Every finding on record at Regency at Chene

This citation pertains to intake 3030345.Based on observation, interview, and record review, the facility failed to notify the legal guardian, when an injury occurred for one resident (R102) out of five residents reviewed for notification of change. Findings include: A complaint was reported to the State Agency that the facility failed to notify R102's legal guardian, when a fall with injury occurred within the facility. Record review of the Electronic Health Record (EHR) revealed R102 fell on [DATE] and sustained an injury. Record review further revealed guardianship papers dated [DATE], listed Family Member H as R102's Legal Guardian and uploaded into the Electronic Health Record on [DATE]. On [DATE] at 2:57 PM, Family Member H was interviewed by telephone and stated, The facility called (R102's) friend but did not call me (the legal guardian) when R102 was sent to the hospital due to a fall. Family Member H said she called the facility after hearing about the injury from Family Friend R and was informed by a staff member that they were unaware of the guardianship. Family Member H stated, I'm contacted regarding (R102's) bills and for care conferences but not in the event of an emergency. Record review of progress note written by Nurse Q dated [DATE] revealed the following: Approximately 2013hrs, writer heard a loud sound down the hallway. Resident sustained an unwitnessed fall, found resident in room face down on the floor, bleeding from nose. Slight swelling to left eyebrow. Alert, but slow to respond, appeared confused patient transferred to emergency department for further assessment and testing due to patient's condition. Patient's emergency contact (Family Friend R) informed at 2049hrs. 2100hrs patient taken to hospital via EMS. On [DATE] at 3:44 PM, Unit Manager M was interviewed and stated, (Family Member H) was upset because the nurse was busy when she called with questions about the incident and was also upset because she heard about the injury from (Family Friend R) instead of the facility. Record review of a [DATE] progress note by Nurse Q revealed the following: Writer did not contact (R102's) Family Member H because it documented the following; Invitation expired [DATE]. On [DATE] at 4:45 PM, the Nursing Home Administrator (NHA) was interviewed and stated, Nurse Q misinterpreted the information in the Electronic Health Record (EHR). The statement, 'Invitation expired [DATE]', in the EHR is associated with point click care access for legal guardians not the expiration of guardianship. Queried the NHA regarding expectations of notification in the event of a change in condition. The NHA stated, The legal guardian should be notified in the event of a change in condition within the facility. On [DATE] at 3:25 PM, the Director of Nursing (DON) was interviewed and stated, It was a clerical error. We had it wrong and corrected it as soon as we could. Queried as to who is responsible for ensuring accurate information is placed in the EHR. The DON stated, Admissions put this information in incorrectly. It's expected that we provide notification to the responsible party, but it was listed incorrectly in the record. A review of R101's Electronic Health Record revealed an admission to the facility on [DATE]. A review of the facility policy entitled, Notification of Change last revised [DATE], read in part: The facility must inform the resident representative when there is a change in status. A change in status includes the following: an accident involving the resident .A significant change in the residents physical, mental, or psychosocial status .

This citation pertains to intake 3051950.Based on observation, interview, and record review, the facility failed to provide a homelike environment by not ensuring the availability of an adequate supply of linen for two residents (R101 and R104) of three residents reviewed for care, resulting in residents having unmet care needs. This deficient practice has the potential to affect all 152 residents who resided in the facility. Findings include:A complainant reported to the State Agency that the facility has an insufficient supply of linen. On 07/15/2026 at 10:06 AM, R101 was interviewed and stated, The facility is always out of linen and sometimes the staff have to pat me dry with paper towels. R101 also said that the facility runs out of bed pads, which are placed on top of the mattress to absorb leakage. R101 stated, Just yesterday, there were no washcloths to clean me, so they had to use my wipes. A review of R101's Electronic Health Record revealed an admission to the facility on [DATE] and the Minimum Data Set, dated [DATE] revealed a Brief Interview of Mental Status Score of 13/15 (cognitively intact). Record review of R101's Care Plan dated 05/04/2026 revealed the following: Requires substantial/maximum assistance for hygiene/grooming and set up assistance. On 07/15/2026 at 9:32 AM, R104 was interviewed and stated, They always say they don't have any towels and washcloths. My daughter had to tell the aide that I need towels! R104 further stated, Sometimes, the staff have to use sheets to clean me up. A review of R104's Electronic Health Record revealed an admission to the facility on [DATE]. Record review of R104's care plan dated 03/30/2026 revealed the following: Partial/Moderate assistance needed for care needs including showering/bathing/hygiene care.On 07/17/2026 at 1:15 PM, an interview was conducted with a Certified Nurse Assistant (CNA) who requested to remain anonymous. Queried CNA about the availability of towels and washcloths. The CNA stated, We run out sometimes, especially at night. On 07/15/2026 at 3:55 PM, observed three clean linen supply rooms; two on the first floor and one on the second floor. Observation of the clean linen closet #1 located on first floor revealed: 0 washcloths, 0 towels, 8 hospital gowns, 19 blankets,1 pillow and 14 sheets. Observation of the clean linen closet #2 on first floor revealed: 0 washcloths, 0 towels, 6 pillows,11 blankets,12 hospital gowns, 50 sheets, 8 blankets and 8 bed mats.Observation of the clean linen closet #3 on the second floor revealed: 0 washcloths, 0 towels,1 Personal Blanket, 2 Bed Mats, 8 hospital gowns,15 sheets and 9 blankets. On 07/15/2026 at 4:15 PM, Housekeeping/Laundry Aide D was interviewed in the laundry room and stated, I do a load of laundry every hour during my 8-hour shift, and I deliver the clean linen to each unit twice a day. Queried about the lack of an emergency supply of linen and no additional washcloths and towels in the clean linen closets, Housekeeping/Laundry Aide D stated, The linen is low because staff hide supplies to ensure they have enough during their shift. Queried if the facility has enough linen to service 152 residents without the need for staff to hide supplies, Housekeeping/Laundry Aide D stated, We're low on towels and washcloths because the laundry service doesn't send back everything we send to them. Upon further investigation it was discovered that the facility utilizes in-house laundry services in addition to contracted laundry services. An attempt to contact the Laundry Services Manager was made on 7/15/26 at approximately 4:25 PM. On 07/15/2026 at 4:30 PM, the Nursing Home Administrator (NHA) was interviewed about the expectation of a homelike environment in regard to accessible linen. The NHA stated, I've only been here for three months, but we are aware of this issue, and we are trying to address the linen shortage . We are suspecting that we are not getting back the same amount of laundry that we send out to the contracted laundry supplier. Discussed the provision of sufficient clean linen with the NHA. The NHA stated, Staff may be disposing of the soiled linen which is causing the depletion of supplies. The NHA produced invoices dated the following for 2026: January 2, January 8, January 26, February 2, March 2, March 26, April 7, May 4, June 2, June 22, July 1, and July 8, 2026, for orders for washcloths, towels, sheets and bed mats. However, when asked the NHA was unable to share with the SA that the bath and bed linens were actually delivered to the facility. A review of the facility policy entitled, Laundry Services, revised 08/26/2025, read in part: POLICY- to assure a clean supply of linen.The policy did not address facility par levels for resident bed and bath linens.

This citation pertains to intake 3051950.Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for two residents (R101 and R104) of three residents reviewed, resulting in the potential for dissatisfaction with the meal experience.Findings include:The State Agency received an intake regarding the facility serving cold and unpalatable food.On 07/15/2026 at 9:32 AM, R104 was interviewed regarding meals at the facility. R104 frowned and grimaced and stated, I don't like the food because it's always cold.On 7/15/2026 at 10:05 AM, R101 was interviewed and provided pictures from a personal cell phone of unpalatable food items including a hamburger with dark, crusted edges, which R101 described as burnt- picture dated 5/25/2026; a hot dog with undetermined white residue on the end of the casing- picture dated 05/27/2026; an unrecognizable dinner item picture dated 05/29/2026. R101 also produced pictures of food items which were described as cold with the following dates: 06/23/2026-eggs and sausage (cold), 07/03/2026- potatoes, grits, omelet (cold), R101 also said she received an unbalanced meal on 07/05/2026 which included sun chips, juice and applesauce for dinner. Queried R101 if this information was reported to staff. R101 stated, Yes, I call the kitchen myself or the CNA's call for me. R101 said the food is terrible, unrecognizable or cold.Record review of monthly menus from May, June and July 2026 revealed menu items consistent with the food shown in pictures provided by R101 coincided with R101 dates, reports, and pictures.On 07/15/2026 at 12:04 PM, while in the facility kitchen, observed Kitchen Aide P check the temperature of lunch items. The temperature of the chicken was 158 degrees Fahrenheit. The temperature of the macaroni and cheese was 171.2 degrees Fahrenheit. The temperature of the mashed potatoes was 167.8 degrees Fahrenheit. The temperature of the greens was 164.9 degrees Fahrenheit.On 07/15/2026 at 1:04 PM, observed a meal cart being delivered to the second floor 600-unit.On 07/15/2026 at 1:14 PM, observed a 10-minute delay in food distribution to residents once food cart arrived on the unit. Observed door of the unheated meal cart left open between deliveries. On 07/15/2026 at 1:17 PM, the last tray on the second-floor meal cart was obtained and used as a test tray to determine food temperatures when delivered to residents. Kitchen Manager B was present during the testing of food temperatures. The following temperatures were obtained using a metal stem thermometer:Chicken: 103 F (Fahrenheit)Macaroni and Cheese: 129.8 FMashed Potatoes: 120.8 FGreens: 127 degrees [NAME] 07/15/2026 at 1:25 PM, Kitchen Manager B was queried regarding meal service and stated, The dietary staff leaves the food carts in the unit hallways and the CNA's (Certified Nursing Assistants) distributes the trays to each room. Kitchen Manager B also stated, We don't have heated carts, and we cannot determine how long it takes for CNA's to deliver the food to the rooms once we bring the carts to the units. It should be All Hands On Deck when the food arrives in order to get the food to the residents while it's hot. Queried if residents ever complain about cold or unpalatable food. Kitchen Manager B stated, Sometimes. but we do offer alternatives when they complain! Queried as to the expected temperature of hot food. Kitchen Manager B stated, Food should be above 135 degrees.During an interview on 07/15/2026 at 12:46 PM, the Nursing Home Administrator (NHA) stated, I've only been here for three months, but I'm surprised to hear this about the food. On 07/15/2026 at 4:50 PM, Director of Nursing (DON) stated, We need to consider the purchase of heated meal carts. Reviewed the facility policy titled, Meal Service last updated on 01/9/2025 which read in part: It is the policy of this facility to provide a dining experience that is conducive to meal acceptance . which includes an attractive meal presentation. 6. Resident meals will be distributed promptly by facility staff.

This citation pertains to Intake Number(s): 3022409 and 3022328. Based on interview and record review, the facility failed to report an allegation of physical abuse to the Abuse Coordinator for one (R801) of two residents reviewed for abuse. Findings include:A review of complaints submitted to the State Agency revealed allegation that R801 had a black eye and reported someone hit her. On 6/10/26, an onsite investigation was conducted. On 6/10/26 at 11:00 AM, an interview was conducted with the Administrator, who was identified as the Abuse Coordinator for the facility. The Administrator reported a detective came to the facility after receiving a concern that R801 had a black eye and said she was hit. At that time, the Administrator reported the allegation was reported to the State Agency, an investigation was conducted, and they concluded there was no evidence that abuse occurred. At that time, the Administrator provided the facility's investigation. A review of R801's clinical record revealed R801 was admitted into the facility on 7/25/25, readmitted on [DATE], and discharged on 5/30/26 with diagnoses that included: metabolic encephalopathy. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had severely impaired cognition, could sometimes make herself understood, and rarely/never understood others. R801 was assessed to be dependent on staff for all activities of daily living and mobility needs. A review of the investigation conducted by the facility revealed the following: On 5/22/26 at 2:00 PM, A detective from .police department presented to the center and asked to speak with management. The detective advised that an assault allegation had been made to the police department related to an eye injury .Per the detective's report, the resident's daughter alleges that the resident had a bruised and bloodshot eye and that the resident answered in the affirmative twice when asked if she had been hit by someone .facility is aware that in the recent days the resident had redness or a possible ruptured blood vessel in the white area of her eye, but neither the nursing department nor the attending physician suspected trauma as the cause based on the clinical presentation .no observed bruising, swelling or other injuries near the eye area have been observed .The physician evaluated the eye redness prior to today's date and did not suspect trauma . A review of a Recertification progress note written by Physician 'A', dated 5/19/26 (three days prior to the detective coming to the facility and the facility's report to the State Agency and investigation), revealed, .red left eye .The patient's daughter has expressed concern that last week the patient developed a 'red left eye.' She reports seeing the eye on Friday and noting that it appeared swollen and bruised. She also states that her mother reported 'someone hit her,' although given the patient's mentation and dementia, this report is considered unreliable. At the time of examination on Tuesday, there is minimal redness to the left eye with no evidence of ecchymosis (bruising) or swelling around the eye. The daughter has requested a CT (computed tomography) of the head, which has been ordered. Clinical suspicion for trauma at this time is low . Further review of R801's progress notes revealed redness to the left eye was first identified by the facility on 5/14/26 and the resident was evaluated by the Nurse Practitioner (NP) on 5/15/26. At that time, no trauma was suspected and the NP noted the redness most likely attributable to age-related fragility of the small conjunctival blood vessels . On 6/10/26 at 12:31 PM, an interview was conducted with Physician 'A' via the telephone. Physician 'A' reported he was familiar with the resident. When queried about what was going on with R801's eye and how he received the allegation that R801 was hit by someone on 5/19/26, Physician 'A' reported R801's daughter told him that R801 said someone hit her, but he questioned the validity of that statement due to R801's dementia and said she did not have purposeful interactions. Physician 'A' reported he evaluated R801 and there was a very minute red spot to the sclera (white part of eye) with no orbital swelling, no bruising, and no evidence of trauma that the daughter alleged. When queried about whether he reported the daughter's allegation of abuse to the Abuse Coordinator, Physician 'A' said he talked to the Administrator and DON. On 6/10/26 at approximately 12:50 PM, an interview was conducted with the Administrator. When queried about why the allegation of physical abuse alleged by R801's daughter was not reported to the State Agency until 5/22/26 when it was documented in the clinical record by Physician 'A' that the allegation was made three days earlier on 5/19/26, the Administrator reported Physician 'A' did not report the allegation to him and they discovered his note while conducting the investigation after the detective came to the facility on 5/22/26. The Administrator reported in hindsight, he would have expected Physician 'A' to discuss his clinical findings with the daughter and if the daughter still had a concern that it was due to abuse, he would have been expected to report the allegation to the Administrator. The Administrator reported that it was likely Physician 'A' did not report the allegation because the clinical presentation was not indicative of trauma when he evaluated R801, and either was the previous evaluation by the NP. A review of a facility policy titled, Abuse Prohibition Policy, revised 9/9/22, revealed, in part, the following, .Allegations by anyone who becomes aware of .physical .abuse .must immediately report it to his/her Administrator .The staff will report any allegations or suspicions of .abuse .to the Administrator and DON immediately .The Administrator or designee will notify .any State or Federal agencies of allegations .2 hours if abuse allegation .

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area and maintenance of equiptment resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: On 4/14/2026 at 8:53 AM observed the hand sink near the walk in cooler with a self-closing faucet motion activated sensor. When turned on the sink ran for approximately 5 seconds before turning off. On 4/14/2026 at 9:17 AM observed the hand sink near the cookware with a self-closing faucet motion activated sensor. When turned on the sink ran for approximately 5 seconds before turning off. According to the 2022 FDA Food Code section 5-202.12 Handwashing Sink, Installation, (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 29.4 C (85 F) through a mixing valve or combination faucet. (B) A steam mixing valve may not be used at a HANDWASHING SINK.(C) A self-closing, slow-closing, or metering faucet shall provide a flow of water for atleast 15 seconds without the need to reactivate the faucet.On 4/14/2026 at 9:14 AM observed multiple rust colored areas and rough, worn surfaces on the metal chemical storage rack located in the janitor's closet within the kitchen. Culinary Manager (CM) D acknowledged the condition of the rack.According to the 2022 FDA Food Code section 4-202.16 Nonfood-Contact Surfaces, NonFOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.On 4/14/2026 at 9:20 AM an interview with CM D found the cooks refrigerator and beverage cooler were currently out of order due to an electrical problem. CM D indicated maintenance is working on it.On 4/14/2026 at 9:36 AM in an interview with CM D when asked how long the equipment in kitchen has been down, CM D indicated it has been two months. When asked if it interferes in the kitchen operations, CM D indicated it somewhat interferes with efficiency of operations, and they do not have a maintenance director currently. CM D indicated Housekeeping and Laundry Supervisor E has been trying to cover for maintenance and filling some kitchen requests.On 4/14/2026 at 10:02 AM observed water dripping from the drain line of the hand sink when turned on in the second floor kitchenette. CM D indicated they would put it in TELS. On 4/14/2026 at 12:41 PM an interview with CM D found maintenance requests are slow to be completed when put into TELS due to the fact there is not currently a Maintenance Director.On 4/14/2026 at 3:16 PM in an interview with CM D when asked about the equipment in the kitchen that is out of order, CM D indicated the previous maintenance director was looking at it prior to leaving and before they had left, an outside resource was called to investigate it. According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.On 4/14/2026 at 9:42 AM observed an ice cooler filled with ice on the counter in the 300-400 unit nutrition room. A stack of Styrofoam cups was placed beside the cooler. When asked if there was an ice scoop at this time, CM D indicated there was not, and staff must be using cups to scoop. Further observation found a plastic bag covering a plate with no date or label in the refrigerator. CM D removed the plate to be discarded.According to the 2022 FDA Food Code section 4-101.11 Characteristics, Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: P (A) Safe; P (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.Record review of the facility provided invoice from a heating and cooling contractor provides a service date of 3/6/26. The technician notes include, Reach in freezer by stove breaker tripping found compressor shorted out . compressor or new unit will be quoted.

Based on observation, 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 waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 4/14/2026 beginning at 10:22 AM a facility tour was conducted with Housekeeping and Laundry Supervisor (HLS) EOn 4/14/2026 at 10:27 AM observed a hopper with black particles along the inside edge of the hopper bowl in the soiled utility laundry room. An interview at this time with HLS E found the hopper is not used. Further observation found the faucet handle missing from the hand sink. HLS E indicated that it was in the facility maintenance system TELS.On 4/14/2026 at 10:51 AM observed dried brown particulate matter coating the interior bowl of the hopper in the soiled linen 300-400 hall. A shallow pool of brown colored water was observed in the hopper drain line, indicating infrequent use of the fixture. When the hot water faucet was turned on, discolored brown water discharged from the faucet for a few seconds before running clear. On 4/14/2026 at 10:58 AM observed green buildup along the inside wall of the hopper bowl, extending onto the water surface in the soiled linen 100-200 hall. HLS E acknowledge the green buildup and indicated they would get someone to clean the hopper.On 4/14/2026 at 11:06 AM observed a therapy tub in the second floor spa room. When asked if it is used HLS E stated not really.On 4/14/2026 at 11:12 AM observed black particulates accumulated in the bowl of the hopper in the soiled utility 500-600 hall. A plastic straw and lid was observed floating at the surface of the water in the bowl of the hopper.On 4/14/2026 at 11:19 AM in an interview with HLS E when asked if they were a part of the water management team they indicated they were, when asked if they work with the team HLS E stated kind of.On 4/14/2026 at 1:19 PM an interview was conducted with HLS E and Maintenance Director (MD) I from a neighboring facility. When asked about staff in the maintenance department HLS E confirmed there were two newer maintenance assistants and HLS E had been covering in maintenance as well. Maintenance Director I indicated they had been coming over a few times a week to help with maintenance requests. When asked about water management documentation, MD I indicated the previous MD had unorganized documentation, MD I stated they were supposed to train people starting today on water management and get a team started. When asked who may know more about water management currently, HLS E indicated the Administrator in Training (AT) F may know more. On 4/14/2026 at 1:27 PM in an interview with AT F when asked about controls measures, AT F indicated they believe samples were collected for legionella testing of the water but were unsure of what exactly and at what frequency. AT F was unaware of any other control measures.On 4/14/2026 at 1:41 PM an interview with Interim Nursing Home Administrator (INHA) J and Nursing Home Administrator (NHA) was conducted regarding water management. When asked about the water management team, INHA J indicated they had had a team but are in a transitioning period and stated there has not been a lot of stability in the maintenance director position. When asked when the team last met, INHA J indicated they had not attended a meeting in the three and a half months they had been here. When asked about control measures, INHA J indicated some chlorine testing, and flushing had been done. When asked about frequency of these controls, INHA J stated they had talked to the previous MD late January- early February to ask if tasks were complete and MD indicated they had been. INHA J indicated they had not been able to find logs the past few weeks. NHA indicated they found the water management plan review in TELS as marked on time. When asked if the meeting involved the team, NHA stated they would look for additional information.On 4/14/2026 at 2:07 PM Maintenance Director I provided previous Ph and Chlorine logs from the TELS system. In an interview at this time when asked if anyone has been performing these tasks since the previous MD had left, MD I indicated no.On 4/14/2026 at 3:10 PM an interview with Director of Nursing (DON) found they were on the water management team. When asked if they had attended a water management team meeting, DON indicated they had asked the previous MD about the status of the water management plan when they arrived in December because they knew they were in their survey window. A record review of the facility provided binder entitled Legionella includes a document titled Policy and Procedure Manuals this document includes text stating: The quality Assurance Committee has reviewed all written policies and procedures contained within this manual, and these policies have been approved by the Medical Director, Administrator, and the Director of Nursing. All policies and procedures contained within this manual are renewed annually and approved by the Quality Assurance Committee. The document was signed by the Medical Director, Administrator, and Director of Nursing with a date of 4/8/26. The binder also includes a policy titled Water Management Program this policy states: Seven key activities are routinely performed in a Legionella water management program:Establish a water management program teamDescribe the building water systems using flow diagrams and a written descriptionIdentify areas where Legionella could grow and spreadDecide where control measures should be applied and how to monitor themEstablish ways to intervene when control limits are not metMake sure the program is running as designed (verification) and is effective (validation)Document and communicate all the activitiesThe general principles of an effective water management program include:Maintaining water temperatures outside of the ideal range for Legionella growthPreventing water stagnationEnsuring adequate disinfectionMaintaining devices to prevent sediment, scale, corrosion and biofilm, all of which provide a habitat and nutrients for Legionella growth .The facility will implement measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems with a water management program that is based on nationally accepted standards. No water flow diagrams were noted within the binder.A record review of the facility provided binder entitled Legionella includes the American Society of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE) Proposed Revision of Guideline 12-2000, Managing the Risk of Legionellosis Associated with Building Water Systems and the CDC Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit). The binder includes work orders from the facility TELS program Instructions. Water Temps: Test and log the hot water temperatures. Instructions. Boiler Water Heaters: Flush to remove impurities, test pressure relief valve. Additional TELS order included logbook documentation, Water Treatment: Water Testing under steps it states: Facilities are required to check the Chlorine and PH levels in the domestic water monthly as part of their Water Management plan. Use a test kit available from your vendor that will show free chlorine levels from 0.0-4.0 The best range is between .2-1.0 The PH levels should be 6.5-7.5 Water hardness range 50-180 ppm. The log is marked done and on time on March 6, 2026. The following chlorine levels are documented: Date. 2/24/2026. Chlorine (02-1.0) . 0. 2/25/2026. Chlorine. 0. 2/26/2026. Chlorine. 0. 2/27/2026. Chlorine. 0. 2/28/2026. Chlorine. 0.

Based on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 4/14/2026 at 10:10 AM observed three outdoor waste receptacles in an enclosure. An interview with Housekeeping and Laundry Supervisor (HLS) E at this time found trash is picked up three times a week. One of the waste receptacles was observed with the lids in the open position and cardboard piled above the rim. Scattered debris including plastic bags were observed along the back wall of the enclosure. HLS E indicated they would call someone to move cardboard and close the lid. On 4/14/2026 at 10:27 AM observed a hopper with black particles along the inside edge of the hopper bowl in the soiled utility laundry room. Further observation found the faucet handle missing from the hand sink. HLS E indicated that the hand sink was in the facility maintenance system TELS.On 4/14/2026 at 10:44 AM observed a shower bed with brown buildup accumulated in the center crease of the mat. When the mat was lifted, black residue was observed coating the underside of mat and plastic shower bed surface in the first floor spa room. An interview with HLS E at this time found housekeeping cleans the spa rooms twice a day and shower beds are the Certified Nursing Assistants (CNAs) responsibility to clean.On 4/14/2026 at 10:51 AM observed dried brown particulate matter coating the interior bowl of the hopper in the soiled linen 300-400 hall. A shallow pool of brown colored water was observed in the hopper drain line, and an unpleasant odor was noted in the vicinity of the hopper.On 4/14/2026 at 10:58 AM observed green buildup along the inside wall of the hopper bowl, extending onto the water surface in the soiled linen 100-200 hall. HLS E acknowledge the green buildup and indicated they would get someone to clean.On 4/14/2026 at 11:02 AM observed a plastic bag on the floor containing an opened package of briefs and disposable bed mats in the second floor spa room. HLS E notified a CNA to collect the bag. Further observation found a puddle of water on the side opposite the drain in the shower stall. Slightly yellow discolored water accumulated in approximately a 2 by 3 foot puddle. Observation of a shower bed found spots of black accumulated on the underside of the mat and shower bed surface. The sink in the restroom within the spa room was observed pulling away from the wall leaving cracks in the caulk. HLS E indicated that this is in TELS.On 4/14/2026 at 11:12 AM observed black particulates accumulated in the bowl of the hopper in the soiled utility 500-600 hall. A plastic straw and lid was observed floating at the surface of the water in the bowl of the hopper.On 4/14/2026 at 3:41 PM in an interview with CNA G when asked cleaning procedure for shower equipment CNA G indicated CNA staff are supposed to clean equipment when it is used with sanitation wipes.On 4/14/2026 at 3:46 PM an interview with CNA H found showers are used daily and staff clean equipment after use with a solution. CNA H indicated cleaning under and the top surface of shower beds. CNA H stated everyone is supposed to clean after use and indicated they would clean it before use if visibly dirty. Record review of the facility provided policy entitled Federal & State - Resident Rights & Facility Responsibilities under safe environment states, The facility must provide. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on interview and record review, the facility failed to ensure five residents (R5, R8, R27, R84, R85) out of five residents reviewed for immunizations, were provided pneumococcal vaccination and education resulting in the potential for development and spread of pneumonia among vulnerable residents in the facility. Findings include:On 4/16/2026 at 10:45 AM the Infection Preventionist (IP) M was interviewed and reported the following residents R5, R8, R27, R84 and R85 did not have documentation of a current pneumococcal immunization or declination form signed by the appropriate guardian.-Review of the Electronic Health Record (EHR) for R5 revealed admitted on [DATE] with diagnoses of Bacterial Pneumonia, and Acute Respiratory Failure with Hypoxia. R5 did not have documentation to indicate that the pneumococcal vaccine was declined by his guardian.-Review of the EHR for R8 revealed admitted on [DATE] with diagnoses of Paraplegia and Dementia. R8 did not have documentation to indicate that the pneumococcal vaccine was offered or was contraindicated. -Review of the EHR for R27 revealed admitted on [DATE] with diagnoses of Peripheral Vascular Disease. R27 did not have documentation of a declination form.-Review of the EHR for R84 revealed admitted on [DATE] with diagnoses of Chronic respiratory Failure with Hypoxia. R84 did not have documentation of a declination form signed by the guardian.-Review of the EHR for R85 revealed admitted on [DATE] with diagnosis of Other Specified Symptoms and Signs Involving the Circulatory and Respiratory Systems. R85 did not have documentation of a declination form.On 4/16/2026 at 10:50 AM the Director of Nursing (DON) was interviewed and said residents and or guardians should be educated and offered the pneumococcal vaccine. If the resident refuses, then a declination form should be signed by the appropriate party.Review of the facility policy titled Immunizations: Pneumococcal Vaccination of Residents last revised 11/4/2024 revealed in part.All residents of our facility should receive the pneumococcal vaccine if they are [AGE] years of age or older or younger than 65 years with underlying conditions that are associated with increased susceptibility to infection or increased risk for serious disease and its complications. All residents with undocumented or unknown pneumococcal vaccination status will be offered the vaccine. Informed consent in the form of a discussion regarding risks and benefits of vaccination will occurprior to vaccination. (This may be with the resident's authorized representative when appropriate. Residents may refuse vaccination. Vaccination refusal and reasons why (e.g., allergic, contraindicated, did not want vaccine, etc.) should be documented by the facility. If the resident/family/ legal representative chooses to exercise the right to decline the vaccination, it will be reevaluated annually.

Based on interview and record review, the facility failed to ensure five residents (R5, R8, R27, R84, R85) out of five residents reviewed for immunizations, were provided Covid-19 vaccination and education resulting in the potential for development and spread of Covid-19 among vulnerable residents in the facility. Findings include:On 4/16/2026 at 10:45 AM the Infection Preventionist (IP) M was interviewed and reported the following residents R5, R8, R27, R84 and R85 did not have documentation of a current Covid-19 immunization or declination form signed by the appropriate guardian.-Review of the Electronic Health Record (EHR) for R5 revealed admitted on [DATE] with diagnoses of Bacterial Pneumonia, and Acute Respiratory Failure with Hypoxia. R5 did not have documentation to indicate that the Covid-19 vaccine was declined by his guardian.-Review of the EHR for R8 revealed admitted on [DATE] with diagnoses of Paraplegia and Dementia. R8 did not have documentation to indicate that the Covid-19 vaccine was offered or was contraindicated. -Review of the EHR for R27 revealed admitted on [DATE] with diagnoses of Peripheral Vascular Disease. R27 did not have documentation of a declination form.-Review of the EHR for R84 revealed admitted on [DATE] with diagnoses of Chronic respiratory Failure with Hypoxia. R84 did not have documentation of a declination form signed by the guardian.-Review of the EHR for R85 revealed admitted on [DATE] with diagnosis of Other Specified Symptoms and Signs Involving the Circulatory and Respiratory Systems. R85 did not have documentation of a declination form.On 4/16/2026 at 10:50 AM the Director of Nursing (DON) was interviewed and said residents and or guardians should be educated and offered the Covid-19 vaccine. If the resident refuses, then a declination form should be signed by the appropriate party.Review of the facility policy titled Resident Covid-19 Vaccination last revised 10/6/2025 revealed in part. All new residents and resident representatives will be provided with education COVID-19 vaccination utilizing the approved Food and Drug Administration EAU or VIS Fact Sheet. The facility will obtain a signed consent form for the administration of the COVID-19 vaccine from the resident or the resident's designated health care representative(s). A declination will be signed if consent is not given. Telephone consent is acceptable. The facility will track consents and declinations of all residents in the immunizations section of the medical record. All new and re-admissions will be evaluated by the nurse and/or physician for previous immunization and will be offered the vaccine if appropriate and available.

Based on observation, interview, and record review, the facility failed to inform one resident (R154) of five residents about the risks and benefits of a proposed treatment and to receive consent for the use of the treatment, resulting in the administration of an antipsychotic medication without resident understanding and consent. Findings include: On 4/14/2026 at approximately 11:25 AM, R154 was observed in their room in bed. R154 was awake, alert, and communicative. A record review was conducted on 4/15/2026 and revealed R154 was originally admitted to the facility on [DATE] with diagnoses that included vascular dementia with other behavioral disturbances, cerebral infarction, age-related physical debility, arthritis, hypertension, and osteoarthritis. Section C of the Minimum Data Set with an Assessment Reference Date of 1/31/2026 revealed R154 scored a 14/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. A physician order dated 12/24/2025 revealed, **DAW** (dispense as written) Give 0.5 mg by mouth two times a day for Delirium; Schizophrenia. A review of R154s Medication Administration Record for April 2026 revealed the medication had been administered to them since December 2025. A psychiatry progress note dated 12/24/2025 revealed, Patient is exhibiting paranoid delusions, believing that others are trying to kill her, including staff members and the facility owner. She denies hallucinations, anxiety, or sleep disturbances. Starting risperidone 0.5 mg twice daily for management of psychotic symptoms. There was no further documentation in the progress note or within the electronic health record that revealed R154 or their representative was made aware of the risks and benefits of the antipsychotic medication or that R154 of their representative consented to the use of the medication. On 4/15/2026 at approximately 2:00 PM, the Social Worker (SW A) was asked to provide any documents demonstrating the education was provided and or consent to the medication was made by R154 or their representative. SW A was unable to provide any documentation and was unsure why it was not provided. On 4/16/2026 at approximately 1:05 PM, an interview was conducted with R154. When queried if they were aware of the antipsychotic medication or if they were provided education about the risks and benefits of the medication, R154 stated, no- I was not aware. I do not like taking a lot of medication because they upset my stomach and make me constipated.On 4/16/2026 at approximately 1:20 PM, the Director of Nursing (DON) was interviewed about the process for providing education to the resident or their representative prior to initiation of a new treatment. The DON confirmed that no risk versus benefit education or consent was located in R154s electronic health record and did not provide any further explanation. A policy titled, Psychoactive Medication Management initiated 7/1/2014 revealed, 4. Residents receiving psychoactive medications upon admission, those with new psychoactivemedications orders or an increase in the dose of the medication, will have a psychotropic medication informed consent completed. Before initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.

Based on observation, interview, and review, the facility failed to ensure a call light was within reach of one resident (R162) out of one resident reviewed for accommodation of needs, resulting in unmet care needs and the potential for further unmet care needs Findings include:On 4/14/2026 at 10:40 p.m., R162 was heard from the hallway yelling, I have to go do number two, I have to go do number two, I have to go do number two. Observed multiple staff walking in the hallway without acknowledging R162's request. R162 was observed in bed, bed covers at the knees, attempting to take the brief off yelling, I have to go do number two. R162 was asked about using the call light. R162 stated, I don't know where it is. I'm not embarrassed anymore. This been happening to me for so long, I am used to this now. R162 call light was observed on the left side of the bed on the floor out of reach. R162 then stated, It's (poop) ready to come now, it's too late. I had to do number two, and I had been calling someone, but no one came and now it's too late. I have a bed pan in the closet, but I can't get up to get it. On 4/14/2025 approx. 10:55 a.m. Unit Manager (UM) N and R162's assigned Certified Nursing Assistance (CNA) O entered R162's room and offered care. During an interview after care was provided, CNA O verified there were feces in the brief and that the call light was not in reach. R162's room had a smell of feces after care was provided. UM N was asked did R162 use the call light to make needs known? UM O stated, I am not sure if he can use the call light or not. UM O said to R162 that the call light will be pinned on R162's on the covers of R162's stomach where it can be reached. R162 said no, put it somewhere else on me for I can reach it. UM O asked R162, Can you use the call light? R162 responded, Yes, if I can find it. 04/16/2026 2:37 p.m. R162's Family Member (Q) said during an interview while visiting that there was a problem with R162 call lights not being in reach and being on the floor. Family Member Q said the weekend of (4/11/2026 and 4/12/2026), while walking into the room, R162 was heard yelling for some water because the call light was not in reach and after picking the call light off the floor and turning it on, no one came in the room for about an hour. Family Member Q confirmed R162 can use the call light to make needs known.According to the electronic medical records, R162 was admitted into the facility on 4/9/2026 with diagnoses of pulmonary hypertension, congestive heart failure, pneumonia, chronic obstructive pulmonary disease, and end stage renal disease. R162 was alert and oriented times three. The Minimum Data Set (MDS) was not available. Review of a 4/10/2026 Activity Daily Living ('ADL'S) care plan revealed, R162 has a functional ability deficit and requires assistance with self-care. Interventions: Encourage resident to use bell/call light to call for assistance. On 4/16/2026 at 2:50 p.m. the Director of Nursing (DON) was interviewed and informed of the call lights not being in reach of the residents. The DON was asked for the purpose of a call light being in reach of a resident. The DON said for safety reasons, for example if they were having chest pain, they call for help and communicate to the staff their needs. According to the facility's 3/12/2025 Call Lights policy: Call Lights will be placed within the resident's reach and answered in a timely manner. Procedure: 1. New Residents will be informed about the location of the call light at the bedside and in the bathroom/shower room. 3.When a resident is in bed or confined to a chair ensure the call light is within easy reach of the resident.

Based on observation, interview, and record review the facility failed to ensure the bathroom was free from odors for two (R47 and R107) of four residents reviewed for homelike environment, resulting in unpleasant odors due to poor ventilation.Findings include: R107On 4/14/2026 at 4:52 p.m. upon entering R107's bedroom, the bathroom door was slightly open, and an unpleasant odor came from it. R107 was observed sitting in a wheelchair, at the bedside. R107 presented as alert, oriented to person, place, and situation. R107 stated, It (bathroom) stinks doesn't it. We keep the closed because it smells so bad. R107 said the bathroom has had an odor for a while. Housekeeping cleans it daily and it still has an odor. On 4/14/26 at 4:56 p.m. upon entering the bathroom an odor was immediately detected. The odor smelled like sewage. There was evidence the bathroom was cleaned. A vent was observed in the corner of the bathroom. A piece of toilet paper was thrown towards the vent and immediately fell to the floor (indicating a non-working/poorly working vent).Review of the clinical record documented R107 was admitted into the facility on 1/15/26 with diagnoses that included acute respiratory failure, diabetes mellitus, type 2, sleep apnea, vesical fistula, and congestive heart failure. According to the admission Minimum Data Set assessment, R107 was cognitively intact (BIMS-14) and required max assistance with most activities of daily living. R47On 4/14/2026 at 4:59 p.m. R47 was observed sitting in the hall outside of the bedroom. R47 presented as alert and oriented to person, place, and situation. R47 stated, The bathroom stinks. We have to spray a lot because it smells so bad. It's even worse if one of us goes in there to poop (bowel movement). R47 shook head and frowned face as they spoke of the bathroom. R47 also confirmed the bathroom is cleaned daily by the housekeeping staff. Review of the clinical record documented R47 was admitted into the facility on 1/9/26 with diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus, type 2, ischemic stroke, and right-side hemiparesis. According to the quarter Minimum Data Set assessment dated [DATE], R47 was cognitively intact (BIMS-14) and required partial assistance with activities of daily living.On 4/16/26 at 2:20 p.m. the Nursing Home Administrator was interviewed and said a vent check was done via using a piece of toilet paper and placing near the bathroom vent. The toilet paper did not stick to the vent. The Nursing Home Administrator said the bathroom did not have ventilation which may be the cause of the odor. On 4/16/26 at 2:30 p.m. Housekeeping Supervisor E and Maintenance Worker P who were interviewed in proxy of the Maintenance Director said they were unaware of the bathroom having an odor or of the poor ventilation. Electronic communication about environmental concerns from residents is supposed to be reported by staff.Review of the facility's policy titled Resident Rights & Facility Responsibilities, revision date 5/14/24 documented in part: Safe, Clean, Comfortable & Homelike Environment: The resident has a right to a safe, clean, comfortable and homelike environment. Housekeeping & Maintenance Services. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on interview and record review the facility failed to ensure a Pre-admission Screening and Annual Resident Review (PASARR-determines whether or not an individual who has a diagnosis of Mental Illness or Intellectual/Developmental Disability [ID/DD] meets the criteria for a nursing home and their needs are met) Level I (3877) was completed for one resident (R27) and Level 2 (3878) was completed for two residents (R4, R125) out of five residents reviewed for PASARRs. Findings include:R27 A review of R27's Electronic Health Record (EHR) did not reveal the current 3877 form. There was not a Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening). R27 was admitted to the facility on [DATE] with pertinent diagnoses of Schizophrenia and Delusional Disorders. Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/23/2026 revealed R27 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10/15. On 4/15/2026 at 1:32 PM, Social Worker (SW) A was interviewed and said R27's annual level one PASARR-3877 was not submitted until the State Agency requested it on 4/15/2026. SW A further said it should have been completed on 1/27/26. R4 A review of R4's electronic health record (EHR) revealed that a Level I Screening form 3877 was completed on 9/26/2025 and indicated R4 had Mental Illness and Dementia. A Level II Screening form 3878 was not located in the EHR. On 4/15/2026 a record review was conducted and revealed that R4 originally admitted to the facility on [DATE] with diagnoses that included adjustment disorder with anxiety and depressed mood, major depressive disorder, delusional disorders, and vascular dementia. Section C of the Minimum Data Set with an Assessment Reference Date of 14/7/2026 indicated R4 scored 14/15 on the Brief Interview for Mental Status assessment – indicative of no cognitive impairment. R4s care plan had a focus dated 6/4/2021, which read, Annual Level 2 to be completed as indicated. On 4/15/2026 at approximately 1:35 PM, the Social Worker (SW A) was queried as to the location of the 3878 and Level II evaluation and determination. SW A indicated that the 3878 was not signed by a licensed health care provider until 4/10/2026 and that the Level II determination was not received yet. R125 A review of R125's EHR revealed that a Level I Screening form 3877 was completed on January 10, 2026, and indicated R125 had Mental Illness. A Level II Screening form 3878 was not located in the EHR. A Level II PASARR determination dated March 20, 2025, indicated R125 would need another Level II Evaluation by March 19, 2026, if they continued to reside in the nursing facility. On 4/15/2026 a record review was conducted and revealed that R125 originally admitted to the facility on [DATE] with diagnoses that included Parkinsons and schizoaffective disorder depressive type. Section C of the Minimum Data Set with an Assessment Reference Date of 1/20/2026 indicated R125 scored 11/15 on the Brief Interview for Mental Status assessment- indicative of moderate cognitive impairment. R125s care plan had a focus dated 12/21/2023, which read, Annual Level 2 to be completed as indicated. On 4/15/2026 at approximately 1:35 PM, the Social Worker (SW A) was queried as to the location of the 3878 and Level II evaluation and determination. SW A indicated that it was not completed. SW A confirmed that the information and recommendations received from the Level II Determinations is included in the resident's care plan so that facility staff have interventions that can be used when providing mental health care and treatment to the resident. On 4/16/2026 at 1:31 PM, the Nursing Home administrator was interviewed and said the expectation is for PASARRs to be completed as recommended/required. A policy titled, Pre-admission Screening and Guest/Resident Review- PASRR Michigan last revised 11/12/2021 revealed the following: .a Level 1/3877 is completed annually for all guests/residents and maintained in the electronic medical record. For those who screen positively for a mental illness/intellectual/developmental disability the facility submits the annual Level 1/3877 screen to the local community mental health program for comprehensive screening (Level 2), and All Level 1 screenings and communications between the facility and the local community mental health program, regarding a specific guest/resident, are to be maintained in the guest/resident electronic medical record. and If a comprehensive Level 2 screening is preformed, the recommendations are to be included in the plan of care if the physician chooses to adopt the recommendations.

Based on observation, interview and record review, the facility failed to apply splinting devices and perform range of motion (ROM) exercises as recommended by therapy for one (R5) of four residents reviewed for limited ROM, resulting in the potential for increased joint contracture, loss of range of motion and increased pain.Findings include:On 4/14/2026 at 10:16 AM, R5 was observed in bed with a left-hand flexion contracture, knees bent, legs lying together to one side. When R5 was asked about his hand R5 said he was supposed to have a hand splint. R5 stated, I would wear a splint if they helped me with it, I need it. R5 raised his left hand, indicating his left hand in a closed fist position. R5 further said he wasn't getting exercise.On 4/15/2026 at 10:13 AM, R5 was observed in bed without wearing any splints. Two knee splints and one hand/wrist brace were observed on the dresser.On 4/15/2026 at 2:14 PM, R5 was observed in bed not wearing any splints. R5 stated, They haven't put them on me in a long time, maybe two weeks or more. I need them, especially my hand.On 4/15/2026 3:00 PM, Certified Nursing Assistant (CNA) L and Restorative Aide (RA) K were interviewed regarding R5's restorative program. CNA L said she did not apply splints and/or perform ROM exercises. RA K said she had been applying R5's splints and performing his ROM program. RA K was asked to produce documentation of the restorative program and was unable. On 4/15/2026 at 3:06 PM, R5's Electronic Health Record (EHR) was reviewed with Director of Nursing (DON). The DON was unable to provide restorative records upon request. The DON said she was responsible for the restorative program. Review of R5's EHR revealed the most recent admission to the facility on 2/12/2024 with diagnosis that included Contracture, Left Hand and Other Symptoms and Signs Involving the Musculoskeletal System. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and dependent care for personal hygiene. Review of R5's Therapy to Restorative Program Plan dated 2/25/2026 revealed, Restorative Plan 3x/wk for 12 weeks. Interventions B UE (both upper extremities) and B LE (both lower extremities) AAROM (active assisted range of motion) through tolerated range, L resting hand splint 4hrs daily.Review of R5's orders did not reveal a splint and/or restorative ROM program.Review of R5's care plan revealed R5 is at risk for decline in function and requires functional maintenance r/t impairment in range of motion, muscle weakness. Revision on 3/9/2026. Goal-Will maintain/increase the current level of range of motion and muscle strength by/through the review date revision 3/9/2026. Interventions AAROM progress of the restorative program per the facility policy. Date initiated 3/9/2026. AAROM exercises to upper extremities 2 sets x 10 reps date created 3/9/2026. AAROM exercises to bilateral lower extremities daily as tolerated through ADL care and activities engagement. Revision on 3/9/2026. Observe and document Restorative Nursing Program: AAROM progress of the restorative program per the facility policy. Date initiated 3/9/2026.Review of R5's care plan did not reveal a left-hand splint and knee splint intervention until 4/14/2026. On 4/16/2026 at 10:09 AM, the DON was interviewed and said there were no records of splint care for the R5 prior to the DON adding splints to the care plan on 4/14/26. The DON acknowledged there has been a lax in the restorative program since there has been a leadership change. The DON further acknowledged R5 was not getting the splinting program recommended by therapy and not getting the ROM program consistently.Review of the facility policy titled Restorative Nursing dated 5/1/2024 revealed in part.The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being. The interdisciplinary team (IDT) works with the resident and family to identify measurable restorative goals and practical interventions that can be implemented and achieved with nursing support. A licensed nurse will help manage the restorative nursing process with assistance of nursing assistants trained in restorative care. Sometimes, under licensed nurse supervision, other staff trained in restorative care will be assigned by the nurse to work with specific residents. Nursing Restorative is available up to 6-7 times per week and is provided for residents meeting restorative program criteria.Components of the restorative nursing program include, but are not limited to, the following: Interdisciplinary process to identify residents who would benefit from a Restorative Nursingprogram Referral from skilled therapy services via the Therapy to Restorative Program Plan At care planning and other guest-focused meeting, e.g. behavior management,resident/nutrition at risk, etc. During weekly Interdisciplinary Team Meeting (ITM)/Utilization Review Meeting Morning clinical meetingDocument the resident's daily participation and actual number of minutes participating in in the resident's EHR.The licensed nurse will meet with the restorative aide(s) or nurse aide(s) to evaluate and document the effectiveness of interventions periodically but at least quarterly.

Based on interview and record review, the facility failed to obtain and document a review of Medication Regimen Review (MRR) recommendations or any action taken by the physician in response to pharmacy recommendations for one (R154) of five residents reviewed for Unnecessary Medications, resulting in the potential for the continuance of unnecessary medications. Findings include: A record review was conducted on 4/15/2026 and revealed R154 was originally admitted to the facility on [DATE] with diagnoses that included vascular dementia with other behavioral disturbances, cerebral infarction, age-related physical debility, arthritis, hypertension, and osteoarthritis. Section C of the Minimum Data Set with an Assessment Reference Date of 1/31/2026 revealed R154 scored a 14/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. A physician order dated 12/24/2025 revealed, Risperdal Oral Tablet **DAW** (dispense as written) Give 0.5 mg by mouth two times a day for Delirium; Schizophrenia. A review of R154s Medication Administration Record for April 2026 revealed the medication had been administered to them since December 2025. A monthly pharmacy Medication Regimen Review document dated 1/20/2026 located in R154s electronic health record (EHR) revealed the following was checked by the pharmacist: See report for any noted irregularities and/or recommendations. There was no evidence of a separate report identifying the irregularities and/or recommendations made by the pharmacist within the EHR. In addition, there was no evidence in the EHR that the attending physician reviewed or provided any rationale for accepting/declining the pharmacist recommendations. On 4/16/2026 at approximately 1:25 PM, the Director of Nursing (DON) was queried as to where the attending physician's response to the MRR was located. The DON provided a document dated 1/20/2026 titled, Consultant Pharmacist's Medication Regimen Review. The document revealed the following pharmacist recommendation: This patient is currently receiving antipsychotic therapy with Risperidone and therefore requires an Abnormal Involuntary Movement Test (AIMS) at baseline and every 6 months while on antipsychotic therapy. Please consider monitoring AIMS test now and every 6 months thereafter. When asked how the attending physician is made aware of these reports, the DON said that they were emailed to her and the attending physician. She would then communicate with the physician regarding any medication changes, new orders, etc. The DON then confirmed there was no evidence on the document or within the EHR that demonstrated the physician received the document and/or made any changes related to the pharmacist's recommendations. On 4/16/2026 at approximately 3:15 PM, a telephone interview was conducted with the attending physician (MD C). The DON was present for the interview. MD C said that he received the pharmacist recommendations via email, reviewed them, documented his rationale on the document, and sent them back to the pharmacist. MD C further said that he did not include the DON in his response back to the pharmacist. A policy titled, Timeliness of Medication Regimen Review (MRR) Reports, last revised 9/7/2023 revealed, the attending physician is expected to review the resident's individual MRR and document and sign that he/she has reviewed the pharmacist's identified recommendations within 14 days of receipt. and If the attending physician does not respond to the resident's MRR report within 14 days, the Director of Nursing will notify the physician of pending MRR reports.

Based on interview and record review, the facility failed to ensure a medication regimen was free from unnecessary medications for one resident (R154) of five residents reviewed for unnecessary medications, resulting in the potential for the continuance of unnecessary medications and adverse drug reactions experienced by the resident. Findings include:On 4/14/2026 at approximately 11:25 AM, R154 was observed in their room in bed. R154 was awake, alert, and communicative. A record review was conducted on 4/15/2026 and revealed R154 originally admitted to the facility on [DATE] with diagnoses that included vascular dementia with other behavioral disturbances, cerebral infarction, age-related physical debility, arthritis, hypertension, and osteoarthritis. Section C of the Minimum Data Set with an Assessment Reference Date of 1/31/2026 revealed R154 scored a 14/15 on the Brief Interview for Mental Status assessment - indicative of no cognitive impairment. A physician order dated 12/24/2025 revealed, Risperdal Oral Tablet **DAW** (dispense as written) Give 0.5 mg by mouth two times a day for Delirium; Schizophrenia. A review of R154s Medication Administration Record for April 2026 revealed the medication had been administered to them since December 2025. A monthly pharmacy Medication Regimen Review document dated 1/20/2026 located in R154s electronic health record (EHR) revealed the following was checked by the pharmacist, See report for any noted irregularities and/or recommendations. On 4/16/2026 at approximately 1:25 PM, the Director of Nursing (DON) was queried as to where the attending physician's response to the MRR dated 1/20/2026 was located. The DON provided a document dated 1/20/2026 titled, Consultant Pharmacist's Medication Regimen Review. The document revealed the following pharmacist recommendation: This patient is currently receiving antipsychotic therapy with Risperidone and therefore requires an Abnormal Involuntary Movement Test (AIMS) at baseline and every 6 months while on antipsychotic therapy. Please consider monitoring AIMS test now and every 6 months thereafter. On 4/16/2026, a documented titled, Note to Attending Physician/Prescriber dated 1/20/2026 received from the Director of Nursing revealed that the attending physician agreed to the pharmacist recommendation as noted above and added, Nursing please perform AIMS q (every) 6 months. A further review of the electronic health record revealed no orders for AIMS testing or evidence that an AIMS test was completed at the initiation of the antipsychotic to establish a baseline.On 4/16/2026 at approximately 1:30 PM, the Director of Nursing was queried as to the location of any baseline AIMS testing within the electronic health record for R154 but was unable to provide any information as to where it was located or why it was not completed. A policy titled, Psychoactive Medication Management initiated 7/1/2014 revealed, A resident requiring a psychoactive medication will be monitored by the interdisciplinary team, and dose management reviewed with the practitioner and pharmacist for efficacy and/or adverse consequences and, The Abnormal Involuntary Movement Scale (AIMS) will be completed for residents receiving antipsychotic medications, upon admission, at the start of new antipsychotic therapy, and at a minimum of every six months.

This citation pertains to intake 2735896.Based on interview and record review the facility failed to implement adequate supervision for one cognitively intact resident (R903) from three residents reviewed for safety resulting in R903 exiting the building with family unbeknownst to the facility and unknown whereabouts. Findings include: The State Agency received an anonymous complaint that a resident had eloped from the facility.On 2/18/26 at 11:15 AM, the Director of Nursing (DON) was asked if a resident had eloped from the facility. The DON stated, It was not an elopement. That person was cognitively intact and thought they were going on a Leave of Absence (LOA) with friends and family. The resident was safe with family in their home. The resident said they did not know they were supposed to get permission to leave the building or they would have done that. The staff did not follow the facility's LOA process. The nurse thought the resident was on a LOA but there was no order for it. There was no information on who the resident went out with or for how long the resident would be out of the facility. On 2/2/26 during morning meeting it was reported the resident did not return to the facility from their LOA. We viewed the facility's front door camera and saw the resident was properly dressed and walked out of the facility with several family members on 2/1/26 at approximately 6:00 PM. The resident and the family member were contacted on the phone. The resident said they were returning to the facility to pick up their belongings and then wanted to be discharged . The resident was discharged Against Medical Advice.According to R903's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with diagnoses of leukemia and pneumonia. The Minimum Data Set (MDS) dated [DATE] indicated R903 had intact cognition and was independent with Activities of Daily Living including ambulation. On 1/29/26 an 'elopement risk' assessment indicated that R903 was not at risk for elopement. A progress note written by Licensed Practical Nurse (LPN) A on 2/2/26 at 4:00 AM documented that the resident had not returned from LOA. There was no order, no care plan, and no additional documentation regarding R903 going on a LOA. On 2/19/25 at 3:40 PM, Licensed Practical Nurse (LPN) A was asked about R903. LPN A said a CNA (certified nursing assistant) told her that R903 went on a LOA with her family. LPN A stated, That's what I was told. The resident was on a LOA. LPN A could not recall the name of the CNA who told her R903 went on a LOA. LPN A said she did not look to see if R903 had an order for an LOA, or if there was any documentation regarding who the resident was with. LPN A said she did not report R903 was out of the facility until the end of the shift. LPN A said she had received an in-service from the DON on the LOA process and would go about it differently next time.On 2/19/26 at 1:34 PM Certified Nursing Assistant (CNA) B was interviewed regarding R903 and said, I noticed the resident wasn't in her room when I picked up her dinner tray around 5:30 PM- 6:00 PM. She had been with several visitors in her room earlier. When she wasn't there, I figured she went somewhere with them. I didn't even know she had not returned to her room until end of my shift when I did rounds. I asked the nurse when she would be coming back. The nurse said she had until midnight to return. I wasn't worried because she was with her people. I didn't take it as an elopement, or I'd have called a code green. I thought it was a LOA. CNA B acknowledged that R903 had not been seen since early in the shift when the dinner tray was served around 5:00 PM. On 2/19/26 at 12:15 PM Receptionist (RE) D was interviewed regarding R903 and said, I don't recall anything being off that evening. I don't remember seeing that resident leave. We get a lot of visitors on Sunday. I have an elopement book with pictures of to review, but that resident wasn't on it. We now have a LOA book and are asking all visitors to sign out before they leave. There has always been that sign at the door that reminds visitors to sign out it they leave with a resident. A black sign with white lettering at the exit door asks that visitors sign out the resident at the desk if they are leaving the facility.R903 was unable to be interviewed prior to end of survey.According to the facility's Leave of Absence Policy last revised 11/16/2022 in part reads:IDENTIFICATIONS, AND CARE PLANS. Based upon the evaluation(s) completed above, the Resident's attending physician shall issue an applicable order addressing the Resident's leave classification, such as leave not permitted without approved supervision due to lack of competency or capacity; no concerns with leave; leave not recommended without-approved supervision; and/or leave not recommended with or without supervision. Additional recommendations may also be made, such as leaves not to exceed a certain number of hours or leaves at certain hours. A corresponding care plan shall also be developed and initiated. The care plan shall address any applicable clinical issues such as the Resident's possible need for medication(s) during leaves, education related to the administration of such medication, and possible dietary issues during leaves. Any other potential concerns or problems should also be addressed. Finally, the Facility shall provide a means for identifying the Resident's leave classification in the medical record, and educate staff regarding such classification. If staff are not aware of a Resident's leave classification, they shall seek clarification prior to permitting the Resident to leave the Facility.IV. LEAVE PROCEDURE1. If a Resident lacks legal competency or capacity as described above, he/she shall not be permitted to leave the Facility without approved supervision.2. If the Resident has been approved for a Leave of Absence or is Leaving the Facility Against Medical Advice, the Resident and/or Responsible Party shall make an effort to notify the Facility in advance regarding the date, time location and expected length of a planned leave of absence from the Facility.3. Residents and/or Responsible Parties shall Sign Out before leaving the Facility for a Leave of Absence by indicating the time of the leave, any family or friends accompanying the Resident during the leave, applicable contact information and the proposed location and estimated length for the leave. Residents or Responsible Parties shall also 'Sign in upon returning to the Facility following a Leave of Absence. If the Resident refuses or fails to Sign In or Out relative to a Leave of Absence, Facility staff should document such information, if known, in the medical record.4. If a Resident leaves the Facility without the Facility's knowledge and the Facility is unable to identify the whereabouts of the Resident, the leave shall be treated as an unavoidable elopement, and the Facility should implement its elopement protocol procedures.5. Staff shall document any pertinent information or concerns regarding a Resident's Leave of Absence in the medical record

Based on observation, interview, and record review the facility failed to provide timely required information upon facility entry and during the annual recertification survey affecting all residents who reside in the facility causing a delay in the survey process. On 5/5/2025 at 8:30 AM upon facility entry the survey team leader requested a facility census, a resident list, and facility matrix from Registered Nurse (RN) H. RN H did not provide the requested information. On 5/5/2025 at approximately 9:15 AM the facility census, resident list, WIFI access, and facility matrix were requested from the Director of Nursing (DON). On 5/5/2025 at approximately 9:45 AM the Nursing Home Administrator (NHA) provided the facility census, resident list, facility matrix, electronic medical record (EMR) access and WIFI access. The facility provided WIFI access did not work throughout the survey. On 5/5/2025 at 9:56 AM the NHA was emailed the entrance conference worksheet which stipulates the timeframe for documents and information to be provided to the survey team. On 5/5/2025 at 10:06 AM the entrance conference was performed with the NHA. The NHA was provided with access to Egress (the State Agency electronic file sharing platform) and indicated they were familiar with the program. On 5/6/25 at 4:16 PM the NHA was interviewed regarding the delay in providing survey requested documents and said they did not have full access to the clinical portions of the EMR. The NHA further said DON was new and was getting acclimated to the EMR system. On 5/07/2025 at 3:04 PM the hospice agreements, and dialysis contracts were requested due to the correct information not being provided on day one of the survey within four hours of facility entry. On 5/12/25 at 12:25 PM the DON was interviewed regarding the delay in providing the survey team with the required survey information timely and said any of the unit managers should be able to provide a census upon surveyor entry to the facility. The DON agreed that the survey team was not provided timely documentation upon entry to the facility.

Based on observation, interview and record review the facility failed to assist in the removal of facial hair and ensure showers were provided for one female resident (R54) and provide nail care for three residents (R10, R17, R100) of 29 residents reviewed, resulting in unmet hygiene needs and the potential for feelings of diminished dignity. Findings included On 5/6/25 at 12:24 PM R54 was observed with excessive hair on the chin and both sides of the lower face. The resident had dark matter protruding from the nail bed of the left index finger. On 5/7/25 at approximately 2:00 PM the facial hair and dark matter under the left index finger were still present. R54 asked how long the facial hair had been present? R54 stated during shower days she was able to remove the facial hair, however, R54 stated she had not received a shower recently because of the pain from arthritis and that alone made her sad and down. R54 stated I am supposed to get a shower on Wednesday and Saturday each week on the day shift, it's been a while, I cannot do it without help. Review of the Shower Logbook on the unit revealed R54 had one undated shower sheet, with a note stating, asked to get one in morning. The shower sheet was signed by CNA GG. While reviewing the shower Logbook nurse DD was asked for assistance in locating other shower sheets for R54. Nurse DD reported the old shower sheets were pulled off the units for audit and filing and Unit Manager A probably could provide additional information where the old shower sheets were filed. UM A joined the search for R54's shower sheets and indicated documentation of the resident's showers and or refusal should be in the nurse Aides kiosk on the unit. The manager requested the assigned nurse aid for that shift to provide a copy of last month's shower sheet from the kiosk. The information could not be retrieved from the kiosk and UM A stated I will find out how to get the document. While reviewing the One shower sheet the Electronic Medical Record was reviewed for refusals for R54. There were no entries by the nursing staff indicating R54 refused showers or was resistant to staff assisting with the removal of the facial hair On 5/12/25 at 2:00 P.M. of the Admission Record stated R54 was readmitted to the facility on [DATE], with diagnoses of rheumatoid arthritis, dysphagia (oropharyngeal) low back pain, diabetes mellitus, with diabetic neuropathy, hypertension, acute kidney failure, spinal stenosis, lumbar region with neurogenic claudication. According to the minimum data set (MDS) 2/3/2025 R54 required supervision or touching assistant with shower/bath , assistance with personal hygiene. 47964 Resident # 10 (R10) On 5/06/25 at 11:31 AM, Guardian I was interviewed about R10's care and said sometimes R10 does not get his nails cut. On 5/07/25 at 9:20 AM, R10 was observed with observed long jagged fingernails. On 5/08/25 09:24 AM, R10 was observed with long jagged fingernails. On 5/12/25 at 10:23 AM, R10 was observed with Registered Nurse (RN) J. RN J said int R10 had long dirty nails and they need to be cut. Record review of R10's EMR revealed he was admitted to the facility on [DATE] with diagnoses that included Acute Cerebral vascular insufficiency (obstruction of blood flow to the brain) and dysphagia. Review of the MDS dated [DATE] for R10 revealed a Brief interview for Mental Status (BIMS) of 0/15 which indicated severe cognitive impairment and dependent assistance for personal hygiene. Review of the EMR did not reveal refusals of care. Review of the Kardex revealed, Observe finger and toenails on shower days to see if they need to be trimmed. Resident #17 (R17) On 5/06/25 at 11:04 AM, R17 was interviewed about care in the facility and said she gets showers. R17's fingernails were observed long and jagged. On 5/08/25 at 10:22 AM, R17 was observed with Registered Nurse (RN) K. RN K said R17 had debris under her finger nails they needed to be clipped. Record review of R17's EMR revealed he was admitted to the facility on [DATE] with diagnoses that included Paraplegia (paralysis affecting the lower half of the body). Review of the MDS dated [DATE] for R17 revealed a BIMS of 12/15 which indicated moderately cognitive impairment and substantial/maximal assistance for personal hygiene. Review of the Kardex revealed, Bathing: Resident requires Physical help limited to transfer only, Physical help in part of bathing activity assistance with (no-setup, set-up, one, two) staff assistance to bath, observe finger and toenails on shower days to see if they need to be trimmed. Review of the EMR did not reveal refusal of care. Resident #100 (R100) On 5/06/25 at 10:51 AM, R100 was interviewed about care in the facility and stated, They don't do enough; my nails are long. R100's fingernails were observed long and jagged. On 5/08/25 at 10:06 AM, R100 was observed with RN K. RN K said R100's fingernails were long and needed to be trimmed. Record review of R100's EMR revealed he was admitted to the facility on [DATE] with diagnoses that included Epilepsy, Hemiplegia and Hemiparesis (weakness) following Cerebral Infarction (stroke) affecting Right Dominant Side. Review of the MDS dated [DATE] for R100 revealed a BIMS of 11/15 which indicated moderate cognitive impairment and dependent assistance for personal hygiene. Review of R100's Kardex revealed, Observe finger and toe nails on shower days to see if they need to be trimmed. Review of the EMR did not reveal refusals of care. On 5/12/25 at 12:25 PM, the Director of Nursing (DON) was interviewed and said the Certified Nursing Assistants should check on shower days and during regular care to see if residents' nails should be cut and/or cleaned. On 5/8/2025 at 3:03 PM, an Activities of daily living, shower and nail care policies were requested and not received by survey exit.

Based on observation, interview, and record review, the facility failed to secure, label and dispose of expired medication by professional standards for two of four medication carts reviewed for secured, expired and unlabeled medications, resulting in the potential for unsafe medication administration. Findings include: On [DATE] at 12:55pm, an observation of Hall ,d+[DATE] Medication Cart was conducted with Registered Nurse BB (RN BB). The cart contained the following: -Humulin R, (insulin) U-100 - One vial expired ,d+[DATE]. - Lantus (insulin) U-100 one vial-Opened and undated. -Vitamin E Pills - one opened bottle expired ,d+[DATE] - Fish Oil Pills expired ,d+[DATE] At this time RN BB was queried regarding the expired, and undated medication. RN BB was unable to provide an explanation. On [DATE] at 1:10pm The Director of Nursing (DON) was interviewed and queried about the storage of expired and undated medication. The DON stated, Staff should follow policy for medication cart storage. A review of the facility's policy Medication Management dated [DATE] revealed the following: Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws . 11. Medications will be dated and discarded per manufactures guidelines . 50634 On [DATE] at 9:30 AM, a medication cart was observed left unattended in the hallway on unit 300. On top of the cart, three medications prescribed for R306 were found unsecured: Amlodipine 5 mg, Lisinopril 20 mg and Metoprolol 50 mg. On [DATE] at 9:40 AM, Licensed Practical Nurse (LPN) C was observed exiting R306's room. Upon interview, LPN C confirmed they left the cart unattended and acknowledged the medications were left unsecured on top of the cart. LPN C said they had been in R306 room taking R306's vial signs. [DATE] 9:53 AM, the unit manager (LPN) B was interviewed and said the medication cart should have been secured, and no medications should be left unattended on the cart. [DATE] 10:52 AM, the Director of Nursing (DON) was interviewed and confirmed the facility policy requires medication carts to be locked. The DON said staff are expected to lock all medications away when not in use. Record review of R306's EMR revealed that R306 was admitted on [DATE] with a diagnosis of unilateral osteoarthritis of the left knee and operative recovery from a total left knee replacement. R306 also has a history of borderline diabetes, lipidemia, and hypertension. Record review of R306 for minimum data set for brief interview for mental status indicated R306 was cognitively intact with a score of 13 out of 15. Review of facility policy titled 'Medication Treatment Cart Use revised [DATE] documented that no medications are to be kept on top of the cart, and the cart must remain visible to the person administering medications.

This citation has two deficient practices. Deficient Practice Statement 1 Based on observation, interview, and record review, the facility failed to ensure an emergency tracheostomy (an incision into the windpipe made to relieve an obstruction to breathing) was accessible, resulting in the likelihood of serious injury, serious harm, serious impairment, or death for one resident (R138) who required mechanical ventilation. In an observation on 4/16/24 at 9:55 a.m., R138 laid in bed and had a tracheostomy (trach). There was not an emergency trach visible in R138's room. In an observation and interview on 4/16/24 at 10:32 a.m., Licensed Practical Nurse (LPN) L was asked about R138's emergency backup trach and could not locate one in R138's room. LPN L reported there was not an emergency backup trach in R138's room. In an observation and interview on 04/16/24 at 10:34 a.m., the Director of Nursing (DON) was asked about an emergency backup trach for R138. The DON then searched R138's room and could not locate an emergency trach. The DON reported there should be an emergency trach in R138's room and they had to look in the storage room to locate one. On 4/16/24 at 10:50 a.m., after 18 minutes the DON located an emergency trach for R138. In an interview and observation on 4/16/24 at 10:59 a.m., the DON reported the unit manager went to get some more. A Shiley 6 trach sat on the nurse's desk and was not in R138's room. Review of an Admission Record revealed, R138 admitted to the facility on [DATE] with pertinent diagnosis which included Respiratory Failure with Hypoxia and Hypercapnia (inadequate respiration). Review of a Minimum Data Set (MDS) assessment dated of 3/23/24 revealed R138 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 0 out of 15 and required a tracheostomy. Review of a Care plan revealed R138 had focus, (R138) is at risk for respiratory distress, decannulation, infection r/t (related to) has a Tracheostomy. 6 Shiley uncuffed, tracheostomy mask at oxygen flow 2 L revised on 4/16/24. Review of Physician orders revealed R138 did not have an order that included the size of R138's trach and nothing to indicate a spare tracheostomy should be at the bedside. Review of a progress notes with a date of 4/11/2024 at 5:22 p.m., Resident sent out 911 to (hospital) d/t (due to) decannulation (removal of tracheostomy) . Review of a progress note with a date of 4/16/2024 at 12:00 a.m. revealed, . Follow up with ER visit due to tracheostomy dislodged . Patient is seen today for following up with ER visit due to tracheostomy dislodged. Patient's tracheostomy tube dislodged on 4/11/24 and sent patient to the ER immediately . Communicate with nurse to continue trach mask at 2 liter and contact the hospital for instruction of the new trach care and keep extra trach set at bedside . In an interview on 4/17/24 at 1:44 p.m., LPN K reported R138 had a decannulation on 4/11/24 and was sent to the hospital after the staff attempted to put another trach in but the position of head blocked the insertion. In an interview on 4/19/24 at 11:02 a.m., the DON reported on 4/11/24 R138 coughed, and the trach came out and had to be sent to the hospital because of the contracture of R138's neck. The DON reported there should have been a backup trach in R138's room. The DON then confirmed R138 did not have a current order for a tracheostomy that included size of trach, which has been changed to a size 4. The DON reported the size of the trach should be included in the order. Review of a Tracheostomy tube cannula and stoma care. Procedure with no date documented, . Make sure that the extra tracheostomy tube and obturator as well as the handheld resuscitation bag with an attached oxygen source are readily available for easy access in case of an emergency . The immediate jeopardy was identified on 4/16/24 at 9:55 a.m. The immediate jeopardy began on 4/16/24 at 10:32 a.m. when R138 was observed with a tracheostomy (trach) and did not have an emergency trach easily accessible. The Administrator was notified of the Immediate Jeopardy on 4/16/24 at 2:11 p.m. and a plan for removal was requested. The immediacy was removed on 4/16/24 when an emergency tracheostomy was placed in R138's room at the bedside. The surveyor verified that the Immediate Jeopardy was removed by observation and interview on 4/16/24. Although immediacy was removed, the facility's deficit practice was no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The Immediate Jeopardy that began on 4/16/24 was removed on 4/16/24 when the facility took the following actions to remove the immediacy: 1. R138 was provided with an accessible emergency back-up tracheostomy. 2. The Tracheostomy tube cannula and stoma care policy was reviewed and deemed appropriate. Nursing staff were re-educated on the Tracheostomy tube cannula and stoma care policy. The remaining nurses will receive education on the Tracheostomy tube cannula and stoma care policy on or before their next schedule day. 3. The DON, Administrator, and nurses made rounds on the residents with tracheostomies to ensure they have a back-up emergency equipment that is easily accessible in case of accidental extubation. 39465 Deficient Practice#2: Based on observation, interview, and record review the facility failed to label and date an oxygen tubing for oxygen administration on a concentrator for one resident (48) out of six residents reviewed for oxygen therapy. Findings include: R48 On 4/16/2024 at 10:20 a.m., R48 was observed lying in bed with oxygen administering via nasal cannula.(The nasal cannula is a device used to deliver supplemental oxygen or increased air flow to a patient or person in need of respiratory help). Observed R48's oxygen tubing connected to an oxygen concentrator unlabeled with no date (Oxygen Concentrator s collect oxygen from the surrounding air, concentrate it, and then deliver it to the patient, removing the need for replacement or refiling). R48 unable to recall the last time the oxygen tubing was changed. On 4/18/2024 at 10:22 a.m., Licensed Practical Nurse (LPN) J was interviewed regarding oxygen tubing labeling and dating. LPN J said the oxygen tubing are changed once a week and as needed. LPN J stated, oxygen tubing should be dated, it tells me it's been changed, how long, and if it needs to be change if over a week. On 4/19/2024 at 12:02 p.m., the Director of Nursing (DON) said during an interview regarding the labeling and dating of oxygen tubing that oxygen tubing should be dated, and the importance of dating the tubing is to know how long it's been in use for cleanliness. The DON stated, The hazard of having a tubing not clean could cause a respiratory infection. According to the electronic medical record, R48 was initially admitted into the facility on [DATE] and readmitted on [DATE] with Diagnoses of pneumonia, dementia, and diabetes mellitus type two. R48 quarterly Minimum Data Set (MDS) with a reference date of 2/18/2024 indicated R48 was cognitively intact with a BIMS (brief interview for mental status) score of 14/15. Review of the 2/11/2024 Respiratory care plan revealed, Resident has a potential for difficulty breathing and risk for respiratory complications related to Asthma, Emphysema/Chronic Obstruction Pulmonary Disease (COPD), and Diaphragmatic hernia. Review of the facility's 8/17/2021 Use of oxygen policy documented, Purpose: To promote guest/resident safety in administering oxygen. The oxygen cannula or mask should be changed weekly and dated.

This citation pertains to MI00129879, MI00130059, and MI00131366. Based on interview and record review the facility failed to assess and implement interventions to prevent the development of pressure ulcers for one (R196) of six residents reviewed for pressure ulcers resulting in the development of one unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) and one Stage 3 pressure ulcer (Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present) that went untreated during a12-day, Covid Unit stay. Findings include: The State Agency received a complaint that R196 developed pressure ulcers that went untreated while at the facility from 8/3/22 - 8/15/22 when he was quarantined for Covid-19. According to R196's Electronic Health Record (EHR), the resident directly admitted into the facility's Covid unit from another long-term care facility on 8/3/22 because he tested positive for Covid-19. R196 had additional diagnoses that included vascular dementia and cellulitis of his left lower leg, right foot/3rd toe, and right lateral heel. Admission orders included prescribed skin treatments for left lower leg, right foot/3rd toe and right lateral heel everyday and prn (as needed). According to a nurse's progress note dated 8/4/22 at 12:15 PM, R196 had 'open areas' to his right elbow and sacrococcyx area (tailbone) with multiple open areas to right gluteal area and denuded skin (loss of skin due to moisture and friction). No further description was provided. A 'Braden Scale' form dated 8/4/22 (tool used to predict the risk for developing pressure ulcers) identified R196 to be at 'moderate' risk for developing pressure ulcers. A nurse's comprehensive assessment dated [DATE] indicated R196 had 'actual open areas' on right heel, right toes, and left lower leg. There was no documentation of open areas to the right buttock or right elbow. A physician's note dated 8/10/22 reported R196 had a right buttock wound. There was no additional documentation provided regarding the buttock wound. No orders for skin treatments for the buttock wound were written. The Minimum Data Set (MDS) dated [DATE], indicated that R196 had moderately impaired cognition and required extensive assistance for bed mobility from one staff member and extensive assistance from two staff members to transfer from surface to surface. Section M. skin condition identified R196 to have 'No' pressure ulcers at the time of the assessment. R196 was identified to be 'at risk' for pressure ulcers but had 'No' pressure reducing device for chair, 'No' turning/repositioning program, and 'No' nutrition/hydration intervention to manage skin problems. A wound care note created by Licensed Practical Nurse (LPN) E on 8/12/22 (9 days after admission) identified six wounds for R196 that included pictures. Wound #1: right anterior abrasion knee 14 cm (centimeters) x 18 cm. No drainage. Wound #2: left anterior lower leg/ankle is full thickness venous ulcer 11.5 cm x 5.0 cm x 1.2 cm with necrotic (dead/blackened) tendon exposed large amount of serous (clear fluid) drainage wound bed is yellow necrotic. Wound #3: right buttock 'unstageable' obscured full-thickness skin/tissue loss. 3.4 cm x 4.1 cm x 0.2 cm with a yellow necrotic base and moderate amount of serous drainage. Wound #4: right elbow 'stage 3' pressure ulcer 1.1. cm x 0.7 cm x 0.3 cm with serous drainage. Wound #5 left knee abrasion 1.7 cm x 1.6 cm, with small amount of serous drainage. Wound #6 right lower leg/ankle/foot/toes are gangrene. Wound measurements are 34 cm length with large amount of yellow drainage. Multiple scattered necrotic gangrene tissue noted. A review of R196's August 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there were no skin treatments prescribed or administered to R196's saccrococcyx/right gluteal area or his right elbow area while he was at the facility (8/3/22 - 8/15/22). R196 did receive the prescribed skin treatments to his right toes, right heel and left lower lateral leg. On 9/12/22 (28 days after R196 had discharged from the facility) Physician F ordered the following skin treatments; Cleanse right buttock/right elbow with wound cleanser, pat dry, apply santyl ointment 250 mg/GM and cover with border gauze every day and prn (as needed). On 2/9/23 at 2:00 PM the Director of Nursing (DON) was asked about R196's pressure ulcer treatments. The DON reviewed R196's EHR and confirmed R196 did develop the right buttock and right elbow pressure ulcers while at the facility and did not receive any prescribed skin treatments for his pressure ulcers. The DON reviewed R196's MDS that was dated 8/10/22 and acknowledged that section M was incorrect regarding pressure ulcers. She could not explain the delay of the physician's skin treatment orders. The DON said that LPN E no longer worked at the facility. LPN E was left voice messages on 2/9/23 at 2:30 PM and 2/13/23 at 9:15 AM to request interviews. No return calls were received prior to the survey exit date. On 2/13/23 at 9:53 AM Physician F said R196's pressure ulcers were not addressed as quickly as they should have been. Physician F could not fully explain why the pressure ulcer treatments had been ordered on 9/12/22, 28 days after R196 had been discharged from the facility. He said, Sometimes the wi-fi in the building doesn't work and there are delays when the orders actually go through. According to the facility's Skin Management policy last revised 7/14/21, the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. Guest/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing.

This citation pertains to MI00130059. Based on observation, interview, and record review the facility failed to properly transfer one resident (R61) of six residents reviewed for falls resulting in the fracture of R61's right femur (thigh bone), right tibia (shin bone of calf), and right fibula (lateral bone of the calf, top of outer ankle) during a transfer from toilet to wheelchair. Findings include: On 2/7/23 at 2:40 PM R61 was observed seated in her wheelchair watching TV in the room. R61 said she had a recent fall in the bathroom because the CNA (certified nursing assistant) did not transfer her the right way. R61 stated, She (CNA K) took me to the bathroom and then pulled my wheelchair out away from me. When she came back to take me off the toilet, she tried to do it by herself by grabbing onto my pants and yanking me up and over to the wheelchair while I held onto the bar. I told her 'No'. Bring the wheelchair closer so I can pivot from the toilet onto the wheelchair while I hold on to the bar, and she wouldn't do it. I felt myself sliding down the bar and off the toilet. I was trying to hold myself up with the bar but couldn't any longer. I told her to call for help. I needed two people. Instead she (CNA K) just left me to go get another CNA without pushing the wheelchair to me. I slid down to the floor with my right leg underneath me. I could hear my bones popping as I was sliding down. When she came back it was too late. It took four people to get me up. I have rods, screws and over 65 staples in my right leg. I am very upset this happened. I know how to get on and off a toilet from being in therapy. She (CNA K) should've had the wheelchair closer to me like I asked her to. She shouldn't have left me hanging there on the bar by myself. I should have been a two person assist. According to the facility's Incident report on 1/10/23 at approximately 2:30 PM, Resident slid on to the floor from toilet while CNA (K) was present. CNA (K) entered the room and resident was standing up holding the grab bar attempting to self-transfer to wheelchair however the resident's legs gave out and the CNA (K) lowered her to the floor. Resident's right leg was bent underneath her body. Resident was transported to the hospital. X-ray reported that R61's right femur, right tibia, and right fibula were fractured. Resident underwent ORIF surgery (Open Reduction and Internal Fixation to stabilize broken bones) and 65 staples to the outer right leg. According to R61's Quarterly Minimum Data Set, dated dated dated [DATE] the resident had no cognition or memory deficits with a BIMS (brief interview for mental status) score of 15/15. Section G. Functional Status indicated that R61 required two persons for assistance when transferring between surfaces. Section G 0300. D. Moving on and off toilet: Resident not steady. Only able to stabilize with human assistance. G 0400. Functional Limitations/Range of Motion indicated that resident was impaired on both upper and lower extremities on one side. The Annual MDS dated [DATE] identified R61 as a 'fall risk' and a care plan was initiated. An 'Activities of Daily Living' Care Plan revised on 7/23/21 included the following intervention: resident requires two persons assist with transfers. Review of the Kardex/Task section (area of the Electronic Health Record where interventions of care plans and documentation can be completed by unlicensed staff) initiated on 8/4/2020 revealed the following instruction for transferring the resident, 2 persons assist with transfers. On 2/09/23 at approximately 9:30 AM, Nurse Manager, Licensed Practical Nurse (LPN) A was asked about R61's fall in the bathroom. LPN A said R61 had been a two person assist for transfers but was recently discharged from therapy and had been changed to a one person assist. LPN A reviewed the MDS, Kardex, and care plan and acknowledged R61 was documented to be a 2 person assist for transfers during the time of the incident. LPN A said that the resident was already trying to get up off the toilet by herself when CNA K entered the room. The resident was unable to be transferred from the toilet back to the wheelchair and the resident was then lowered to the floor. On 2/9/23 at 10:01 AM, CNA K was interviewed regarding the incident with R61 on 1/10/23. CNA K said that her and another (unknown) CNA had transferred the resident from the wheelchair to the toilet and then they went to assist another resident. CNA K said she saw that R61's bathroom call light was on and when she went to assist R61. When I went in her room, she (R61) was already standing with her pants on and holding on to the grab bar. My intuition was to bring the wheelchair back in the bathroom, but it was too late she (R61) was going down. I went to the hall to call for help and then all four of us lowered her to the floor. CNA K could not recall the names of the four staff members that assisted lowering the resident to the floor. CNA K could not say for certain if R61 required a one or two person assist for transfers during the time of the incident. CNA K said, I usually work a different set. Review of the 'post fall evaluation' on 1/10/23 at 2:30 PM indicated CNA K was the only staff present who observed R61 after the fall. The 'fall summary' documented R61's fall to the floor was witnessed by CNA K. There are no additional staff members identified. Interventions to prevent future falls included use hoyer lift and two persons assist with transfer. On 2/09/23 at 10:42 AM Physical Therapist (PT) L was interviewed regarding R61's transfer status. PT L said, She (R61) can pivot transfer from surface to surface with one person assist for us, while in the therapy department. The resident tires easily and there are times when she requested two of us in therapy for transfers because she felt very unsteady. She tells you what she needs. She made very good progress with therapy and had just been discharged from us (therapy) before her fall. On 2/8/23 at 2:24 PM R61's Physician (MD) F reviewed the resident's EHR and said the resident was a two person assist for transfers during the time of the incident on 1/10/23. According to the facility's 'Fall Management' Policy last revised 7/14/21; Practice Guidelines: 2. Guests identified at risk for falls will have an initial plan of care developed to meet each guest's needs. Interventions should be related to the risk factors as well as incorporating the guest's choice to help minimize the risk of a fall.

Based on observation, interview, and record review the facility failed to consistently assess, document, and manage resident's pain, for three sampled residents (R31, R110 and R336) out of five residents reviewed for pain management, resulting in resident complaints of pain. Findings include: R31 Record review on 12/8/21 of R31's face sheet revealed admission into the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) dated [DATE], R31 had intact cognition and was extensive assist with Activities of Daily Living (ADLs). During an observation of wound care on 12/8/21 at 10:58 AM in R31's room, after observation of wound care R31 was observed tears streaming down face. R31 confirmed a 9 out of 10 pain level (10 is worst) saying Wound care is always painful. Record review of Medication Summary Review (Physician orders) dated 12/8/21 at 11:30 AM, documented that resident had Acetaminophen (Tylenol) Extra Strength Tablet 500 MG (pain medication) Give 1 tablet by mouth every 4 hours as needed for Pain. Record review of pain care plan initiated on 10/20/21 had no interventions to monitor pain during wound care treatments Review of pressure ulcer care plan dated 10/21/20 documented, (R31) has actual impairment to skin integrity r/t (related to) actual pressure injuries noted on admission with an intervention of Administer medications as ordered and Observe for ineffectiveness and side effects, report abnormal findings to the physician. R110 Record review on 12/7/21 of R110's face sheet revealed admission into the facility on [DATE] with a pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE], R110 had intact cognition and was extensive assist with most ADLs. During interview on 12/6/21 at 11:56 AM, R110 confirmed that pain levels are always between 7-8 out of 10. R110 stated, I use to be able to get a [MEDICATION(S)] (pain medication). During an observation of wound care with LPN K on 12/8/21 at 11:12 AM in R110's room, R110 was not assessed for pain prior or during wound care. R110 confirmed a pain level of 8 out of 10. Record review of Weights and Vitals Summary dated 12/9/21 at 10:31AM, documented no pain assessments from 12/1/21-12/6/21. Record review of Medication Review Summary dated 12/7/21 at 10:59AM, revealed no ordered pain medications. Review of pain care plan dated 5/11/21 documented R110 is at risk for pain and has acute pain r/t DX (diagnosis): Muscle spasms with interventions to administer medications as ordered and observe for pain every shift. During interview on 12/8/21 at 11:25 AM with LPN K, she confirmed that a pain assessment was not performed before or during wound care for R31 and R110. R336 Record review on 12/6/21 of R336's face sheet revealed admission into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) dated [DATE], R336 had intact cognition and was provided with supervision with Activities of Daily Living (ADLs). During interview on 12/06/21 at 01:10 PM, R336 stated, My pain is always a 7 out of 10 because of the kidney stones and the weight of the urine collection bags. Record review of R336's Medication Review Summary dated 12/7/21 at 1:15 PM revealed orders to monitor pain Q shift (2 x a day). Further review revealed pain assessment were only being performed once a day between 11/30/21 and 12/6/21. Continued review revealed orders for Acetaminophen Tablet 325 MG: Give 2 tablet by mouth every 6 hours as needed for pain. Review of Medication Administration for the month of December 2021, revealed no use of PRN medications being administered. Record review of pain care plan initiated 11/16/21, documented the following: R336 is at risk for pain and/or has pain r/t Arthritis with the following interventions: .Evaluate the effectiveness of pain interventions as given. Observe for pain presence Q (every) shift as needed. Observe for probable cause of pain. During interview on 12/8/21 at 11:30 AM with Director of Nursing (DON) A, It was confirmed all residents should be monitored for pain as ordered, all residents should be assessed for pain before and during wound care treatments. It was confirmed that several opportunities were missed by nursing staff to assess residents for pain. Record review of facility's policy Pain Management last revised 10/2019 documented the following: The facility will evaluate and identify guests/residents for pain, determine the type, location and severity and develop a care plan for pain management.

This citation pertains to intake MI 340. Based on interview and record review, the facility failed to provide notification of a significant change in condition due to not revising the family contact information in a timely manner for one (R#917) of 12 residents reviewed for change in condition, resulting in the family not knowing the resident required hospitalization for a medical emergency, the opportunity to participate in medical decisions regarding care, and mental anguish. Findings include: On 10/12/21 at 11:07 a.m. R917's emergency contact (EC) R was contacted via telephone regarding the resident's care while at the facility. EC stated, My father went to the hospital on 9/30/21 and the facility did not notify us. I had not heard from my father in four days and decided to call the facility (10/4/21). That's when I was finally told he went to the hospital. I called the facility again on 10/4/21 to inform the facility my father passed away on 9/30/21. I left my phone number with facility staff when I visited the facility. I couldn't see my father because of COVID, so I left clothes and money for him. I put my contact information on a form for the items I brought in. The family member was crying and very angry and stated, I am devastated I didn't get to tell my father goodbye. It was the worst experience ever. My family is very hurt over the actions of the facility. On 10/12/21 at 12:17 p.m., review of the electronic medical record face sheet documented R#917 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the admission Minimum Data Set assessment dated [DATE], R#922 had intact cognition (BIMS 15) and required total two-persons assistance with most activities of daily living. R#917 discharged to the hospital on 9/30/21. Review of nurse progress notes documented the following: 9/30/21 21:38 Resident sent to (hospital's name) via 911, elevated heart rate and low blood pressure. Resident was becoming less responsive. Dr. notified . Late Entry: 9/30/21 21:38, created on 10/4/21 13:22:28 Daughter is aware of transfer to the hospital. On 10/18/21 at 3:36 p.m. Licensed Practical Nurse (LPN) N was interviewed and stated, If contact information is not on the face sheet, we talk to the social worker to get the information. If the family is reached, its documented. We will usually contact the family to notify what's going on within an hour. On 10/18/21 at 3:47 p.m. the Director of Nursing was interviewed and stated, When the resident was admitted , there were no contacts. The family was told he transferred to the hospital when they called, and the contact information was updated that day. Social Services and admissions are responsible to make sure contacts are current. Review of the facility's policy titled Change in Status, Identifying and Communicating dated August 20, 2021, documented: .Notify the resident's family about the change in the resident's condition and the subsequent treatment plan . Record communication with the resident's family.

This citation refers to MI 423. Based on observation, interview and record review the facility failed to adequately supervise a resident to prevent a fall accident and ensure a resident's fall was reported and the resident was assessed subsequent to a fall for one resident (#904) of three sampled residents reviewed for fall management in a total sample of 11 residents resulting in a fractured left ankle, a delay in treatment of [REDACTED]. Findings include: On 02/05/17 at 7:19 a.m., resident #904 was observed in bed, appeared asleep, barefoot-without non-skid footwear in place and the call light cord hanging straight down and parallel to the wall at the head of the bed, not clipped to the bed within easy reach of the resident. On 02/05/17 at 1:38 p.m., resident #904 was observed seated in a wheelchair in the day room. No attempt to propel the wheel chair was noted. Resident #904 was observed laying in bed at 2:35 p.m. and was observed to remain in bed on 02/06/17 and 02/07/17. On 02/06/17 at 1:00 p.m., a review of the facility Incident and Accident report revealed on 10/28/16 at 12:30 p.m., Resident #904 was observed with a left foot and ankle that was bruised and swollen by CNA (certified nurse assistant) 'A'. The report did not indicate that a fall had occurred. The five day follow up investigation to the State of Michigan prepared by the DON (Director Of Nursing) revealed interviews with three staff members. CNA 'B' stated, On 10/27/16 observed (resident #904) ambulating without assistance in the small day room, (resident #904) lost balance and fell , she and another nursing assistant proceeded to put (resident #904) back in a wheelchair and did not report incident to a nurse, thought someone else reported the incident. CNA/Activity Aide 'C' stated, On 10/27/16 observed (resident #904) standing up from the dining room chair, ambulating without assistance, (resident #904) lost balance and fell , held wheelchair in place while staff 'B' and D placed (resident #904) into the wheelchair. The statement did indicate the fall was reported to a nurse for assessment. CNA/Activity Aide 'D' stated, On 10/27/16 and observed CNA 'B' alongside (resident #904) while the resident was on the floor. The statement did not indicate the fall was reported to a nurse for assessment. On 02/06/17 at 1:15 p.m., the medical record for Resident #904 was reviewed and revealed: Resident #904 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] indicated locomotion as without a wheelchair and required only supervision and setup. The 11/07/16 significant change MDS indicated locomotion required the extensive assistance of one person and the need for a wheelchair. The MDS dated [DATE], indicated locomotion required the extensive assistance of one person and the need of a wheelchair. Bed mobility and transfer required the extensive assist of one person. Resident #904 was transferred to the hospital via EMS on 10/28/16. The nursing progress notes, assessments nor documents sections identified that a fall which involved resident #904 had occurred on 10/27/16 nor that the resident was assessed by a nurse after the 10/27/16 fall prior to the discovery of the bruises and swelling to the left ankle on 10/28/16 by CNA 'A'. The last nursing progress note before 10/28/16 was entered on 10/21/16. The facility X-ray of resident #904's ankle on 10/28/16 at 2:10 p.m., concluded: There is a fracture involving the lateral malleolus with displacement. There is associated soft tissue swelling. The hospital X-ray dated 10/28/17 revealed: fall one or two days ago, severe bruising and swelling over medial malleolus, bimalleolar fracture of the left ankle. The hospital X-ray dated 10/29/17 indicated, internal fixation plates across a fracture of the distal fibula and a third across the border of the tibia (both lower leg bones). The resident is at risk for fall r/t Cognition nursing care plan dated 09/24/16 indicated interventions as call light in reach, one assist with transfer, call light in reach. The is at risk for fall r/t Cognition decreased mobility, muscle weakness, unsteady gait, left ankle fracture. nursing care plan dated 10/31/16 indicated, call light in reach, ensure appropriate footwear. On 02/07/17 at 12:45 p.m., the DON was queried about the reported ankle fracture to Resident #904 and stated, I watched the fall on the camera and saw the staff involved. There were two facility staff in the room. The DON also reported the staff thought the other staff member had reported the fall. The DON confirmed no report nor assessment of the fall was completed prior to the report on 10/28/16. On 02/06/17 at 4:45 p.m., The Fall Management policy revised 8/2016 revealed, Overview: Each resident is assisted in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices and or functional programs as appropriate to minimize the risk for falls. 3. When a fall occurs, the licensed nurse will assess the resident for injury. Do not move the individual until he/she has been examined by a nurse. The first responder will summon a nurse after ensuring the resident is safe. 4. The licensed nurse will complete: Incident/accident Report, Document in medical record, Initiate the post fall evaluation, Document in the progress notes for 72 hours following the fall. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT HOT WATER TEMPERATURES AT THE HAND WASHING SINKS WERE WITHIN A SAFE TEMPERATURE RANGE FOR SIX (#'S 706, 707, 708, 716, 717, AND 718) OF 18 SAMPLED RESIDENTS, AND TWO ( #'S 16 AND 35) OFF SAMPLED RESIDENTS out of 29 total residents ON THE SECOND FLOOR . THE HOT WATER TEMPERATURES MEASURED BETWEEN 123.8 DEGREES FAHRENHEIT TO 127.4 DEGREES FAHRENHEIT, RESULTING IN AN IMMEDIATE JEOPARDY (IJ) TO THE RESIDENT'S HEALTH AND SAFETY, AND THE POTENTIAL FOR SERIOUS BURNS, INJURIES, OR DEATH. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 2/22/12 AT 11:00 A.M. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 2/22/12 AT 2:30 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 2/22/12 BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS ON 2/22/12, AS VERIFIED ONSITE ON 2/23/12. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE REMAINED AS A PATTERN, NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 2/22/12 AT 10:00 A.M., DURING THE INITIAL TOUR WITH THE ASSISTANT DIRECTOR OF NURSING, HOT WATER TEMPERATURES WERE CHECKED. THE FOLLOWING HOT WATER TEMPERATURES WERE FOUND TO EXCEED THE MAXIMUM ALLOWABLE TEMPERATURE OF 120 DEGREES FAHRENHEIT, FOR THE HANDWASHING SINKS ON THE SECOND FLOOR "ODD AND EVEN" HALL: 1. THE WATER TEMPERATURE OF THE HANDWASHING SINK IN ROOM 201 MEASURED 125.4 DEGREES FAHRENHEIT. THIS AFFECTED RESIDENT'S 708 AND 35. RESIDENTS 708 AND 35 WERE ABLE TO AMBULATE WITH A ROLLING WALKER. 2. THE WATER TEMPERATURE OF THE HANDWASHING SINK IN ROOM 203 MEASURED 124.1 DEGREES FAHRENHEIT. THIS AFFECTED RESIDENT 707, WHO WAS ABLE TO AMBULATE WITH A WHEELCHAIR. 3. THE WATER TEMPERATURE OF THE HANDWASHING SINK IN ROOM 207 MEASURED 127.4 DEGREES FAHRENHEIT. THIS AFFECTED RESIDENT'S 716 AND 16. RESIDENT 716 WAS OBSERVED IN THE WHEELCHAIR, WASHING HER FACE AT THE SINK. RESIDENT 16 WAS ABLE TO AMBULATE VIA WHEELCHAIR. 4. THE WATER TEMPERATURE OF THE HANDWASHING SINK IN ROOM 219 MEASURED 123.8 DEGREES FAHRENHEIT. THIS AFFECTED RESIDENT 706, WHO WAS ABLE TO PROPEL HERSELF WHILE IN THE WHEELCHAIR. 5. THE WATER TEMPERATURE OF THE HANDWASHING SINK IN ROOM 221 MEASURED 126.3 DEGREES FAHRENHEIT. THIS AFFECTED RESIDENTS 717 AND 718. RESIDENT 717 CAN PROPEL HIMSELF WHILE IN THE WHEELCHAIR, AND RESIDENT 718 AMBULATES INDEPENDENTLY. 6. THE WATER TEMPERATURE OF THE SECOND FLOOR "ODD" HALL BATHROOM HAND SINK MEASURED 123 DEGREES FAHRENHEIT AND THE SECOND FLOOR "EVEN" HALL BATHROOM HAND SINK MEASURED 127.9 DEGREES. ON 2/22/12 AT 11:00 A.M., THE HOT WATER TEMPERATURE LOGS WERE REQUESTED FROM THE MAINTENANCE SUPERVISOR. REVIEW OF THE HOT WATER TEMPERATURE LOGS REVEALED THAT THE FACILITY WAS MONITORING WATER TEMPERATURES IN THE RESIDENT ROOMS ON A WEEKLY BASIS. THE WATER TEMPERATURES FOR FEBRUARY WERE RECORDED FOR "WEEK 1" AND "WEEK 2", BUT THERE WERE NO ACTUAL DATES DOCUMENTED FOR WHEN THE WATER TEMPERATURES HAD BEEN TAKEN. IN ADDITION, THERE WERE NO DOCUMENTED WATER TEMPERATURES FOR THE THIRD WEEK OF FEBRUARY. ON 2/22/12 AT 2:45 P.M., THE MAINTENANCE SUPERVISOR WAS QUERIED REGARDING THE HOT WATER TEMPERATURES ON THE SECOND FLOOR "ODD" HALL, AND STATED THAT HE WOULD HAVE TO "BUMP DOWN THE TEMPERATURE A FEW DEGREES". REVIEW OF THE FACILITY'S POLICY TITLED, "POLICY AND PROCEDURE FOR TAKING WATER TEMPERATURES", DATED 2/22/12, NOTED: "...STAFF SHOULD DOCUMENT THE FOLLOWING INFORMATION WHEN MEASURING WATER TEMPERATURES: THE DATE AND TIME THE TEMPERATURE WAS MEASURED...". THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE FACILITY IMPLEMENTED THE FOLLOWING: Eastwood Convalescent Center believes that as of February 22, 2011 the measures implemented are sufficient to demonstrate the water temperatures are within a safe range according to the requirement and the safety of the residents. Resident Identified to be affected by the alleged deficient practice. The domestic water heater was assessed and adjusted by the Maintenance Supervisor on 2/22/12 at 3:00 pm to meet a safe range (105-120 degrees Fahrenheit) for the following eight off sampled resident (#1, 2, 15, 16, 36, 45, 54, and 59) on the second floor. There are no sinks in resident rooms located on the first floor. Residents with the potential to be affected by the alleged deficient practice. The domestic water heater was also inspected by an independent Contractor that was onsite at 4:00 pm on 2/22/12 and has assessed the mechanical functioning of the domestic hot water heater and determined that the domestic hot water heater and mixing valves are working appropriately and there were no other concerns with hot water temperatures identified. All residents who occupy the identified rooms were interviewed and reported no ill effects related to water temperature. At approximately 5:00 pm on 2/22/12 Maintenance re-checked all wash sink temperatures on the 2"d floor as well as common areas on the first floor (i.e. shower rooms and common bathrooms) and verified that the hot water temperatures were with in the 105 -120 degree Fahrenheit requirement. System Measures The Maintenance Staff will monitor hot water temperatures at all wash sinks hourly for twenty four hours, then every shift for 24 hours for 3 days, then random daily. Then the facility will complete random daily water temperatures five times weekly. Any noted irregularities will be adjusted immediately. The facility has in-serviced the Maintenance Supervisor and maintenance assistant 2/22/12 on proper procedure for taking hot water temperatures and the importance of maintaining safe hot water temperatures. As of 2/22/12 66 out of 77 licensed and non-licensed staff has been in serviced on how to report unsafe/irregular water temperatures. The remaining licensed and non licensed personnel will be in-serviced on the importance of reporting irregular water temperature prior to returning to work on their next scheduled day. All new employees will be in-serviced on the importance of reporting irregular water temperature Seven licensed and non-licensed staff currently on LOA/Maternity Leave/vacation and will be educated prior to returning to duty. Quality Assessment and Assurance The Maintenance Supervisor or designee will perform random daily water temperatures in the wash sinks, five times weekly to ensure the temperatures are within a safe range. Any areas of concern will be addressed immediately. The audits will be reviewed and forwarded to the Quality Assurance Committee. The Administrator or designee will report finding to the Quality Assessment and Assurance Committee on a monthly basis until the Committee determines that compliance with this plan has been maintained. The Administrator is responsible for overall sustained compliance. Compliance date is 2/22/12. ( ) ( ) ( ) ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE TREATMENT AND SERVICES TO PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES FOR ONE ( # 512) RESIDENT admitted TO THE FACILITY WITHOUT PRESSURES SORES OUT OF 6 RESIDENTS REVIEWED FOR PRESSURE SORES FROM A TOTAL SAMPLE OF 15, AND FAILED TO CONSISTENTLY ASSESS AND MONITOR AN EXISTING PRESSURE SORE FOR ONE ( #501) RESIDENT, RESULTING IN THE DEVELOPMENT OF AVOIDABLE PRESSURES SORES AND THE POTENTIAL FOR WORSENING OF PRESSURE SORES. FINDINGS INCLUDE: RESIDENT #512'S CLINICAL RECORD WAS REVIEWED ON 4/14/11 AT 9:00 A.M. THE ADMISSION FACE SHEET RECORD DATED 2/25/11, INDICATED RESIDENT #512 WAS RECENTLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM (MDS) data set [DATE], INDICATED RESIDENT #512 WAS ALERT AND ORIENTED TO TIME, PLACE AND PERSON. RESIDENT #512 WAS NON-AMBULATORY, REQUIRED EXTENSIVE ASSISTANCE IN BED MOBILITY AND TRANSFERS. THE NURSING ADMISSION assessment dated [DATE], INDICATED RESIDENT #512 ENTERED THE FACILITY WITHOUT ANY WOUNDS ON HIS FEET, BUT DID HAVE AN OPEN AREA ON HIS COCCYX. NO OTHER DESCRIPTION WAS PROVIDED. THE BRADEN SCALE (TOOL USED FOR PREDICTING PRESSURE SORE RISK) DATED 1/31/11, INDICATED RESIDENT #512 WAS AT MODERATE RISK FOR THE DEVELOPMENT OF PRESSURE SORES. THE "NURSING WEEKLY (HEAD TO TOE) SKIN ASSESSMENT", SHEET DATED 2/03/11 INDICATED RESIDENT #512 HAD A STAGE TWO (II) SACRAL ULCER THAT MEASURED 0.5 CENTIMETERS (CM) X 0.6 CM, AND THAT THE LEFT AND RIGHT HEELS WERE FRAGILE. THE WEEKLY (HEAD TO TOE) SKIN assessment dated [DATE], INDICATED RESIDENT # 512 HAD NO OPEN AREAS AND NO EXCORIATIONS. THIS INDICATED THAT THE WOUNDS HAD RESOLVED OR WERE HEALED AT THAT TIME. NURSING WEEKLY (HEAD TO TOE) SKIN ASSESSMENTS NOTES DATED 3/02/11 THROUGH 3/30/11, INDICATED RESIDENT #512'S SKIN WAS INTACT. A WOUND SHEET DATED 4/04/11 INDICATED RESIDENT #512 HAD ACQUIRED A WOUND ON HIS RIGHT HEEL THAT MEASURED 1.8 X 3.0 CM WITH A DRY WOUND BASE. A WOUND SHEET DATED 4/04/11 INDICATED RESIDENT #512 HAD A WOUND ON HIS LEFT HEEL THAT MEASURED 3.2 X 5.8 CM WITH BLACK ESCHAR (DEAD TISSUE) A PHYSICIAN TREATMENT ORDER DATED 4/01/11 THROUGH 4/30/11 FOR RESIDENT #512 INCLUDED FLOAT BILATERAL HEELS WHILE IN BED, FREQUENT REPOSITIONING. THE "PRESSURE SORE ALTERATION/IMPAIRED SKIN INTEGRITY" PLAN OF CARE FOR RESIDENT #512 DATED 2/02/11, STATED RESIDENT #512 HAD A RIGHT AND LEFT HEEL DIABETIC ULCER RELATED TO DIABETES, [MEDICAL CONDITION] AND IMPAIRED MOBILITY. APPROACHES AND INTERVENTION INCLUDED: 1. FLOAT HEELS WHILE IN BED TO ENSURE THAT HE HAS ON HIS HEEL PROTECTORS. 2. ASSIST/TEACH RESIDENT TO REPOSITION SELF. THE RESIDENT CARE GUIDE DATED 4/07/11, INDICATED THAT RESIDENT #512 WAS DEPENDENT ON STAFF FOR AMBULATION AND TRANSFERS. THE CARE GUIDE DID NOT INCLUDE INTERVENTIONS TO ASSIST RESIDENT #512 WITH BED MOBILITY SUCH AS TURNING AND REPOSITIONING (THE SECTION WAS LEFT BLANK). FURTHER REVIEW OF THE RESIDENT CARE GUIDE (USED TO DIRECT NURSE ASSISTANT PLAN OF CARE FOR RESIDENT #512) REVEALED THAT THERE WERE NO INTERVENTIONS IN PLACE OR DEVICES USED TO ELEVATE RESIDENT #512'S HEELS OFF THE MATTRESS. ON 4/13/11 AT 12:30 P.M., AND AT 2:15 P.M., RESIDENT #512 WAS OBSERVED LYING IN BED. RESIDENT #512 HAD DRESSINGS ON BOTH HIS LEFT AND RIGHT FEET AND HEELS. RESIDENT #512'S HEELS WERE PRESSED DIRECTLY AGAINST THE MATTRESS. RESIDENT #512'S HEELS HAD NOT BEEN ELEVATED OR FLOATED AS INDICATED IN THE PHYSICIAN'S TREATMENT ORDERS AND THE NURSING PLAN OF CARE. ON 4/14/11 AT 3:45 P.M., A DRESSING CHANGE AND WOUND CARE OBSERVATION FOR RESIDENT #512 WAS CONDUCTED WITH THE TREATMENT NURSE (E). RESIDENT #512 HAD AN UNSTAGEABLE WOUND ON HIS RIGHT OUTER HEEL THAT MEASURED 2.0 CM X 3.0 CM., WITH BROWN ESCHAR (DEAD TISSUE). RESIDENT #512 HAD AN UNSTAGEABLE WOUND ON HIS LEFT HEEL THAT MEASURED 4.0 CM X 2.8 CM, WITH BROWNISH ESCHAR. TREATMENT NURSE (E) PALPATED (TOUCHED) RESIDENT #512'S PEDAL PULSES AND STATED RESIDENT #512 HAD POSITIVE AND STRONG PEDAL PULSES (INDICATES GOOD BLOOD CIRCULATION IN THE AREA). AFTER THE DRESSING CHANGE HAD BEEN COMPLETED, TREATMENT NURSE (E) AND NURSE MANAGER (A) WERE INTERVIEWED REGARDING RELIEVING PRESSURE ON RESIDENT #512'S HEELS (PRESSURE POINTS) AND DEVICES TO RELIEVE PRESSURE ON RESIDENT #512'S HEELS. UNIT MANGER (A) STATED RESIDENT #512 HEELS WERE TO BE ELEVATED WHILE RESIDENT #512 WAS IN BED. TREATMENT NURSE (E) STATED RESIDENT #512'S HEELS PROTECTORS HAD BEEN SENT TO THE LAUNDRY AND WERE OUT OF THE FACILITY AND HAD NOT YET RETURNED. ( ) ON 4/13/11 AT 9:20 A.M., RESIDENT #501 WAS OBSERVED IN BED. THE RESIDENT WAS ALERT HOWEVER DID NOT RESPOND VERBALLY. THE RESIDENT WAS ON LOW AIR LOSS MATTRESS AT 210 PRESSURE. ON 4/13/11 AT 12:00 NOON, RESIDENT #501 WAS OBSERVED IN A GERI-RECLINER CHAIR, ALERT AND RESPONDED TO HER NAME. RECORD REVIEW ON 4/13/11 AT 2:45 P.M. REVEALED THAT RESIDENT #501 WAS readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE ADMISSION NURSING NOTES, DATED 5/20/10, RESIDENT #501 WAS admitted WITH LEFT HEEL BLISTER WITH DARK BASE. ACCORDING TO THE NURSES NOTES, THE FOLLOWING SKIN CONDITIONS WERE "NOTED" : 1) THE LEFT HEEL HAD NO REDNESS AND NO TENDERNESS. 2).THE RIGHT LATERAL FOOT PROXIMAL HAD "FLUID FILLED BLISTER" MEASURING 3.2 CM. BY 4.8 CM . 3) RIGHT LATERAL FOOT DISTAL-STAGE II FLUID FILLED BLISTER MEASURING 2.4 CM. BY 3.2 CM. RESIDENT #501 WAS SEEN AND EVALUATED BY THE WOUND CARE DOCTOR ON 6/1/10 AND DOCUMENTED THE FOLLOWING SKIN CONDITIONS: 1) LEFT HEEL 3.3 CM. BY 2.2 CM WITH A DRY DISCOLORED BASE 2) RIGHT HEEL-3.0 CM BY 2.5 CM SEROUS FLUID FILLED BLISTER. ON 6/7/10, THE WOUND CARE PHYSICIAN REEVALUATED RESIDENT #501. THE WOUND CARE DOCTOR DOCUMENTED THE SAME CONDITION OF THE LEFT HEEL AND THE RIGHT HEEL. ON 6/12/10, THE NURSES NOTES DOCUMENTED THAT THERE WAS AN "OPEN" AREA ON THE RIGHT KNEE OF RESIDENT #501. THE OPEN AREA WAS DESCRIBED AS STAGE II MEASURING .0.7 CM. BY 1.5 CM. WITH PINK PALE BASE, IRREGULAR EDGES WITH SEROUS EXUDATE. THE NURSES NOTES ALSO DOCUMENTED AN "OPEN" AREA ON THE RIGHT GLUTEAL ,DESCRIBED AS STAGE II. THE RIGHT GLUTEAL "OPEN" AREA MEASURED 0.6 CM BY 1.5 CM WITH PALE PINK BASE IRREGULAR EDGES WITH SEROUS EXUDATE. ON 7/12/10, THE WOUND CARE DOCTOR WAS CONSULTED FOR RESIDENT#501'S "OPEN AREAS". THE WOUND CARE DOCTOR DOCUMENTED THE FOLLOWING: 1) PRESSURE ULCER STAGE III RIGHT BUTTOCK DESCRIBED AS 7.5 CM BY 1.5 CM BY 0.7 CM ,PIK BASES MODERATE SEROSANGUINOUS (LIGHT BLOODY WATERY) DRAINAGE 2) RIGHT HEEL RESOLVED 3)RIGHT LATERAL FOOT 1.5 BY 1.2 CM 4) LEFT HEEL 2.5 CM BY 1.5 CM ESCHAR 4) RIGHT KNEE 0.5 CM BY 1.0 CM -SUPERFICIAL PINK BASE WITH MINIMAL SEROUS DRAINAGE AND 5)LEFT BUNION 1.5 CM BY 1.0 CM POST BLISTER. THE WOUND CARE NURSE (NO LONGER EMPLOYED BY THE FACILITY) PROGRESS NOTES FOR THE SKIN CONDITION OF RESIDENT #501 WAS ON 8/2/10. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING ON 4/14/11 AT 3:45 P.M. ABOUT THE INCONSISTENCIES IN DOCUMENTING THE STATUS OF THE RESIDENT'S WOUND, THE DIRECTOR OF NURSING STATED THAT A RELIEF TREATMENT NURSE WAS HIRED BY THE FACILITY. THE DIRECTOR OF NURSING STATED THAT RESIDENT #501 WAS ON HOSPICE CARE EFFECTIVE 6/4/10. FURTHER REVIEW OF THE RESIDENT'S CLINICAL RECORD REVEALED THE FOLLOWING BATH AND SKIN REPORTS: 1) 11/9/10 - YES WAS THE REPORT ON SKIN BREAK, NO DRAINAGE, REVIEWED BY AN R.N. 2) 12/10/10- NOT COMPLETED -BUT REVIEWED BY AN R.N. 3)12/14/10- NOT COMPLETED-REVIEWED BY AN RN. THERE WERE NO FURTHER SKIN REPORT UNTIL 3/4/11. RESIDENT #501 WAS admitted TO HOSPICE CARE ON 6/4/10. HOWEVER, THE WOUND CARE PHYSICIAN EVALUATED THE RESIDENT FROM JULY 2010 UNTIL JANUARY 2011. ON 4/11/11, THE WOUND CARE DOCTOR REEVALUATED RESIDENT #501'S WOUNDS. THE WOUND CARE PHYSICIAN DOCUMENTED THE FOLLOWING: SACROCOCCYX WOUND MEASURED 5.5 CM BY 2.8 CM BY 0.5 CM, PINK BASE WITH SCATTERED NECROSIS WITH HEAVY SEROSANGUINOUS DRAINAGE 2) RIGHT LATERAL FOOT 0.7 CM BY 0.5 CM PINK BASE WITH SCANT SEROSANGUINOUS DRAINAGE 3) RIGHT POSTERIOR HEEL WAS RESOLVED 4) LEFT HIP 4.6 CM BY 7.5 CM BY 0.4 CM -PINK BASE SCATTERED NECROSIS WITH HEAVY SEROSANGUINOUS DRAINAGE 5) LEFT GLUTEAL DESCRIBED AS 2.0 CM BY 3.0 CM -NECROTIC BASE WITH MINIMAL DRAINAGE 6) LEFT HEEL 4.0 CM BY 2.0 CM BY 0.2 CM WITH NECROTIC CORE WITH MINIMAL SEROSANGUINOUS DRAINAGE. DURING AN INTERVIEW ON 4/15/11 AT 11:00 A.M., THE DIRECTOR OF NURSING STATED THAT WHEN A RESIDENT WAS ON HOSPICE CARE THE WOUND CARE PHYSICIAN WAS TO EVALUATE AND TREAT THE RESIDENT MONTHLY AND THE HOSPICE PROVIDER WILL CERTIFY THE VISIT. HOWEVER, THE DIRECTOR OF NURSING WAS NOT ABLE TO EXPLAIN THE INCONSISTENT ASSESSMENT AND MONITORING OF THE TREATMENT NURSE. ( )