Every finding on record at Porter Hills Health Center

Based on observation, interview, and record review the facility failed to ensure personal resident information was kept private for 20 (Resident #5, #19, #32, #22, #37, #21, #20, #28, #10, #26, #14, #34, #12, #36, #9, #27, #29, #38, #17, & #8) of 37 residents reviewed for privacy resulting in the feeling of being uncomfortable with others having access to their personal information and the potential for further personal information to be accessed by unauthorized persons. Findings include:Resident #5:Review of Resident #5's brief interview for mental status, dated 6/19/25, was scored 15 which reflected intact cognition. During an observation and interview on 07/22/2025 at 10:34 AM, in Resident #5's room there was an approximately 8 inches by 11 inches piece of paper, untitled and undated, with various pieces of information on 20 residents (Resident #5, #19, #32, #22, #37, #21, #20, #28, #10, #26, #14, #34, #12, #36, #9, #27, #29, #38, #17, & #8) facing up with the information visible. This document was on an approximately thigh high table next to the window in Resident #5's room. This document included columns titled Resident (the residents' last name), Room (resident room number), Size (incontinence brief size; which indicated the residents were incontinent of bowel (feces) and/or bladder (urine)), Underwear, Brief (incontinence brief), or [Brand Name] Pads (type of incontinence pads for bladder leaks) and noted Residents #37, 34, and 38 were on hospice services. Resident #5 was in bed but reported he would get up in his wheelchair at various times during the day and would have been able to view the information on the paper when he was out of bed. Resident #5's Family Member R was visiting and saw the paper/resident information and reported the information appeared to be personal resident information. During an observation on 07/22/2025 at 3:09 PM, the document from the observation on 07/22/2025 at 10:34 AM remained in the same place in Resident #5's room, with personal resident information visible. During an observation on 07/23/2025 at 9:01 AM, the document from the observation on 07/22/2025 at 10:34 AM and 07/22/2025 at 3:09 PM remained in the same place in Resident #5's room. During an interview on 07/24/2025 at 7:57 AM, Certified Nurse Aide (CNA) E reported staff will do Brief rounds (incontinence brief inventory) on Tuesdays and Thursdays and take the list with them for documentation. CNA E reported it would bother her if she was on the list and people had access to her incontinence, brief size, or hospice information.During an interview on 07/24/2025 at 8:04 AM, Certified Nurse Aide (CNA) K confirmed normally when she is done with the incontinence brief inventory sheet, she gives it to a nurse but forgot to do that this time. CNA K reported she usually takes the sheet with her from the resident room and if she has to put it down, she puts it face down so information would not be viewable. CNA K reported if she was on a list like the one being discussed she would not want people (unauthorized persons) to know she was incontinent, knowing her hospice status, and it was a dignity issue having that information viewable to another resident or visitors. During an interview on 07/24/2025 at 10:13 AM, Social Services Coordinator G confirmed Resident #5 gets up into his wheelchair around lunch and dinner time. Resident #19:During an interview on 07/24/2025 at 9:20 AM, Resident #19 was sitting upright in his wheelchair in his room and reported it made him uncomfortable knowing non-staff members had access to information regarding his incontinence status, brief use, and brief size.Review of the facility's Safeguarding of Resident Identifiable Information policy, revised 3/2025, stated, It is the community's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records.Medical records will not be left in open areas where unauthorized persons could access identifiable resident information.Paper notes or reminders with resident's personal or medical information will not be left unattended or viewable by unauthorized persons. These paper notes and reminders will be disposed of in a way that will not compromise resident's personal or medical information. Applying the reasonable person concept, regarding residents on the incontinence brief list with cognitive deficits who were unable to answer questions, one likely would not desire other residents or visitors to have information about their incontinence, brief use, brief size, or hospice status.

Based on observation, interview, and record review, the facility failed to store and prepare 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 who consume food from the kitchen. Findings include: During a tour of the facility, starting at 9:40 AM on 7/30/24, an interview with Chef Manager U found that the facility does not cool much, but they do maintain a log for cooling. During a tour of the walk-in cooler, at 9:46 AM on 7/30/24, it was observed that three 1/8th pans of leftover breakfast puree items were found in the walk in cooler warm to the touch and covered in saran wrap. When asked about the items, Chef Manager U stated they don't typically keep those items. During a revisit to the kitchen, at 3:12 PM on 7/30/24, it was observed that a 1.5 gallon container of Corn chowder soup was found in the walk in cooler covered with saran wrap. A temperature of the soup was taken at this time and was found to be 107 F in the middle. An interview with [NAME] V and Dining Services Manager X found that food being cooled should get to 135 to 70 within 2 hours, When asked what time the soup was at 135 F? [NAME] V and Dining Services Manager X were unsure, but knew it was pulled from lunch today which was done around 12:30-12:45 PM. When asked what should be done with the soup, [NAME] V and Dining Services Manager X agreed to discard the soup. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. During a tour of the cooks walk in cooler, at 10:04 AM on 7/30/24, it was found that packages of cooked shredded beef were thawing on an expediting rack under thawing portions of whole muscle raw animal product. When asked if this was the proper way to store raw animal product with ready to eat foods, Chef Manager U stated he would rearrange the items so that raw goes underneath, and placed the cooked shredded beef on the top of the rack. During a tour of the preparation cooler on the front serving line, at 3:16 PM on 7/30/24, it was observed that five raw hamburger patties were found stored on the top of the wire rack in a plastic bag. Next to and under the raw patties, were a container of grape jelly and a plastic bag of sliced turkey. According to the 2017 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables,(b) Cooked READY-TO-EAT FOOD . During a tour of the health center pantry, at 10:41 AM on 7/30/24, it was observed that the single door freezer was found with a loose seal and gasket which is allowing humid air to accumulate ice inside the freezer. During a tour of the health center pantry, at 10:45 AM on 7/30/24, it was observed that the underside of the drink spouts found heavy black accumulation around the base of the juice dispensers. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to thoroughly assess, investigate and prevent falls, in one of three residents reviewed for falls (Resident #37), resulting in likelihood of additional falls and injuries. Findings include: Resident #37 (R37) On 7/30/2024 at 9:56 AM, R37 was observed lying in bed and stated he fell from his wheelchair recently attempting to reach for his call light and had scraped his back. In review of R37's Minimum Data Set (MDS) with assessment reference date of 6/11/2024, he was admitted at the facility on 2/29/2024; had a Brief Interview for Mental Status (BIMS, a short cognitive screener) score of 13 (13-15 Cognitively intact). The same MDS indicated R37 had a diagnosis of dementia and had a history of a stroke with weakness/paralysis on one side of his body. Incident Report dated 3/07/2024 at 9:45 AM revealed R37 fell in his room and called a family member for help. The same report revealed R37 was observed lying on his left side next to the bed in his room and stated to staff he was reaching for his cell phone with his right hand, the phone was on his bedside dresser on his left side. The same report indicated R37 was not able to grasp anything with his left hand. R37 reported he scraped his right shoulder and upper back on the bed. R37 could not reach his call light and was able to grab the cord of his cell phone to call his family for help after falling from his bed. R37's items were all moved to a bedside table on the right side of his bed, including his cell phone. Certified nurse assistants (CNA's) were all instructed to be sure R37's cell phone and call light were always placed on his right side. Post fall evaluation dated 3/07/24 at 9:45 AM included fall details, contributing factors, physical finds, medication review, vital signs, skin assessment and clinical comments. R37's risk for falls Care Plan dated 3/08/2024 instructed to ensure personal items were within reach and cell phone was placed on his right side. Incident Report dated 3/12/2024 at 4:16 PM indicated R37 was observed lying on the floor with his wheelchair behind him. The same report indicated the CNA had witnessed R37 sliding out of his wheelchair as she entered his room. In review of R37's medical record, there was no post fall evaluation completed after R37's fall on 3/12/2024. Occupational Therapy (OT) Evaluation and Plan of Treatment dated 5/01/2024 indicated R37 had impaired range of motion and strength of his left upper extremity and a contracture of his left elbow. The same evaluation revealed R37 was unable to functionally use his left upper extremity for activities of daily living (ADL). The same treatment plan indicated R37's goal was to improve function of his left arm.

Based on interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessments in 2 of 12 residents (Resident #18 & #33) reviewed for accuracy of assessments, resulting in an inaccurate reflection of the resident's status. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.18.11, Chapter 3 Section O: Special Treatments, Procedures, and Programs, revealed .The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods .The treatments, procedures, and programs listed in Item O0110, Special Treatments, Procedures, and Programs, can have a profound effect on an individual's health status, self-image, dignity, and quality of life .Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs .Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider . Resident #18 Review of an Admission Record revealed Resident #18 was a female, with pertinent diagnoses which included Alzheimer's disease, dementia, anxiety, depression, Parkinson's disease, diabetes, high blood pressure, heart disease, and arthritis. Review of an Order Summary Report for Resident #18 revealed the active physician order .Hospice to treat . with a start date of 1/22/24. Review of a current Care Plan for Resident #18 revealed the focus .I have a terminal prognosis r/t (related to) Alzheimer's Disease . revised 1/31/24, with interventions which included .I am on hospice care. Adjust provision of ADLS (Activities of Daily Living) to compensate for my changing abilities. Encourage (participation) to the extent I wish to participate . initiated 1/31/24. Review of a Minimum Data Set (MDS) assessment for Resident #18, with a reference date of 4/12/24, revealed the Section O0110. Special Treatments, Procedures, and Programs, K1. Hospice care was marked No for While a Resident. In an interview on 8/1/24 at 11:07 AM, Nurse Manager E reported Resident #18 admitted to the facility on Hospice care, and has remained on Hospice for the duration of her stay. Nurse Manager E reported that the MDS Assessment for Resident #18, with a reference date of 4/12/24, should have Hospice care marked Yes and would need to be corrected. Resident #33 Review of an Admission Record revealed Resident #33 was a male, with pertinent diagnoses which included Alzheimer's disease, dementia, anxiety, and heart disease. Review of an Order Summary Report for Resident #33 revealed the active physician order .Admit to (Company Name) Hospice Services . with a start date of 4/2/24. Review of a current Care Plan for Resident #33 revealed the focus .I have a terminal prognosis r/t (related to) Alzheimer's Disease . revised 4/2/24, with interventions which included .I am on hospice care. Adjust provision of ADLS (Activities of Daily Living) to compensate for my changing abilities. Encourage (particpation) to the extent I wish to participate . initiated 4/2/24. Review of a Minimum Data Set (MDS) assessment for Resident #33, with a reference date of 4/12/24, revealed the Section O0110. Special Treatments, Procedures, and Programs, K1. Hospice care was marked No for While a Resident. In an interview on 8/1/24 at 12:58 PM, Nurse Manager E reported that she is responsible for completion of the MDS assessments. Nurse Manager E reported the information in regard to Hospice is manually entered into the MDS assessments. Nurse Manager E reported Resident #33's MDS assessment, with a reference date of 4/12/24, was a Significant Change assessment due to his enrollment with Hospice care, and the question about Hospice care in Section O should have been marked Yes and would need to be corrected.

Based on observation, interview, and record review, the facility failed to update/revise a comprehensive care plan after a change in resident condition in 3 of 12 residents (Resident #18, #8, & #37) reviewed for comprehensive care plans, resulting in an inaccurate reflection of the resident's status, and the potential for unmet medical, physical, mental, and psychosocial needs. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.18.11, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . Resident #18 Review of an Admission Record revealed Resident #18 was a female, with pertinent diagnoses which included Alzheimer's disease, dementia, anxiety, major depression with psychotic symptoms, insomnia, Parkinson's disease, and claustrophobia. Review of a Hospice Interdisciplinary Group Conference Communication note for Resident #18, dated 6/27/24, revealed .writer informed by staff nurse .that patient having episode of extreme agitation and restlessness, and that they are unable to redirect patient. Writer also attempted to verbally redirect and de-escalate patient, she was repeatedly tearful and demanding that staff push her around (in) wheelchair, however, due to patients positioning, she was only half seated (in) wheelchair and staff and writer tried to explain that they could not push her until she sat further back in the wheelchair, further angering patient .(Nurse Manager E) contacted facility physician and received new order for 1 mg haldol scheduled every 3 hours, as well as to discontinue scheduled seroquel . Review of an Order Summary Report for Resident #18 revealed the physician order .SEROquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 2 tablet by mouth two times a day for anxiety, psychosis . which was ordered on 6/3/24 had a status of discontinued. Review of an Order Summary Report for Resident #18 revealed the active physician order Haloperidol Lactate Concentrate 2 MG/ML Give 0.5 milliliter by mouth every 3 hours . with a start date of 6/27/24. No active order noted for Seroquel. Review of a Health Status Note for Resident #18, dated 7/3/24, revealed .Resident doing well on new medication change to Haldol. Resident is enjoying activities with many of the resident and eating with them. Resident is less anxious and smiles more frequently . In an observation on 7/31/24 at 11:47 AM, Registered Nurse (RN) L prepared and administered 0.5 mL of Haloperidol Lactate Concentrate 2 MG/ML to Resident #18 at the medication cart. Noted Resident #18 took the medication with no issue. No negative mood or behaviors noted at this time. Review of a current Care Plan for Resident #18 revealed the focus .I use antipsychotic medication .r/t (related to) psychosis, depression. I am prescribed Seroquel . revised 4/22/24, with interventions which included .I am getting (an) increase in Seroquel for my hallucinations . initiated 6/3/24. Note the Seroquel for Resident #18 was discontinued on 6/27/24. In an interview on 8/1/24 at 11:07 AM, Nurse Manager E reported Resident #18 is .much more stable . after the medication change from Seroquel to Haldol on 6/27/24. Nurse Manager E reported they attempted to increase Resident #18's Seroquel dose prior to the medication change, however, the increased dose did not reduce Resident #18's episodes of tearfulness and anxiety. Nurse Manager E reported Care Plans should be updated by the Interdisciplinary Team after changes in resident condition/status. According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 15861 of 76897). Elsevier Health Sciences.A nursing care plan includes nursing diagnoses, goals and/or expected outcomes, individualized nursing interventions, and a section for evaluation findings .The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures. Nurses revise a plan when a patient's status changes .The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care . 30337 Resident #8 (R8) On 7/30/2024 at 11:00 AM, R8 was observed sitting in a wheelchair in her room and asked what the objects were that she saw from her window; R8 was not wearing glasses. R8's Minimum Data Set (MDS) with an assessment reference date of 5/13/2024 revealed she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status, (BIMS) a brief cognitive screener score of 06 (00-07 Severe Cognitive Impairment). The same MDS assessment revealed R8 had the diagnoses of glaucoma, diabetes mellitus, and dementia. In review of R8's medical record, she had an eye exam on 6/05/2024 and eyeglasses with bifocals were ordered. Progress Notes dated 6/16/2024 at 11:16 AM revealed R8 received eyeglasses with a light purple frame in a black case. In review of R8's care plans, there was no mention she wore glasses. Nurse Manager (NM) E was interviewed on 7/31/2024 at 1:18 PM and stated R8 did not wear glasses. After review of R8's medical record, NM E stated the nurse should have updated R8's care plan when she received her glasses and would have to do some education with the nurse. Certified Nurse Assistant (CNA) H was interviewed on 8/01/2024 at 11:38 AM and stated she had been caring for R8 for a few weeks and haven't seen any glasses for her. Resident #37 (R37) In review of R37's MDS with assessment reference date of 6/11/2024, he was admitted to the facility on [DATE]; had a BIMS score of 13 (13-15 Cognitively intact). The same MDS indicated R37 had a diagnosis of dementia and had a history of a stroke with weakness/paralysis on one side of his body. Occupational Therapy (OT) Evaluation and Plan of Treatment dated 5/01/2024 indicated R37 had impaired range of motion and strength of his left upper extremity and a contracture of his left elbow. The same evaluation revealed R37 was unable to functionally use his left upper extremity for activities of daily living (ADL). The same treatment plan indicated R37's goal was to improve function of his left arm. OT Discharge Summary dated 7/11/2024 revealed R37 was discharged from OT due to highest practical level had been achieved. Discharge recommendations included R37 continue with home exercise program, staff to complete passive range of motion of his left upper extremity. The same summary indicated R37's written program was left in his room for staff to complete. In review of R37's care plans, a home exercise program with passive range of motion was not included. CNA H was interviewed on 8/01/2024 at 1:37 PM and stated she was not aware of R37's home exercise program that was to be completed with staff. OT Q was interviewed on 8/01/2024 at 11:56 AM and stated a detailed range of motion plan for R37 was put in his room, prior to his discharge from OT on 7/11/24. OT Q stated he probably should have given a copy of R37's home exercise plan to the nurse manager. During an interview on 8/01/2024 at 12:17 PM, NM E stated when residents were discharged from therapy services, they were to give exercise plans to the nurse and the nurse was to update the care plan.

Based on interview, and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal vaccinations and receive vaccination if eligible for 2 (Resident #9 and #18) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Resident #9 Review of an Admission Record revealed Resident #9 was originally admitted to the facility on [DATE] with pertinent diagnoses which included type 2 diabetes. Review of Resident #9's Immunization Record indicated that Resident #9 received a PCV13 (pneumococcal vaccination) on 5/2/2017. During an interview on 7/31/24 at 2:35 PM, Director of Nursing (DON) B reported that she was responsible for ensuring all residents were screened for vaccination eligibility and administration. DON B was unable to report when Resident #9 was last reviewed for pneumococcal vaccination eligibility. In a communication via email on 7/31/24 at 5:10 PM, DON B reported that .(Resident #9) was due for the PCV20 vaccination and was just offered the vaccination today by nurse manager . On 7/31/24, at 6:05 PM, the facility provided a copy of Resident #9's Patient Vaccination/Informed Consent/Declination form dated 7/31/24. The form indicated that Resident #9 was eligible to receive the PCV20 (pneumococcal vaccination) and Resident #9's guardian gave verbal consent for Resident #9 to receive the vaccination on 7/31/24. During a follow up interview on 8/01/24 at 8:44 AM, DON B reported that Resident #9's screening for the pneumococcal vaccination was missed by the facility. Resident #18 Review of an Admission Record revealed Resident #18 was originally admitted to the facility on [DATE] with pertinent diagnoses which included Alzheimer's disease. Review of Resident #18's Immunization Record indicated that Resident #18 received the PPSV23 (pneumococcal vaccination) on 6/25/2019. During an interview on 7/31/24 at 2:35 PM, DON B was unable to report when Resident #18 was last reviewed for pneumococcal vaccination eligibility. On 7/31/24, at 6:04 PM, the facility provided a copy of Resident #18's Patient Vaccination/Informed Consent/Declination form dated 7/31/24. The form indicated that Resident #18 was eligible to receive the PCV20 and Resident #18's guardian gave verbal consent for Resident #18 to receive the PCV20 (pneumococcal vaccination) on 7/31/24. During an interview on 8/01/24 at 12:35 PM, DON B reported that Resident #18 had not been screened for pneumococcal vaccination eligibility until 7/31/24. DON B reported that Resident #18 was eligible to receive the PCV20. Review of the facility's Resident Pneumococcal Vaccination Policy dated January 2021 revealed, It is our policy to offer our residents immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations .

Based on interview and record review, the facility failed to assure a Registered Nurse was on duty for eight consecutive hours a day seven days a week, resulting in the potential for inadequate coordination of emergent or routine care with negative clinical outcome affecting all residents in the facility. Findings include: Review of the Payroll Based Journal (PBJ) report revealed: the facility triggered for No RN Hours .four (4 ) or more days within the quarter with no RN hours. for the Fiscal Year (FY) Quarter 2 2023 ([DATE] - [DATE]) On the following dates: No RN Hours Triggered for 1/2/23 (Mon); 1/7/23 (Sat); 1/8/23 (Sun); 1/15/23 (Sun); 1/21/23 (Sat); 1/22/23 (Sun); 2/4/23 (Sat); 2/11/23 (Sat); 2/12/23 (Sun); 2/25/23 (Sat) . During an interview on 6/14/23 at 12:30 PM., Nursing Home Administrator (NHA) A reported during the beginning of the year (January and February 2023) their (the facilities) weekend Registered Nurse (RN) that typically worked the weekend shifts had broken her ankle. NHA A reported she had a difficult time trying to fill the RN position for the weekends. NHA A reported there was not the appropriate RN covered for the dates of 1/2/23 (Mon); 1/7/23 (Sat); 1/8/23 (Sun); 1/15/23 (Sun); 1/21/23 (Sat); 1/22/23 (Sun); 2/4/23 (Sat); 2/11/23 (Sat); 2/12/23 (Sun); 2/25/23 (Sat).

Based on observation, interview, and record review, the facility failed to perform proper hand hygiene during wound care dressing change for 1 resident (Resident #185) reviewed for wound care resulting in the potential for the spread of infection, cross-contamination, and disease transmission for residents residing in the facility. Findings include: Resident #185 Review of an Admission Record revealed Resident #185, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: lymphedema (Tissue swelling caused by an accumulation of fluid, most commonly occurring in the arms and legs) Review of a Minimum Data Set (MDS) assessment for Resident #185, with a reference date of 5/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #185 was cognitively intact. During an observation on 06/13/23 at 10:57 AM., Licensed Practical Nurse (LPN) O entered Resident #185's room, applied gloves, and did not perform hand hygiene. LPN O removed a plastic bag from around Resident #185's left foot, placed the bag into garbage can. LPN O then picked up the garbage can and moved it to the end of bed, removing a plastic bag from Resident #185's right foot placing it into garbage. LPN O opened dressing supplies on the bedside table, cut open the tops of triple antibiotic ointment packages with scissors from the table, and squeezed ointment onto non-adherent pads. LPN O rubbed together the non-adherent pads to spread ointment. LPN O picked up the scissors from the bedside table to cut the dressing free from Resident #185's right leg and placed the scissors back onto the bedside table. LPN O removed the dressing from Resident #185's right leg and used the supplies from the bedside table to cleanse and redress the wound. LPN O picked up the scissors from the bedside table to cut the blood saturated dressing from Resident #185's left leg. LPN O placed the scissors onto the bedside table, removed the blood saturated dressing and moved the blood-soaked linen from under Resident #185's left leg to the foot of the bed. LPN O then applied the new dressing to Resident #185's left leg. LPN O did not perform hand hygiene when transitioning between right and left legs or from clean to soiled supplies. LPN O placed the scissors into his pocket without cleaning. At no time during the dressing change did LPN O perform hand hygiene or change gloves. In an interview on 06/14/2023 at 11:30 AM., LPN O reported hand hygiene was supposed to be completed before going into a resident's room and when coming out of a resident's room. LPN O reported hand hygiene should be done before, during, and after a dressing change. In an interview on 06/14/23 at 01:33 PM., Director of Nursing, (DON) B reported that hand hygiene should be completed before entering any resident room and after exiting a resident room. DON B reported during wound dressing changes the expectation was for nursing staff to perform proper hand hygiene (which includes the use of hand sanitizer and/or hand washing with soap) according to Centers for Disease Control and Prevention (CDC) guidelines and facility policy. DON B reported during wound dressing changes for Resident #185, LPN O should have performed hand hygiene and changed gloves when transitioning between clean and soiled items. Review of a facility Policy titled Hand Hygiene with no date and a reference from (CDC Guidelines) revealed: Policy- hand hygiene should be performed before applying and after removing personal protective equipment (PPE), including gloves . before and after handling clean or soiled dressings, linens . before performing resident care procedures .after handling items potentially contaminated with blood .when during resident care moving from a contaminated body site to a clean body site . Centers for Disease Control and Prevention. Guidelines for Hand Hygiene in Health-Care Settings, 2002. Accessible version located at https://www.cdc.gov/handhygiene/providers/index.html. Accessed May 2019 .

Based on interview and record review, the facility failed to implement a home exercise program (HEP also known as restorative exercise program) per physician order for 1 (Resident #18) of 1 resident reviewed for rehabilitation and restorative services resulting in the potential for decline in range of motion and mobility and increased weakness. Findings include: Resident #18 Review of a Face Sheet revealed Resident #18 was a male, with pertinent diagnoses which included: weakness; primary osteoarthritis, left shoulder; and primary osteoarthritis, right shoulder. Review of a Minimum Data Set (MDS) assessment for Resident #18, with a reference date of 4/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #12 was cognitively impaired. In an interview on 6/12/23 at 11:40 AM, Resident #18 reported would like to have more therapy. Resident #18 reported had been receiving therapy 2-3 times per week to work on his arms but thought therapy was done with him on that. Resident #18 reported facility staff had not done any exercises with him. Review of a Physician Order for Resident #18 revealed, OT (occupational therapy) clarification order: OT discharged with HEP (home exercise program) in place 6/7/23 Verbal Active 6/9/23 In an interview on 6/14/23 at 11:07 AM, Nurse Manager (NM) R reported the facility did not have a rehabilitation program and that people who received Medicare Part B went to outpatient therapy if needed. NM R reported when residents were discharged from outpatient therapy, a home exercise program (HEP) was developed by therapy (when needed) and communicated to the facility for implementation. NM R reported when a resident was on a HEP, there would be a physician order in place, and it would be care planned and entered on the resident Kardex (individualized care guide about the resident) for the staff to know what exercises to do with the resident. In an interview on 6/14/23 at 11:27 AM, Licensed Practical Nurse (LPN) O reported as a nurse, did not perform any exercises with Resident #18. LPN O stated, If we were supposed to, we would be prompted to on the computer. In an interview on 6/14/23 at 11:33 AM, Certified Nurse Aide (CENA) DD reported had done HEP with some residents, but that Resident #18 did not have a HEP in place. CENA DD reported usually had Resident #18 on their assignment every time they worked, and I haven't had to do anything with him yet. CENA DD reported the HEP for the resident would be on their Care Plan and Kardex in the computer. CENA DD looked at Resident #18's Care Plan and Kardex on their hand-held computer and reported there was nothing in the computer for him. On 6/14/23 at 11:45 AM, this surveyor reviewed Resident #18's current Care Plan and Kardex and found no documentation of a HEP for Resident #18. In an interview on 6/14/23 at 11:52 AM, NM R was requested to provide SA (State Agency) with a copy of Resident #18's HEP in place since 6/7/23 per physician order. NM R reported would have to follow up with the therapy manager from homecare because had not received the HEP to enter into Resident #18's Care Plan and Kardex.

Based on observation, interview, and record review, the facility failed to implement proper safety interventions and adequate supervision to prevent a fall with injury for 1 of 19 residents (R18) reviewed for falls, resulting in a fall with [CONDITION(S)] requiring surgery, and the potential for additional falls with injuries, Findings include: According to the Minimal Data Set (MDS) dated [DATE], R18 scored 15/15 (cognitively intact) on the BIMS (Brief Interview Mental Status), had clear speech making her needs known, understood others, used a walker for assistance during walking, transfers between surfaces required limited assistance of one-person physical assist providing guided maneuvering of limbs or other non-weight-bearing assistance, toilet use with extensive assistance of one-person physical assistance providing weight-bearing support, turning around and facing the opposite direction resident was not steady, only able to stabilize with human assistance, occasionally incontinent of urine, and diagnoses that included non-traumatic [CONDITION(S)]. (After a significant change in condition on 2/4/2022 related to a fall with [CONDITION(S)] requiring surgery, R18, used a walker and wheelchair for assistance during ambulation, transfers between surfaces required extensive assistance of two-plus persons physical assistance providing weight-bearing support, and toilet use required extensive assistance of one-person providing weight-bearing support). Review of R18's Incident Audit Report #1968 dated 1/29/2022 at 6:40 (AM) revealed a fall occurred in the resident's bathroom. R18 was wearing gripper socks and using a walker while walking to the sink to get an incontinence pad. A CNA (Certified Nursing Assistant) was within view of the R18. R18 reported she lost her balance and fell backwards. R18 was unable to move her right leg and right foot was externally rotated (turned). X-ray of right leg was ordered. Predisposing situation included the resident's gait was unsteady at times. Review of R18's Progress Note 1/29/2022 10:14 (AM) eINTERACT SBARS Summary for Providers reported the resident was unable to move right leg after the fall with external rotation of right foot. The Primary Care Providers recommended an X-ray of the right hip. Review of R18's Progress Note 1/29/2022 10:57 (AM) reported the resident was in her bathroom when she had lost her balance and fallen backwards. The CNA was with her. The resident was unable to move her right leg and right foot was externally rotated. A right hip X-ray was ordered. Review of R18's Progress Note 1/29/2022 13:22 (1:22 PM) reported a mobile X-ray was called twice to obtain right hip X-ray results. The resident's right hip intertrochanteric was broken and was transferred to the hospital per order. Review of R18's Progress Note 1/29/2022 13:55 (1:55 PM) reported the resident was sent to the emergency room via an ambulance. Review of R18's Progress note 1/29/2022 22:17 (10:17 PM) reported the resident was admitted to the hospital. During an observation and interview on 4/13/22 at 10:34 AM, R18 was propelling self in a wheelchair around her room. R18 stated, I came here in January this year (2022) and went to go use the toilet with the assistance of a CNA (Certified Nursing Assistant). At that time, I was using a walker. We were in the bathroom together. The CNA was in the doorway of the bathroom. I turned to get some pads and a brief because I'm incontinent at times (of urine), my walker got caught on my slipper and I fell . I did not have a gait belt on me at the time. The CNA did not help me get what I needed. I broke my right hip and required surgical repair with a rod to connect from my hip to my knee. It messed up the progress I had in therapy, and I missed using my therapy bike. I'm slowly gaining back momentum in therapy, but not like I would have had if I had not fallen. During an interview on 4/13/22 at 11:22 AM Licensed Practical Nurse (LPN) N stated, A gait belt should be used anytime a resident looks like they are having difficulty walking or not using a mechanical lift. It should be in a resident's care plan. During an interview on 4/14/22 at 11:03 AM Therapy Director MM stated, (R18) was admitted on [DATE]. Therapy saw her for the first time on 1/18/2022. (R18) transfer status at that time (1/18/2022) was Minimum Assist in which a gait-belt would be used. (R18's) Care Plan was updated to reflect this and should have been followed. (R18's) standing balance is Fair-Minus which means she is not safe to stand on her own. A gait-belt would be needed to help support her. (R18) was active in therapy with PT (physical therapy) and OT (occupational therapy). (R18) fell on [DATE] breaking her right hip. During an interview and record review on 4/14/2022 at 11:20 AM Unit Manager (UM) C stated, (R18) was a fall risk when she was admitted on [DATE]. She was placed on a Fall Risk Care Plan when she came in (admitted ). The CNA was helping (R18) when the resident lost her balance and fell . I do not believe a gait belt was being used. I was the on-call manager January 29th (2022) when (R18) fell . I reported the fall to the Administrator (Nursing Home Administrator (NHA A)). (NHA A) asked if the resident's Care Plan was being followed. I told her Yes. The Surveyor reviewed R18's Therapy Notes with UM C who stated, (R18) was evaluated by Therapy the day after her admission, 1/18/2022. Her admission was 1/17/2022. Therapy recommended (R18) transfers be Minimum Assist which means a gait belt and physical assist should be used for the resident. The Surveyor reviewed R18's Care Plans with UM C who stated, Minimum Assist was placed on (R18's) Care Plans 1/18/2022. I did not know Minimum Assist was on her (R18's) Care Plans. I thought she was just a Standby Assist. During an interview on 4/14/22 at 1:11 PM, NHA A stated, A resident's Care Plan is reviewed at a fall. The Care Plan is again reviewed and updated when the Post Fall Evaluation is completed. Apparently, (R18's) Care Plan was not reviewed completely. It was only brought to my attention today, 4/14/2022, that (R18's) Care Plan was not followed until after you interviewed (UM C). Review of facility Use of Gait Belt date reviewed/revised January 2022 revealed, Policy: It is the policy of this facility to use gait belts with residents that cannot .transfer for the purpose of safety. Policy Explanation and Compliance Guidelines .2. All employees will receive education on the proper use of gait belt during orientation and annually .

Based on observation, interview and record review, the facility failed to ensure residents received the necessary care and services, consistent with professional standards of practice to prevent, treat, and promote healing of pressure ulcers in 3 (Resident #305, #54 & #41) of 4 residents reviewed for pressure ulcers, resulting in harm when Resident #305 developed pressure injuries to bilateral heels and did not receive wound treatments according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: Resident #305 Review of an Admission Record revealed Resident #305 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #305, not available due to recent admission. Review of Resident #305's Pressure Ulcer Care Plan revealed, I have a pressure ulcer on my coccyx (see SKIN BREAKDOWN POTENTIAL care plan for more interventions) Date Initiated: 4/10/2022. Interventions: I have a pressure ulcer on my coccyx. Assist, encourage to offload pressure to this area. Date Initiated: 4/10/2022. In house wound doctor referral and treat. Date Initiated: 4/10/2022. Treatment as ordered. Notify MD (medical doctor) if healing stalled or worsened. Date Initiated: 4/10/2022. Review of Resident #305's Skin Breakdown potential Care Plan revealed no care plan. Review of Resident #305's Braden Scale for Predicting Pressure Ulcer Risk dated 4/9/22 at 15:31 (3:31 P.M.) revealed a score of 13, which indicated moderate risk. During an observation on 4/12/22 at 2:51 P.M. Resident #305 was lying on his back in bed, head of bed was 45 degrees, feet and legs were flat on the bed. There were no protective boots or pillows observed for offloading of pressure areas. Review of Resident #305's Skin Only Evaluation dated 4/9/2022 at 15:44 (3:44 P.M.) revealed, Skin Issue: Deep Tissue Pressure Injury (DTPI). Skin Issue Location: coccyx dark red open area Pressure Ulcer / Injury Stage: Stage II - Partial thickness skin loss. Length: 4 cm Width: 3.5 cm Wound Bed: Granulation. Wound Exudate: None. Peri Wound Condition: Fragile .No wound odor .Other Skin Issue: bilateral heels mushy Skin Issue Location: heels Length: 2 cm . Review of Resident #305's Skilled Evaluation dated 4/13/2022 at 10:01 A.M. revealed, .Skin: (no documentation) Skin note: [MEDICATION(S)] (bandage) intact to buttocks. (Wound Doctor (WD) E) to see today. APM (pressure reducing mattress) in place. Frequent positioning . There was no documentation regarding Resident #305's heels. During an interview on 4/13/22 at 12:55 P.M., WD E reported that he was not familiar with Resident #305, and that the resident was not on the list for wound rounds today. During an observation on 4/13/22 at 11:55 A.M. Resident #305 was sitting in a wheelchair in his room with his head hanging down and his eyes closed. During an observation and interview on 4/13/22 at 2:00 P.M. Resident #305 was sitting in his room in his wheelchair. Family Member (FM) NN reported that Resident #305 has been waiting for staff get him back into bed and stated, .he has been up since before lunch. Resident #305 had been sitting in his chair for >2 hours. During an observation on 04/13/22 at 3:18 P.M. Resident #305 was lying on his back in bed, with HOB (head of bed) approximately 30 degrees and both feet laying directly on the surface of the bed. Resident #305 was not wearing protective boots and heels were not floating. During an observation on 4/13/22 at 3:53 P.M. Resident #305 was lying on his back in bed, with HOB approximately 30 degrees and both feet laying directly on the surface of the bed. Resident #305 was not wearing protective boots and heels were not floating. During an observation on 4/13/22 at 4:37 P.M. Resident #305 was lying on his back in bed, with HOB approximately 30 degrees and both feet laying directly on the surface of the bed. Resident #305 was not wearing protective boots and heels were not floating. During an interview on 4/13/22 at 3:26 P.M., Certified Nursing Assistant (CNA) Y reported that Resident #305 had a wound on his coccyx, is incontinent of BM (bowel movement) and leaks BM constantly. During an interview on 4/13/22 at 3:30 P.M., CNA J reported that Resident #305 required assistance to reposition in bed and the use of pillows for offloading pressure and stated, .he has a wound on his bottom .I haven't seen it .it's covered with a bandage .no other wounds that I know of . Review of Resident #305's Nurse's Note dated 4/13/2022 at 17:51 (5:51 P.M.) revealed, Bilateral mushy heels were noted on admission. Today both heels noted to have 2.5 cm firm dark colored skin. Non tender. Non blanchable. No open areas. Skin prep and heel booties ordered while in bed. (FM BB) and (Medical Doctor MD F) notified. During an observation on 4/14/22 at 8:30 A.M. Resident #305 was on his back in bed, HOB 90 degrees, feet pressed firmly against the foot board of the bed. Resident #305 was not wearing protective boots and did not have his heels floating, but there was a flat pillow noted laying on the bed. During an observation on 4/14/22 at 9:11 A.M. Resident #305 was on his back in bed, HOB 90 degrees, both feet pressed firmly against the foot board of the bed. Resident #305 was not wearing protective boots and did not have his heels floating. During an observation and interview on 4/14/22 at 9:42 A.M. Resident #305 was on his back in bed, HOB 90 degrees, both feet pressed firmly against the foot board of the bed, slumped down in bed, and his legs bent at the knees due to the foot board not allowing him to straighten his legs. Resident #305 reported that BM is his biggest problem and stated, .its inconvenient for them (facility staff). During an interview on 4/14/22 at 9:48 A.M., Licensed Practical Nurse (LPN) D reported that she admitted Resident #305 on 4/9/22 with multiple skin issues and stated, .we recognized that he was less mobile .he had a coccyx wound .both heels were mushy .it was not concerning at the time . LPN D reported that she assessed Resident #305's heels on 4/13/22, and both heels had worsened since admission on 4/9/22. LPN D reported that she did not create a skin prevention care plan upon admission for Resident #305. During an observation and interview on 4/14/22 at 10:21 A.M. Resident #305 was observed in the same position as the previous observation (approximately 2 hours). CNA J and CNA M entered the room to provide cares. Both of Resident #305's heels were observed to have a large area of purple colored skin in an oval shape. CNA J reported that the APM mattress and a pillow to float heels were the interventions that were being used until protective boots were available. Resident #305's bottom was observed with a large dressing covering the coccyx. The dressing was dated 4/10/22, was saturated with BM along the bottom edge and partially detached from the skin. CNA J stated, .the date says 4/10 .I don't deal with bandages .I will let the nurse know about the BM on it . CNA J proceeded with cares and toileting for Resident #305, then transferred him into his wheelchair. Resident #305 did not have the saturated dressing replaced. During an observation on 4/14/22 at 12:57 P.M. Resident #305 was observed in the dining room in his wheelchair. Resident #305 had been in the wheelchair with a soiled, partially detached bandage covering his pressure ulcer for approximately 2 1/2 hours. Review of Resident #305's Treatment Administration Record (TAR) revealed .Dressing to coccyx/buttocks- Cleanse with normal saline, gently pat dry, apply sacral Foam Dressing. Change MON-WED-FRI and prn (as needed) every day shift every Mon, Wed, Fri for Dressing change. Start Date 04/11/2022 at 7:00 A.M. The record indicated that the treatment was performed on 4/11/22 and 4/13/22. This was not consistent with the date of 4/10/22 that was observed written on Resident #305's dressing on 4/14/22. During an interview on 4/14/22 at 10:58 A.M., LPN D reported that she did not change Resident #305's coccyx dressing yesterday (4/13/22). During an interview on 4/14/22 at 11:03 A.M., Nurse Manager (NM) C reported that Wound Doctor (WD) E had not seen Resident #305 yet and stated, .there were some concerns with billing .then he ran out of time . NM C reported that Resident #305 should have had a general skin prevention care plan in place upon admission to include floating heels, and then should have had a specific intervention put in place when it was discovered that his heels were mushy and stated, .heel interventions were added to the care plan yesterday .after the wounds were found to be worsened . NM C reported that LPN L initialed Resident #305's TAR 4/13/22 attesting that the coccyx dressing change was performed. During an interview on 4/14/22 at (unknown time), LPN L reported that she had initialed Resident #305's coccyx dressing order on the TAR for 4/13/22, but did not perform the treatment and stated, .I thought the wound doctor was going to do it . During an interview on 4/14/22 at 11:26 A.M., MD F reported that he examined Resident #305 on 4/12/22 and again on 4/13/22 and stated, .I did not assess his wounds .(WD E) would do that .should have seen him yesterday . MD F reported that he was not aware of any concerns with Resident #305's heels and stated, .I would like to have been notified .the nurses can enter orders and then I see them and sign them off .I do not recall any orders for heels . During an interview on 4/14/22 at 12:49 P.M., FM BB reported that she was concerned about Resident #305's wounds healing due to being diabetic and stated, .he has never had an issue on his heels before . During an observation and interview on 4/14/22 at 1:31 P.M. Resident #305 was lying in bed, positioned on his right side, a large area of pink skin covering on coccyx was observed, with dark red non-blanchable blotches within the pink area, and an open area on the left middle buttock approximately the size of a quarter. Resident #305 winced in pain during the cleaning and dressing change. LPN L reported that the dressing removed prior to this surveyor entering the room was dated 4/10/22 and stated, .the wound looks about the same as it did on admission . Resident #54 Review of an Admission Record revealed Resident #54 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #54, with a reference date of 10/1/21 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #54 was cognitively impaired. Review of the Functional Status revealed that Resident # 54 required extensive assistance of 2 people for mobility in bed. During an observation on 4/12/22 at 1:29 P.M. Resident #54 was lying in bed on her back, HOB was 90 degrees and her legs and feet were laying directly on the surface of the bed. There were no protective boots or pillows noted for offloading or repositioning. Review of Resident #54's Kardex (care guide) revealed, .I have a pressure ulcer on left heel. Assist, encourage to offload pressure to this area .Use pillows, pads, or wedges to reduce pressure to heels . Review of Resident #54's TAR revealed the following .left heel wound: (1) Swab with NS and gauze, skin prep all around and generously to hind foot. Cover wound with foam dressing with adhesive borders, then generous Derma-Fix tape to hind foot, not around ankle. (2) Frequent bilateral leg elevation with pillows in bed to float heels. Back in bed bed x2 hours each am and after lunch. (3) Cushion boots in bed or w/c (wheelchair). (5) Socks on during the day and at noc (night). every day shift every Mon, Wed, Fri. Active 1/31/2022 at 7:00 A.M. Review of Resident #54's most recent Wound assessment dated [DATE] revealed, .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .There subsequent necrotic tissue with out significant depth, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .beefy red .periwound (around the wound) is poorly defined maceration . During an observation and interview on 4/13/22 at 1:02 P.M. in Resident #54's room, WD E reported that Resident #54 was scheduled for a wound assessment today and LPN G was going to be assisting. Resident #54 was observed lying in bed on her back, HOB 45 degrees and feet laying directly on the surface of the bed. WD E reported that Resident #54 has orders for cushion boots but often refuses them and stated, .but she will elevate her legs on a fluffy pillow to float her heels . Resident #54 was positioned on her right side to assess the wound on her left heel. Resident #54 reported that she has had increased pain in her left heel recently. LPN G measured the wound, and reported 3 cm length x 2.5 cm width x 0.1 cm depth. During the assessment WD E reported that the wound appeared to look about the same and stated, .it has stalled a bit. The measurements were larger than the last wound assessment. Resident #41 Review of a Face Sheet revealed Resident #41 admitted to the facility on [DATE] with a pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Brief Interview for Mental Status (BIMS) assessment for Resident #41, dated 3/13/2022, revealed a score of 15, out of a total possible score of 15, which indicated that the resident was cognitively intact. Review of a current Care Plan for Resident #41 revealed .I (Resident #41) have the potential for skin integrity impairment (due to) decreased mobility and weakness (related to) [CONDITION(S)] . Intervention/Task . blue boots to both feet when in bed (date initiated: 12/17/2017) . Review of Resident #41's orders revealed an active order to wear . cushion boots day and night. Review of a Nurse's Note dated 4/13/2022 at 10:11 a.m. revealed .(Registered Nurse) notified (physician) of new purple spot on left heel. (wound physician) to evaluate later today. In an observation and interview on 4/13/2022 at 1:36 p.m., Resident #41's wound care was observed with Wound Physician E. During care, Wound Physician E found a new stage one pressure ulcer on Resident #41's left heel measuring 1.2 cm by 0.6 cm. Wound Physician E found a second new stage one pressure ulcer on Resident #41's left medial forefoot measuring 1.1 cm by 0.4 cm. Resident #41 reported that there was a period of about 3 weeks that her protective boots recently went down to laundry and she did not have boots to wear. Review of a Health Status Note dated 4/2/2022 at 12:45 a.m. revealed .Resident requires . protective boots while in bed for pressure relief, as per resident, we need to order another pair, those went down to the laundry and I don't have them back. In an interview on 4/13/2022 at 2:14 p.m., Certified Nursing Assistant (CNA) H reported that Resident #41 went without her protective boots for about a week. In at interview on 4/13/2022 at 4:17 p.m., Certified Nursing Assistant (CNA) H reported that about three days after Resident #41's protective boots went down to laundry she contacted laundry to find out where they were, at which time laundry was unable to locate them. CNA H reported that it typically takes 1 or 2 days to receive boots back from the laundry department, during which time it is usual for the resident to go without them. In at interview on 4/14/2022 at 10:06 a.m., Director of Nursing (DON) B reported that in situations where protective boots are sent to the laundry, it is best that the resident not go without the boots if at all possible. DON B reported that spare boots should be used, or some other form of offloading. Review of a facility policy Pressure Ulcers/Skin Breakdown reviewed April 2021 revealed, .1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 2. The physician will help identify medical interventions related to wound management; for example, treat-ing a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc .3. The physician will help staff characterize the likelihood of wound healing, based on a review of perti-nent factors; .2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . Review of Fundamentals of Nursing (Potter and Perry) 9th edition revealed, Positioning interventions reduce pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces .patient's need repositioning on a schedule of at least every 2 hours .Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Elsevier Health Sciences. Kindle Edition. Review of the National Pressure Injury Advisory Panel Pressure Injury Stages revealed, Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions) .Medical Device Related Pressure Injury: This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. Mucosal Membrane Pressure Injury: Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these ulcers cannot be staged.

Based on observation, interview, and record review the facility failed to: 1. Properly date and discard food product; 2. Thoroughly clean food and non-food contact surfaces; and 3. Ensure proper working order of the dish machine. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 59 residents who consume food from the kitchen. Findings include: 1. During an initial tour of the kitchen, starting at 11:55 AM on 4/12/22, an interview with Chef Manager RR found that most items are dated for a seven-day discard. During the initial tour of the kitchen, at 12:00 PM on 4/12/22, it was observed that an open bag of hot dogs were found in the three door low boy preparation cooler, with a date of 4/6 to 5/6. When asked if this date was right, Director of Dining Services (DODS) SS stated it was, too many days. During an initial tour of the East Station refrigeration unit, at 1:08 PM on 4/12/22, an interview with Healthcare Dining Services Manager TT, found that dietary doesn't do much with the refrigeration units on the stations. At this time, a review of the East Station refrigerator found nine great shake supplements and two pizza slices with no date. The manufactures label on the mighty shakes state the item is good 14 days from thaw. During an initial tour of the North Station refrigeration unit, at 1:14 PM on 4/12/22, it was observed that one mighty shake was found with no date. Further review of the unit found staff items such as salad dressings, An interview with North Station Registered Nurse VV found that, staff sometimes use these refrigeration units. During an initial tour of the West Station refrigeration unit, at 1:25 PM on 4/12/22, it was observed that an open container of Thickened Apple Juice was found in the unit, not dated. A review of the manufacturer's instructions state the item is good for up to 7 days under refrigeration. According to the 2013 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . According to the 2013 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is appropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A) . 2. During an initial tour of the kitchen, at 12:05 PM on 4/12/22, an interview with Chef Manager RR found that clean utensils were stored in the top drawer of the food prep table. Review of the drawer found multiple mechanical scoops with stuck on food debris and an accumulation of crumbs in the corners and back of the drawer. At this time, DODS SS asked that the entire drawer be taken back and cleaned out. During an initial tour of the kitchen, at 12:12 PM on 4/12/22, an interview with Chef Manager RR found that the standup floor mixer was not used today. A review of the mixer found some splatter debris on the back shield and under arm of the unit. During an initial tour of the kitchen, at 12:19 PM on 4/12/22, observation of a clean utensil drawer on the cook line found a wire egg slicer with some small bits of egg debris stuck on the slicer. Once found the item was taken to the dish area. During an initial tour of the kitchen, at 12:47 PM on 4/12/22, it was observed that the ice scoop holder, on the wall next to the main ice machine, was found with an accumulation of black staining and crusted debris. It was also observed that no holes were present in the ice scoop holder, allowing stagnant water to accumulate and leave residue while it slowly evaporates. During an initial tour of the Healthcare kitchen, at 12:50 PM on 4/12/22, it was observed that an accumulation of sticky and caked on debris was found under the spouts for the juice and coffee machines. When pointed out to Healthcare Dining Manager TT and DODS SS, they acknowledge the accumulation. According to the 2013 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3. During the initial tour of the kitchen, at 12:28 PM on 4/12/22, it was observed that the dish machine was leaking water at the vacuum breaker cross connection that supplies hot water to the dish machine. At this time, it was observed that the rinse pressure was only achieving 10-12 pressure per square inch (psi). A review of the dish machines informational data plate found the unit requires 20 psi +/- 5 psi. When asked, staff and DODS SS was not aware of the issue with the water leak and pressure loss. At this time, It was also observed that the atmospheric vacuum breaker for the submerged inlet on the disposal, was missing the top metal portion that covers up the internal workings of the vacuum breaker, leaving an increased susceptibility to failure. According to the 2013 FDA Food Code section 4-501.113 Mechanical Warewashing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate . According to the 2013 FDA Food code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.

This citation pertains to intake MI 937. Based on observation, interview, and record review the facility failed to ensure resident bathing preferences were honored and staff failed to announce themselves before entering resident rooms for eight (Residents # 7, 9, 34, 35, 36, 43, 44, 45) of 59 residents reviewed for dignity resulting in anger and resident rooms being entered by facility staff without permission or announcement. Findings include: During an interview on 04/14/22 at 01:23 PM, Licensed Practical Nurse K reported facility staff should knock and announce themselves before entering a resident's room and no one had any preference for not having this dignified act completed. Resident #7 and 36: During an observation on 04/12/22 at 12:37 PM, Certified Nursing Aide JJ entered Resident #7 and #36's room while laughing loudly and didn't knock or announce her entrance to let the two residents know she was present and entering their room/space. During an observation on 04/12/22 at 01:11 PM, Certified Nursing Aide JJ entered Resident #7 and #36's room without knocking or announcing her entrance to let the two residents know she was present and entering their room/space. During an observation and interview on 04/12/22 at 12:42 PM, Resident #7 appeared pleasantly confused and was unable to answer the surveyor's questions on if the unannounced staff entrances bothered her. During an observation and interview on 04/13/22 at 09:10 AM, Resident #36 was non-verbal and unable to answer the surveyor's questions on if the unannounced staff entrances bothered her. Review of Resident #36's brief interview for mental status score, dated 3/4/22, was scored 99 which indicated Resident #36 was unable to complete the interview. Review of Resident #36's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's brief interview for mental status score, dated 1/15/22, was scored 99 which indicated she was unable to complete the interview. Review of Resident #7's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 and #44: During an observation on 04/12/22 at 01:14 PM, Certified Nursing Aide JJ entered Resident #9 and #44's room without knocking or announcing her entrance to let the two residents know she was present and entering their room/space. During an interview on 04/12/22 at 01:54 PM, Resident #44 appeared pleasantly confused and was unable to answer if staff entering her room without knocking, announcing, and/or getting permission bothered her. Review of Resident #44's brief interview for mental status score, dated 3/21/22, was scored 5 which was indicative of severely impaired cognition. Review of Resident #44's medical diagnosis, dated 9/14/21, included unspecified dementia. Review of Resident #9's brief interview for mental status score, dated 1/13/22, was scored 1 which was indicative of severely impaired cognition. Review of Resident #9's medical diagnosis, dated 9/21/21, indicated dementia. Resident #34: During an observation on 04/14/22 at 01:32 PM, Resident #34's door to her room was closed with a sign posted on the door that stated, Please knock and wait before entering. Thank you, (Resident #34). During an interview on 04/14/22 at 01:32 PM, Resident #34 reported approximately three or four times daily staff would walk into her room unannounced, it bothered her when they did that, and stated when they did that she was caught off guard which she didn't like. Resident #34 reported staff entering her room unannounced was why she wanted the sign posted on her door. Review of Resident #34's most recent brief interview for mental status score, dated 2/25/22, was scored 15 which indicated intact cognition. Resident #35 and #43: During an observation on 04/12/22 at 01:14 PM, Certified Nursing Aide JJ entered Resident #35 and #43's room without knocking or announcing her entrance to let the two residents know she was present and entering their space. Review of Resident #43's brief interview for mental status score, dated 3/20/22, was scored 3 which was indicative of severely impaired cognition. Review of Resident #43's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Quality of Life - Dignity policy, reviewed 6/2019, stated, Residents' private space and property shall be respected at all times .Staff will knock and request permission before entering residents' rooms. Applying the reasonable person concept a person would not want staff to enter their room without announcing themselves before entering. A resident room is part of the resident's home and a dignified notification, for example a knock and/or a verbal announcement, would be expected before entering their home/space. A reasonable person would be bothered and/or alarmed if someone entered their home/living space without announcing themselves and/or getting permission first. Resident #45 Review of a Face Sheet revealed Resident #45 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Brief Interview for Mental Status (BIMS) assessment for Resident #45, dated 3/19/2022, revealed a score of 15, out of a total possible score of 15, which indicated that the resident was cognitively intact. Review of a current Care Plan for Resident #45 revealed .I (Resident #45) require assistance with self care (related to) weakness, left [CONDITION(S)] . BATHING/SHOWERING: 1 ASSIST . In an interview on 4/13/2022 at 8:13 a.m., Resident #45 reported that her showers are scheduled for Mondays and Fridays, but about half the time staff do not come to her to assist her. Resident #45 reported that she did not get a shower on Monday as scheduled. Resident #45 reported that the shower did not take place until Tuesday when she asked for assistance. Resident #45 reported that she feels that her showers should take place on the scheduled dates and that she should not have to ask staff to assist her. Resident #45 reported that she feels angry when she does not get her shower as scheduled. Review of the policy/procedure Activities of Daily Living (ADLs), Supporting, dated December 2021, revealed .residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

Based on interview and record review, the facility failed to develop a baseline care plan for skin breakdown prevention for 1 (Resident #305) of 19 residents reviewed for care planning, resulting in the development of pressure injuries to bilateral heels. Findings include: Resident #305 Review of an Admission Record revealed Resident #305 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #305, not available due to recent admission. Review of Resident #305's Skin Only Evaluation dated 4/9/2022 at 15:44 (3:44 P.M.) revealed, Skin Issue: Deep Tissue Pressure Injury (DTPI). Skin Issue Location: coccyx dark red open area Pressure Ulcer / Injury Stage: Stage II - Partial thickness skin loss. Length: 4 cm Width: 3.5 cm Wound Bed: Granulation. Wound Exudate: None. Peri Wound Condition: Fragile .No wound odor .Other Skin Issue: bilateral heels mushy Skin Issue Location: heels Length: 2 cm . Review of Resident #305's Braden Scale for Predicting Pressure Ulcer Risk dated 4/9/22 at 15:31 (3:31 P.M.) revealed a score of 13, which indicated moderate risk. Review of Resident #305's Pressure Ulcer Care Plan revealed, I have a pressure ulcer on my coccyx (see SKIN BREAKDOWN POTENTIAL care plan for more interventions) Date Initiated: 4/10/2022. Interventions: I have a pressure ulcer on my coccyx. Assist, encourage to offload pressure to this area. Date Initiated: 4/10/2022. In house wound doctor referral and treat. Date Initiated: 4/10/2022. Treatment as ordered. Notify MD (medical doctor) if healing stalled or worsened. Date Initiated: 4/10/2022. Review of Resident #305's Skin Breakdown potential Care Plan revealed no care plan. During an observation on 4/12/22 at 2:51 P.M. Resident #305 was lying on his back in bed, head of bed (HOB) was 45 degrees, feet and legs were flat on the bed. There were no protective boots or pillows observed for offloading of pressure areas. During an observation on 04/13/22 at 3:18 P.M. Resident #305 was lying on his back in bed, with HOB approximately 30 degrees and both feet laying directly on the surface of the bed. Resident #305 was not wearing protective boots and heels were not floating. During an interview on 4/13/22 at 3:30 P.M., CNA J reported that Resident #305 required assistance to reposition in bed and the use of pillows for offloading pressure and stated, .he has a wound on his bottom .no other wounds that I know of . Review of Resident #305's Nurse's Note dated 4/13/2022 at 17:51 (5:51 P.M.) revealed, Bilateral mushy heels were noted on admission. Today both heels noted to have 2.5 cm firm dark colored skin. Non tender. Non blanchable. No open areas. Skin prep and heel booties ordered while in bed. (FM BB) and (Medical Doctor MD F) notified. During an interview on 4/14/22 at 9:48 A.M., Licensed Practical Nurse (LPN) D reported that she admitted Resident #305 on 4/9/22 with multiple skin issues and stated, .we recognized that he was less mobile .he had a coccyx wound .both heels were mushy .it was not concerning at the time . LPN D reported that she assessed Resident #305's heels on 4/13/22, and both heels had worsened since admission on 4/9/22. LPN D reported that she did not create a baseline care plan for skin prevention or Resident #305's mushy heels. During an interview on 4/14/22 at 11:03 A.M., Nurse Manager (NM) C reported that Resident #305 should have had a general skin prevention care plan in place upon admission to include floating heels, and then should have had a specific intervention put in place when it was discovered that his heels were mushy.

Based on observation, interview, and record review, the facility failed to implement care planned interventions for skin integrity in 1 (Resident #305) of 19 residents reviewed for care plan implementation, resulting in the potential for worsening of pressure injuries for Resident #305, and the potential to not meet the highest practicable level of well-being. Findings include: Resident #305 Review of an Admission Record revealed Resident #305 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #305, not available due to recent admission. Review of Resident #305's Skin Only Evaluation dated 4/9/2022 at 15:44 (3:44 P.M.) revealed, Skin Issue: Deep Tissue Pressure Injury (DTPI). Skin Issue Location: coccyx dark red open area Pressure Ulcer / Injury Stage: Stage II - Partial thickness skin loss. Length: 4 cm Width: 3.5 cm Wound Bed: Granulation. Wound Exudate: None. Peri Wound Condition: Fragile .No wound odor .Other Skin Issue: bilateral heels mushy Skin Issue Location: heels Length: 2 cm . Review of Resident #305's Braden Scale for Predicting Pressure Ulcer Risk dated 4/9/22 at 15:31 (3:31 P.M.) revealed a score of 13, which indicated moderate risk. Review of Resident #305's Pressure Ulcer Care Plan revealed, I have a pressure ulcer on my coccyx (see SKIN BREAKDOWN POTENTIAL care plan for more interventions) Date Initiated: 4/10/2022. Interventions: I have a pressure ulcer on my coccyx. Assist, encourage to offload pressure to this area. Date Initiated: 4/10/2022. In house wound doctor referral and treat. Date Initiated: 4/10/2022. Treatment as ordered. Notify MD (medical doctor) if healing stalled or worsened. Date Initiated: 4/10/2022. I have compromised skin bilateral Heels skin prep to my heels as ordered.Date Initiated: 04/13/2022. Blue boots on when in bed to off load my heels. Date Initiated: 04/13/2022. Review of Resident #305's Skin Breakdown potential Care Plan revealed no care plan. During an observation on 4/12/22 at 2:51 P.M. Resident #305 was lying on his back in bed, head of bed was 45 degrees, feet and legs were flat on the bed. There were no protective boots or pillows observed for offloading of pressure areas. Review of Resident #305's Skilled Evaluation dated 4/13/2022 at 10:01 A.M. revealed, .Skin: (no documentation) Skin note: [MEDICATION(S)] (bandage) intact to buttocks. (Wound Doctor (WD) E) to see today. APM (pressure reducing mattress) in place. Frequent positioning . During an observation on 4/13/22 at 11:55 A.M. Resident #305 was sitting in a wheelchair in his room with his head hanging down and his eyes closed. During an observation and interview on 4/13/22 at 2:00 P.M. Resident #305 was sitting in his room in his wheelchair. Family Member (FM) NN reported that Resident #305 has been waiting for staff get him back into bed and stated, .he has been up since before lunch. Resident #305 had been sitting in his chair for >2 hours. During an observation on 04/13/22 at 3:18 P.M. Resident #305 was lying on his back in bed, with HOB (head of bed) approximately 30 degrees and both feet laying directly on the surface of the bed. Resident #305 was not wearing protective boots and heels were not floating. During an interview on 4/13/22 at 3:30 P.M., Certified Nursing Assistanct (CNA) J reported that Resident #305 required assistance to reposition in bed and the use of pillows for offloading pressure and stated, .he has a wound on his bottom .no other wounds that I know of . Review of Resident #305's Nurse's Note dated 4/13/2022 at 17:51 (5:51 P.M.) revealed, Bilateral mushy heels were noted on admission. Today both heels noted to have 2.5 cm firm dark colored skin. Non tender. Non blanchable. No open areas. Skin prep and heel booties ordered while in bed. (FM BB) and (Medical Doctor MD F) notified. During an observation on 4/14/22 at 8:30 A.M. Resident #305 was on his back in bed, HOB 90 degrees, feet pressed firmly against the foot board of the bed. Resident #305 was not wearing protective boots and did not have his heels floating, and there was a flat pillow noted laying on the bed. During an observation and interview on 4/14/22 at 9:42 A.M. Resident #305 was on his back in bed, HOB 90 degrees, both feet pressed firmly against the foot board of the bed, slumped down in bed, and his legs bent at the knees due to the foot board not allowing him to straighten his legs. Resident #305 reported that bowel movement is his biggest problem and stated, .its inconvenient for them (facility staff). During an interview on 4/14/22 at 9:48 A.M., Licensed Practical Nurse (LPN) D reported that she admitted Resident #305 on 4/9/22 with multiple skin issues and stated, .we recognized that he was less mobile .he had a coccyx wound .both heels were mushy .it was not concerning at the time . LPN D reported that she assessed Resident #305's heels on 4/13/22, and both heels had worsened since admission on 4/9/22. LPN D reported that she did not create a baseline care plan for skin prevention or Resident #305's mushy heels. During an observation and interview on 4/14/22 at 10:21 A.M. Resident #305 was observed in the same position as the previous observation. CNA J and CNA M entered the room to provide cares. Staff proceeded with cares and toileting for Resident #305, then transferred him into his wheelchair. During an observation on 4/14/22 at 12:57 P.M. Resident #305 was observed in the dining room in his wheelchair. Resident #305 had been in the wheelchair for approximately 2 1/2 hours. During an interview on 4/14/22 at 11:03 A.M., Nurse Manager (NM) C reported that Wound Director (WD) E had not seen Resident #305 yet and stated, .there were some concerns with billing .then he (WD E) ran out of time . NM C reported that Resident #305 should have had a general skin prevention care plan in place upon admission to include floating heels, and then should have had a specific intervention put in place when it was discovered that his heels were mushy and stated, .heel interventions were added to the care plan yesterday .after the wounds were found to be worsened .the boots take a couple days to get .we can use a pillow to float heels . Review of Fundamentals of Nursing (Potter and Perry) 9th edition revealed, Positioning interventions reduce pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces .patient's need repositioning on a schedule of at least every 2 hours .Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. This interval is shortened in patients who are at very high risk for skin breakdown. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review the facility failed to ensure consistent bathing and nail care was provided for 2 of 4 residents (Residents #39 and 35) reviewed for activities of daily living, resulting in residents not being bathed, feeling bothered, and the potential for impaired skin integrity. Findings include: Resident #39 During an observation and interview on 04/12/22 at 11:55 AM, Resident #39 had long fingernails on all 10 fingers with 6 of them being jagged. Resident #39 reported he didn't like his fingernails that long and it bothered him. Resident #39 couldn't remember the last time staff had trimmed or offered to trim his fingernails. Resident #39 stated, It would be nice to have his nails cut. During an observation and interview on 04/13/22 at 07:54 AM, Resident #39 was seated in his wheelchair in his doorway. Resident #39's fingernails presented the same as they did on 04/12/22 at 11:55 AM. Resident #39's fingernails were still long, untrimmed, and had jagged edges. Resident #39 reported staff still had not cut them, offered to cut them, and he wanted them cut. During an interview on 04/13/22 at 01:16 PM, Director of Nursing B confirmed Resident #39 is not his own person/was deemed incapable of making medical decisions. During an observation and interview on 04/13/22 at 02:01 PM, Resident #39 was seated in his wheelchair in his room. Resident #39's fingernails remained the same as previous observations on 04/12/22 at 11:55 AM and 04/13/22 at 07:54 AM. Resident #39 reported his fingernails were bothering him and he was waiting for them to be cut. Resident #39 attempted to push buttons on his television remote, but his nails were touching the remote before his finger pads pressed the buttons. During an interview on 04/14/22 at 08:23 AM, Director of Nursing B stated, We (facility staff) could not find anything when asked about when Resident #39's fingernails were cared for last or if Resident #39 had refused/chosen not to have nail care completed. During a record review on 04/13/22 at 11:13 AM, in the task section of the electronic medical record for Resident #39 nail care was not noted. Review of Resident #39's care plan, print date 4/13/2022, did not indicate anything regarding nail care, that the resident preferred long fingernails, or for them to be left untrimmed. There was no noted refusals/resident choosing not to have nail care offered and/or provided. Reviewing Resident #39's progress notes, dated 9/3/2021 - 4/13/2022, revealed one note that addressed Resident #39's fingernails. This progress note, dated 9/3/2021, stated, .Thick and long fingernails . Review of Resident #39's physician diagnoses, undated, included Alzheimer's disease and dementia without behavioral disturbance. Review of Resident #39's most recent brief interview for mental status score, dated 3/10/2022, had a score of 14 which indicated intact cognition. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, reviewed 12/2021, stated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .Hygiene (bathing, dressing, grooming, and oral care) . Resident #35 Review of an Admission Record revealed Resident #35 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #35, with a reference date of 3/3/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #35 was cognitively intact. Review of the Functional Status revealed that Resident #35 required extensive assistance of 2 people for bathing, and the Interview for Daily Preferences revealed that Resident #35 indicated that it was very important to choose between a tub bath, shower, bed bath, or sponge bath. During an interview on 4/13/22 at 4:14 P.M., Resident #35 reported that she felt great today because she had a shower last night and stated, .it was my first shower since I've been here .usually they just wash my bottom and sometimes my top .I like a shower, that's what I always did at the other place . Resident #35 reported that the aide said she (Resident #35) was not on a regular schedule for showers. During an interview on 4/14/22 at 8:37 A.M., Certified Nursing Assistant (CNA) OO stated that he has not ever given Resident #35 a shower. During an interview on 4/14/22 at 12:12 P.M., CNA HH reported that she had not given Resident #35 a shower and stated, .if I give a shower, I mark it on the POC (point of care) charting in the computer . Review of Resident #35's POC Charting for ADL - Bathing Wednesday and Sunday, indicated that 1 shower (4/12/22) had been performed during the past 30 days.

This citation has two Deficiency Practice Statements, A & B. Deficiency Practice Statement A Based on observation, interview, and record review, the facility failed to disinfect glucometers per manufacturer's instructions in 1 of 9 residents (Resident #53) reviewed for infection control during medication administration, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population. Findings include: Review of a Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a current Care Plan for Resident #53 revealed the focus .I have Diabetes Mellitus . with interventions which included .report PRN (as needed) any s/sx (signs/symptoms) of infection to any open areas: Redness, Pain, Heat, swelling or pus formation . initiated 3/5/20. Review of an Order Summary Report for Resident #53 revealed .Blood Sugar (BS) before meals and at bedtime. Notify MD (Physician) if BS < 70 before meals and at bedtime . with a start date of 10/6/21. In an observation and interview on 4/14/22 at 11:46 a.m., Licensed Practical Nurse (LPN) N checked Resident #53's blood sugar level with a glucometer in his room. Observed LPN N obtain a blood sample using a finger stick device, squeeze a droplet of blood from Resident #53's finger, and collect the blood with a test strip connected to the glucometer. Observed LPN N discard the sharps and trash, and return to the medication cart with the soiled glucometer. Observed LPN N wipe the soiled glucometer with a 70% Isopropyl Alcohol wipe, wrap the glucometer in the wipe, and place the wrapped glucometer in a single use plastic cup as a barrier. LPN N reported the glucometer is wrapped in the 70% Isopropyl Alcohol wipe for five minutes, and then allowed to air dry. LPN N reported the facility provided bleach wipes give her a headache, therefore the alcohol wipes were provided to disinfect the glucometer. Observed the container of Pharma-C Wipes First Aid Antiseptic 70% Isopropyl Alcohol wipes. Noted no contact time for disinfection of equipment listed on container, and no information as to whether or not the wipes utilized were effective against [CONDITION(S)], [CONDITION(S)] C and [CONDITION(S)] B virus. Noted a statement on the container of wipes which read .Helps prevent the risk of infection in minor cuts and abrasions . LPN N reported the PDI SANI-CLOTH BLEACH wipes have a wet contact time of one to three minutes to ensure proper disinfection. In an interview on 4/14/22 at 12:01 p.m., LPN K reported PDI SANI-CLOTH BLEACH wipes are used to disinfect glucometers after each use. LPN K reported the PDI SANI-CLOTH BLEACH wipes have a wet contact time of two minutes to ensure proper disinfection, and then should be allowed to air dry. In an interview on 4/14/22 at 12:06 p.m., LPN L reported PDI SANI-CLOTH BLEACH wipes are used to disinfect glucometers after each use. LPN L reported all surfaces of the glucometer should be wiped with a PDI SANI-CLOTH BLEACH wipe for three minutes, and then the device should be allowed to air dry. LPN L reported alcohol wipes should not be used to disinfect glucometers. In an interview on 4/14/22 at 2:07 p.m., Nurse Manager C reported PDI SANI-CLOTH BLEACH wipes should be used to disinfect glucometers after each use, with a wet contact time of three minutes. Nurse Manager C recalled that permission had been given to a nurse to use alcohol wipes due to a history of sensitivities, however, stated .I don't think we have anything documented . Requested information related to the use of 70% Isopropyl Alcohol wipes to disinfect a glucometer. No additional documentation or information provided prior to survey exit. Review of the PDI SANI-CLOTH BLEACH wipe packaging revealed .GERMICIDAL DISPOSABLE WIPE .Bactericidal, Fungicidal, Tuberculocidal and Virucidal** in 4 minutes (wet contact time) .ACTIVE INGREDIENT .Sodium Hypochlorite (Bleach) . Review of the policy/procedure Glucometer Disinfection, dated 12/2001, revealed .The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees .Cleaning is the removal of visible soil from objects and surfaces normally accomplished manually or mechanically using water with detergents or enzymatic products. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects .The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use .The glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against [CONDITION(S)], [CONDITION(S)] C and [CONDITION(S)] B virus .Procedure .Retrieve (2) disinfectant wipes from container .Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer .After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry . Review of the [NAME] RealTime Blood Glucose Monitoring System Owner's Manual, dated 7/2018, revealed .This manual provides important information to help you to use they system properly .Users need to adhere to Standard Precautions when handling or using this device. All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting bloodborne pathogens between patients and healthcare professionals .The meter should be disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed .Caring for Your Meter .You should disinfect the meter between each patient to prevent infection .The meter must be cleaned prior to the disinfection. Use one disinfecting wipe to clean exposed surfaces of the meter thoroughly and remove any visible dirt, blood or any other body fluid with the wipe. Use a second wipe to disinfect the meter .We recommend using the product listed below to clean and disinfect your meter. It has been shown to be safe when used on the [NAME] RealTime blood glucose meter .Micro-Kill+ (Trademark) (Micro-Kill Plus (Trademark)) by [MEDICATION(S)] .Disinfecting Procedures .Put on non-sterile gloves .Take out one disinfecting wipe from the package and squeeze out any excess liquid in order to prevent damage to the meter .Wipe all exterior surface of the meter including the display and buttons. Hold the meter with the test strip slot pointing down and wipe the area around the test slot, be careful not to allow excess liquid to get inside. Keep the meter moist with disinfection solution contained in the wipe for a minimum of 2 minutes for Micro-Kill+ (Trademark) wipes. Follow the instructions on the package label of disinfecting wipe. Use two or more wipes if necessary .Remove the wipe. Allow the meter surface to dry completely . Deficiency Practice Statement B Based on interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the 59 residents in the facility. Findings include: During an interview with Senior Director of Environment (SDE) QQ and Director of Environmental Services (DES) PP, starting at 3:00 PM on 4/12/22, it was found that the facility was lacking an established policy and procedure to carry out an effective Water Management Plan (WMP). When asked if the facility had performed a risk assessment to identify where legionella and other OPPP could grow and spread in the facility. SDE QQ stated that the facility has a flow chart, but does not have a document that would show the risk areas presented in the facility. When asked if the facility had a policy and procedure, had utilized the CDC-toolkit, or the American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) Guidelines, SDE QQ stated, No. When asked if the facility had a WMP team, DES PP stated, there is no team at the moment. When asked if there was currently testing or sampling of the water to better understand the risk the facility may pose in the growth of Legionella or other OPPP, SDE QQ stated, No. SDE QQ stated that the facility started to get things around to regular testing, including the purchase of a digital colorimeter to sample and test for total free chlorine residual, but needed to start using it.

Based on interview and record review the facility failed to notify the State Long-Term Care Ombudsman (SLTCO) office of facility initiated transfers and discharges for 2 (Resident #42 & #18) of 2 residents, reviewed for change of condition notifications, resulting in SLTCO office to not be aware of practices and activities related to transfers and discharges and the potential for residents to be inappropriately discharged , and/or not have an advocate to ensure their rights. Findings include: Resident #42 Review of an Admission Record revealed Resident #42 was originally admitted to the facility on [DATE]. Review of Resident #42's Progress Note dated 3/6/2022 at 11:34 A.M. revealed, .observed the resident having a possible TIA (stroke) .Immediately called 911 to have resident sent to ER (emergency room ) .EMS (emergency medical services) arrived to transport resident to [NAME] hospital .Resident left the facility via stretcher at 1130 . During an interview on 04/14/22 at 1:50 P.M., Intake Specialist (IS) KK reported that she notified the SLTCO office monthly of all facility initiated discharges and emergency transfers. At 2:01 P.M., after efforts to locate the information were exhausted, IS KK stated, .I cannot find it right now ., but indicated that she would continue to search for the documents. Review of a log Emergency Transfer Report submitted in an email from NHA on 4/14/22 at 2:49 P.M., indicated Resident #42 transferred to acute care, but did not include a date, and Resident #18 transferred to acute care on 1/29/22. These documents did not include evidence that the reports were sent to SLTCO office. In an email on 4/14/22 at 4:33 P.M., State Certified Long Term Care Ombudsman (SCLTCO) LL reported that the SLTCO office had not received any transfer or discharge notifications from the facility since October 2021, and did not have any emergency transfer record for Resident #42's emergency transfer on 3/6/22 & Resident #18's emergency transfer on 1/29/22. During an interview on 4/14/22 at 4:40 P.M. NHA reported that she was not able to provide documentation that notifications of facility initiated transfers/discharges were sent to SLTCO office on a monthly basis. R18 (Resident #18) According to the Minimal Data Set (MDS) Discharge assessment dated [DATE], R18 scored 15/15 (cognitively intact) on the BIMS (Brief Interview Mental Status) related to a fall with [CONDITION(S)] requiring hospitalization and surgery. Entry tracking record dated 2/1/2022 with the resident's return to the facility. Review of R18's Progress Notes 1/29/2022 at 10:57 (AM) reported the resident was in her bathroom when she had lost her balance and fallen. The resident was unable to move her right leg and right foot was externally rotated. A right hip x-ray was ordered. On 1/29/2022 at 13:22 (1:22 PM) reported a mobile x-ray was called to obtain right hip x-ray results. The resident's right hip Intertrochanteric was broken and resident was transferred to the hospital per order. On 1/29/2022 at 13:55 (1:55 PM) reported the resident was sent to the emergency room via an ambulance and was admitted to the hospital.

Based on observation, interview, and record review, the facility failed to fully develop and implement the policy and procedure for non-fully vaccinated staff in 1 of 5 staff members reviewed for COVID-19 vaccination status, resulting in the potential for transmission of COVID-19 to all residents within the facility. Findings include: In an email correspondence on 4/14/2022 at 12:47 p.m., Director of Nursing (DON) B stated, .The recent change to recommend unvaccinated wear n95 is not in a policy because it is continuously changing. We put it into practice and sent out the memo . Review of facility memo Updated Mask Guidance, Testing Reminders, dated February 11, 2022, revealed .Effective 2/14/22 all unvaccinated team members who work in/for skilled nursing (if you are classified as CMS) must wear an N95 mask while at work . In an observation and interview on 4/14/2022 at 11:35 a.m., Certified Nursing Assistant (CNA) Y was observed wearing a surgical face mask. CNA Y reported that she is unvaccinated and has a valid COVID-19 vaccine exemption. CNA Y reported that she was wearing a surgical mask but is required to wear an N-95.

Based on observation, interview, and record review the facility failed to recognize signs and symptoms of Covid-19, implement isolation precautions, and notify the Local Health Department of Covid-19 symptoms for 2 of 3 Residents (Resident #101, #102) reviewed for infection control, resulting in facility staff did not perform surveillance or follow the CDC guidance to prevent the spread of Covid-19 to residents in the facility. Findings include: Review of the facility policy Novel Coronavirus Prevention and Response last revised 3/27/20 revealed, Policy: This community will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of [MEDICAL CONDITION] . Policy Explanation and Compliance Guidelines: The Infection Preventionist or designee will assess community risk associated with COVID-19 through surveillance activities of emerging diseases in the community and illnesses present in the community. No current risk - the community will implement interventions for prevention and prepare for a potential outbreak. Threat detected - the community will respond promptly and implement emergency and/or outbreak procedures. Staff shall be alert to signs of COVID-19 and notify the resident's physician if evident: Fever Cough Shortness of breath . Interventions to prevent the spread of respiratory germs within the community: Keep residents and employees informed by answering questions and explaining what they can do to protect themselves and their fell ow residents (i.e. handwashing, spatial separation, respiratory hygiene/cough etiquette). Monitor residents and employees for fever or respiratory symptoms. Restrict residents with fever or acute respiratory symptoms to their room. Have them wear a facemask (if tolerated) if they must leave the room for medically necessary procedures. In general, for care of residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless suspected [DIAGNOSES REDACTED].g., [MEDICAL CONDITION]). Implement heightened surveillance activities or consult public health authorities for additional guidance if there is transmission of COVID-19 in the community . Procedure when COVID-19 is suspected: a. Notify physician, Director of Nursing, Infection Preventionist, and family. b. Place resident in a private room (containing a private bathroom) with the door closed. c. Limit the number of people who enter the resident's room. Maintain a log of all people who enter the room. d. Implement standard, contact, and airborne precautions (droplet precautions if no airborne isolation room available). Wear gloves, gowns, goggles/face shields, and masks (N95 if available) upon entering room and when caring for the resident. e. Dedicated medical equipment (preferably disposable, when possible) should be used for the provision of care. Clean and disinfect all other equipment used for care. f. Avoid aerosol-generating procedures (i.e. suctioning) as possible. g. Utilize Checklist COVID-19 Suspected or Confirmed. Review of the facility policy Respiratory (COVID) Surveillance and Illness- Resident (no date) revealed, To prevent the spread of illness, all residents residing within the facility during the pandemic will be monitored for fever and for the presence of symptoms of COVID like illness. For the purposes of general monitoring, COVID like illness is defined as a respiratory illness with: Fever (Temperature >100?); and at least one of the following symptoms: a. Cough, sore throat, headache, fatigue, myalgia, loss of taste or smell, vomiting, or diarrhea in the absence of other known cause. b. (blank). Policy Interpretation and Implementation-1. Monitoring of resident infection status will occur in accordance with department policies governing the monitoring of resident infection within the facility. 2. In addition, during this pandemic the facility will monitor residents for symptoms of COVID-like illness. This includes initiation of checking temperature and Oxygen saturation levels, along with respiratory status monitoring as suggested by CDC, CMS, or other local/state guidance. 3. When 2 or more residents of a unit present with COVID- like symptoms, it will be reported to the infection preventionist for tracking and monitoring. 4. Resident care staff are responsible for routine monitoring of the resident's overall health status and reporting change in condition to the nurse supervisor. Resident care staff should immediately report residents exhibiting signs of COVID-like illness to their supervisor. 5. Staff should also monitor and report any symptoms they develop during this time. 6. The nursing supervisor (of designee) is responsible for: a. Notifying the resident's physician. b. Obtaining culture specimen and initiating treatment as ordered by the resident's physician. c. Initiating Droplet Precautions per facility policy and as directed. d. Notifying the department manager per department policy for monitoring and tracking of resident infections. 7. Residents exhibiting symptoms of serious illness will be transferred to an acute care facility as indicated and/or ordered by resident's attending physician and in conjunction with their wishes/Advance Directives. 8. The Department Manager (or designee) is responsible for monitoring the infection status of all residents and consulting the Infection Control Manager as needed. 9. The Department Manager (or designee) will monitor residents on a daily basis for the development of new infection and notify the Infection Control Manager of all cases of newly reported COVID-like-illness. 10. The Infection Control Manager (or designee) will be responsible for monitoring COVID activity throughout the facility. Infection control recommendations and employee and/or resident education will be provided as needed. 11. During this pandemic, the Infection Control Manager will report residents who are PUI, those tested Negative and those tested Positive. This information will be shared with the COVID Ops team at daily meetings. 12. Information will also be summarized and shared at the facility QAPI Committee meetings. Review of Fundamentals of Nursing (Potter and Perry) 9th edition revealed, The temperature of older adults is at the lower end of the normal temperature range, 36 ° to 36.8 ° ? C (96.8 ° to 98.3 ° ? F) orally and 36.6 ° to 37.2 ° ? C (98 ° to 99 ° ? F) rectally. Therefore temperatures considered within normal range sometimes reflect a fever in an older adult .Older adults are very sensitive to slight changes in environmental temperature because their thermoregulatory systems are not as efficient .Be especially attentive to subtle temperature changes and other manifestations of fever in this population such as tachypnea, anorexia, falls, [MEDICAL CONDITION], and overall functional decline. Older adults without teeth or with poor muscle control may be unable to close their mouths tightly to obtain accurate oral temperature readings. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing (Potter and Perry) 9th edition revealed, Need to immediately report any significant changes or abnormalities and any SpO2 reading lower than 90% to nurse immediately .Hypoxemia refers to a decrease in the amount of arterial oxygen. Nurses monitor arterial oxygen saturation (SpO2) using a noninvasive oxygen saturation monitor pulse oximeter. Normally SpO2 is greater than or equal to 95% .[MEDICAL CONDITION] is inadequate tissue oxygenation at the cellular level. It results from a deficiency in oxygen delivery or oxygen use at the cellular level. It is a life-threatening condition. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - , - , - ). Elsevier Health Sciences. Kindle Edition. During an interview on 05/20/2020 at 12:54 P.M., Nursing Home Administrator (NHA) A and Director of Nursing (DON) B reported that each morning during morning meeting the Unit Managers run the Vital Sign report and abnormal vital signs are discussed. During an interview on 05/19/20 at 11:08 A.M., Infection Control Nurse (ICN) N reported that staff are monitoring Covid-19 symptoms which include: new shortness of breath, cough, fatigue, body aches, and loss of taste and smell. ICN N reported that twice a day the temperature and oxygenation level of all residents residing in the facility is assessed and documented in the Electronic Health Record (EHR). ICN N reported that temperature trends are watched and if there is an change in the baseline further assessment is completed. ICN N reported that a temperature (for a resident) that is 100 degrees Fahrenheit or higher is considered a fever. During an interview on 05/19/20 at 11:12 A.M. DON B reported that any resident temperature over 99 degrees Fahrenheit would warrant further investigation for Covid-19. DON B reported that all vital signs are reviewed each morning in the Stand Up meeting. DON B reported that any communication with the physician is documented in the EHR. During an interview on 05/19/20 at 2:04 P.M. with DON B and NHA A. DON B reported that if there is an abnormal result or a new symptom in a resident the nursing staff notify the Unit Manager and the Unit Managers then notify the Infection Control Nurse. During an interview on 05/20/20 at 11:48 A.M., DON B reported that if a staff member arrived to work with a fever they would be sent home to prevent the spread of Covid-19 even if there were no other symptoms. During an interview on 5/20/20 at 8:30 AM, Health Department Epidemiologist (HDE) F stated symptoms of Covid-19 were cough, fever, congestion, fatigue, headache and body aches. HDE F further stated, if someone was experiencing symptoms then yes they would get tested for Covid-19. During an interview on 5/20/20 at 2:45 PM, Certified Nurse Aide (CNA) P stated she performed vital signs at the start of my shift and if (the vital signs) were not right (sic, indicated out of normal range) then talk to the nurse and have me redo (sic) them (vital signs). CNA P stated, yes I have documented every vital sign taken on residents in the computer and if I didn't document (the vital signs) then I gave it (vital sign results) to the nurse and they take care of it. Resident #101: Review of the Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a brief interview for mental status (BIMS) score of 13 out of 15 which indicated she was cognitively intact. During an observation on 5/19/20 at 10:28 AM, Resident #101 was noted to be in her bed. No isolation precaution signage was observed on her door and no personal protective equipment was observed outside her doorway into her room. During an observation on 5/20/20 at 11:10 A.M. Resident #101 was in her room with no isolation precautions in place. During an interview on 05/19/20 at 12:33 P.M. DON B reported that that there was no documentation that the physician was notified of Resident #101's abnormal temperature on 5/8/20 but she was not exhibiting any other symptoms at that time. During an interview on 05/19/20 at 2:04 P.M. with DON B and NHA A. DON B reported that Resident #101 was assessed by the Nurse Practitioner on 5/12/20 regarding her hypoxemia (low oxygen level) and had a chest X-ray ordered. No further testing was completed at that time. DON B reported that Resident #101's last blood draw for a Complete Blood Count (CBC) was completed on 5/4/20. Review of an email from DON B to this surveyor dated 5/19/20 at 1:34 P.M. revealed, I have reviewed the medical record with my team for (Resident #101) and have not been able to locate any additional information regarding the temp(erature). There was a follow up temp(erature) on 5/9 @0055 (12:55 P.M.) of 98.8 and no additional symptoms noted on the respiratory assessments conducted. Review of Resident #101's Health Status Note dated 4/25/20 at 7:34 P.M. revealed, Note Text: Residents mood is pleasant and cooperative. Noted to be more lethargic this shift. No s/sx (signs or symptoms) of acute respiratory illness noted. Continues on Oxygen at 2L via nasal canula PRN (as needed). 88% o2 (oxygen) noted on room air, oxygen therapy initiated for comfort. Res (Resident) denies feeling anxious but stated she is depressed due to covid-19 isolation. Res is currently resting in bed watching television. Staff assisted in calling daughter this afternoon. Review of Resident #101's Vital Signs dated 4/26/20 at 9:46 A.M. revealed a temperature of 100.2 Review of Resident #101's Health Status Note dated 4/26/20 at 2:22 P.M. revealed, Residents mood is calm and cooperative. No s/sx of acute respiratory illness observed. Fever of 100.2 noted. Lung sounds diminished in bases. denies SOB, cough, sore throat. Denies pain. Resident voiced concerned of Left toe not healing. Unit manager notified. Review of Resident #101's Health Status Note dated 5/2/2020 at 5:26 P.M. further revealed, Res A&Ox3 (Alert and Oriented to person, place, and time), Mood is lethargic today. Res complains of dizziness this afternoon, O2 (oxygen) Obtained O2 85% RA, PRN (as needed) O2 applied and HOB (head of bed) elevated. O2 increased to 95% on 2L. Denies sore throat, Mild productive cough noted. Res did not want to eat dinner, but did request 2 great shakes. Res continues with RTN treatments. No s/sx of Respiratory Illness. Review of Resident #101's Respiratory Screener Evaluation dated 5/3/20 at 5:37 P.M. revealed, T (temperature) 89.2 - 5/3/2020 10:33 Route: Axilla .Recent change in disorientation / mental status. New onset [MEDICAL CONDITION] (a change in resident level of consciousness). Acute functional decline: Yes. Review of Resident #101's Health Status Note dated 5/3/20 at 5:31 P.M. revealed, Res (Resident #101) A&Ox3, Res presents with confusion this afternoon, after waking up from a nap. Kept talking about a game that she was in. Res presents with a syncopial episode ([MEDICAL CONDITION]) with an episode of [MEDICAL CONDITION] (low blood pressure), while sitting in her wheelchair, Res said she felt dizzy and wanted to lay down. O2 85% RA (oxygen level 85% on room air), and BP (blood pressure) 84/56, Pulse 68. Res given O2 and assisted back into bed, BP rechecked and WNL (within normal limits), 122/66, O2 94% via NC (nasal cannula) on 2L. Continues on RTN (routine) Neb (nebulizer) treatments. Review of Resident #101's Health Status Note dated 5/4/20 at 2:05 P.M. revealed, Resident mood is lethargic. Resident c/o (complains of) not feeling well and being overly tired . Review of Resident #101's Respiratory Screener Evaluation dated 5/6/20 at 12:32 P.M. revealed, Recent change in disorientation / mental status . Malaise (c/o generally not feeling well): Yes. Review of Resident #101's Respiratory Screener Evaluation dated 5/7/20 at 8:35 A.M. revealed, No [DIAGNOSES REDACTED]. New or increased cough: Yes. Cough: Dry / Non-productive . Recent change in lung sounds: Yes. Malaise (c/o generally not feeling well): Yes. Acute functional decline: Yes. Was a CXR recently completed: No. Review of Resident #101's Hospice note dated 5/7/20 at 4:37 P.M. revealed, Facility nurse reported (Resident #101) had coarse lung sounds all over and a cough this morning .(Resident #101) was pleasant and engaged but appeared fatigue (sic). Review of Resident #101's Vital Signs dated 5/8/20 at 8:47 P.M. revealed a temperature of 100.3 degrees Fahrenheit. Review of Resident #101's Progress Notes dated 4/1/20 to 5/20/20 revealed no documentation Resident #101 was tested for Covid-19 or that the Health Department was notified of Resident #101's Covid-19 symptoms. Review of Resident #101's Results revealed no laboratory testing was completed since 3/10/20. During an interview on 5/21/20 at 11:53 A.M., Licensed Practical Nurse (LPN) V stated Resident #101 had a respirations of around 22 breaths per minute and had increased cough, worsening cough and wheezing. LPN V stated after Resident #101 received breathing medications, she (Resident #101) can breathe better but she's (Resident #101) still not the greatest (indicated Resident #101's condition had improved but not to baseline). Resident #102: Review of the Face Sheet revealed Resident #102 was an [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the MDS dated [DATE] revealed Resident #102 had a BIMS score of 11 out of 15 which indicated she had moderately impaired cognition. Review of Resident #102's Vital Signs dated 5/3/20 at 4:24 A.M. revealed a temperature of 99.6 degrees Fahrenheit. Review of Resident #102's Vital Signs dated 4/3/20 at 3:36 P.M. revealed a temperature of 99.6 degrees Fahrenheit. Review of Resident #102's Vital Signs dated 5/4/20 at 3:53 A.M. revealed a temperature of 99.6 degrees Fahrenheit. Review of Resident #102's Vital Signs dated 5/10/20 at 11:21 A.M. revealed a temperature of 99.6 degrees Fahrenheit. Review of Resident #102's Vital Signs dated 5/17/20 at 12:15 A.M. revealed a temperature of 99.5 degrees Fahrenheit. Review of Resident #102's Vital Signs dated 5/18/20 at 9:55 P.M. revealed a temperature of 100.5 degrees Fahrenheit. Review of Resident #102's Progress Notes for May 2020 revealed no documentation that Resident #102 was tested for Covid-19, the Health Department was notified of elevated temperatures, or that the physician was notified of elevated temperatures. Review of Resident #102's Results revealed no laboratory testing was completed since 3/6/20. During an observation on 5/19/20 at 12:10 PM, Resident #102 was noted to be in her room. No isolation precaution signage was observed on her door and no personal protective equipment was observed outside her doorway into her room. During an interview on 05/20/20 at 9:47 A.M., ICN N reported that she just notified the Health Department of Resident #102's placement into isolation. When asked if she reported Resident #102's fever of 100.5 from 5/18/20 she stated, Yes. During an interview on 05/20/20 at 11:45 A.M. ICN N (DON B and NHA A present) reported that she reported Resident #102's symptoms to the Local Health Department and stated, frankly it's ridiculous. During an email interview with NP O on 5/20/20 at 8:42 A.M., this surveyor asked, If you had a resident that had a fever greater than 100, a cough, and/or shortness of breath would you suspect Covid? Would you have them tested ? When would you place them in isolation? On 5/20/20 at 9:22 A.M.NP O replied, Yes. With all those symptoms, I would test for Covid and place on droplet precautions immediately until results of swab. Review of Resident #103's Progress Notes for May 2020 (up to 5/19/20) revealed no documentation that Resident #102 was tested for Covid-19 or that the Health Department was notified of respiratory symptoms. During an interview on 05/20/20 at 08:30 A.M., DON B reported that the Local Health Department was not notified of Resident #101, #102, symptoms. DON B reported that Resident #102 was placed in isolation because of her fever. DON B reported the physician was notified and Resident #102 was placed into isolation to monitor her fevers. DON B reported that Resident #101 was not placed into isolation because she had been afebrile and exhibited no other symptoms of Covid-19.

This citation pertains to intake number MI 673. Based on observation, interview, and record review, the facility failed to prevent the elopement of 1 sampled resident (Resident #100) of 5 residents reviewed for elopement, resulting in an Immediate Jeopardy when (Resident #5) who had been assessed as an elopement risk and wore a WanderGuard bracelet, and who eloped from the facility, unbeknownst to staff, after an unknown system malfunction, allowing Resident #5 to elope from the facility by the elevator on 11/29/19 at 7:57 PM and was brought back to the facility about two minutes later when a visitor alerted staff members that Resident #5 was outside the facility. This deficient practice placed Resident #5 and 7 other residents who were assessed as being at risk for elopement, at risk for serious harm, injury and or death from hazards outside the facility. Findings include: Review of an Admission Record revealed Resident #100 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 7/3/19, revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #100 was severely cognitively impaired. Review of the Wandering Risk assessment dated [DATE], revealed Resident #100 was High Risk for Wandering, B. Behavior/Mood 1. combative/severely agitated 3. does not understand surroundings D. Mobility 1. Ambulates with one assist E. Early dementia [NAME] Known wanderer/history of wandering. Review of the Elopement/Wandering Care Plan dated 6/28/19, revealed I am at risk for elopement/wandering Disoriented to place impaired safety awareness, statement of wanting to leave to get his car Goal: My safety will be maintained through the review. Date Initiated: 6/28/19. Review of Nursing Notes dated 11/29/19 at 10:18 PM revelaed, Skin warm and dry, skin color within normal limits, mucous membranes moist, turgor normal. No current skin issues noted at this time. No changes to skin. Review of the Treatment Administration Record (TAR) dated (MONTH) 2019, revealed wander guard to left wrist. Check placement and function each shift. Bring near a beacon to ensure proper function every day and night shift. TAR revealed all opportunities were completed. Review of the Treatment Administration Record (TAR) dated (MONTH) 2019, revealed wander guard to left wrist. Check placement and function each shift. Bring near a beacon to ensure proper function every day and night shift. TAR revealed all opportunities were completed. Review of the Incident Summary dated 11/29/19 at 8:45 PM, revealed (name of resident) exited (name of facility) via elevator, along with people who had been there to visit. When (name of resident) got to the parking lot, just outside the door, a couple who visits regularly saw him and the wife of the couple went upstairs to the Health and Rehabilitation Center to get a nurse while the husband of the couple stayed with (name of resident). The nurse went down and assisted (name of the resident) back to the Health and Rehabilitation Center. (Name of the resident) stated he was going to his car. Surveillance cameras indicate the time (name of resident) was outside of the Health and Rehabilitation Center was two minutes and he was not unattended. (Name of resident) was evaluated and is wearing a Wander Guard bracelet which is designed to lock down the elevator from use and alert staff - it also is designed to alarm at exit doors and alert staff. During an interview on 12/23/19 at 11:15 AM, Licensed Practical Nurse (LPN) J reported that a visitor came to get her on 11/29/19 at about 8:00 PM to tell her that there was a gentleman in a wheelchair downstairs not sure if he belongs here, they were trying to go out the double doors and noticed that he did not have a coat on, and he was stating that he was looking for his car. LPN J reported that she went down the elevator to the exit and noted that Resident #100 was outside the building, LPN J repored she was able to bring him back up in the elevator without the WanderGuard going off. LPN J reported that Resident #100 was assessed for injuries and put on 15 minute checks. LPN J reported maintenance and the Director of Nursing (DON) B were called. During an interview on 12/23/19 at 11:58 AM, Director of Environmental Services (DES) C reported that the video from 11/29/19 showed Resident #100 exiting the building at 7:57 PM, with someone (a man) at his side, but not touching him, just appeared to be talking to him while the resident self propelled his wheelchair in the area just outside the double doors, but that the video had been taped over and was not available to be viewed. DES C reported that (Resident #100) was only out of the building 2 minutes according to the video before the nurse came to get him and take him back inside the building. DES C reported that after calling the elevator vendor, we found that the WanderGuard beacon in the elevator was knocked off line due to the power outage experienced on 11/29/19. DES C reported that staff were not aware that power outages or interruptions to the power would affect the WanderGuard beacon in the elevator. During an interview on 12/23/19 at 12:15 PM, DON B reported that all 8 residents who were at risk for elopement were immediately put on 15 minute checks until the WanderGuard beacon in the elevator could be repaired. DON B reported that a head count of all residents in the building was completed per protocol. DON B reported that all exit doors were checked to verify that the WanderGuard alarms were working. During an interview on 12/23/19 at 9:30 AM, Registered Nurse (RN) K reported that they have taken checking WanderGuard's to a new level, they check the resident to verify the WanderGuard placement twice daily and they have a phone which shows the resident, so if the resident with a WanderGuard were to go by a door we would know which door they were at. During an interview on 12/26/19 at 2:00 PM, RN H reported that staff were educated on checking the WanderGuard's twice a day to verify they were in place and functioning and the phones were working. RN H was working the floor at the time and reported that she had checked the residents this morning. During an observation on 12/26/19 at 8:30 AM, Maintenance checking doors by using a WanderGuard to set them off. During an observations on 12/26/19 at 12:00 and 3:10 PM, Resident #100 was noted to self propelling on the facility unit and to have his WanderGuard's in place and functioning. On 12/23/19 at Administrator A and DON B was notified of an Immediate Jeopardy that began on 11/29/19 when Resident #100, who was identified as an elopement risk, eloped from the facility, unbeknownst to facility staff. On 12/26/19, this surveyor verified the facility completed the following to remove the Immediate Jeopardy: On 11/29/19 all residents who have been deemed to be at risk for elopement were placed on 15-minute checks until the elevator WanderGuard beacon was reset. On 11/29/19 WanderGuard placement and functionality was verified for all residents deemed to be at risk for elopement. WanderGuard's are checked for placement and functionality two times per day (once on each 12-hour shift), on all residents deemed to be at risk for elopement. On 11/30/19 the wander guard system was verified to be working properly. On 11/29/19 signs to educate visitors to not allow residents to leave with them were changed from white paper to yellow paper and pink paper, to make it more visible. On 11/29/19 Environmental Services (EVS) staff has been educated on the updated process to check WanderGuard beacons daily and to add elevator check to list of secure areas after a power outage or interruption to ensure they function properly. Education was started on 11/29/19 and all EVS staff have been educated. On 11/29/19 Nursing staff started receiving re-education about the WanderGuard. To date, 85% of nursing staff have been educated. All remaining staff will be educated prior to working the next scheduled shift. The facility was granted a Past Non-Compliance at the time of exit due to no further like incidents had occurred since 11/29/19 to present, the facility re-trained pertinent staff, the elevator beacon was being tested , the Elopment and Wandering Resident Policy was reviewed and deemed appropriate, and the facility had achieved sustained compliance. Therefore, no plan of correction will be required.

This citation pertains to intake #MI 499. Based on interview and record review the facility failed to provide a safe transfer for 1 of 3 residents (Resident #100) reviewed for safety, resulting in a fracture of Resident #100's leg. Findings include: Review of the facility policy, Safe Lifting and Movement of Residents last revised (MONTH) (YEAR) revealed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. Review of a Face Sheet revealed Resident #100 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of 8/2/19 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #100 was moderately cognitively impaired. Review of the Functional Status revealed that Resident #100 required extensive one person assist for bed mobility, transferring, dressing, toileting, and personal hygiene. Review of Resident #100's care plan revealed, I (Resident #100) have an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Impaired balance, Limited Mobility, Musculoskeletal impairment, Weight bearing restriction RLE (right lower extremity) w (with) immobilizer, LUE (left upper extremity) decreased ROM (range of motion) Date Initiated: 05/03/2018 .I will continue to safely transfer with the assistance of staff, and appropriate transfer device .Date Initiated 5/3/18 (sic). During an interview on 08/27/2019 at 10:44 A.M., Resident #100 stated, I was waiting to get into bed. We (staff) did that with a slide board (device used to assist residents to move from one location to another). (Certified Nursing Assistant (CNA) F) came in. Resident #100 felt that CNA F did not respond to her call light in a timely manner and felt that CNA F was rude when she entered Resident #100's room. Resident #100 reported that CNA F grabbed me and shoved me towards the bed. I landed on the bed but I also landed with a broken leg. Resident #100 stated, My one leg would never do me any good (right leg from a previous injury) and then she crippled my other leg. Resident #100 reported that now she has to use a lift and it's plain uncomfortable to be transferred. During an interview on 08/28/2019 at 9:11 A.M., CNA F reported that on 8/11/19 she was the CNA caring for Resident #100. CNA F reported that Resident #100 was upset when CNA F entered the room because of the amount of time she had to wait for assistance. CNA F stated that she had assisted Resident #100 with transferring using the slide board prior to this incident. CNA F stated, I think when I transferred her (Resident #100) I did it a little too quick (sic). CNA F reported that after she got Resident #100 in bed she realized I went a little bit too fast. CNA F stated, In that moment I felt very overwhelmed. I know I could have been warmer. I realize that now. CNA F stated, I needed at least a little more training and learn more with dementia. CNA F reported that she had been feeling burned out and had frustration and anger. I started feeling like I needed a new job. Review of a witness statement written by CNA F dated 8/11/19 revealed, I went straight to (Resident #100) after helping (name omitted). She was very cold/quiet towards me. She said she had to use the bedpan right away .I explained to her I understood I'm sorry she had to wait and I was going as fast as I humanly could .I put the gait belt on first then the slide board. I asked her if her feet were on the ground. She replied, why would my feet be on the ground?' I helped (using the gait belt) move her a little bit forward. Then I said 1-2-3 (with the help of the slide board) moved her into bed. She yelled out right away you hit my knee on the railing. I told her I was very sorry. I didn't mean to hit her knee/hurt her in the slightest. Like I've already explained I think I transferred her too quickly .Then I peeked my head out the door to the nurse. I did say to her (before the transfer) 'I don't know if I can be her aide today' outside of the door which I understand is very inappropriate .I know I transferred her safely. I believe I just transferred too quick .I do think I could've went above and beyond (sic). During an interview on 08/28/2019 at 12:27 P.M., CNA G reported that she believed that CNA F's care of Resident #100 on 8/11/19 could have been from burnout with the job. Review of a witness statement written by CNA G dated 8/11/19 revealed, I was walking past room (omitted) approximately around 0930 (9:30 A.M.) or later. The door was half open and I saw (CNA F) making (Resident #100's) bed. She was stating '(Resident #100) don't talk to me like that or I won't be your aide. During an interview on 08/28/2019 at 1:38 P.M., Licensed Practical Nurse (LPN) H reported that CNA F appeared to be overwhelmed on 8/11/19. Review of a witness statement written by LPN H dated 8/11/19 revealed, On Sunday (8/11/19) CNA F was assigned to take care of (Resident #100) for the entire shift .(LPN H) heard (Resident #100) yell to (CNA F) 'I need help now' .CNA F left and went to answer a different call light. CNA F came back to (Resident #100's) room and closed the door to assist her. (LPN H) observed (CNA F) come out of (Resident #100's) room and in the doorway, (CNA F) pointed at (Resident #100) and stated (LPN H) 'I can't do her today' this was stated twice .(LPN H) talked to (CNA F) about concerns with communication, professionalism, attitude and demeanor. (CNA F) acknowledged that she was wrong regarding her interactions with (Resident #100). (CNA F) made a comment to (LPN H) that she felt (Resident #100) was being rude to her. (LPN H) provided feedback regarding how she could have handled the situation differently and (CNA F) mentioned that sometimes she (Resident #100) 'gets in her head' LPN H stopped and (Resident #100) stated that (CNA F) was 'getting her up' talking about a transfer and that she asked (CNA F) to stop and that she wouldn't listen. (Resident #100) states 'she hurt my good leg'. Review of Resident #100's Progress Note from (name omitted) Orthopedic Trauma dated 8/15/19 revealed, (Resident #100) is permanently non-weight bearing on the right lower extremity from her old injury. She presents today with a new lateral tibial plateau fracture (left lower leg fracture), sustained while being transferred at her living facility .She is mainly wheelchair bound, however, she was standing to pivot transfer and use a slide board .She is here today with a new finding of a left lateral tibial plateau fracture (upper portion of the shin bone) as well as a left medial femoral condyle fracture (where the femur meets the knee). Due to her age, comorbidities and functional status, I am recommending non-operative treatment (no surgery) at this time. Review of Resident #100's Health Status Note dated 8/3/2019 revealed, Able to make needs known, uses call light. Transfers 1 assist with slide board. (Indicating her ability to transfer prior to the injury). Review of Resident #100's Appointment Note dated 8/15/2019 revealed, (Resident #100) had a (sic) apt (appointment) this am with the ortho MD (orthopedic doctor) (name omitted) regarding her left tibia fracture .Resident NWB (non-weight bearing) for at least 12 weeks-follow up apt in 4 weeks. Hoyer lift for transfers. (Indicating an increase in the amount of assistance required for transferring). On 8/28/19, this surveyor confirmed that the facility implemented the following: On 8/11/19 CNA F was sent home immediately following the incident pending an investigation. On 8/11/19 residents receiving care from CNA F were interviewed and statements were obtained. On 8/12/19 CNA F was terminated from her position as a CNA at the facility. On 8/13/19 all nursing staff were educated on Burnout Prevention and Treatment. This education was done in person and via telephone. On 8/13/19 job burnout had been added to the new hire orientation education, job burnout education had been added to annual education, and job burnout had been added to QAPI (Quality Assurance and Performance Improvement) agenda for (MONTH) 2019. The monitoring procedure to ensure compliance includes: Director of Nursing (or designee(s)) will conduct staff interviews of 10% of staff monthly x2, quarterly x2, and then randomly thereafter to ensure knowledge of job burn-out signs, symptoms and reporting and results of audits will be submitted to the QAPI committee.

Based on observation, interview, and record review the facility failed to properly clean and decontaminate a kitchen after an ABC Chemical Fire Extinguisher was discharged resulting in an immediate jeopardy when, beginning on 5/24/2019, facility staff did not effectively clean and disinfect 100% of surfaces in the kitchen and continued to prepare meals in the kitchen. This deficient practice placed all residents consuming food from the kitchen at risk for serious negative health effects/outcomes. Findings include: ABC Fire Extinguishers. They use monoammonium [MEDICATION NAME] which is a dry chemical that is able to quickly put out the fire. It is a pale yellow powder that is able to put out all three classes of fire; Class A for trash, wood and paper, Class B for liquids and gases, and Class C for energized electrical sources. The dry chemical smothers the fire. It can leave a residue once the fire has been put out so keep this in mind when choosing this type of extinguisher. Monoammonium [MEDICATION NAME], ABC Dry Chemical, ABE Powder, tri-class, or multi-purpose dry chemical is a dry chemical extinguishing agent used on class A, class B, and class C fires. It uses a specially fluidized and siliconized monoammonium [MEDICATION NAME] powder. When a person is exposed to high concentrations of these chemicals in the air, such as might occur after the use of a fire extinguisher in an enclosed space, monoammonium [MEDICATION NAME] and ammonium sulfate have mild irritant effects. If large amounts of these substances are swallowed, some nausea and vomiting can occur. Review of the Safety Data Sheet 2012 OSHA Hazard Communication Standard ( 29CFR 1910.1200) for the ABC Chemical Fire Extinguisher revealed, 2. Hazards Identification Emergency overview WARNING Irritating to eyes and skin. OSHA regulatory status This product is considered hazardous under 29 CFR 1910.1200 (Hazard Communication). Potential health effects Routes of exposure Eye contact. Skin contact. Inhalation. Ingestion. Eyes Avoid contact with eyes. Contact with eyes may cause irritation. Skin Avoid contact with the skin. (MONTH) cause skin irritation. Inhalation of dusts may cause respiratory irritation. Ingestion Not a likely route of entry. Target organs Eyes. Respiratory system. Skin. Signs and symptoms Irritation of eyes and mucous membranes. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: .(5) At any time during the operation when contamination may have occurred . 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the facility REPORT OF ACTUAL OR STAGED FIRE DRILL CHECKLIST dated 5/24/19 at 2:30 P.M. revealed, Simulated Fire Location: kitchen above hand sink 1st Shift (7am-3pm). Called By: (blank) 1. Were all residents removed from point of simulated or actual point of danger? Yes 2. Were doors and windows closed? No 3. Were halls cleared of equipment? No 4. Did all employees report to their designated areas? No 5. Did HCN staff page the fire drill alarm properly? No 6. (If not a drill) Was Fire Department called and by who? (blank) No 7. (If not a drill) did staff report to the Front Lobby to direct Emergency Responders(?) No 8. Were fans and motors turned off in kitchen? No 9. Was alarm properly silenced by Maintenance/Security? No 10. Was alarm properly reactivated by Maintenance/Security? No 11. Was all-clear given by Maintenance/Security? No 12. Was all-clear properly paged by Health Center North staff? No 13. What was the total time that elapsed between the fire alarm onset and all clear page? (Blank) 14. Was Central Station called to confirm signal and to have system placed back on-line? No-Name and ID # of agent spoken to: (Blank) 15. Was staff in HRV and Village quizzed on RACE/PASS? No 16. Were fire extinguishers brought to the area? Yes 17. Were staff members posted at all exit doors in HRC, Harmony Hall & Cedar Court? No 18. Did all door magnetic locks to doors release and were all doors shut? No Comments: Piece of paper caught fire inside old electrical box. (Staff member) extinguished. No alarms went off. Box was removed by (staff member). During an interview on 06/12/19 at 12:44 P.M., Dining Services Director (DSD) I reported that there was a fire in the kitchen on 5/24/19. DSD I reported that the fire was extinguished by a chef. During an interview on 06/12/19 at 12:45 P.M., Cook D reported that there had been a fire on the electrical box on the wall which produced green smoke. Cook D reported that the ABC Chemical Fire Extinguisher was utilized at that time. Cook D reported that surface areas in the kitchen were cleaned to remove the white chemical/powder. On 06/12/2019 at approximately 12:20 PM, observation and interview revealed the facility failed to implement the fire safety plan on (MONTH) 24, 2019 at 2:30 PM, during an electrical fire in the kitchen. Cook D stated he used a fire extinguisher to put out an electrical fire near the dish washing equipment. The electrical wiring was powering an old garbage disposal. Cook D turned off the electrical breaker after extinguishing the fire. Listed is all of the fire safety plan elements that were not activated. 1.) No fire alarm activated during the fire. 2.) No fire alarm was transmitted to alarm company. 3.) No call to 911 or fire department. 4.) No evacuation of the immediate area. 5.) No evacuation of the smoke compartment. 6.) No preparation of occupant floors/building for evacuation. During an observation on 06/12/19 at 12:46 P.M., white residue was found on top of the steamer and on top of the double oven. During an interview on 06/12/2019 at 12:47 P.M., Cook D reported that no professional cleaning company came in to clean after the ABC Chemical Fire Extinguisher was utilized. During an interview on 06/12/2019 at 12:49 P.M., DSD I reported that DSD I believed that maintenance had cleaned the chemical residue properly. DSD I reported that the use of the ABC Chemical Fire Extinguisher was not reported to the State of Michigan. During an interview on 06/12/19 at 12:52 P.M., Custodian N reported that smoke was observed coming out of the electrical box. Custodian N notified Cook D. Cook D used the ABC Chemical Fire Extinguisher. Custodian N stated, I'm still finding left over powder (chemical residue). During an interview on 06/12/19 at 01:45 P.M., Administrator A reported that she and Director of Nursing (DON) B were not notified of the fire in the kitchen until several days later. Administrator A stated, The kitchen staff said everything was taken care of. DON B reported that the kitchen staff thought they handled it (the fire and the cleaning following the use of a fire extinguisher). On 6/12/2019 the Administrator was verbally notified and received written notification on 6/12/2019 of the immediate jeopardy that began on 5/24/19 and was identified on 6/12/2019 due to the facility's failure to effectively clean and decontaminate the kitchen following the discharge of an ABC Chemical Fire Extinguisher which placed all residents that consume food from the kitchen at risk for serious negative health effects/outcomes. A written plan for removal for the immediate jeopardy was received on 6/13/2019 and the following was verified on 6/13/2019: 1. Kitchen was closed on 6/12/19 at 1:47pm to eliminate further risk 2. Effective cleaning of kitchen to be completed by professional cleaning and restoration company, (name omitted), started at 4 pm on 6/12/19. a.Air scrubbers were set to help purify/filter the air. The air scrubbers have high efficiency particulate air filters which filters the air down to 99.97% at 0.3 microns. This means that it collects 99.97% of the particulates down to 0.3 microns in size. These machines have a 3-stage filtration - First, poly pre-filter; second, pleated Merv7; third, HEPA filter. b.All horizontal surfaces were hepa-vacuumed to collect loose particulates. Our hepa-vacuums have the same 3-stage filtration system as the air scrubbers. This prevents cross-contamination. c.After vacuuming, a dry sponge clean was done on the walls and ceilings. d.All surfaces were cleaned with a wet wash method - wash, rinse, dry. Any surfaces that come into contact with food (food prep areas) were washed with Dawn dish soap and thoroughly rinsed with fresh water and then dried. e.The floors were scrubbed and cleaned with cleaning agent and then steam cleaned to ensure a thorough rinse. f.All internal duct work is in the process of being cleaned. This process also uses 3-stage filtration and will be sanitized after cleaning is completed. g.After the duct work is cleaned, SERVPRO will dispatch a cleaning crew this evening yet to do touch up cleaning to ensure that there is no left over debris from the duct cleaning. All horizontal surfaces will again be damp wiped. Food prep areas will be cleaned with dawn dish soap and fresh water rinse and all other horizontal surfaces will be damp wiped. 3. On 6/13/19, the kitchen duct work will be cleaned. All cleaning will be cleaned by 10 pm on 6/13/19. 4. Physical assessments on 59 out of 60 residents were assessed by 6pm on 6/12/19 for gastrointestinal and respiratory ailments, none were noted. One resident was on LOA with family, returned at night on 6/12/19 and physically assessed on 6/13/19. No gastrointestinal or respiratory ailments were noted. 5. Any food in the area was disposed of on 6/12/19. 6. Any items that were brought out to pantries was cleaned or disposed on 6/12/19 by 7pm. 7. Any disposable items including silverware, napkins, straws, etc., were disposed on 6/12/19 by 7pm. 8. Dishes were disinfected in the dishwasher on 6/12/19 by 8pm. 9. Emergency food plan was implemented for dinner on 6/12/19 and plan in place for meals on 6/13/19 in case duct work takes all day. 10. The Dining Services Director was educated by the administrator on 6/12/19. The Director of Dining Services, or designee(s), will educate dining staff beginning on 6/13/19 at 8am, on proper procedure to ensure kitchen is properly cleaned following discharge of a fire extinguisher in the kitchen. No dining services employees will work until they are educated. The Dining Services Director will check educated staff against a roster of employees to ensure all employees receive education. 11. The Director of Dining Services, or designee(s), will interview a minimum of five (5) dining services employees each week until dining services employees have been interviewed, to ensure dining services employees are competent in knowledge of proper fire extinguisher clean-up following fire extinguisher discharge in the kitchen. 12. The Director of Dining Services, or designee(s), will incorporate into new hire orientation, training on effective cleaning procedure following fire extinguisher discharge in the kitchen. 13. Other staff (maintenance, housekeeping) will be educated by 3pm on 6/13/19. Maintenance and housekeeping staff will not work until they are educated. Although the immediate jeopardy was removed on 6/13/19, the facility remained out of compliance at a scope of widespread and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to not all education had been completed and sustained compliance had not yet been verified.

Based on observation, interview and record review the facility failed to provide adequate supervision and assistance to prevent accidents for two Residents (#1 and #2) resulting in resident #1 falling and sustaining multiple injuries including a hip fracture and Resident #2 falling and sustaining multiple injuries: Findings include: Resident #1 Review of Resident #1's medical record revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #1 last Brief Interview of Mental Status Score (BIMS) was 8/26/16 and she scored 2/15 (severe cognitive impairment). Review of Resident #1's care plan for Activities of Daily Living revealed Resident #1 was able to walk with a front wheeled walker, gait belt and assistance of one person starting 7/15/16 and this was discontinued on 8/18/16 when Resident #1 returned from the hospital due to a hip fracture. Resident #1 has not walked since her fall on 8/10/16. Resident #1 now requires assistance to 2 people for transfers and only required supervision prior to the fall on 8/10/16. Review of Resident #1's Skilled Nursing Incident Report Overview dated 8/10/16, revealed Resident #1 sustained an unwitnessed fall at 7:35 AM and suffered a left hip fracture and left scalp hematoma. Resident #1 was sent to the emergency room for evaluation. The incident report documented the Registered Nurse (RN) on Duty was RN E. During an interview with RN E on 9/7/16, RN E said she has only worked at the facility for a few months and only worked with Resident #1 a few times before Resident #1 fell and fractured her hip on 8/10/16. RN E confirmed she was the nurse that completed the incident report for Resident #1 on 8/10/16 and Resident #1 had an unwitnessed fall on 8/10/16 that resulted in a hip fracture. RN E said they attempt to check on residents like Resident #1 every 15 to 30 minutes but do not have any area for Residents to be under constant supervision. RN E was aware Resident #1 had a history of [REDACTED].#1 attempting to transfer without assistance. Review of Resident #1's falls from February 2016 to September 2016 revealed Resident #1 had 8 unwitnessed falls. The facility did not do a root cause analysis or any investigation into the first 6 falls and did not increase Resident #1 supervision after any of the falls except the one on 2/12/16 at 3:30 PM. The facility only increased supervision of the fall on 2/12/16 for a short time (not ongoing). Resident #1 suffered injures from the falls on 2/5/16 (abrasions), 2/12/16 at 6:05 AM (scratch to right eye lid and hematoma above right eye), 3/8/16 (contusion/bruise), 7/1/16 (contusion/bruise), 8/10/16 (hip fracture requiring hospitalization and surgical repair). Resident #1 was observed in an activity room with about 12 other Residents on 9/7/16 at 10:42 AM. According to the staff person running the activity, Resident #1 stays in the activity room until 11:30 AM and goes back to the unit and normally sits at the nurses station until lunch. Resident #1 was observed at the north station near the nurses station on 9/7/16 at 1:15 PM with 8 other residents. There were no staff with in eye sight of the 9 residents. One employee was back in the nurses station but would not be able to see any residents due to her placement back in the nurses station facing a wall. Physical Therapist (PT) D approached Resident #1 asking if he could take her to physical therapy or her room and Resident #1 refused. PT D said Resident #1's ability to participate in therapy varies and it would be best to attempt again later. PT D said Resident #1 had been discontinued from PT due to lack of participation which he felt was due to pain, but staff are reporting decreased pain and an increase in Resident #1's attempts to stand. PT D said once Resident #1's pain resolves he felt she had potential to walk again. During an interview with the Nursing Home Administration (NHA) A and Director of Nursing (DON) on 9/7/16 at 3:30 PM, Resident #1's falls were reviewed from February 2016 to September 2016 and DON B confirmed the facility only increased supervision after one fall for a short time and just started doing root cause analysis of falls in July 2016. NHA A and DON B said they do not currently have any structured programs or areas around the clock for the Dementia residents to attend for supervision. DON B said she was aware staff cannot see the Residents when they are in the nurses station charting and is currently looking into ways to provide closer supervision of residents with Dementia. Resident #2 Review of Resident #2's medical record revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #2's last Brief Interview of Mental Status (BIMS) score dated 8/22/16 was 4/15 (severe cognitive impairment) Review of Resident #2 falls since admission on 5/10/16 revealed Resident #2 had 11 unwitnessed falls resulting in minor injures. The facility did not have any investigations of the falls or any root cause analysis completed on any of the falls to determine the cause. No increase in supervision or assistance was care planned after any of the 10 falls. The following incident reports indicated Resident #2 had unwitnessed falls 5/10/16, 5/11/16, 5/13/16 at 10:25 AM and 2:50 PM, 5/24/16, 5/27/16, 5/30/16, 6/14/16, 6/18/16 and 9/3/16. The following incident reports for Resident #2 indicated Resident #2 suffered injuries from her falls: 5/13/16 (abrasion to right eye brow), 6/18/16 (skin tear to right forearm and a large hematoma on right forearm). Review of Resident #2's clinical note dated 9/2/16 documented Resident #2 had frequent falls despite being on 15 minute checks. There was no indication of any supervised activities or documentation that staff were to keep Resident #2 within eye sight when up despite the knowledge at 15 minute checks were not adequate to prevent falls. Resident #2 suffered another unwitnessed fall 9/3/16 after this note was written.

This citation pertains to intake #MI 308 Based on interview and record review, the Facility failed to provide appropriate supervision (checked to assure alarm was in place) and assistive devices (pull-string alarm on at all times when up) in 1 of 6 sampled residents (#101), from a total sample of 6 residents, resulting in Resident #101 falling out of a wheelchair with no alarm sounding and sustaining a facial laceration, hematoma, and a delay in assistance after a fall. Resident #101 subsequently died . Findings include: Review of the closed record face sheet, revealed Resident #101 was a [AGE] year old woman, admitted to the facility on [DATE] from a Hospital following treatment for [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 was cognitively impaired and unable to completed the Brief Interview for Mental Status. Resident #101 [DIAGNOSES REDACTED]. Resident #101 was totally dependant on staff for Activities of Daily Living. Review of the fall risk assessment dated [DATE] revealed Resident #101's score was 15. A score of 10 or greater indicated a high risk for falls. Review of the Fall prevention care plan for Resident #101 dated [DATE] revealed an intervention written, "Body alarm on when up out of bed". Review of the Care Guide for Nurse Assistants, dated [DATE], for Resident #101 had instructions for a body alarm (pull-string alarm) to be in place at all times when up out of bed due to increased poor safety awareness and to monitor for self transfers. Review of the Treatment Administration Record (TAR) dated for [DATE] revealed facility staffs were to complete an "Alarm check, check two times daily starting [DATE]...Check body alarm in place when up out of bed. Note; on at all times when up." The box, to be initialed by the Licensed nurse as checked, was blank for [DATE] for Resident #101. Review of the Nurses notes dated [DATE] at 12:48 PM, signed by Registered Nurse (RN) #6, was written, "At 11:15 AM resident (Resident #101) observed on floor face down. wheelchair in front of TV in middle of room. Feet located right next to wheelchair. Resident on floor at 2:00 position to wheelchair. Color of skin was cyanotic (bluish) to entire body. Turned Resident over using body roll procedure with 2 assistance to open airway. Faint, thready radial pulse was re-established. Oxygen still in place at 3 liter per nasal canula. CNA instructed to get assistance and call light placed on by this nurse to alert staff needing assistance. Doctor (Dr. #8), was observed walking in hallway. He came into scene, checking lungs, heart rate and respirations. Resident was unresponsive to stimuli, eyes closed. Laceration seen over right eye with trickle of blood only. Minimal swelling and bruising to right eye and face area...Resident is a Do Not Resuscitate. Cessation of all vital signes was determined at 11:32 AM by (Dr. #8). The Coroner was called by deferred case to (Dr. #8) due to age and numerous health conditions." In a telephone interview on [DATE] at 8:50 AM, Certified Occupational Therapy Assistant (COTA) #4 said on [DATE] in the later morning (could not recall exact time), she was walking a Resident (not on the sample), in the hallway and saw Resident #101's face turned and down on the floor in her room. "She was lying on her right side, next to her wheelchair and her face was grey or darker". COTA #4 said she did not see any movement and she did not enter the room. COTA #4 said she called for the Nurse and then continued down the hall walking the Resident she was with. In an interview on [DATE] at 9:30 AM, Certified Nurse aide (CNA) #7 said she was at the nurse's station desk on [DATE] at 11:15 AM when she heard COTA #4 yell "you guys, (Resident #101) is on the floor". CNA #7 said she was the first one who went into Resident #101's room and she didn't think Resident #101 was alive. CNA #7 said Resident #101 was, "very grey". CNA #7 said RN #6 came in the room and instructed her to get the Administrator (Admin #1) and Director of Nursing (DON #2). CNA #7 said Admin. #1 came back with her. CNA #7 said the Physician (Dr. #8), was in the room and they turned Resident #101 onto her back. CNA #7 said, "I've been an aide for [AGE] years and it was the worst fall I've ever seen. It was a bloody mess! There was blood all over her face, in her hair and her whole face was bruised and swollen." CNA #7 said, "when we turned her over she was breathing and still had a blood pressure and pulse but they were not strong". In an interview on [DATE] at 9:11 AM, RN #6 said she was the Charge Nurse on [DATE] for Resident #101 during the day. RN #6 said someone from therapy was walking a Resident (not on the sample), down the hall and yelled Resident #101 was on the floor. RN #6 said she went into the room and saw Resident #101 on the floor and said she was "basically cyanotic from the waist up". RN #6 said she knew she was a "Do Not Resuscitate" (DNR). RN #6 said Resident #101's respirations were 2 per minute (normal is ,[DATE] per minute) and she died within 17 minutes. RN #6 said Resident #101 died of Heart Disease. RN #6 said the aide did not re-apply the personal alarm to Resident #101 after breakfast. RN #6 said the alarm was on the wheelchair and functioning, but unfortunately it was not connected to Resident #101. RN#6 said Resident #101, "needed an alarm because if she did fall and needed help we could get to her sooner." In an interview on [DATE] at 9:22 AM, CNA #5 said she was assigned to Resident #101 on [DATE], during the day. CNA #5 said after Resident #101 ate breakfast, she dressed her for the day but forgot to apply the pull-string alarm to Resident #101, which was attached to the wheelchair she was sitting in. CNA #5 said she went to lunch at approximately 10:30 AM, and when she came back she saw the Doctor (Dr. #8) in Resident #101's room, but she did not go in. CNA #5 said Resident #101 was in bed so she left to answer other Resident's call lights. CNA #5 said she was very sorry she forgot to put Resident #101's alarm on, which would have alerted staff, when sounded, that Resident #101 had fallen or was attempting to self transfer. Review of Resident #101's code status dated [DATE] and signed revealed a "Do Not Resuscitate Order". Review of the Death Certificate dated ,[DATE] at 11:32 AM, signed by Dr. #8, revealed Resident #101's cause of death was listed as "Atherosclerotic Cardiovascular Disease". #