not indicate Vitamin A&D was ordered and no prescriber's order to self-administer. On 7/7/26 at 12:21 PM, R46 was interviewed with their daughter at bedside. When inquired about having Vitamin A&D ointment and Calmoseptine, R46 could not explain the purpose of the medications and per the daughter, R46 had confusion and would not understand their use. The daughter further stated that R46 had a history of dry skin over their eye and had a history of chaffing in between their legs. Per the daughter, they assumed it may have been for those skin conditions but was not certain. R30 On 7/7/2026 at 12:20 PM, an observation of R30's room revealed a tube of Zinc Oxide (mild antiseptic skin protectant) observed at bedside. Record review of R30's MAR did not indicate Vitamin A&D was ordered and no prescriber's order to self-administer. On 7/7/26 at 4:34 PM, the Director of Nursing (DON) was interviewed and confirmed that Vitamin A&D ointment, Calmoseptine, and Zinc Oxide are medications and would have to be documented on the MAR. The DON acknowledged residents must have an order to self-administer and medications are not left at the bedside. R5 On 7/6/26 at approximately 9:25 AM, R5 was observed lying in bed. The resident was alert and able to answer questions asked. During the interview two bottles of anti-fungal powder were observed on top of the resident's nightstand. R5 was asked about the powder and noted that they apply it underneath their breast because their fungus causes itchiness. A review of R5's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: encephalopathy, dementia, anxiety and psychotic disorder. Continued review of R5's clinical record did not note any orders for fungal powder, nor were there any orders that the R5 could self-administer medication. On 7/7/26 at approximately 10:31 AM, a second observation was made of R5. The two bottles of fungus powder were still in their room. On 7/7/26 at approximately 11:25 AM, an interview was conducted with the Director of Nursing (DON). The DON was queried as to the fungus powder and whether R5 could self-administer the medication. The DON reported that the resident did not have an order to self-administer medication.

Based on observation, interview and record review, the facility failed to ensure medications were stored safely, securely, and properly, in one of two medication administration carts, two of two treatment carts, and one of one medication room observed for medication storage and labeling. Findings include:On 7/7/26 at 7:56 AM, the [NAME] Trail treatment cart was observed unlocked, the top drawer revealed resident treatment medications.On 7/7/26 at 8:16 AM, the [NAME] Trail medication cart was observed for medication storage with Licensed Practical Nurse (LPN) C and revealed a bottle of lubricating eye drop medication and a nasal spray medication with no patient identifiers. LPN C acknowledged they did not know who they were prescribed to and commented they would have to find out. The second drawer revealed a round orange colored pill tablet unpackaged. The third drawer was observed with two round white colored pills unpackaged.On 7/7/26 at 8:56 AM, the Assistant Director of Nursing (ADON) E provided access to the [NAME] Lane medication room. The lower drawer of a medication cart in the medication room revealed bags of intravenous (IV) fluids. ADON E acknowledged they were current medications and available for residents who required intravenous fluid replacement. The bags were examined for expiration dates and revealed the following: two bags of D5 (dextrose) expired in October 2025, one bag of D10 (dextrose) expired in April 2025, one bag 0.45 (half normal saline) expired April 2025, and one bag of D5 with normal saline expired January 2026. ADON E acknowledged the medications were expired and was observed immediately throwing them into a garbage bag.On 7/7/26 at 4:34 PM, the Director of Nursing (DON) was interviewed and remarked Nursing staff had informed them of the medication storage concerns including unidentified medications in the medication carts and expired IV fluids. The DON was also informed of the treatment cart being unlocked and acknowledged the concerns.On 7/8/26 at 8:21 AM, the [NAME] treatment cart was observed unlocked and the top drawer revealed resident treatment medications.On 7/8/26 at 8:31 AM, ADON E was made aware of the unlocked treatment cart and acknowledged it should not be left unlocked.Record review of the policy titled Medication Storage in the Facility documented; Medications and biologicals are stored safely, securely, and properly.All expired medications will be removed from the active supply.

Based on observation, interview and record review the facility failed to ensure a resident's medical record was accurate and complete for one (R73) of one resident reviewed for accurate resident records. Findings include:On 7/6/26 at approximately 10:39 AM, R73 was observed lying in bed. The resident was alert but had difficulty answering questions asked due to a language barrier. The resident's family member was present and noted that the resident was admitted to the facility on [DATE] following a fall at home.A review of R73's electronic medical record was conducted utilizing the Quick Guide for Surveyor form. The form noted that to obtain resident's diagnoses the Surveyor should review the residents face sheet by scrolling to current IDC-10 (international classification of diseases). An attempt was made to obtain R73's diagnoses via their face sheet, but no diagnoses were noted.Continued review of R73's clinical record revealed, in part the following:7/7/26 (9:24 AM): Resident admitted with dx (diagnosis) of depression & insomnia and will remain on trazadone (an antidepressant used to regulate mood and also acts as a sedative). Authored by Social Service Director (SSD) B.On 7/7/26 at approximately 12:22 PM, an interview was conducted with SSD B. SSD B was asked as to how they obtained the diagnoses of depression and insomnia for R73 as nothing had been noted on the resident's face sheet. SSD B reported that when no diagnoses are noted on a face sheet, they are instructed to view the resident's hospital records provided upon entry. SSD B noted that it is often difficult to find the diagnoses via hospital records. When asked how they determined the resident had a diagnosis of depression and insomnia, SSD B pulled up R73's hospital record, scrolled though several pages and pointed out an area on the documentation that noted the resident had a H/o (history of) Insomnia. SSD B could not locate a diagnosis of depression and noted that they would revise their note as Depression was not noted.On 7/8/26 at approximately 9:35 AM, the Administrator was queried as to why R73 did not have accurate diagnoses in their medical record face sheet. The Administrator reported that they were aware that newly admitted residents' diagnoses are not placed in the residents' records by facility staff and suggested speaking with Corporate Clinical Registered Nurse (CCRN) A.On 7/8/26 at approximately 9:41 AM, an interview was conducted with CCRN A. CCRN A was asked about the delay in putting in residents diagnoses on their face sheets and the issue that occurred with R73. CCRNA noted that they were aware of the delay with residents' diagnoses being entered into their medical records and confirmed that putting in incorrect diagnoses is a concern.On 7/8/26 at approximately 8:44 AM, a request for the facility policy pertaining to accurate medical records was made. No policy was provided before the end of the survey.

Based on observation, interview and record review the facility failed to ensure tube feeding automatic water flush was administered per the physician order for one [R70] of one resident reviewed for tube feeding. Findings include:On 7/6/26 at 9:45 AM, R70 was observed lying in bed. A tube feeding pole was observed next to R70's bed. Two bags were hanging from the top of the pole, one contained the tube feeding formula and one contained water. The tube feeding pump indicated it was delivering the formula. The bag containing the water for automatic flush appeared to be full, it was at the 1000 milliliters [ml] mark at the top of the bag. Upon further observation, the pump was not set for automatic water flush, the settings were blank. R70 was asked if they were able to eat or drink food or water in addition to their tube feeding. R70 explained they only received tube feedings, they did not eat or drink any food or water.Review of the clinical record revealed R70 was admitted into the facility on 7/3/26 with diagnoses that included: stroke, dysphagia [difficulty swallowing] and lung cancer. According to a Brief Interview for Mental Status [BIMS] exam dated 7/3/26, R70 was cognitively intact.Review of R70's tube feeding care plan initiated 7/6/26 revealed interventions that included, .Administer enteral feeding per doctor's order. Assess for dehydration.Review of physician orders for R70 revealed an order with a start date of 7/5/26 for automatic water flushes with a rate of 40 ml/hr [milliliters per hour].On 7/6/26 at 2:59 PM and 7/7/26 at 9:00 AM, observation of R70's tube feeding revealed a full bag of water, 1000 ml, and the pump not set to deliver automatic flushes.On 7/7/26 at 10:04 AM, R70's automatic flush settings was observed with the Director of Nursing [DON]. The DON verified the flush bag was full, and that the pump was not set to deliver automatic flushes. On 7/7/26 at 11:16 AM, the DON explained R70 should have been getting automatic flushes at 40 ml/hr, and she had contacted the doctor and told the dietician that R70 had not been receiving flushes. Review of a facility policy titled, Tube Feedings undated read in part, .Pumps allow rates to be set for feeding product and water flushes.

Based on observation, interview and record review, the facility failed to provide a clean, comfortable, homelike environment for one [R69] of two residents reviewed for environment. Findings include:On 7/6/26 at 9:27 AM, R69 was observed sitting in a wheelchair in their room. R69 was asked if they had any concerns about the facility. R69 explained on Saturday [7/4/26] they were taking a shower in the bathroom when they had an accident [bowel movement]. the aide just put a towel over it. on Sunday [7/5/26] they told Licensed Practical Nurse [LPN] 'L' about the bathroom floor not being cleaned up and he sent three people in to clean it, but it still was not clean. Observation of the floor in R69's bathroom between the toilet and the shower area revealed multiple spots of brown material, some approximately the size of a quarter, some approximately the size of a dime and some dot like. An area of grout between the tiles that had the appearance of a brown colored liquid dried on the grout. When told of the observation of the bathroom floor, R69 explained they kept a very clean, tidy house and it was upsetting that the bathroom floor at the facility was not clean.Review of the clinical record revealed R69 was admitted into the facility on 7/3/26 with diagnoses that included: hydrocephalus [buildup of cerebrospinal fluid in the brain], anxiety disorder and paroxysmal atrial fibrillation. According to a Brief Interview for Mental Status [BIMS] exam dated 7/6/26, R69 was cognitively intact.On 7/7/26 at 9:03 AM, observation of R69's bathroom floor revealed the same spots of brown material and grout staining.On 7/7/26 at 2:11 PM, LPN 'L' was interviewed and asked about R69's bathroom floor. LPN 'L' explained R69 was getting a shower on Saturday when they had a bowel movement. had thought Certified Nursing Assistant [CNA] 'M' had cleaned it up, but on Sunday R69 told him the floor was still not clean. the CNA on Sunday was a different CNA and he did not think she should have to clean up the mess because CNA 'M' was working on a different hall, so he went and told CNA 'M' to clean R69's bathroom floor. CNA 'M' came with two other staff members and said they cleaned the floor. then R69 had told him the floor still was not clean that morning, so he had housekeeping go in and clean it.On 7/8/26 at 12:49 PM, CNA 'M' was interviewed by phone and asked about R69's bathroom floor. CNA 'M' explained she was giving R69 a shower on Saturday when R69 had a bowel movement. she put a towel on top of the bowel movement and continued the shower. tried cleaning it up with towels as best as she could. the next day she and a friend finished trying to clean it up. CNA 'M' was told of the observation of the spots of brown matter that were still present on Monday and Tuesday. CNA 'M' explained she had cleaned it up the best she could.On 7/8/26 at 1:43 PM, the Administrator was interviewed and asked if it was acceptable for brown matter to be present on a bathroom floor from Saturday to Tuesday. The Administrator explained that was not acceptable and it was his expectation that the floor should have been cleaned on Saturday.Review of a facility policy titled, Room Cleaning-Health Center Rooms undated read in part, .Clean floor and remove trash replacing bags. Use the room. Service Standards checklist to ensure room meets standards.

This citation pertains to intake #MI00153247. Based on interview and record review the facility failed to administer blood pressure medications per physician's orders for one resident, (R901) of one resident reviewed for medication administration. Findings include: On 6/18/25 at 8:30 AM, a review of R901's closed clinical record revealed they re-admitted to the facility after a hospital stay on 5/7/25 with diagnoses that included: chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, chronic kidney disease, diabetes, and anxiety disorder. A review of R901's physician's orders and medication administration record (MAR) for May 2025 was conducted and revealed an order for metoprolol (a blood pressure medication) 25 milligrams to be given daily between 6 AM and 10 AM. The order contained, Special Instructions that read, HOLD FOR SBP (systolic blood pressure) LESS THAN 110 OR HR (heart rate) LESS THAN 60. R901's MAR indicated indicated the medication had been given on 5/8/25 with a documented blood pressure of 101/56, and on 5/11/25 with a documented blood pressure of 101/59. A progress note entered into the record on 5/8/25 at 11:24 AM by Nurse 'A' after the morning administration of the metoprolol with the documented blood pressure of 101/56 was reviewed and read, Resident blood pressure has been low all morning. Last reading was 85/57 .NP (Nurse Practitioner) notified. New order for one time dose of Midodrine (a medication used to increase low blood pressure) and once daily if systolic is less than 90. R901's MAR indicated they received a 10 milligram dose of Midodrine at 11:30 AM on 5/8/25. On 6/17/25 at 12:10 PM, an interview was conducted with the facility's Director of Nursing and they indicated the metoprolol should have been held per the instructions. A review of a facility provided policy titled, MEDICATION ADMINISTRATION GENERAL GUIDELINES was conducted and read, .B. Administration .2. Medications are administered in accordance with written orders of the prescriber .

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On [DATE] during an initial observation of the kitchen between 7:10 AM-7:40 AM, the following items were observed with the Dining Services Assistant (Staff 'B'): The top loading/reach-in ice cream cooler did not have an internal thermometer and had visible thick build-up of ice around the top perimeter of the inside wall (near the top sliding doors about 8 inches in depth. Four of the six large cardboard containers of ice cream had a sticker with a use by date of ,d+[DATE], but the lids were not fitted properly and exposed the ice cream which was observed to have a darker colored top layer of ice cream covering. Staff 'B' reported the ice cream freezer was not hooked up to their electronic temperature monitoring via the iPad as the other walk-in/reach-in coolers and freezers were and should have a manual thermometer one for sure. Staff 'B' looked throughout the ice cream cooler and was unable to locate a manual thermometer. The bulk dry food items (sugar, bread crumbs, powdered sugar, and flour) were observed stored loosely in plastic bins. The clear, plastic lids for four of the six containers were observed broken with missing corner pieces and cracks which exposed the internal contents. Staff 'B' confirmed the same observation and reported those would need to be ordered. The wire shelf next to the bulk dry food items contained two large, black, rectangular containers that contained two broken plastic lids for the bulk dry food items, several silicone molds for pureed food, and four containers of five pound baking powder with a manufacturer's use by date of Best if Used By APR (April) 21, 2024 and a facility sticker that read Received on [DATE]. When asked about why the baking powder was stored there, and why it was still available for use if it expired in 2024 and was labeled as received after it had already been expired, Staff 'B' reported they weren't sure why those were there in the black container and further reported maybe they were intended to be discarded by the Director of Food Services and accidentally left there. The dry storage room had a bag of popcorn kernels with a sticker that identified it was received on [DATE]. The built-in zipper on the bag was not sealed properly and left the inner contents exposed. Staff 'B' reported the popcorn should not have been left unsealed and removed the bag from the shelf. There was a stainless steel storage rack just outside the dry food storage room that had several empty cans that were stored in a box as well as several loose cans stored on the shelf outside the box. There were two food equipment items stored directly next to these empty cans that were loosely covered with a clear trash bag. The bottom (base) portion of the food equipment was not covered. Staff 'B' confirmed the empty cans were from a resident and they should've been stored in a bag away from that area. When asked to identify the specific food equipment, the Staff 'B' reported they were two waffle machines. On [DATE] during additional observations of the kitchen between 11:35 AM-11:50 AM, the following items were observed with the Director of Food Services (DFS): The ice cream cooler was now observed unplugged and defrosted in front of the three compartment sink. When asked about the earlier observations and concerns, the DFS reported there was a thermometer in the ice cream cooler. The DFS was informed that was put in after the observation with Staff 'B' when they were unable to locate the thermometer. When asked about the build-up inside the cooler and poorly fitted ice cream lids, the DFS reported that was how the containers came. When asked if staff should be making sure the containers are properly fitted to preserve the internal contents, the DFS reported they should. The DFS further reported they suspected the ice build-up was because staff let the top open at times and staff went in/out to help themselves to the ice cream as well. The bulk dry storage lids remained broken and in place. When asked about the broken lids, the DFS reported new bins were ordered already and asked if that would help. They were asked in the mean time, the concern was that the food items remained not properly stored. When asked about the expired baking powder and facility labeling, the DFS reported they had no explanation for that. When asked about the storage of the popcorn, the DFS reported staff should've made sure the bag was adequately closed. According to the 2017 FDA Food Code section ,d+[DATE].11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (A) Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. According to the 2017 FDA (Food and Drug Administration) Food Code section ,d+[DATE].11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, (A) Food shall be protected from cross contamination by: .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: .(b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented,. According to the 2017 FDA Food Code section ,d+[DATE].12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. According to the 2017 FDA Food Code section ,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 . According to the facility's policy titled, Food Labeling and Dating Policy dated [DATE]: .Any food product removed from its original container, has a broken seal, has been processed in any way must have a label that contains the following .Date and Time the food was labeled .Use by date .Securely cover the food item . According to the facility's policy titled, Hot & Cold Temperature Holding Guideline dated [DATE]: .Thermometers should be in all refrigerators, freezers, and storage areas .

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices during medication administration for one (R88) of three residents observed. Findings include: On 5/6/25 at 7:48 AM, Nurse 'C' was requested to observe medication pass with R88. Nurse 'C' reported they had just obtained the resident's vital signs and began retrieving medication from the medication cart. Nurse 'C' was not observed using hand sanitizer, or washing their hands after opening the medication drawers, touching the water pitcher, or using the laptop to review the medications. On 5/6/25 at 7:55 AM, while Nurse 'C' poured out the medication from the pre-packaged plastic packets into a small clear plastic cup, one of the pills fell on to the top of the medication cart. Nurse 'C' picked the pill up with their bare hands and placed the pill into the plastic cup and proceeded to administer the medication to R88. Nurse 'C' was not observed to use hand sanitizer until after the med pass was completed (not after opening of the med cart drawers, touching the water pitcher, or using the laptop keyboard). On 5/6/25 at 10:25 AM, Nurse 'C' was informed of the concerns with infection control during the earlier observation during medication administration and reported they should not have done that. On 5/6/25 at 10:30 AM, the Director of Nursing (DON) was informed of the concerns with infection control during observation of the medication administration with Nurse 'C' and they reported they would follow-up with the nurse. According to the facility's policy titled, Specific Medication Administration Procedures dated 11/2018: .Wash hands when beginning a med pass, or when contact with resident is expected or has occurred .For solid medications .Pour or push the correct number of tablets or capsules into the souffle cup, taking care to avoid touching the tablet or capsule, unless wearing gloves .

Based on observation, interview, and record review, the facility failed to maintain the exterior dumpster area in a clean manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 5/6/25 at 11:45 AM, during an observation of the garbage/refuse area with the Director of Food Services (DFS), there was an accumulation of trash and leaf debris around and behind the two dumpsters. Additionally, one of the two dumpsters was unable to be closed properly due to a large wooden object that prevented the lid from closing. When asked how often garbage was picked up, the DFS reported daily. When asked who was responsible for maintaining the surrounding area, they reported that was between Dietary staff and Maintenance. On 5/6/25 at 11:52 AM, an interview was conducted with the Maintenance Director (Staff 'G'). When informed of the observation with DFS, they reported they were aware there was some debris on the ground behind the dumpsters which was mostly leaves. They were informed that there was much more than leaves, including gloves and other trash. They reported that area should've been maintained and would follow-up. According to the facility's policy titled, Garbage and Refuse dated January 2025: .Garbage and refuse will be deposited in sealed containers outside of the organization to prevent the harborage and feeding of pests. The dumpster area will be maintained in sanitary condition, clear of trash and spills. Drain plugs must be in place and lids kept closed .

Based on interview and record review, the facility failed to ensure Physician/Physician Extender progress notes were entered into the clinical record in a timely manner for four residents (R#'s 13, 29, 138, and 37 ) of four resident's reviewed for Physician/Physician Extender progress notes. Findings include: R13 On 5/7/25 at 10:00 AM, a review of R13's clinical record revealed a note entered into the record by Nurse Practitioner (NP) 'I' on 3/30/25 for an acute care visit for pain management that occurred on 2/26/25. R29 On 5/7/25 at 10:08 AM, a review of R29's clinical record revealed the following: A note entered into the record by NP 'I' on 3/28/25 for an acute care visit that occurred on 2/25/25. A note entered into the record by NP 'I' on 2/19/25 for an acute care visit that occurred on 1/29/25. A note entered into the record by NP 'I' on 2/4/25 for an acute care visit that occurred on 1/13/25. R138 On 5/7/25 at 9:10 AM, a review of R138's clinical record revealed they admitted to the facility on [DATE] and discharged on [DATE]. R138's progress notes entered into the record by Dr. 'J' revealed two notes dated 3/31/25 (after R138's discharge) for an admission visit and a history and physical visit that occurred on 3/6/25. 38271 R37 On 5/6/25 the medical record for R37 was reviewed and revealed the following: R37 was initially admitted to the facility on [DATE]. A review of R37's MDS (minimum data set) with an ARD (assessment reference date) of 2/11/25 revealed R37 needed assistance from staff with most of their activities of daily living. R37's BIMS score (brief interview for mental status) was nine indicating severely impaired cognition. A review of R37's Medical Provider evaluations conducted by NP I revealed the following: A note dated 3/19/2025 at 6:37 AM. had a DATE OF SERVICE of [DATE] .VISIT TYPE: Acute- A note dated 2/28/2025 at 8:45 PM. had a DATE OF SERVICE of [DATE] .VISIT TYPE: Acute- A note dated 2/24/2025 at 7:04 AM. had a DATE OF SERVICE of [DATE] . VISIT TYPE: Lab (review)- On 5/7/25 at approximately 10:01 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the delay in having the medical provider documentation in the EMR (electronic medical record) for timely review and they indicated that the medical provider group uses a different software program than what the facility uses and when the providers sign their notes is when the documentation gets implemented in the EMR. The DON was queried how staff could read what the provider had written on their evaluations of a resident after their visit and they indicated they could not read anything until the provider's put their notes in the EMR. The DON was queried how long do providers have to put in their notes and they indicated it should be a few days. The DON acknowledged the potential for miscommunication when the providers were putting in their notes weeks after their visits. On 5/07/25 at approximately 10:35 a.m., NP I was queried regarding the delay in having their notes in the EMR for review and they reported that the software they use delays the implementation of their evaluations and notes.

Based on interview and record review, the facility failed to obtain a resident's code status in a timely manner for two residents, (R#'s 138 and 139) who were their own responsible parties, of two resident's reviewed for code status, resulting in the potential for end of life wishes not being met. Findings include: R138 On [DATE] at 11:06 AM, a review of R138's clinical record revealed they admitted to the facility on [DATE] with intact cognition and was their own responsible party. A review of an admission note entered into the record by Nurse 'A' on [DATE] read, .Resident requested status for DNR (Do Not Resuscitate, or no Cardiopulmonary Resuscitation) and was given DNR paperwork but was educated that she would remain a CPR (Full Code) until she speaks with social worker and Consent to Treat signed, dated and recorded . A review of R138's orders revealed an order dated [DATE] that indicated they were a full code. The order was discontinued on [DATE] and an order for DNR was entered on [DATE]. R139 On [DATE] at 10:56 AM, a review of R139's clinical record revealed they admitted to the facility on [DATE] with intact cognition and was their own responsible party. R139's nursing and physician's assistant admission notes on [DATE] did not address R139's preference for code status. A review of R139's orders revealed an order for a full code entered on [DATE]. A Social Services progress note dated [DATE] was reviewed and read, Resident wishes to be DNR and signed the form . R139's order for a DNR was entered on [DATE], five days after they admitted to the facility. On [DATE] at 2:11 PM, an interview was conducted with the facility's Director of Nursing (DON). They were asked about the process for obtaining code status for residents who were their own responsible parties and said the admission nurse should ask their preference and if they wish to be a DNR, two other staff members should witness the decision, and the admitting nurse, the resident, and two staff witnesses should sign the form. They went on to explain that after the form was signed, the Nurse was to electronically send the form to the medical provider group and a practitioner would sign the order. They were asked what a reasonable time would be to obtain the order from the practitioner group and said it should ideally be no later than the next business day or Monday if someone admits over a weekend. A review of a facility provided policy titled, Guidelines for DNR Orders dated ,d+[DATE] was conducted, however; the policy did not address timeframe guidelines for obtaining the resident's DNR wishes.

Based on interview and record review, the facility failed to provide readily accessible Medication Regimen Review (MMR) documentation within the Electronic Medical Record (EMR) to ensure the residents condition, care, and services were obtainable by all disciplines for five residents (R17, R27, R33, R150, R15, R251) of five reviewed for unnecessary medications. Findings include: On 4/15/24, The following Residents (R17, R27, R33, R150, R15) were selected for an unnecessary medication review investigation and included evaluation of the facilities MMR process, documentation, and pharmacy recommendations. On 4/16/24, The EMR was reviewed for R17, R27, R33, R150, and R15, and MMR documentation was not readily accessible. The Director of Nursing (DON) was questioned how to obtain the MMR within the EMR and confirmed MMR documentation is not located in EMR and uploaded into a different software program. The DON indicated to obtain the MMR medical records, the names of the residents would have to be disclosed and forwarded and retrieved by designated staff members. 49272 R251 On 04/15/24 at 1:36 PM R251 was observed lying in bed with the power cord for the overhead light wrapped tightly around two of her fingers, aggressively pulling the cord to power the light on and then off again. The Resident appeared anxious and restless. Family member N at resident's bedside reported that the Resident will get fixated on the cord/light sometimes and can be difficult to re-direct at times. On 04/16/24 at approximately 12:30 PM an attempt was made to review R251's activity records, no records were found within electronic health record (EHR). On 04/16/24 at 2:11 PM, an interview was conducted with Life Enrichment Director O who reported that they had just completed a change of condition assessment for R251, however those records are documented within a separate EHR system. The survey team was not given access to that system. 34275 On 4/17/24 at approximately 2:34 PM, a Quality Assurance Performance Assurance (QAPI) interview was conducted with the Administrator. The Administrator was queried as to the facility's protocol for ensuring resident's medical records are readily accessible and systematically stored, including, but not limited to pharmacy recommendations, physician responses, and activity notes. The Administrator reported that they were aware that the documents were not all located in the residents' electronic records and noted that a sister facility was working on a pilot program that they possibly would develop as well.

Based on observation, interview and record review the facility failed to ensure proper infection control protocols and practices including enhanced barrier precautions (EBP), hand hygiene during medication pass and proper cleanliness of medical equipment for R150, R44 R202, R203, R204 and R20. This deficient practice had the potential to affect multiply residents residing at the facility. Findings include: On 4/15/24 at approximately 9:30 AM, an entrance conference meeting was conducted with the Administrator. The Administrator was asked if there were any resident's in the building with COVID-19 and/or on EBP. At that time the Administrator reported that to their knowledge there were none. R150 On 4/15/24 at approximately 10:03 AM, upon entry into the resident's room, there was no precaution signs on the resident's door. During the interview, the resident reported that they went to dialysis three times per week. A review of R150's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: urinary tract infection, dependent on renal dialysis and sepsis. A review of R150's care plan (dated 4/9/24) documented, in part: Problem: Resident requires enhanced barrier precautions (EBP) during high-contact care related to presence of: Dialysis catheter .Approach: Don/doff and dispose of PPE .Utilize gown and gloves per EBP policy during high contact ADL care .and during linen change . On 4/16/24 at approximately 8:35 AM, there was no EBP documentation on their door. On 4/17/24 at approximately 10:00 AM, there was no EBP documentation on their door. R44 On 4/15/24 at approximately 11:02 AM, the surveyor entered into the resident room. There were no infection control precautions noted on the resident's door. R44 was observed lying in bed and was able to answer questions asked. The resident reported they had a stroke and was at the facility for rehabilitation and had received feeding assistance via a peg tube. Upon entry to the R44's room and after leaving the interview there was no precaution instructions on the resident's door. At approximately 11:25 AM, an EBP notification was observed on the resident's door. The Director of Nursing (DON) reported that the instructions had just been posted on the resident's door as the resident had an open area for feeding tube placement. A review of R44's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: hemiplegia following cerebral infarction (paralysis from stroke), pneumonia and dysphasia. The resident's care plan documented, in part: Problem: Resident required tube feeding d/t (due to) dysphasia. This places resident at risk for complications. Transitioned to oral diet. Feeding tube remains in place .Approach: check placement and patency of feeding tube . 49083 Medication Administration Observation R202, R203, R204 Record review of the facility policy, Medication Administration General Guidelines Revised 11/18 stated, .Handwashing and Hand Sanitation: The person administering medications adheres to good hygiene before and after administration of medications . R202 On 4/16/224 at 3:48 PM, During medication administration for R202, Licensed Practical Nurse (LPN) C was observed not performing hand hygiene prior to resident contact for administering medications. R203 On 4/17/24 at 7:24 AM, LPN D was observed for medication administration for R203 and did not perform hand hygiene prior to resident contact for administering medications. R204 On 4/17/24 at 8:10 AM, LPN E was observed for medication administration for R204. LPN E picked up a paper towel off the floor and proceeded to administer medications to R204 without performing hand hygiene. On 4/17/24 at 12:27 PM, The Director of Nursing (DON) was informed of the above findings and confirmed hand washing should have been performed prior to administering medications. Tube Feeding, Enhanced Barrier Protection R18 On 4/15/2023, A Clinical record review revealed R18 was admitted to this facility on 1/16/24 with an intracranial hemorrhage (bleeding in the skull), non-Hodgkin's lymphoma (blood cancer), atrial fibrillation (abnormal heartbeat), hypertension, and dependent on parental nutrition via a Percutaneous Endoscopic Gastronomy (PEG) Tube (nutrition provided by tube surgically placed into the stomach). Brief Interview for Mental Status (BIMS) dated 2/15/2024 for R18 equaled 0/15 indicating severe cognitive impairment. Review of the facility EBP Operating Procedure stated, .EBP will be in place for residents with the following conditions: All residents with indwelling medical devices, includes feeding tubes . PPE should be used even if blood and body fluid exposure is not anticipated . Cleaning and disinfecting any shared reusable equipment and surfaces on a more frequent schedule are encouraged . On 4/15/24 at 09:13 AM, R18 was observed lying in bed receiving parental liquid nutrition via PEG Tube. The nutrition formula bag hanging on the pole was infusing by an electronic tube feeding pump. The face of the electronic pump, pole, and four wheeled base of pole was visibly soiled with substantial amounts of brown colored dried matter. Signage alerting R18 required Enhanced Barrier Precautions (EBP) related to indwelling PEG Tube was not posted and personal protective equipment (PPE) was not visible in or around the room. Further Record Review revealed the facility did not execute an order for EBP until 4/15/2024 at 4:17 PM. On 4/16/24 at 10:49 AM, A second observation identified R18's tube feeding equipment remained visibly soiled with substantial amounts of brown colored dried matter on the face of the electronic pump, pole, and four wheeled base of pole. When questioned who is responsible for cleaning medical equipment, R18's assigned Registered Nurse (RN) G replied, housekeeping is responsible for keeping the equipment clean. RN G was shown the condition of the pump and pole and proceeded to clean the face of pump and top portion of the pole. On 4/16/24 at 10:54 AM, The Director of Nursing (DON) was brought to R18's bedside and visualized the condition of the tube feeding equipment. The DON confirmed the equipment was not sanitary and would have cleaned. On 4/16/24 at 1:24 PM, a request for the facility policy on cleaning medical equipment was made. The Nursing Home Administrator (NHA) confirmed there was no policy but is the responsibility of housekeeping when providing routine room cleaning. 49272 R20 On 4/15/24 at 9:57 AM, R20 was observed sitting in a wheelchair, upon entering the room there was no precaution sign on the resident's door. The Resident was observed to have a foley catheter with a collection bag hanging from the underside of the wheelchair. On 4/15/24 at approximately 11 AM, there was no EBP documentation on their door. A review of R20's clinical record revealed the resident was initially admitted on [DATE] with diagnoses that included: urinary tract infection, sepsis and kidney failure. A review of Resident Progress Notes from 3/4/24 at 9:29 PM revealed that the resident had a foley catheter in place at that time. A review of R20's order history revealed an order for Enhanced Barrier Precautions entered on 4/15/24 at 3:41 PM which read in part Staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities. A review of the facility Enhanced Barrier Precautions (EBP) policy stated EBP will be in place during high-contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO acquisition which include: .All Residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers .All Residents with indwelling medical devices .Includes but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes.

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) detailing estimated charges of continued services for three residents (R26, R7, and R33) out of three sampled residents reviewed for SNF Beneficiary Protection Notification. Findings include: On 4/15/24 at approximately 3:47 PM, the facility provided a completed resident SNF Beneficiary Protection Notification Review form. The form contained the 88 residents who were discharged from Medicare covered part A stay (10/16/24-4/12/24) with benefit days remaining who either discharged from the facility or decided to remain. The following residents were selected for review to determine when they were notified of their discontinuance of service coverage and rights to proceed: 1. R7: discharged from the facility on 4/3/24. 2. R26: Date of discharge 3/4/24 (remained in the facility). 3. R33: Date of discharge: 2/27/24 (remained at the facility). On 4/16/24 at approximately 1:15 PM, an interview was conducted with Social Service staff F. When asked if they were responsible for issuing SNFABN forms to residents, they indicated that they were. However, they noted that they were newly employed and was not able to provide the requested forms for R7, R26 and R33. On 4/17/24 at approximately 8:36 AM, the Administrator reported that they were not able to locate the requested documents that would indicate notification of discontinuation of service and options available for the residents. A review of the facility policy titled, NOMNC (Notification of Non-Coverage)-Standard Operating Procedure-Social Services documented, in part: Overview: To streamline communication for completion of the NOMNC and SNFABN, this .outlines the expectations for completion .If a resident is within their 100-day benefit period but we are notifying them that their coverage is ending (i.e. therapy or nursing can no longer skill them), the NOMNC should be issued. For residents being notified of discontinuation of their Medicare coverage, the NOMNC is required to be issued 2 calendar days prior to the actual discharge from Medicare .

Based on observation, interview and record review the facility failed to ensure a dependent resident was provided unwanted facial hair removal for one (R39) of three residents reviewed for Activities of Daily Living (ADL). Findings include: On 4/15/24 at approximately 10:00 AM, R39 was observed lying in bed with long facial hair (approximately 1/2 inch) on their chin. The resident was asked about ADL care provided by facility staff including facial hair removal. R39 reported that they were receiving bed baths only and had not had their hair removed in a long time. R39 stated that they would like it removed. On 4/16/24 at approximately 8:30 AM, R39 was observed in their room. The resident still had long chin hair and again reported that they would like them removed. A review of R39's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: bacteremia (bacteria in the blood stream), pneumonia and respiratory failure. A review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition). Review of the R39's care plan dated 3/17/24, documented, in part: .Category: ADLs resident requires staff assistance to complete self-care .Approach: Offer facial shaving on shower days, prn, or as requested . A review of R39's shower schedule noted the last shower/bath was provided on 4/13/24. There was no documentation noted for the removal of facial hair. On 4/16/24 at approximately 11:12 AM, an interview was conducted with Certified Nursing Assistant (CNA) B. CNA B was assigned to R39. When asked about R39's long chin hairs, they reported that they were aware of their long chin hairs and stated the resident did not ask them. When asked how staff are aware of the ADL care that should be provided, they reported that the information is in the resident's care plan. On 4/16/24 at approximately 4:36 PM, the Director of Nursing (DON) was interviewed regarding ADL care for residents, including facial hair removal for R39. The DON reported that the resident should have had their facial hair removed as noted in their care plan. The facility policy titled, Nursing ADL Documentation Guidelines was reviewed and documented, in part: Purpose: To document the type and amount of assistance provided to the resident for ADLs .ADL services will be conducted and documented by the CNA each shift at the point of care or as reasonably possible after care .

Based on interview and record review, the facility failed to provide competency documentation with proficiency of skills and techniques necessary to care and assure resident safety for three Certified Resident Care Associate/Certified Nursing Assistants (CRCA/CNA J, K, M) out of five reviewed resulting in the potential for staff incompetency and/or harm to the residents' well-being. Findings include: On 4/16/2024 at 12:01 PM, the Nursing Home Administrator was requested to provide documentation of proficiency of skills and techniques for the following CRCA's: CRCA J Hired 1/20/2023 CRCA K Hired 12/5/2017 CRCA M Hired 7/1/2020 On 4/16/24 at 3:27 PM, the Nursing Home Administrator (NHA) indicated there was a delay in retrieving three of the five CRCA's competencies and a support call was placed (to the company) into the Internal Technology (IT) department. On 4/17/24 at 11:21 AM, the NHA confirmed retrieval of CRCA J, K, M was unsuccessful, and the facility could not verify documentation of proficiency of skills and techniques were complete. The NHA revealed there is no acting staff educator for the facility. On 4/17/24 at 11:47 AM, The NHA confirmed the facility does not have a policy regarding CRCA regular in-service education, they follow the regulations.

Based on interview and record review, the facility failed to provide documentation of annual performance reviews and minimum 12-hour in-service education competencies for three Certified Resident Care Associate/Certified Nursing Assistants (CRCA/CNA J, K, M) out of five reviewed resulting in the potential for staff incompetency and/or harm to the residents' well-being. Findings include: On 4/16/2024 at 12:01 PM, the Nursing Home Administrator was asked to provide the annual competencies/inservice hours for the following CRCA's: CRCA J Hired 1/20/2023 CRCA K Hired 12/5/2017 CRCA M Hired 7/1/2020 On 4/16/24 at 3:27 PM The Nursing Home Administrator (NHA) indicated there was a delay in retrieving three of the five CRCA's competencies . and a support call was placed into the Internal Technology (IT) department. On 4/17/24 at 11:21 AM, The NHA confirmed retrieval of CRCA J, K, M was unsuccessful, and the facility could not verify if annual performance reviews and minimum 12-hour in-service education competencies were complete. The NHA revealed there is no acting staff educator for the facility. On 4/17/24 at 11:47 AM, The NHA confirmed the facility does not have a policy regarding CRCA regular in-service education, they follow the regulations.

Based on observation, interview, and record review, the facility failed to identify and assess/monitor a change in condition timely for one (R99) of two resident reviewed for diarrhea/condition change, resulting in a resident who exhibited increased fatigue, decreased participation in therapy, loose stools, and increased confusion to be transferred to the hospital initiated by a family member and the resident being admitted to the hospital with critically low sodium levels. Findings include: On 5/2/23 at 9:35 AM, R99 was observed lying in bed. At that time, R99 was asked about the care in the facility. R99 reported they had not been feeling well lately and they had diarrhea that was causing bad pain in their stomach. R99 began moaning in pain and stated, Hold on. I have to go again. R99 was observed to grimace, moan, and place a pillow on her head. R99 was not able to answer any further questions at that time and requested to resume the interview later. At 9:43 AM, R99 was heard from the hallway yelling out in pain and from the hallway was observed holding a pillow around the back of their head and grimacing. On 5/2/23 at approximately 11:00 AM, family members were observed in R99's room. Review of R99's clinical record revealed R99 was admitted into the facility on [DATE] with diagnoses that included: wedge compression fracture of first lumbar vertebra, low back pain, hypomagnesemia, hypertension, mixed hyperlipidemia, asthma, gastro-esophageal reflux disease, dementia, osteoporosis, and constipation. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R99 was cognitively intact and was always continent of urine and stool. On 5/2/23 at approximately 3:00 PM, R99 was not observed in their room. On 5/2/23 at 3:30 PM, review of R99's progress notes dated 05/02/2023 at 01:00 PM, revealed a Nursing progress note written by Nurse 'C' that read, Daughter called EMS (emergency medical services) to transfer her mother to the hospital. Patient is stable and was transfer to the hospital via ambulance per family request. On 5/2/23 at 9:00 AM, it was observed that R99 had not returned from the hospital. On 5/03/23 at 9:30 AM, an interview was conducted with Nurse 'C'. Nurse 'C' confirmed they were assigned to R99 on 5/2/23. When queried about when residents' vital signs were taken, Nurse 'C' reported during medication pass or when there was a change in condition and they were documented on the Medication Administration Record (MAR). When queried about the protocol when a resident had a change in condition, Nurse 'C' reported they would take vital signs, assess the resident, and contact the in-house Nurse Practitioner (NP 'N') and follow their orders. When queried about why R99 was transferred to the hospital, Nurse 'C' stated, From my understanding the daughter thought she was weak and called 911 without notifying the nurse. When queried about what was done about R99 having diarrhea, Nurse 'C' reported they were not aware R99 had diarrhea and nobody notified them. When queried about whether R99's vital signs were taken on 5/2/23, Nurse 'C' reported they were taken during medication pass and they passed medications to R99 around 7:45 AM or 8:00 AM. When queried about whether there was anything abnormal identified with R99, Nurse 'C' reported they did not recall anything and nobody reported anything to them. On 5/3/23 at 9:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 'G'. CNA 'G' confirmed they were assigned to R99 on 5/2/23. When queried about R99 having diarrhea, CNA 'G' reported R99 did not have diarrhea on their shift but the resident reported her bottom hurt badly because she had diarrhea all night the night before. CNA 'G' explained that they reported it to Nurse 'C'. On 5/3/23 at 10:13 AM, a phone interview was conducted with R99's family member due to the limited information documented in R99's clinical record. It was reported R99 was admitted into the facility for rehabilitation after back surgery, was doing well in therapy, and eating in the dining room. It was reported R99 had dementia, but it was not severe and was just confused at times. The family member reported R99 had increased confusion recently, had a change in appetite, and was unable to participate in therapy at times due to weakness. The family member reported they visited R99 on 5/1/23 and R99 seemed weak and sick. When they visited on 5/2/23, R99 did not look well, kept their head down, and did not want to get out of bed. R99's family member reported they contacted the facility the morning of 5/2/23 and spoke with Assistant Director of Nursing (ADON) 'A'. At that time, they requested that the NP or physician be contacted to send R99 to the hospital. ADON 'A' explained to the family member that they would contact the provider and let them know what they said. The family member reported they did not hear back so they came to the facility and saw R99 looked sick. The family member reported they asked someone if a provider could evaluate R99 and they said they would see if someone was available. After two to three hours, nobody came, and the family member decided to have R99 transferred to the hospital and called 911. The family member explained they tried to have R99 sent via non-emergent transportation, but they instructed them to call 911 and to stay on the telephone. So they were unable to notify the staff that R99 would be going to the hospital. The family member explained that R99 had been declining for a while and they talked to a physical therapist who reported R99 had not been participating much in therapy due to weakness. When queried about whether they were aware of R99 having diarrhea, the family member reported R99 had been complaining of diarrhea and pain during bowel movement. It was reported that the hospital had diagnosed R99 with low sodium and a urinary tract infection and R99 was admitted for further treatment. On 5/3/23 at 10:25 AM, an interview was conducted with Physical Therapy Assistant (PTA) 'P' who provided physical therapy to R99 on 4/29/23. When queried about how R99's session went on 4/29/23, PTA 'P' reported on that day, R99 was complaining of loose stools and they could not really work with them in therapy. PTA 'P' reported they notified nursing of the loose stools. PTA 'P' reported R99 did really well during their evaluation, was active in therapy, but more recently had fluctuating levels of participation, was lying in bed more and having trouble with their bowels. According to PTA 'P', the Nurse Practitioner (NP 'N') was notified of these changes and R99's family member spoke with the NP also as they were concerned that she had become more confused. That was discussed between therapy, social work, family, and nursing, per PTA 'P'. Review of Physical Therapy Treatment Encounter Notes for R99 revealed the following: On 4/28/23 it was documented Patient c/o (complained of) increased fatigue today. On 4/29/23 it was documented, Attempted x 3, pt need max encouragement to participate. Discussed with COTA (certified occupational therapy assistant) and family members that pt (patient) fluctuates each session and has seemed to become more confused .Unable to do pt's progress report due to bathroom breaks, max encouragement to participate . On 5/1/23 it was documented, .needing several rest breaks .Patient showing some decline in mobility today, but states she is constipated. Spoke with nursing which stated she was given something for it . Review of Occupational Therapy Treatment Encounter Notes for R99 revealed the following: On 4/28/23 it was documented, .Pt appearing fatigued and reporting unable to do it and continues to fluctuate within tx (treatment) sessions . Further review of R99's clinical record revealed the following: Review of the CNA documentation of Bowel Movements (BM) revealed R99 had a medium BM on 5/2/23 at 8:02 AM and 12:02 AM, 5/1/23 at 9:36 PM, a large BM on 4/30/23 at 9:07 AM, and a medium BM on 4/29/23 at 9:06 AM. The consistency of the BM was not documented. Review of R99's Physician's Orders and Medication Administration Record revealed R99 was prescribed a stool softener twice a day since 4/17/23 and did not receive anything additional for constipation as documented in the PT progress note on 5/1/23. On 5/1/23 at 6:47 AM, Nurse 'Q' documented R99's oxygen saturation was 89 percent (less than 93 percent is typically considered abnormal for a resident who did not require oxygen therapy). There were no nursing progress notes that addressed the low oxygen saturation, additional monitoring was conducted, or that indicated a medical provider was notified. On 5/1/23 at 4:40 PM, Nurse 'O' documented R99's oxygen saturation was 91 percent. There were no nursing progress notes that addressed the low oxygen saturation, additional monitoring was conducted, or that indicated a medical provider was notified. On 5/3/23 at 12:20 PM, an interview was conducted with Nurse 'Q'. Nurse 'Q' confirmed they worked on 5/1/23 and they were assigned to R99. When queried about R99's low oxygen saturation during that shift, Nurse 'Q' reported R99 was lying diagonally so they were repositioned and their oxygen went up above 93 percent. Nurse 'Q' did not document that R99's oxygen level was rechecked, interventions were applied (repositioning), and that it increased. Nurse 'Q' reported they did not notify the medical provider. On 5/3/23 at 12:43 PM, a phone interview was conducted with Nurse 'O'. When queried about oxygen monitoring and when a medical provider should be notified, Nurse 'O' stated, Anything less than 93 percent. When queried about whether they contacted the medical provider on 5/1/23 when R99's oxygen saturation was 91 percent, Nurse 'O' reported they did not. When asked why, Nurse 'O' reported they continued monitoring the resident, they did not have shortness of breath, and their blood pressure was normal. When queried about any changes with R99 during their shift on 5/1/23, Nurse 'O' reported there was not. When queried about diarrhea, Nurse 'O' reported they were not aware of diarrhea and only worked from 2:00 PM until 6:00 PM. On 5/3/23 at 1:00 PM, an interview was conducted with ADON 'A'. When queried about whether they were contacted with any concerns by R99's family members, ADON 'A' reported on 5/2/23, R99's family member called and said they were concerned and wanted to send R99 to the hospital. ADON 'A reported they asked the family member to hold off on sending the resident and they would have NP 'N' evaluate R99. ADON 'A' reported NP 'N' was seated in the same office during the phone call and they provided NP 'N' with the family member's number and asked them to evaluate the resident. ADON 'A' reported they did not personally assess the resident or ask the assigned nurse to. Further review of R99's clinical record on 5/3/23 at 1:05 PM revealed the following: No documented indication that R99 was evaluated by a medical provider after the family expressed concerns on 5/2/23. A progress note written by NP 'N' on 5/1/23 that revealed R99 was seen for Lab review. The following was documented, Patient is being seen today for lab review. Patient's labs were reviewed and discussed with patient. Patient denies having questions on labs. patient denies nausea, vomiting, diarrhea, constipation .patient vitals stable .No acute concerns per nursing or per the patient .Vital signs .Oxygen Saturation: 89 % (percent) . There were no other progress notes from a medical provider between the dates of 4/21/23 and 5/1/23. On 5/3/23 at 1:11 PM, an interview was conducted with NP 'N'. When queried about whether they evaluated R99 on 5/2/23 after the family contacted ADON 'A', NP 'N' stated, I could not evaluate her yesterday (5/2/23). NP 'N' reported she was in the office with ADON 'A' and ADON 'A' gave them a sticky note saying R99's daughter wanted to talk with them. NP 'N' stated, I knew the patient's status and nursing said the vitals were within normal limits so they did not evaluate R99 per ADON 'A' at the family's request. When queried about where they obtained R99's vital signs, NP 'N' reported the nurse verbally told them they were normal. When queried about why they would not evaluate a resident when onsite when the family wanted to send the resident to the hospital, NP 'N' reported they did not know they wanted to send R99 to the hospital. When queried about when they expected to be notified regarding a resident's oxygen status, NP 'N' reported they expected to be contacted if oxygen levels were below 93 percent. When queried about whether they were contacted on 5/1/23 about R99's oxygen levels of 89 percent and 91 percent, NP O reported they were not notified. NP 'O' reported they were not aware of any loose stools or increased confusion or difficulty in participating in therapy. NP 'O' reported the last time they saw the resident was last week. When queried about the documented evaluations in the clinical record dated 5/1/23, NP 'O' reported they only reviewed laboratory results with the resident while they were in the wheelchair on their way to therapy. On 5/3/23 at 1:20 PM, an interview was conducted with the Director of Nursing (DON). When queried about why R99 was sent to the hospital on 5/2/23, the DON reported R99's family member felt the resident had a UTI (urinary tract infection) because of an altered mental status. When queried if they were aware of who the family talked to, the DON reported they were not aware and stated, The family just called 911. The DON reported they were not aware that the family had spoken to the ADON 'A' earlier that morning to have R99 evaluated by NP 'N' and that R99 was never evaluated. When queried about whether changes such as increased confusion, decreased therapy participation, and bowel issues should be documented in the medical record and discussed with the medical provider, the DON reported they should. When queried about the documented low oxygen levels on 5/1/23, the DON reported the nurse said she repositioned the resident and they were fine after that. When queried about whether R99 should have been monitored more frequently after having low oxygen levels, the DON reported she was monitored each shift (It should be noted that there was not additional monitoring in the medical record). When queried if they knew what R99 was diagnosed with in the hospital, the DON reported low sodium and a UTI that I could not even justify her being treated for. On 5/3/23 at 2:34 PM, the DON provided R99's laboratory results from the hospital. Review of R99's hospital Chemistry report, R99's Sodium Level on 5/2/23 was 123 mmol/L (millimoles per liter) which was a critical result (The reference range for normal sodium level is 136-145 mmol/L). The DON stated, If the family would have waited we could have just treated that here. When queried about when R99 would have been seen if NP 'N' did not evaluate them after the family requested an evaluation and their concerns, the DON reported that was not acceptable and they would address it. In regards to the lack of documentation in the clinical record regarding R99's condition and monitoring done, the DON reported if it was not documented, they could not prove it was done. According to Merck Manual (Professional Version) article on Hyponatremia modified September 2022, Hyponatremia is decrease in serum sodium concentration . (< (less than) 136 mmol/L) caused by an excess of water relative to solute. Common causes include diuretic use, diarrhea, heart failure, liver disease, renal disease .Treatment involved restricting water intake and promoting water loss, replacing any sodium deficit, and correcting the underlying disorder .Symptoms can be subtle and consist mainly of changes in mental status .lethargy, and confusion .Hyponatremia can be life threatening and requires prompt recognition and proper treatment . A policy regarding the facility's change of condition protocols was requested. The facility provided a policy titled, Notification of Change in Condition, dated 12/31/22, that revealed the following: .The facility must inform the resident, consult with the resident's physician .A significant change in the resident's physical, mental or psychosocial status .Resident assessments for change in condition .should be completed in a timely manner .The .provider should be notified of change in condition .in a timely manner .Documentation of notification or notification attempts should be recorded in the resident electronic health record . No other policies regarding changes in condition were provided by the facility by the end of the survey.

This citation pertains to Intake Numbers: MI 674 and MI 812 Based on interview and record review, the facility failed to 1) prevent the development of pressure ulcers, 2) ensure accurate wound assessments and coordination of care with outside consultants, and 3) implement treatments timely for one (R603) of three residents reviewed for pressure ulcers, resulting in the development of multiple facility acquired pressure ulcers. Findings include: A complaint was filed with the State Agency that alleged in part, .they reported that she had a deep tissue injury (DTI - intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to her right heel . I spoke to the nurse and was told (R603) also had a wound on her left buttocks . I emailed the DON (Director of Nursing) and asked her why I wasn't made aware of the wound on the buttocks . The DON told me . that she didn't have a wound on her buttock, because she was looking in the chart and there was no treatment order. She did indeed have a wound and was discharged to home . with nursing care for a stage III (full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer, slough and eschar may be visible) to the buttock, deep tissue injury to the right heel and stage 1 (intact skin with a localized area of non-blanchable redness) . Review of the closed record revealed R603 was originally admitted into the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R603 was cognitively intact and required the extensive assistance of staff for all activities of daily living (ADL's). Review of progress and wound management notes for R603's wounds revealed: A nursing progress note dated 8/2/21 at 4:51 PM read in part, .Right heel appears to have a DTI about 2.8cm (centimeters) x 3cm . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .right heel: DTI present with overlying blister . A nursing progress note dated 8/5/21 at 10:06 PM, read in part, Resident c/o (complained of) bottom hurting. Upon assessment writer noticed an open area 0.3cm X 0.3cm . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .right heel: DTI present with overlying blister . coccyx: stage 2 (partial-thickness loss of skin with exposed dermis) present bilateral buttock . Wound Management notes dated 8/11/21 by Licensed Practical Nurse (LPN) F, who served as the wound treatment nurse, read in part, right heel deep tissue wound assessed, appears dark with black areas and peri (surrounding) area normal, measures 4x3.5cm . Residents had a MRSD [sic] (MASD - moisture associated skin damage), to right buttock . reassessed today during wound rounds it appears to be full thickness with slough (non-viable yellow, tan, gray, green or brown tissue), no drainage, no odor, measuring 2.5cm x 2cm . It should be noted MASD is not staged, only pressure ulcers are staged. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .right heel: DTI present with overlying blister . 3.5 x 3 cm . coccyx: 2 x2 Worsened presentation. Stage 2 present to coccyx and right (1.5 cm x 1 cm) and left (3.6 cm x 1.5 cm) buttock. There is active bleeding. Maceration present . Wound Management notes dated 8/17/21 by LPN F read in part, .MRSD [sic] to right buttock . it appears to be full thickness with slough . measuring 1.5cm x 1cm . new area noted on the coccyx, it appear to be MRSD [sic], measure 2.2cm, full thickness, slough at base . new MRSD [sic] noted on the left buttocks, appears full thickness, red, slough to base . measures 3.6x1.5cm . right heel DTI . measures 3.5x3cm . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .right heel: DTI present . coccyx: Improved . Right and left buttock: Improvement in size, presentation - There is moisture related [CONDITION(S)] around wound edges. Left upper gluteal wound??--3.5 cm x 2.5 cm . Differentials: Pressure, shearing (occurs when the skin remains stationary, and the underlying tissue moves and stretches and angulated or tears the underlying capillaries and blood vessels causing tissue damage) injury? . Reason for visit: Assessment right heel DTI injury, pressure ulcer to buttock . Wound Management notes by LPN F dated 8/24/21 read in part, .area on the coccyx, it appear to be MRSD [sic], measure 1.5x1cm, full thickness, slough at base . right buttock . appears to be full thickness with slough . measuring 1.5cm x 0.8cm . left buttock: increase in size from last visit, presentation - There is moisture related [CONDITION(S)] around wound edges Left upper gluteal wound 3.5 cm x 2.5 cm. Top layer of skin is removed . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . right heel: DTI present Size 4.1 x 3.3 cm . coccyx, right/left buttock: All openings have been scabbed over. Right (left) buttock: Slight increase in size. Current: 5 x 3.5 cm . The upper 50% has formation of scab . Wound Management notes by LPN F dated 8/31/21 read in part, .left buttock: increase in size from last visit . Left upper gluteal wound 5 cm x 3.0 cm . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Increase in size. 5.6 cm x 2.5 cm. Edges are reddened with slight maceration. There is grey [sic]eschar (dead or devitalized tissue that is hard or soft in texture) present to the wound bed. It is dried, necrotic tissue . Referral given . for debridement . Wound Management notes by LPN F dated 9/7/21 read in part, .left upper Gluteal increase in size from last visit 5.6x2.5cm. presentation eschar tissue with slough at wound base . refer . for sharpe debridement . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] An order dated 8/6/21 for, buttock - cleanse wound with wound cleanser or normal saline, apply triad wound cream. Twice A Day. It should be noted, the wound on R603's coccyx was first documented on 8/5/21. An order dated 8/28/21 for, clean skin to left upper buttock with n/s and apply allevyn q3 (every three) days. Every 72 Hours'. It should be noted, the wound on R603's left upper buttock (gluteal) was first documented on 8/24/21. On 9/22/21 at 1:03 PM, the DON and Clinical Care Coordinator, Registered Nurse (RN) E were interviewed concurrently and asked about R603's wounds. The DON explained R603 had acquired a DTI to her right heel at the facility. When asked about the wound on R603's left buttock that developed slough, eschar and a referral for debridement, RN E explained the wound on R603's left buttock was MASD. RN E was asked if MASD usually required debridement. RN E explained any type of wound could progress to full-thickness depth. The DON was asked who provided wound care at the facility. The DON explained NP H came once a week to stage and measure wounds and LPN F did the treatments and dressing changes. On 9/23/21 at 8:18 AM, NP H was interviewed via phone. NP H was asked about R603's wounds. NP H explained R603 developed a DTI to her right heel, then had skin breakdown on her coccyx and between the left and right buttock. NP H continued to explain she had ruled these breakdowns as Stage 2 pressure ulcers, and they had all healed on 8/31/21. NP H was asked about the wound on R603's left buttock that required debridement. NP H explained that wound was one she herself had discovered on 8/24/21, and was on R603's upper left gluteal, not between the buttocks, it was a new wound. When asked about the progress note written 8/31/21 where the right buttock was documented, NP H explained that was an error, it should have read left instead of right. NP H was asked if the wound on R603's left upper gluteal was a pressure ulcer. NP H explained she wasn't sure if it was from pressure or from shearing, as its placement fit with shearing from being pulled up in bed. When asked if a shearing injury was from pressure, NP H agreed it was. On 9/23/21 at 9:45 AM, the DON was interviewed by phone and informed that NP H had confirmed the wounds on R603's coccyx and right and left buttocks were pressure ulcers, and that there had been a new wound discovered on R603's left upper gluteal, but the facility's documentation combined it with a wound that healed. The DON had no response. Review of a facility policy titled, Pressure/Stasis/Diabetic Wound Guidelines revised 5/10/16 read in part, .1. Appropriate skin Event is completed by a RN/LPN in EHR (electronic health record). a. Complete event for each impaired area .

This citation pertains to MI 3459 Based on interview and record review, the facility failed to administer medication per a physician's order and obtain medication from the pharmacy in a timely manner for 1 of 1 resident reviewed for medications (Resident #189), resulting in R#189 being admitted to the hospital for the treatment of [REDACTED]. Findings Include: A complaint was filed with the State Agency (SA) on 7/20/20 that alleged the facility failed to provide the resident with medication to treat his salt levels . Review of the complaint revealed the following: On or around 7/9/20 (named redacted) R#189 was sent to a rehab facility, (Named Redacted). His medication prescriptions were sent over for him so the home (facility) could get them filled and continue providing them . (Named Redacted) R#189 was getting blood draws at the facility to continue monitoring his salt levels. However, the whole time he was in the rehab center, they weren't providing (named redacted) R#189 with is his medication for his salt levels. When (named redacted) (Complainant) asked why, they informed her their pharmacy didn't carry the medication. Complainant was never told about this in order to try and make arrangements. This led to R#189's salt levels becoming too low, which led to another hospitalization . On 10/6/20 at 3:23 p.m., during a phone conversation, the complainant reported, this all ended up happening on July 14 @ 11:35 a.m. I was told their (facility) pharmacy did not carry the medication, and that (named redacted) R#189 did not get it. The nurse first told me that. Then (named redacted) Nurse Practitioner (NP) 'M' called me back. I asked what his blood levels were. They (staff) had not taken his blood levels. When they did, that's when (name redacted) R#189 ended up back in the hospital. They had to give him more of the medication to get his levels back up. He was there for 3 days before coming home . A review of the clinical record revealed R#189 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the discharge MDS dated [DATE] revealed R#189's BIMS was documented as modified independence (some difficulty in new situations only) and required limited to two-person physical assistance with ADL care. The facility's baseline Care Plan dated 7/9/20 revealed the following, .Approaches: Administer meds per MD (physician) order. Maintain resident on lowest therapeutic dose. Labs per MD order . Notify MD of any abnormal labs . Physician's orders were reviewed and revealed the following: [MEDICATION NAME] (tolvaptan, a medication used to treat low sodium) tablet 6:00 AM - 10:00 AM 15 mg; Amount to Administer: 15 mg; oral; Order Once A Day Frequency low sodium for 15 days . Review of the MAR for July 2020 revealed the following: 07/10/2020 11:43 AM Late Administration: Other Comment: On time charted late . 07/11/2020 08:22 AM Not Administered: Drug/Item unavailable . 07/12/2020 07:41 AM Not Administered: Drug/Item unavailable . 07/13/2020 09:54 AM Not Administered: Drug/Item unavailable Comment: np made aware . 07/14/2020 08:11 AM Not Administered: Drug/Item unavailable . 07/15/2020 08:11 AM Not Administered: Drug/Item unavailable . 07/16/2020 08:11 AM Initialed on the MAR by (name redacted) . There was no note in the Reasons/ Comments section of the MAR 07/17/2020 08:11 AM Not Administered: Drug/Item unavailable . On 10/7/20 at 11:35 a.m., during an interview with the Director of Health Services (DHS), when asked if there was documentation that the physician had been notified prior to the progress note on 7/13/20 that R#189's [MEDICATION NAME] medication was unavailable, the DHS stated, Our main pharmacy didn't provide it. It's a specialty medication at an extremely high cost . On 10/7/20 at 11:40 a.m., an interview was conducted with NP 'M'. When queried about R#189's missed [MEDICATION NAME] medication, NP 'M' stated, I called the doctor that ordered it to see if there was something else, I could use like sodium chloride tablet. When asked if staff had notified her that R#189's [MEDICATION NAME] medication was unavailable before 7/13/20, NP 'M' reported she saw R#189 on Friday (7/10/20). I would not have known until I came back on the 13th (Monday - 7/13/20). When asked if staff had contacted her before 7/13/20 regarding the unavailability of R#189's [MEDICATION NAME] medication, NP 'M' stated, No. The facility's Progress Notes for R#189 were reviewed and revealed the following: 07/10/2020 12:50 PM Admission Note NP 'M' Labs reviewed: Sodium (Na) 130 (normal is 135-145). 07/12/2020 7:41 AM Nursing RN 'E' Pharmacy called about medication [MEDICATION NAME] (tolvaptan). Medication not available, pharmacy stated they do not provide this medication due to it being a specialty medication. 07/14/2020 7:14 AM Physician NP 'M' Reason for visit: f/u [MEDICAL CONDITIONS] disorder {Name Redacted) R#189 seen today . PCA Pharmacy is not able to supply [MEDICATION NAME] due to it being a special drug. I discussed this with nephrologist (Named Redacted) states that (Named Redacted) R#189 will need to be on a strict 1500cc (cubic centimeter) fluid restriction at this time and to monitor sodium. Prescription has also been sent to (Name Redacted) local speciality <sic> pharmacy to obtain this medication. This plan of care has been discussed with patient's wife (Named Redacted). 7/17/2020 8:51 PM Discharge Disposition: (Name Redacted) R#189 d/c'd (discharged ) to (Name of Hospital Redacted) due to low sodium 124. Unable to obtain [MEDICATION NAME] at this time due to waiting for prior authorization from (Name of Local Pharmacy Redacted). Plan of care d/w (discussed with) (Named of Physician Redacted) decided it best to sent <sic> (Named Redacted) R#189 to the hospital due to drop in sodium level. A review of a facility provided document Provided by (Name Redacted) Pharmacy Consultants dated March 2015 revealed the following: If a medication is withheld for any reason the prescriber must be notified. Potential reasons medications might be held . Omission (error) . After discussion with the prescriber, document conversation in nurse's notes, and transcribe any new orders .