Every finding on record at Regency at Waterford

Based on observation, interview and record reviews the facility failed to ensure professional standards of services and care from one Licensed Practical Nurse (LPN) F of two Nurses observed for the Medication Administration task. Findings include:On 7/27/26 at 8:44 AM, LPN F was observed preparing the morning medications for R85. Included in the medications was Metoprolol Succinate ER (extended release). LPN F was observed crushing the Metoprolol Succinate and explained all medications for R85 are crushed and administered with pudding. LPN F was observed emptying the crushed medication into a medication cup and placing a spoonful of vanilla pudding on top. At 9:02 AM, LPN F was observed to have administered the crushed medications to R85.A review of R85's physician orders revealed an order implemented on 9/12/25 May Crush Allowable Meds.A review of the manufacturer's administration instructions noted in part . Metoprolol succinate extended-release tablets are scored and can be divided; however, the whole or half tablet should be swallowed whole and not chewed or crushed. (https://www.fda.gov/drugsatfda)On 7/27/26 at 1:19 PM, the Director of Nursing (DON) was interviewed and the observation with LPN F was discussed. The DON was asked the correct protocol for this situation and responded the process was to call the doctor to get the medication in a different form. The DON stated they would follow up immediately on the matter. Shortly after, the facility's staffing educator followed up with a Do Not Crush medication list that the facility provides to all Nurses and showed that the Metoprolol succinate extended-release medication was on the list. The staffing educator provided documentation of LPN F to have been re-educated on the correct protocol.

Based on observation, interview and record review, the facility failed to ensure bathing/showers were provided according to the plan of care for two residents (R26 and R40) of three residents reviewed for activities of daily living (ADL's). Findings include:R40 On 7/27/2026 at approximately 12:19 p.m., R40 was observed in their room, sitting up in their bed. R40 was asked if they had any concerns regarding their care in the facility and they reported they do not get showered at a minimum of least twice per week. On 7/28/26 at approximately 9:16 a.m., R40 was observed in their room, laying in their bed. R40 was asked if they had any concerns and they indicated that in the middle of the month they went about 10 days without getting a shower. R40 reported they were incontinent and needed to be showered at a minimum of twice per week. On 7/28/26 the medical record for R40 was reviewed and revealed the following: R40 was initially admitted to the facility on [DATE], last readmitted on [DATE] and had diagnoses that included Paraplegia and Multiple Sclerosis (MS). A review of R40's MDS (minimum data set) with an ARD (assessment reference date) of 7/13/26 revealed R40 needed assistance from facility staff with most of their activities of daily living including showers/bathing. R40's BIMS score (brief interview for mental status) was 15 that indicated intact cognition. A review of R40's care plan revealed the following: Focus-[R40] has a functional ability deficit and requires assistance with self-care/mobility r/t (related to) decreased mobility and weakness secondary to MS (Multiple sclerosis) Comorbidities: paraplegia, RLS (restless leg syndrome), anemia, lumbar spinal stenosis, anxiety, depression, polyneuropathy, insomnia Date Initiated: 07/06/2026 .Interventions- BATH/SHOWER: Resident requires dependent assistance with two helpers. Date Initiated: 07/07/2026 . A review of R40's Certified Nursing Assistant (CNA) bathing documentation for the previous 30 days revealed R40 was to be showered on Monday and Thursday evenings. Further review of R40's bathing documentation revealed R40 was not provided any bathing from 7/10/26 until 7/20/26. R26 On 7/28/26 at approximately 10:37 a.m., R26 was observed in the activity room, up in their wheelchair. R26 was asked if they had any concerns regarding their care and they reported they needed assistance from staff in the shower and because they needed help, they were not getting showered. On 7/29/26 the medical record for R26 was reviewed and revealed the following: R26 was initially admitted to the facility on [DATE] and had diagnoses that included Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. A review of R26's MDS with an ARD of 7/11/26 revealed R26 needed assistance from staff with showers/bathing. R26's BIMS score was 15 that indicated intact cognition. A review of R26's care plan revealed the following: Focus-[R26] has a functional ability deficit and requires assistance with self-care/mobility R/T: decreased mobility, CVA (stroke) with right sided weakness, HTN (Hypertension) Date Initiated: 07/05/2025 .Interventions-BATH/SHOWER Wednesday Saturday Evening Shift & PRN .Date Initiated: 07/07/2025 A review of R26's CNA bathing documentation for the previous 30 days revealed R26 had only four documented days of being showered. On 7/29/26 at approximately 9:29 a.m., The Director of Nursing (DON) was interviewed pertaining to the multiple residents that were alleging they were not receiving regular showers due to staffing issues. The DON indicated that the facility provides regular showers at a minimum of twice per week and as needed (PRN). The DON was asked about the lack of documented showers for R40 and R26 and they indicated that the only form of documentation for bathing was in the CNA task documentation. On 7/29/26 a facility document titled Routine Resident Care was reviewed and revealed the following: Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to ensure that a resident's capacity for self-performance of these activities does not diminish unless circumstances of the resident's clinical condition demonstrate the decline is unavoidable. Care is taken to ensure resident safety at all times. Guidlines-1. Residents who are capable of performing their own personal care are encouraged to do so. 2. Showers, tub baths, and/or shampoos are scheduled according to person centered care or state specific guidelines; Bed linens are changed at this time. Additional showers are given as requested No additional documentation that R40 and R26 had been offered showers at a minimum of twice weekly was provided by the end of the survey.

Based on observation, interview and record review, the facility failed to implement preventative pressure ulcer interventions per plan of care for two (R14 and R73) of four residents reviewed for pressure ulcers. Findings include: R14 On 7/27/26 at 9:58 AM, R14 was observed lying directly on their back while in bed which had a low air loss mattress and positioning wedges were observed at the edges of the side of the bed under the fitted sheet (not in contact with the resident). R14 was attempted to be interviewed but did not respond to simple questions when asked. On 7/28/26 from 8:20 AM until 12:20 PM, R14 was observed positioned in their bed, directly on their back. There were no pillows, wedges, or any repositioning attempts by staff observed during these observations. On 7/28/26 at 8:30 AM, an interview was conducted with the Wound Care Nurse (Nurse 'C'). When asked about R14's wounds, they confirmed R14 currently had a pressure ulcer on their coccyx which was acquired while in the facility and had first been identified on 6/9/26. On 7/28/26 at 8:39 AM, Nurse 'C' reported they needed to report a correction that R14's pressure ulcer was on their sacrum, not the coccyx. Review of the clinical record revealed R14 was initially admitted into the facility on 3/19/25, and recently readmitted on [DATE] with diagnoses that included: unstageable pressure ulcer/injury sacrum (obscured full-thickness skin and tissue loss), hypertensive encephalopathy, chronic respiratory failure with hypoxia, polyneuropathy, and dependence on renal dialysis. According to the Minimum Data Set (MDS) assessment dated [DATE], R14 had intact cognition, was dependent upon staff for assistance with rolling left and right while in bed, and had one or more unhealed pressure ulcer/injuries that were not present on admission. Review of R14's care plans included: (R14) has Actual impairment to skin integrity.Unstageable PI (pressure injury) of Sacrum. This was initiated on 5/22/26, revised on 7/21/26. Interventions included: Assist resident to Turn and Reposition frequently and PRN (as needed), initiated on 5/5/26. Resident needs assistance to apply pillows/wedge., initiated on 5/5/26. The assessment/note documented by the Nurse 'D' on 7/21/26 documented, in part: .Skin Issue: #005: Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure ulcer / injury. Unstageable ulcer due to slough and / or eschar. Wound acquired in-house.Staged by: Health care provider. Length (cm/centimeters): 1.26 Width (cm): 0.65 Depth (cm): 0.2 Area (cm2): 0.68.Additional care: Positioning wedge. Additional care: Pressure reducing device for bed.Additional care: Repositioning device(s). Additional care: Turning / repositioning program. On 7/28/26 at 12:20 PM, an interview was conducted with Nurse Manager (Nurse 'D'). When asked to observe R14, Nurse Manager 'D' confirmed R14 was positioned directly on top of their back. When informed of the observations of lack of repositioning by staff since observations started at 8:20 AM, Nurse Manager 'D' reported that should not have happened and proceeded to go to Nurse 'A' (R14's assigned Nurse) and Certified Nursing Assistant (CNA 'E') about the concerns. At that time, CNA 'E' stated, I'm saying she can't be moved. She screams in pain when I do. CNA 'E' was asked about any wedges or repositioning devices and they reported there were none in R14's room and would have to go look. Nurse Manager 'D' then confirmed there were wedges under the fitted sheet on the bed that CNA 'E' was not aware of. Nurse 'A' was asked if they had been informed of any concerns with R14 that they were screaming in pain, or unable to be repositioned per plan of care, Nurse 'A' reported they were not. Nurse Manager 'D' reported they would need to provide additional education to CNA 'E'. According to the policy titled, Skin Management dated 1/28/26: .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 .Appropriate preventative measures will be implemented on residents identified at risk and the interventions are documented on the care plan . R73 On 7/27/26 at 10:55 AM, R73 was observed lying in bed on their left side. Foam heel protectors were observed on R73's bed and not applied to their feet. R73 did not wish to participate in an interview. R73 was observed to have a specialty air mattress (used to assist in prevention of pressure ulcers). A mechanical console was attached to the foot of the bed. The power switch was in the on position. However, the console was not lit up to indicate the power was activated. On 7/27/26 at 2:35 PM, R73 was sleeping positioned on their left side and the air mattress appeared to have no power, despite the power switch being in the on position. On 7/28/26 at 11:36 AM, R73 was observed sleeping on their left side. The air mattress remained with no power. On 7/28/26 at 2:40 PM, R73 was observed sleeping on their left side with the air mattress with no power. At that time, Licensed Practical Nurse (LPN) 'A' was asked to assess the functioning of R73's air mattress. LPN 'A' acknowledged that the power switch was in the on position, but that the console was not lit up to indicate the mattress was receiving power. LPN 'A' did not check to confirm if the air mattress console was plugged in and said she would go get the Maintenance Director. Maintenance Director 'B' was asked to confirm if R73's air mattress was functioning properly. Maintenance Director 'B' picked the power cord off the floor under the bed and plugged it into the console which then powered on. At that time, an interview was conducted with LPN 'A'. When queried about the nursing staff's responsibility to ensure specialty mattresses were turned on and functioning, LPN 'A' stated, If we notice it is not working we tell maintenance. When queried about whether the nursing staff regularly checked to see if the mattresses were on, functioning, and/or at the proper settings, LPN 'A' stated, Yes and No. If we notice it. LPN 'A' acknowledged she had not noticed R73's mattress was not powered on prior to the above mentioned observation. A review of R73's clinical record revealed R73 was admitted into the facility on 2/15/22 and readmitted on [DATE] with diagnoses that included: schizoaffective disorder bipolar type, insomnia, and dementia with behavioral disturbance. A review of a MDS assessment dated [DATE] revealed R73 had intact cognition and no behaviors. R73 was dependent on staff for assistance with rolling left and right and with transfers from the chair to the bed and the bed to the chair. It was documented R73 was at risk for development of pressure ulcers. A review of R73's Skin Issues assessments revealed R73 had a history of multiple facility acquired pressure ulcers to the rear right hip, rear left hip, right gluteus (buttock) and left gluteus between the dates of 5/28/26 and 7/7/28. A review of R73's care plans revealed a care plan initiated on 7/11/23 and revised on 6/9/26 that read, (R73) is at risk for impaired skin integrity/pressure injury R/T (related to): decreased mobility .h/o (history of) pressure ulcers. (R73) declines positioning. Prefers to lay on right side while in bed . An intervention initiated on 5/28/26 noted, Specialty mattress with pump. On 7/28/26 at 2:56 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's protocols to ensure pressure ulcer preventative interventions, specifically functioning air mattresses, were in place, the DON reported the Unit Managers and floor nurses rounded and should check to ensure the mattresses were powered on and functioning. Certified Nursing Assistants (CNAs) should inform the nurse if they noticed the air mattress was not on or functioning.

This citation pertains to Complaint # 2788554Based on observation, interview and record review the facility failed to ensure a resident was safely transferred in a facility contracted transportation vehicle for one (R701) out of two residents reviewed for accidents/transportation, resulting in R701 sustaining a C6 fracture (broken bone in the sixth cervical vertebra), a C7 compression fracture (structural collapse or break in the seventh cervical vertebra), hospitalization and pain. Findings include:A complaint was filed with the State Agency (SA) that alleged R701, who is bedridden, was being transported to the hospital for a routine checkup and upon return to the facility their wheelchair was not secured properly. The wheelchair flipped over in the transfer van causing a neck injury and hospitalizationA review of R701's hospital records revealed the following: (Hospital).(R701).History and Physical Reports.Service date: 12/18/2025.Chief Complaint: states she was in a W/C (wheelchair) and the driver took a turn and her whole W/C fell over on its side.History of Present Illness:.today patient was on her wheelchair in a transport vehicle, when she hit her head on the vehicle wall as her wheelchair was not properly secured and the vehicle made a sudden movement. Upon arrival patient had pain in mid back, neck.In ED (emergency department) she found out to have a C6 and C7 fracture and admitted for further evaluation by surgery team.Imaging Results:.Nondisplaced fracture of the left-sided at C6.questionable minimal compression fracture at C7.Plan/recommendations:.Pain control as needed.Maintain cervical collar.On 5/27/26 at approximately 9:10 AM, R701 was observed lying in bed. The resident was alert and able to answer all questions asked. R701 was queried as to the incident that occurred in December 2025 while in a transfer van returning to the facility. R701 reported they were scheduled for an appointment and was picked up by the Transportation Company and accompanied Certified Nursing Assistance (CNA) A'. On the way home from the appointment, they were in their wheelchair and felt the van start to shake and they started to fall backwards. CNA A ran out of the van and entered through another door to try and help her. R701 reported that they were in pain and was taken to the hospital and sustained fractures to their neck. R701 noted that they needed to wear a cervical collar for months and received pain medication. R701 noted they continue to have pain in their neck. R701 further noted that they believed something might have been wrong with their wheelchair on the right side and recalled telling a facility staff member about it and further noted that the driver could not secure it correctly.On 5/27/26 at approximately 9:50 AM, a phone interview was conducted with CNA A. CNA A reported that they had been employed by the facility for over 18 years. CNA A was asked about the incident that occurred in the van that was transferring R701 back to the facility on [DATE]. CNA A reported that upon return to the facility the driver was in charge of locking R701's wheelchair in transportation vehicle. They noted that something appeared wrong with the leg rest, but the driver struggled to secure it. They believed it eventually was locked but could not substantiate how it was secured. R701 further reported that as they were a mile or so from the facility there was some jerking and when they looked to the back of the van the resident had fallen back and the chair and resident were folded up like a pretzel. CNA A reported that they opened the back of the vehicle and saw the resident again looking like a pretzel and called EMS (emergency medical services). They then called the facility to inform them of what occurred. CNA A noted that they had been informed there would be a delay in picking up the resident via EMS and they flagged down a police officer who called the fire department and R701 was then transferred to the hospital.A review of the facility Incident/Accident (IA) report was reviewed and documented: (R701).Summary of Alleged Incident: On 12/18/25, (R701) fell backwards in her wheelchair in a transportation van (Transportation Company) upon return from a medical appointment. She was transferred to the hospital after the incident. (R701) was admitted to (Hospital) and was diagnosed with a C6 cervical fracture.(R701) Interview #1: (R701) was interviewed by the Director of Nursing (DON) on 12/22/25.Per (R701), she went out to her appointment with (Transportation Company) and when she left the (female) driver strapped her into the van and she felt steady and secure. (R701) said upon return from the appointment, the (male) driver strapped her in around her abdominal area but couldn't strap her legs. (R701) said when arriving back from her appointment she felt like someone was yanking on her and she fell backwards. (R701) said they transported her to the hospital and when EMS arrived, the driver .told them she wasn't secured.(Interview with CNA A): (CNA A) .accompanying (R701) on her appointment on 12/18/25. (CNA A) said they were on the way back to the facility.when (R701)'s wheelchair flipped over.they called 911. (Interview with Owner of Transportation Company herein after Owner B).(Owner B).interviewed by DON and Administrator on 12/19/25 via telephone. (Owner B) stated he was made aware of the incident and considered it a 'procedural issue' and said the driver didn't follow the proper procedure.driver has been suspended.(Owner B) stated there is video inside and outside of their vans.The team met with (Daughter of R701).regarding care concerns.(Daughter of R701) stated she doesn't feel comfortable in this wheelchair and she had to have the man adjust her wheelchair.(Daughter of R701) said everything was fine going there.but it was coming back she wasn't strapped in and tipped over.Summary of Investigation: The facility can substantiate resident (R701) sustained a c6 cervical fracture. The incident occurred while returning for an outside medical appointment with facility's transportation vendor (Transportation Company) .Additional documentation to the IA revealed the following: .12/23/25.started meeting.Contact #1 (Daughter of R701) .Contact #2 (Son of R701).I do fault the Transportation Company.my mother told them I don't feel comfortable in this wheelchair.My mother did not feel safe but they put her in the wheelchair any way and had to have 'the man' adjust her wheelchair.(name redacted) asked why she wasn't going by stretcher .appointment couldn't accompany a stretcher.coming back she wasn't strapped down.A review of R701 clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: type II diabetes, nondisplaced fracture of sixth cervical vertebra, and nondisplaced fracture of seventh cervical vertebra. A review of R701 Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (intact cognition).Continued review of R701 clinical record revealed, in part, the following:12/22/26 Physical Exam: .Patient.seen today for readmission into the facility.was transferred to the hospital following a fall with transportation staff.Per patient,.EMS admitted to not strapping her into the wheelchair properly on her way out of the appointment to the van, and fell backwards.patient was transferred to the hospital.found to have a C7 compression fracture and C6 fracture. Patient was placed in a c collar.and discharged back to the facility.patient is admitting to increased neck pain at this time.states she was give a pain shot in the hospital (tramadol) that significantly helped with the pain.patient states she is scared to get out of bed.Assessment and Plans.Unspecified nondisplaced fracture of sixth cervical vertebra.continue with robaxin (muscle relaxer), lyrica (nerve pain medication) and Tylenol.start tramadol (pain medication).Wear C Collar as much as possible.On 5/27/26 at approximately 11:20 AM, an interview was conducted with the Administrator. The Administrator was queried about the transportation incident that occurred with R701 on 12/18/25. The Administrator reported that they had been working with Owner B and was able to substantiate the transport driver did not safely secure R701 in the transportation vehicle upon return from the appointment. The Administrator was asked if they had a copy of the Transportation Company's report and they noted they did not.On 5/27/26 at approximately 11:30 AM, a phone interview was conducted with Owner B. Owner B was able to confirm that based on interviews and videos in and out of the vehicle they were able to substantiate that R701 was not properly secured in the transportation vehicle. Owner B was asked to provide a copy of the incident report involving R701. Owner B reported that that they would provide the report via email. No report was received by the end of the Survey.The Transportation Contract with (Transportation Company) was reviewed and documented the following: .Agreement made on 12-10-24 by and between (Facility) under the laws of the State of Michigan.It is agreed as follows: .SERVICES:.Contractor will provide transport services for wheelchair bound and ambulatory patients of the facility.STANDARDS: Carrier represents and warrants that it is duly qualified and currently authorized and licensed to lawfully transport.wheel-chair bound persons.Contractor shall provide transport services in compliance with Contractor's Service Delivery Standards, as agreed to by Contractor and Facility.Contractor represents and warrants that it must perform the services herein in a manner that does not damage the reputation of Facility.MANDATED EQUIPMENT: Contractor shall provide all equipment necessary for providing safe and comfortable transport of Facility patients.Contractor represents and warrants that all employees who will have contact with Facility patients have had the following training : Pre & Post trip Vehicle Safety Inspections, Wheelchair Tie down & Seatbelt procedures.INDEMNIFICATION: Each party agrees to indemnify the other, including directors, officers, agents and employees, harmless from all claims, suits, judgements and demands arising form the indemnifying party's negligent and/or intention acts and omissions.Signed by (Owner B) and the Administrator on 12/10/24.

This citation pertains to intake #'s 2699473, 2699484, and 2699520.Based on interview and record review, the facility failed to notify the Doctor, Nurse Practitioner, or Physician's assistant of an acute change of condition and ensure a timely transfer to the emergency room (ER) for one resident (R202), of two residents reviewed for an acute change of condition, resulting in R202 not being transferred to the emergency room timely, deemed not a candidate for surgical intervention, and ultimately death from sepsis. Findings include:A complaint received by the State Agency alleged the resident was not appropriately treated for an acute change of condition.On [DATE] at 2:15 PM a phone call was conducted with the complainant. They said R202 admitted to the facility on [DATE] in the afternoon. On the evening of [DATE] they said R202 developed, extreme pain in their abdomen with nausea and vomiting. They said they requested an evaluation from a physician on [DATE] during the evening and was told someone would be in on the morning of [DATE]. They further reported on [DATE] R202's pain intensified, their temperature was extremely low, they were diaphoretic (sweating) and their vital signs were unstable. They said R202 was seen by a Physician's Assistant (PA) on [DATE] around 3 PM. They said the PA ordered labs and an abdominal X-ray, and R202 was treated with Zofran (anti-nausea medication) and Tylenol for pain. They continued to say that on [DATE] in the early evening R202 went into respiratory distress saying her respiratory rate was greater than 30 and her labs came back around 6 PM with a critically high white blood cell count (indicative of an infection). They further reported R202 was sent to the emergency room at approximately 7 PM and when they arrived, it was too late. They were asked what was going on with the resident at the hospital and said R202 had something wrong with her colon (they did not know exactly what), they were septic (a life-threatening medical emergency where the body's extreme response to an infection damages its own tissues and organs, potentially leading to organ failure and death) and nothing could be done. They said R202 died on [DATE] and if they would have known, they would have called an ambulance themselves to transfer R202 to the emergency room. The complainant provided R202's death certificate via e-mail for review.On [DATE] at 4:21 PM, a review of R202's death certificate was conducted and the CAUSE OF DEATH section listed, a. Sepsis and b. Pneumatosis Intestine, a condition where gas collects in the wall of the small or large intestine, and is a sign of an underlying issue, ranging from benign to life-threatening, like bowel ischemia or infection.On [DATE] at 9:48 AM, a review of R202's closed clinical record was conducted and revealed they admitted to the facility on [DATE] with diagnoses that included: heart failure, edema, chronic kidney disease, atrial fibrillation, high blood pressure, muscle wasting and atrophy. A progress note entered into the record on [DATE] at 12:08 AM indicated R202 was alert and oriented to person, place, and time.A review of R202's vital signs and documented pain scores was conducted and revealed the following:[DATE] at 9:27 AM documented by Nurse 'A', Blood pressure 178/105, heart rate 125 (normal is less than 100) with an irregular rhythm, and temperature 94.8 (normal is 98.6)XXX[DATE] at 10:50 AM, pain score documented as [DATE]/25 at 2:38 PM, documented by Nurse 'B', Blood pressure 101/86, heart rate 133 with an irregular rhythm, and temperature 96.6XXX[DATE] at 2:44 PM, pain score documented as 7/10.On [DATE] at 11:40 AM, a telephone interview was conducted with Nurse 'A' and they were asked if they reported R202's abnormal vital signs (high blood pressure, high heart rate, and low temperature) to the Doctor, Nurse Practitioner (NP), or Physician's Assistant (PA). They said, I'm pretty sure I reached out to the NP or PA.A review of R202's clinical record revealed no indication the Doctor, NP, or PA were made aware of the abnormal vital signs on [DATE] at 9:27 AM.Continued review of R202's clinical record revealed a progress note entered into the record by Nurse 'B' on [DATE] at 2:39 PM that read, .Writer assesses resident with daughters at Bed side. PA (PA 'C') present. VS (vital signs) reassessed. Complaint of abdominal pain. Pt has vomited 10cc of green emesis.PA ordered; [sic] Abdominal X-ray for abdominal pain, nausea.It was noted PA 'C' did not include a note in the record regarding their assessment of R202 on [DATE] at approximately 2:40 PM.The last note entered into R202's record by Nurse 'E' on [DATE] at 7:53 PM was reviewed and read, .Writer observed pt (patient) hyperventilating in own room at 1830 (6:30 PM).Writer obtained pt vs (vital signs); 154/78, 120bpm (heart rate), 32resp/min, (respiratory rate). Writer contacts On-Call Prescriber to notify of sepsis like symptoms, as writer is on the phone with On-Call provider, second nurse receives a phone call from (Laboratory Company) with a critically high WBC (white blood cell count) of 31,700 .(Normal WBC 4.0-11.0) Provider is made aware and orders pt to be sent out to ER for sepsis.On [DATE] at 12:05 PM, a telephone interview was conducted with PA 'C' regarding their assessment of R202. They said R202 was, in poor condition when they saw them. They were asked what, poor condition meant and said R202 was flat in bed with a damp towel on her chest. PA 'C' further reported R202 was not actively vomiting but had an emesis basin on the bedside table. They further indicated R202 was complaining of pain to the left upper quadrant of their abdomen. PA 'C' then said they ordered an abdominal X-ray and stat labs. They were asked if they were aware of R202's vitals earlier in the day ([DATE] at 9:27 AM, Blood pressure 178/105, heart rate 125 with an irregular rhythm, and temperature 94.8) and said they had not been made aware, nor did they review R202's previous vital signs. PA 'C' was asked about R202's vitals documented at 2:38 PM on [DATE] and said they suspected sepsis so they ordered the X-ray and the stat labs. PA 'C' was next asked if they considered sending R202 to the emergency room and said they wanted to see what the results of the labs and X-ray were before they sent them. PA 'C' then said later in the evening on [DATE] the labs were reported to them with a critical high white blood cell count so they called the facility to have the resident transferred.On [DATE] at 12:46 PM, an interview was conducted with Dr. 'D', supervising physician for PA 'C'. They were asked if R202's vitals at 9:27 AM on [DATE] should have been reported to either them, a PA, or a NP and said they should have. Dr 'D' was next asked their professional opinion for the variance in the vitals between 9:27 AM on [DATE] and 2:38 PM on [DATE] and said it could be caused by several things including sepsis. They were asked what they would have done had they been contacted and said they may have started fluids and probably would have sent them to the emergency room. At that time, Dr. 'D' was made aware R202 was not sent to the emergency room until approximately 7 PM on the evening of [DATE] to which they replied, That is very concerning. I am disappointed it happened.On [DATE] at 1:25 PM, an interview was conducted with the facility's Director of Nursing (DON). R202's clinical record was reviewed with the DON and they were asked if Nurse 'A' should have contacted a Doctor, NP, or PA regarding R202's vital signs on [DATE] at 9:27 AM and said they should have; agreeing the blood pressure, heart rate, and temperatures recorded on [DATE] were a concern. The DON was then asked why the facility didn't send R202 to the emergency room sooner given their vital signs, pain levels, and clinical condition and offered no response but said PA 'C' waited to see if their ordered interventions would work before they sent R202 out. A review of a facility provided policy titled, Notification of Change revised 2/2024 was reviewed and read, The facility must inform the resident; consult with the resident's practitioner; and notify, consistent with his or her authority.when there is a change in status.A change in status would include any of the following:.A significant change in the resident's physical, mental, or psychological status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications.)A review of a second facility provided policy titled, Transfer and Discharge revised 4/2025 was conducted and read, .1. The facility will transfer or discharge a resident under the following documented conditions in the medical record: A. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.

This citation pertains to Intake 2577773.Based on interview and record review, the facility failed to ensure privacy of medical information was maintained for a one (R201) of two residents reviewed for Protected Health Information (PHI). Findings include:A complaint was filed with the State Agency (SA) that read in part, .an employee of the facility was telling the diagnosis and personal business of the resident to other family members.Review of the clinical record revealed R201 was admitted into the facility on 8/7/20 and readmitted on [DATE] with diagnoses that included: Alzheimer's disease, heart disease and history of lung cancer. According to the Minimum Data Set (MDS) assessment dated [DATE], R201 had a staff assessment that indicated severely impaired cognition. Review of a documented titled, Statement of Capacity revealed an X marking To be incapable and unable to make his/her informed medical decisions. The document had two physician/psychologist signatures dated 11/20/24.On 9/9/25 at 4:19 PM, R201's Durable Power of Attorney (DPOA) was interviewed by phone and asked if a staff member had disclosed PHI about R201. The DPOA explained (Certified Nursing Assistant - CNA B) had been dating her cousin and would video chat with her Cousin ( H) while she was at work and her Cousin H told her he could sometimes see R201 and other residents at the facility. then another time CNA B was at a store and saw another Cousin ( I) of hers and told him R201 was not doing well and was going to pass soon. The DPOA was asked if she had ever given permission for CNA B to talk about R201 to other family members. The DPOA explained she had not and specifically wanted to tell R201's sister about R201's decline herself; she did not want R201's sister to hear the information secondhand.Review of the facility's Employee List revealed CNA B's name was not listed.On 9/10/25 at 10:54 AM, the Administrator was interviewed and asked if CNA B worked at the facility. The Administrator explained CNA B did not work there anymore. The Administrator was asked to provide CNA B's employee file.Review of a document titled, Disciplinary Action Record Work Rules for CNA B read in part, .Termination (effective date: 6-24-25). The above employee disclosed confidential & privileged information to a family member of resident (R201's). This information was given to a family member not on resident (R201's) face sheet and not authorized by resident (R201) Power of Attorney to receive medical information.On 9/10/25 at 1:30 PM, the Administrator was asked about CNA B termination. The Administrator explained CNA B had been terminated due to video chatting with people while at work and for giving resident information to someone. The Administrator was asked if employees were informed of the Health Insurance Portability and Accountability Act (HIPAA). The Administrator explained all employees were aware of HIPAA, and were educated on it.Review of a facility policy titled, HIPAA Definitions revised 10/1/21 read in part, .Health Information: Any information, whether oral or recorded in any form, created or received by the facility that relates to the individual's past, present, or future physical or mental health, or the payment for such health care. Disclosure: Means the release, transfer, provision of access to, or divulging in any other manner of information outside of the entity holding the information.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in foodborne illness among all residents that consume food from the kitchen. Findings include: On 5/20/25 at 8:48 AM, an observation of the main kitchen was conducted with the Certified Dietary Manager (CDM 'O'). The following items were observed: The kitchen flooring was observed to have scattered debris throughout the kitchen including wrappers, used gloves, and food debris near the handwash sink, ice machine, juice machines, and behind the oven. The flooring behind the steamer was observed with various debris, including used gloves. A pull-out drawer on a table next to the meal prep area contained various cooking utensils. The drawer was not closed completely and remained slightly opened. Upon fully opening the drawer, the inside of the drawer and several utensils were observed with a thick layer of dust and various food debris. CDM 'O' reported they didn't use that very often and was more of a back-up drawer. The wall near the meal prep table had several linear metal strips secured to the wall which held several kitchen utensils including ladles and tongs. Several of the ladles were observed to contain dried spills and food debris in the bottom portion of the ladle. CDM 'O' confirmed the same concerns and removed the soiled utensils from the wall storage to clean. The can opener was observed to have a build-up of food debris. When asked how often that was cleaned, CDM 'O' reported the can opener got cleaned at the end of the day. The ice machine had tiled flooring under the machine and to the right of the machine that had a visible build-up of a white, chunky substance and several tiles were lifted. CDM 'O' reported maintenance had just looked at that yesterday and reported someone was going to try to fix it. The surrounding wall of the kitchen between the ice machine and the juice machine was observed to be heavily soiled with splattered brownish colored, dried debris. Several of the boxes of juices were also observed soiled with similar brownish colored, dried debris. When asked about the soiled walls, CDM 'O' reported the wall might've been just uncovered when they moved the ice machine over to the left away from the machine. When asked how often the walls were cleaned, CDM 'O' offered no response. There was a stainless-steel table to the left of the handwashing sink that contained seven stainless steel thermal carafes with black screw-on lids. Some were labeled with tape and stickers as hot water and coffee. Several of the carafes were observed with a thick build-up of white debris around the lid and crevices on the top of the carafe. One of the carafes labeled coffee had a large build-up of brown debris on, around and under the inside of the carafe. When asked about the build-up and whether these items were intended to be used, CDM 'O' confirmed the build-up debris and reported the facility had hard water and had a hard time with the white build-up debris. When asked about the brown debris, CDM 'O' offered no response. CDM 'O' further reported the same carafes were intended for use. They also reported they had several new carafes in their office and proceeded to retrieve three new carafes. When asked if they had purchased new carafes, why were those soiled ones left in circulation for use, CDM 'O' offered no further explanation. At 9:08 AM, CDM 'O' was asked about the facility's dish machine and reported it was a high-temp machine (raises the water temperature to 180 degrees Fahrenheit in the final rinse which kills bacteria therefore sanitizing the dishware and cookware being washed). When asked how often the facility monitored for proper temperatures, CDM 'O' reported the staff logged it three times a day and they (CDM 'O') usually did it when they first came into work. When asked about how they monitor the temperatures, CDM 'O' reported they used the external digital machine on the back wall near the dish machine. When asked if they used any other method to monitor the temperature other than the digital screen, CDM 'O' reported they primarily used the digital and had testing strips available if needed. The clean side of the dish machine had a stainless steel counter that was observed to have several dried food debris on the top of the surface. The surrounding flooring and area next to the dish machine room that contained the clean pots/pans and trays was observed to have food and garbage debris scattered throughout the area. At 9:42 AM, the flooring near the ice cream cooler and along the wall towards the dry storage room was observed to have multiple plastic papers, and food debris scattered throughout the flooring. The flooring throughout the dry storage room had scattered litter and debris. There was a box of diced onions stored underneath the fan unit at the back of the freezer that was observed to have several large chunks of ice build-up on the cardboard box. When asked about the ice build-up, CDM 'O' reported the cooling unit had recently been serviced and proceeded to move the contaminated box to another shelf. When asked if they were going to keep the diced onions in circulation, CDM 'O' removed the box. On 5/20/25 at 11:45 AM, an additional observation of the main kitchen conducted with CDM 'O' revealed the following items: The kitchen flooring remained soiled in the same manner and locations as first observed. During observation of the meal prep on the food line, Dietary Aide 'P' was observed touching their nose/lip area with their bare hands several times and then proceeded to plate up the lunch meals without using any hand sanitizer or washing their hands. At 12:02 PM, the stainless-steel table next to the hand washing sink was observed to have six empty carafes available to be used with several that remained with heavy build-up of white and brown substance. On 5/22/25 a 8:26 AM, observation of the beverage cart in the hallway outside of the dietitian's office contained two thermal carafes labeled coffee and one thermal carafe labeled hot water. The lids on all three contained a build-up of brown and white debris. Registered Dietitian (RD 'T') was asked about the beverage cart and it had been in use. RD 'T' reported that was the cart used to pass beverages with breakfast and staff likely placed the cart there to return. When asked about the soiled condition of the thermal carafes, RD 'T' confirmed the same and reported they had not seen them like that before but knew there were several new ones that had been ordered. According to the 2017 FDA Food Code section 3-305.11 Food Storage, (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . According to the 2017 FDA Food Code section 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing, A. In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature. According to the 2017 FDA Food Code section 6-501.11 Repairing, Physical facilities shall be maintained in good repair. According to the facility's policy titled, Dietary Cleaning and Sanitation dated 11/12/21: .It is the policy of this facility to maintain the sanitation of the kitchen through proper cleaning and sanitizing stationary food service equipment and food contact surfaces to minimize the growth of microorganisms that may result in food contamination .

Based on observation, interview, and record review, the facility failed to implement effective plans of action to correct identified quality deficiencies related to implementation of their abuse policy for obtaining a complete background check for newly hired staff (Certified Nursing Assistant/CNA 'X'), resulting in continued deficient practice. This had the potential to affect all residents who resided in the facility. Findings include: An abbreviated survey was conducted on 4/10/25 with deficiencies identified for abuse policy implementation. A request to accept evidence of deficiency correction in lieu of a revisit was accepted. According to a CMS (Centers for Medicare and Medicaid Services) 2567 form dated 4/10/25, the facility was found to be noncompliant with regulatory requirements related to abuse policy implementation. Review of the facility's Plan of Correction (POC) alleged a compliance date of 5/8/25. The facility's POC documented the facility would do the following to correct the deficient practice related to the failure to implement the abuse policy that requires a complete background check for newly hired staff: .All facility employees have had a fingerprint-based criminal history check and are reflected in their personnel files .The facility Abuse Prohibition Policy was reviewed and deemed appropriate. The Human Resources Director received re-education on the facility Abuse Prohibition Policy with emphasis on ensuring all facility employees receive fingerprinting per the Michigan Long Term Care Workforce Background Check and Disclosure .The Administrator / designee will audit new hires weekly to ensure fingerprint-based criminal history checks are in employee personnel files. Audits will be conducted for (4) weeks and then monthly for (2) months to ensure compliance. Any concerns will be addressed and brought to QAPI (Quality Assurance Performance Improvement) for analysis. The Administrator is responsible for sustained compliance. A review of the facility's auditing tools for Fingerprint-based criminal history checks for employee revealed no identified concerns for CNA 'X' and was documented as yes for having the fingerprint check completed. On 5/22/25 at 11:30 AM, upon review of employee personnel records, it was identified that CNA 'X' had no fingerprint-based criminal history check completed upon hire, or since the identified deficiency on 4/10/25. The only documentation included in the employee file was a fingerprint-based criminal history check from 7/13/18 and had yet to be completed upon being rehired at the facility. On 5/22/25 at 12:22 PM, an interview was conducted with the Administrator. At that time, the Administrator was asked about CNA 'X's lack of current fingerprint-based criminal history check and who was responsible for auditing to ensure that was in place, given they were recently determined to be out of compliance for the same concern. The Administrator reported the HR (Human Resources) Director was responsible for that, but they were on vacation this week. The Administrator attempted to contact the HR Director by phone and left a message. The Administrator reported they had obtained the documentation for employee criminal history checks from other binders and would look again to see if there was additional documentation. The Administrator confirmed CNA 'X's hire date was 1/21/25 and they had pulled up the same result of the fingerprint-based criminal history online and confirmed the only results they had was from 2018 and confirmed none had been completed upon their re-hire in 2025. On 5/22/25 at 1:30 PM, the Administrator was asked about their process for auditing compliance since the recent abbreviated survey and alleged compliance date of 5/8/25. The Administrator reported when the facility was completing the audits, they only looked at the name of the facility and staff name, and didn't look at the dates. The Administrator acknowledged CNA 'X' was a previous employee but should've had a new fingerprint-based criminal history completed upon rehire. The Administrator was requested to provide dates of employment. On 5/22/25 at 2:20 PM, the Administrator provided employment dates for CNA 'X' which documented they had previously worked at the facility from 7/17/18-6/21/19 and rehired on 1/21/25-present. According to the facility's policy titled, Quality Assurance Performance Improvement Committee dated 4/5/2024: .The QAPI Committee oversees and identifies all efforts that improve the quality of care in the facility by monitoring performance measures, develop and implement appropriate performance improvement plans to correct quality concerns, and evaluating the effectiveness of the performance improvement plans .

Based on observation, interview, and record review, the facility failed to implement a comprehensive infection control program and ensure adherence to Center For Disease guidance for infection control practices regarding transmission based precautions and hand hygiene for seven residents, (R#'s 90, 125, 51, 234, 29, 84, and 11) of fourteen residents reviewed for infection control, resulting in the potential for the spread of infection. This deficient practice had the potential to affect all residents who reside in the facility. Findings include: Infection Control Program On On [DATE] at 10:36 AM, a review of the facility's Infection Control Program was conducted and revealed the following: The February 2025 data did not contain a monthly summary of the program, a calculated infection rate, line listings with infection types, symptoms, antibiotics prescribed, mapping for trends and outbreaks, pharmacy reports, lab reports, environmental surveillance, or any education on infection control completed during the month. The [DATE] line listings included thirteen facility acquired infections treated with antibiotics that documented the infection onset date was prior to the resident's admitted . The March line listing further documented eleven infections treated with antibiotics where the type of infection documented was, unknown, with no recorded signs or symptoms. Continued review of the March line listings revealed seven urinary tract infections without adequate documentation to show they met McGeer's Criteria (a set of guidelines used in long-term care facilities to identify infections and justify the use of antibiotic treatment). The [DATE] summary documented five facility acquired infections and eight community acquired infections, however; the line listings listed an additional 24 infections that were not categorized as facility or community acquired. On [DATE] at 11:27 AM, an interview was conducted with the facility's Infection Control Preventionist, Nurse 'M'. They said they assumed the position three weeks ago, and prior to them; the Assistant Director of Nursing and Director of Nursing had been overseeing the program. They were asked if they knew why the March line listings included admitted s that were after the infection date and said the software program they used to compile data automatically fills in the date to default to the most recent re-admitted . They further gave an example of a resident with a facility acquired infection in early March, but discharged to the hospital in late March and readmitted in April, the computer gave the admitted as April. They were asked if this could be problematic when calculating facility versus non-facility acquired infections and they agreed. When further queried about the infection control monthly data for February 2025 and [DATE], Nurse 'M' had no further explanations and acknowledged the concerns. A review of a facility provided policy titled, Infection Prevention Program Overview revised ,d+[DATE] was conducted and read, .The facility establishes a program under which it: Investigates, identifies, prevents, reports and controls infections and communicable disease for all residents, staff, contractors, consultants, volunteers, visitors and others who provided care and services to the residents on behalf of the facility .Decides what procedures such as isolation, should be applied .Maintains a record of incidents and corrective actions related to infections .Antibiotic Stewardship is addressed and maintained . R#'s 125, 234, 51 and 90 On [DATE] at 9:12 AM, an observation of R125 and R234's room was conducted. A sign taped to the door indicated R234 was on contact transmission based precautions (requiring a private room if available and the use of a gown and gloves when interacting with the infected person or their environment) and both R125 and R234 were on enhanced barrier precautions (the use of a gown and gloves during high contact care activities). At that time, Certified Nurse Aide (CNA) 'X' was observed in the room assisting R125 with dressing. CNA 'X' was not wearing an isolation gown. On [DATE] at 11:59 AM, a review of R234's orders revealed an order dated [DATE] for them to be placed on contact precautions for a MRSA (methicillin resistant staphylococcus aureus) infection. On [DATE] at 10:10 AM, CNA 'V' was observed in R125's room providing assistance to them. CNA 'V' was not observed to be wearing an isolation gown. Whey CNA 'V' exited the room, they were asked what type of care they provided to R125 (on enhanced barrier precautions) and they said they washed them up and got them dressed. On [DATE] at approximately 10:40 AM, R125 and R234's room remained with signs that indicated they were both on enhanced barrier precautions and R234 was on contact precautions. On [DATE] at approximately 1:30 PM, an interview was conducted with the facility's Infection Control Preventionist, Nurse 'M'. They were first asked if staff were expected to don gloves and an isolation gown when providing care to resident's on enhanced barrier precautions and they said they were. They were then asked if the facility cohorted residents with infections and said they did not as the facility had enough rooms to give anyone on transmission based precautions (with the exception of enhanced barrier precautions) their own room. They were asked if they were aware R125 was roomed with R234 who was on contact precautions for MRSA. They said they should not have been placed together and R234 should be in a private room. They were further asked if they were aware of any other residents on enhanced barrier precautions sharing a room with a resident on contact precautions, and they did indicate R51 (who was on enhanced barrier precautions) was roomed with R90 who was on contact precautions. A review of a facility provided policy titled, Enhanced Barrier Precautions revised [DATE] was conducted and read, .It is the intent of this facility to use Enhanced Barrier Precautions (EBP) in addition to Standard Precautions for preventing the transmission of CDC (Center For Disease Control) targeted multi-drug resistant organisms .Enhanced Barrier Precautions are indicated for residents with any of the following: 1) infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or 2) a wound or indwelling medical device .GLOVES, GOWNS AND HAND HYGIENE .A. Health care personnel caring for residents on Enhanced Precautions should wear gloves and gowns during high-contact resident care. Examples of high contact resident care activities requiring gown and glove use: Dressing, Bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting . A review of a facility provided policy titled, Multi Route Transmission Based Precautions revised ,d+[DATE] was conducted and read, .Transmission-based precautions are the second tier of basic infection control are to be used in addition to standard precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission .Use contact precautions for residents with known or suspected infections that represent an increased risk for contact transmission .Ensure appropriate resident placement in a single room if available .Use PPE (personal protective equipment) appropriately including gloves and gown for all interactions that may involve contact with the resident or the resident's environment . A review of guidance from the Centers for Disease Control at https://www.cdc.gov/mrsa/hcp/infection-control/index.html was reviewed and read, .CDC recommends the use of Contact Precautions in inpatient acute care settings for patients colonized or infected with MDROs, including MRSA . 39592 R29 On [DATE] at 10:45 AM, observation of R29's coccyx wound treatment revealed after LPN N cleaned R29's wound with Normal Saline, LPN N removed her gloves, then immediately put a new pair of gloves on with no hand hygiene. LPN N then grabbed a piece of Honey coated absorbent dressing and ripped a piece of it off. The Honey coated dressing was adhered to her glove. LPN N was observed to peel the piece of Honey coated dressing off her glove and pack R29's wound with the dressing. LPN N then covered the dressing with an adhesive foam bandage, which appeared to cover R29's rectal area. 49083 Activity Room On [DATE] at 12:40 PM, the facility's community residential activity room, was observed housing a large cage containing two baby chickens. The cage contained hardwood chips, chicken food, an incubator, water source, and a five-gallon bucket on the floor later identified as chicken food. Next to the live chickens was a tray of hot beverage cups, an open box of tea bags, hot beverage supplies and condiments. The opposite side of the chickens stored a single use (Keurig type) coffee maker. The cabinets underneath was labeled kitchen utensils and when opened, confirmed various cooking spoons and spatulas. A second cabinet was opened directly underneath the chicken cage and revealed two shelves containing half used containers of maple syrup, an expired (,d+[DATE]) jar of tomato sauce, half opened bag of pancake mix, multiple used containers of spices, opened cake frosting marked on top St. Pats and various edible cake decorating supplies. The back bottom shelf was observed with black unidentifiable matter. The drawer above the lower cabinet had unused coffee pods and additional hot beverage condiments. The Director of Activities (DOA) U acknowledged the chickens were theirs, and brought the eggs in for the Residents to watch them hatch into chicks and have been hatched, and living on the counter for about two weeks. When questioned why cooking supplies and used food items were stored in the activities room cabinets, DOA U confirmed the facility conducts cooking classes with the Residents once a month and the items stored were still available for current cooking classes. The DOA further confirmed there was no collaboration with food storage and the facility's kitchen. While removing items from the cabinets, DOA U acknowledged the storage of food, beverages, and supplies amongst the chickens was not sanitary. R84 Clinical record review revealed R84 was admitted to the facility on [DATE] with a medical history of End Stage Renal Disease (ESRD) on hemodialysis and required a Percutaneous Endoscopic Gastronomy (PEG) Tube for a history of gastroparesis (stomach muscles cannot move food) and to meet their nutritional needs and was on Enhanced Barrier Precautions (EBP). A Progress note dated [DATE] documented R84 had been assessed for leukopenia (low white blood cell count) and fatigue. Brief Interview of Mental Status (BIMS) scored ,d+[DATE] indicated moderate cognitive impairment. On [DATE] at 12:10 PM, R84 was observed from the hallway up in a reclining chair with assigned Nurse II. While passing by, Nurse II was observed manipulating the PEG tube with a bare hand, not wearing appropriate Personal Protective Equipment (PPE). On [DATE] at 2:59 PM, Licensed Practical Nurse (LPN) Q was observed flushing R84's PEG tube wearing only gloves. Review of the Facility Policy titled; Enhanced Barrier Precautions ,d+[DATE] documented: Health care personnel caring for residents on Enhanced Precautions should wear gloves and gowns during high-contact resident care . R11 On [DATE] at 8:47 AM, a medication observation was conducted with Licensed Practical Nurse (LPN) Q for R11 and was observed preparing the medications without hand hygiene. During the medication preparation, LPN Q was observed opening prepackaged medication containers by puncturing their bare fingernail into the foil top and sliding their fingernail across to release the tablets/capsules. LPN Q was observed donning a pair of gloves touching the medication cart. LPN Q proceeded to retrieve a vital machine, wheeled from another resident's room, and did not cleanse the equipment between residents. Still wearing the donned gloves, LPN Q proceeded to administer oral medications and instill eye drops into R11's eyes. The vital machine was not cleansed after R11's vital were taken. LPN Q removed their gloves and was not observed performing post hand hygiene. Review of the facility policy titled Medication Administration ,d+[DATE] documented: .Follow Infection Control practices .Perform hand hygiene prior to medication preparation for each medication pass .Perform hand hygiene after direct resident contact .place medications into a medicine cup without touching the inside of the cup . On [DATE] at 10:31 AM, The Director of Nursing (DON) was informed of the observations not donning proper PPE for EBP residents and improper hand hygiene for medication administration. The DON confirmed hand hygiene is required before and after medication administration, and medical equipment is to be cleaned before and after every resident use. The DON acknowledged the concerns would be addressed with the Nursing staff.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, resulting in the presence of flies and gnats throughout the facility, including the kitchen. This deficient practice had the potential to affect all residents in the facility. Findings include: According to the 2017 FDA (Food and Drug Administration) Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions. According to the facility's policy titled Pest Control dated 3/5/2025: .There will be emphasis on the pest control program in kitchens, cafeterias, laundries, central sterile supply, loading docks, construction activities, and other areas prone to infestation. Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly . On 5/20/25 observations of the kitchen were conducted with the Certified Dietary Manager (CDM 'O') from 8:48 AM-10:00 AM and 11:45 AM-12:30 PM. Throughout each of these observations, all areas of the kitchen, including the dish machine area were observed to have active, pervasive flies and gnats. CDM 'O' was asked about the flies and gnats observed and confirmed the same. CDM 'O' reported they tried to pour bleach in drains but the concern was that the doors get left open for deliveries and was hard to keep them (insects) out. When asked if there was any routine maintenance done by a pest control company, CDM 'O' reported maintenance arranged for that monthly but denied having anything treated in the kitchen. On 5/20/25 at 11:12 AM, the Administrator was requested to provide pest control logs since the last recertification survey as well as documentation of when/if staff reported any concerns with insects/bugs for the past six months. The Administrator reported they utilized an electronic reporting system and would follow-up. On 5/20/25 at 3:20 PM, review of the facility's documentation for pest control services documented monthly visits. None of these visits specified any details which included the kitchen environment. The most recent service provided on 5/5/25 at 12:28 PM noted a monthly fly bait program as not having any noted pest activity at the time of service. The service visit on 4/7/25 at 9:05 AM noted an insecticide was used to target fruit fly & related in Non Food Production Area. There were no other details available as to what areas were specifically treated. The service visit on 2/5/25 at 8:51 AM noted an insecticide was used to target fruit fly & related in Non Food Production Area. On 5/22/25 at 8:30 AM, an interview was conducted with the Administrator. When informed of the concerns regarding pest control, the Administrator reported they were not aware of any current concerns, and a pest control company came to the facility monthly. The Administrator further reported they were trying to obtain details of when staff reported concerns of insects/bugs on the facility's electronic work order log and confirmed the current documentation they provided for review from 5/23/24 - 5/22/25 identified only the concerns, not when it was first reported and when it was actually addressed. The Administrator was informed of the concern there was no documentation that any pest control had been provided for the kitchen, and that although the facility had monthly visits, concerns remained with the effectiveness of the current process as flies and gnats were observed throughout the kitchen, resident rooms, hallways, offices, and conference rooms. The documentation of the work orders included: gnats round bedside table .Room/Area 163-1 .spray room .Room/Area 163 .We have flies and gnats, throughout resident rooms and common areas .Rooms/Area Rooms/Common Areas .Bugs in All of the ceiling lights need to be cleaned out .Room/Area dialysis den .We found bugs crawling on the floor .Room/Area dialysis den .bugs in room .Room/Area 671 . There was no additional documentation or clarification regarding the pest control provided by the end of the survey. 49083 On 5/20/25 at 9:26 AM, room [ROOM NUMBER] was observed containing a tube feeding pole hanging Nepro Tube Feeding (enteral nutrition for people on dialysis). The pole, base of the pole, carpet and baseboards were observed with dried spilled tube feed and three small fly/gnat like insects were flying around the spilled matter. On 5/21/24 at 9:40 AM, An observation of the Oakland Unit #2 Medication Cart was conducted with Licensed Practical Nurse (LPN) B. While inspecting the inside and outside of the medication cart where resident medications are prepared, two small fly/gnat like insects were observed flying around the top of cart.

This citation has two deficient practices. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to document resident falls in the clinical record, thoroughly investigate the root cause analysis of falls, and immediately implement appropriate interventions after falls for one resident (R63) of two residents reviewed for falls, resulting in the potential for additional avoidable falls. Findings include: On 5/20/25 at 11:36 AM, R63 was observed asleep and snoring in their dialysis chair at the nursing station. At that time, Certified Nurse Aide (CNA) 'AA' was asked why R63 was not taken back to their room to sleep in their chair and they said they kept them up at the nursing station because they were a fall risk. A review of R63's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: stroke, dysphagia, end stage renal disease with dependence on dialysis, atrial fibrillation, depression, diabetes, heart failure, adjustment disorder and delusional disorders. R63's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed R63 had intact cognition, was non-ambulatory, had upper and lower extremity range of motion impairments, required maximal assistance for activities of daily living and was dependent on staff for transferring and bed mobility. A review of R63's Incident/Accident (I/A) Reports with a footer that read, Not part of the Medical Record, progress notes, and care plans was conducted and revealed the following: A progress note dated 1/20/25 that indicated R63 slid out of bed. R63's care plan did not reveal an immediate intervention put in place after the fall. A progress note dated 1/23/25 entered into the record by Nurse 'BB' that read, .Per CNA (Certified Nurse Aide), resident has been trying to get out of the bed throughout the day, writer tried talking to resident and he kept saying he is going to get out of bed, many times, staff had to go into his room and tried to re-direct him .he continue <sic> to be non-compliant with what the staffs <sic> were trying to tell him. about <sic> 2220 (10:20 PM), staff saw him lying on the floor . It was noted the nursing note and accompanying I/A report did not address the root cause of why R63 was trying to get out of bed, or why he wasn't allowed to remain out of bed. An I/A report (not part of the clinical record per the footer on the document) dated 1/26/25 initiated by Nurse 'BB' for an unwitnessed fall in the resident's room. There was no progress note in the record that documented R63's fall on 1/26/25. A progress note and an I/A report for a fall R63 sustained on 2/4/25, but R63 said they did not fall they put themselves on the ground. It was noted there was no root cause analysis investigation into why R63 put themselves on the floor nor any new interventions implemented after R63 was found on the floor. A progress note and an I/A report for a fall R63 sustained on 2/26/25. The I/A report indicated R63 was alert and oriented to person, situation, and time. The progress note documented R63 saying they were trying to get out of bed, however; neither the note or the I/A demonstrated an investigation into the root cause analysis of the fall. An I/A report dated 3/11/25 that indicated R63 had an unwitnessed fall out of bed, the document indicated R63 reported they were trying to get out of bed. It was noted Nurse 'CC' who initiated the I/A report did not document a progress note and the first progress note in the record regarding the fall was entered by Nurse Practitioner 'DD' who sent the resident to the emergency room . Neither the I/A report or progress notes demonstrated an investigation into the root cause analysis of the fall, nor was there an intervention implemented immediately after the fall. An I/A report dated 4/9/25 that indicated R63 slid out of their dialysis chair in front of the nursing station. The accompanying nursing note for the fall entered into the record on 4/9/25 at 1:59 PM read, .resident slid out of hemodialysis chair and during assessment noticed left side of chair was not latched causing the resident to slide out of the chair . It was noted the care plan did include an intervention for a dycem pad the day after the fall, but did not include any interventions that ensured the chair was latched. An I/A report dated 4/17/25 at 4:46 PM entered into the record by Nurse HH that indicated R63 had an unobserved fall from bed and sustained a skin tear to their right arm. Neither the I/A nor the progress notes demonstrated an investigation into the root cause analysis of the fall, and no immediate intervention was placed on the care plan after the fall. An I/A report dated 5/4/25 that indicated R63 had an unwitnessed fall in their room. Neither the I/A report nor the progress notes demonstrated an investigation into the root cause analysis of the fall and it was further noted no interventions had been added to the care plan for the fall. On 5/22/25 at 1:11 PM, an interview was conducted withe the Director of Nursing (DON) regarding falls. They were asked what the nurses were to do after a fall and said they were to assess the resident, implement an immediate intervention after the fall, and make notifications to appropriate people regarding the fall. They were asked if they were to document a progress note aside from initiating the I/A report and they said they were. They were then asked who performed the root cause analysis in an attempt to reduce falls and they said the interdisciplinary team met after falls and they were to perform the root cause analysis investigation. A review of a facility provided policy titled, Fall Management revised 9/2023 was conducted and read, The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls .If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk evaluation, treatment, evaluation, and monitoring of resident falls .4. The licensed nurse will complete: .Review and/or revise care plan Document in the medical record an on the 24 Hour Report . 47283 Deficient Practice #2 Based on observation, interview, and record review facility failed to maintain a comfortable/safe home like environment for R78 (with seizures and history of falls) from exposed sharp areas in bed due to missing foot board with potential for injuries and failed to appropriately use the power strip (two power strips connected to another powerstrip), with potential to affect multiple residents residing near/using the conference room. Findings include: R78 Record review revealed R78 was long-term resident for the facility, admitted on [DATE]. R78's admitting diagnoses included seizures, history of falls, stroke with left sided weakness, and dementia. Based on the Minimum Data Set (MDS) assessment dated [DATE], R78 had Brief Interview for Mental (BIMS) score of 9/15, indicative of moderate cognitive impairment. An initial observation was completed on 5/20/25 at approximately 10:45 AM. R78 was observed in a bariatric (wider) bed. The bed had a concave mattress/wing-tip (mattress with raised sides). The bed did not have a footboard and the sharp areas and hardware from the frame were exposed. R78 was unable to explain when asked about the footboard. Two additional observations were made later that day at approximately 11:45 AM and 5:00 PM. The bed did not have a footboard and the hardware/sharp areas were exposed. Follow-up observations were completed on 5/21/25. At approximately 9:10 AM, R78 was observed in their bed with their eyes closed. A wheelchair was parked in the at the foot end of the bed. The bed did not have a footboard and the sharp areas were exposed. During follow up observations completed at approximately 1:15 PM, R78 was not in their room. The bed did not have a footboard. At approximately 4:35 PM, R78 was in their bed sleeping. The bed did not have a footboard and the sharp areas and hardware were exposed. On 5/22/25, at approximately 8:35 AM, an observation was completed from the doorway. R78 was observed in their bed. The bed did not have a footboard and sharp areas and hardware were exposed. Review of R78's Electronic Medical Record (EMR) revealed that R78 was at risk for falls due to left sided weakness, seizures, muscle spasm, dementia, etc. and interventions included keep the (name omitted) environment as safe as possible: floor free from spills and or clutter, adequate lighting, call light within reach, commonly used items within reach, avoid repositioning furniture, and keep bed in appropriate position and (name omitted) requires a win-tip mattress for perimeter awareness . The care plan also revealed that R78 was at risk for injury and complications related to their diagnosis of seizure disorder. Further review of care plan revealed R78 had impaired visual function related to age related nuclear cataract and interventions included orient to surroundings as needed. An interview with Director of Nursing (DON) was completed on 5/21/25 at approximately 2:35 PM. The DON reported that they were covering for the unit as they were in the process of hiring a unit manager. They were queried if they were aware of the bed with missing a footboard and they reported that they were not aware. The observations and concern associated with the missing foot board for R78 were shared with the DON. The DON reviewed R78's EMR and reported that the resident was a fall risk and they agreed with the concern. They added that they would follow up with maintenance and address fix the bed. An interview with Maintenance Director was completed on 5/22/25 at approximately 9:20 AM. They were queried about the facility's environmental safety rounds process. They reported that they were completed either by them or their assistant daily and as needed. They were queried about the missing footboard in a bariatric bed for resident who was fall risk with exposed hardware and sharp areas. Maintenance Director reported that they were unaware of the situation and they asked the room number and they reported they would address it. Later that day, the maintenance director came back and reported that the maintenance assistant had installed the footboard. They added that the footboard that was in R78's room, staff might have removed it to use Hoyer. An interview with Certified Nursing Assistant (CNA) JJ was completed at approximately 1:35 PM. CNA JJ was working on the unit in the adjacent hallway and they reported they were familiar with the residents and process. They were asked to explain the Hoyer lift process and if they removed the bed foot board to perform the lifts. They explained they performed the transfers from the sides of the bed and they moved the bed to one side. On 5/22/25 at approximately 12 PM, the facility administrator was notified of the concern and observations for R78. A facility provided document titled Environmental Rounds Policy and Procedure with a revision date of 4/29/22 read in part, Purpose: The purpose of environmental rounds is to ensure facility standards reflect federal, state, and local regulations, and to ensure that all guest/resident needs are met. Procedure: 1. The Maintenance Director/designee and /or Housekeeping Supervisor will conduct facility rounds at least five (5) days per week using the Facility Tour Audit Tool. 2. The Administrator will be responsible to in-service the Maintenance and Housekeeping Managers regarding how to use the Facility Tour Audit Tool, standard observations that are considered acceptable, and how to report a concern. 3. When issues are found they will be corrected and addressed by the appropriate department head. Staff members will be educated on corrective action needed to prevent repeated concerns. The completed Facility Tour Audit Tool will be provided to the Administrator for review during the Quality Assurance Performance Improvement Committee and for trend tracking. 39592 On 5/20/25 at approximately 8:35 AM, observation of a conference room at the facility revealed two power strips plugged into another power strip. This conference room was not a patient care area. However, this conference room was used for care conferences with residents and their families. In addition, according to the floor plan, part of one of the conference room wall was shared with a residents' room. Upon unplugging one the the power strips from the one directly plugged into the wall, it was observed the ground pin (third prong - protects against sparks and surges) was missing. On 5/22/25 at 1:42 PM, the Maintenance Director was interviewed and asked about the two power strips plugged into another power strip. The Maintenance Director explained he had been unaware of that, and a power strip should only ever be plugged directly into a wall, never another power strip. When shown the missing ground pin on the one power strip, the Maintenance Director immediately removed the strip from the room and explained he would get rid of that power strip. On 5/22/25 at 1:50 PM, the Administrator was interviewed and informed of the two power strips plugged into another power strip, and one missing the ground pin. The Administrator explained that should not happen, but it might have been like that for a while.

Based on observation and interview, the facility failed to ensure proper storage of medications for four of eight medication carts reviewed for medication storage. Findings include: On 5/21/24 at 9:02 AM, an observation of the [NAME] Unit #1 Medication Cart was conducted with Licensed Practical Nurse (LPN) Q. The following medications were observed throughout the cart unpackaged and without patient identifiers: A plastic cup was observed in drawer #4 containing a clear liquid, and a plastic spoon. LPN Q said it was MiraLAX, (laxative solution medication) for another resident and they kept it in there to give it time for it to dissolve. Three Styrofoam cups were observed dented, dirty, with debris at the bottom of each cup. One cup observed storing two loose double AA batteries amongst three packaged antibiotic ointment and packaged syringes. Second Styrofoam cup observed storing a small black flashlight with two packaged Biofreeze (topical analgesic) and three packaged antibiotic ointment packages. Third Styrofoam cup was observed storing packaged syringes, and antibiotic ointment packages. Compartment storing one bottle of orange flavored fiber powder and one bottle of acetaminophen (pain reliever, fever reducer) amongst three bottles of UTI-Stat Cranberry (ready to drink medical food for urinary tract health). All five bottles were observed sticking to the base of shelf from overspill of the UTI-Stat Cranberry liquid. The Narcotic box was observed with a one loose peach round colored pill identified with the letter R. LPN Q was observed picking up medication with their bare hand and placed on top of the cart. LPN Q did not provide any comment of the above findings. On 5/21/24 at 9:22 AM, an observation of the [NAME] Unit #2 Medication Cart was conducted with LPN N. The following medication was observed throughout the cart unpackaged and without patient identifiers: One bottle Saline nasal spray was observed with unidentifiable black marker writing worn off, stored in a clear plastic cup with the numbers 627 written around the cup. LPN N acknowledged there was no patient identifiers and was not stored properly. On 5/21/24 at 9:40 AM, an observation of the Oakland Unit #2 Medication Cart was conducted with LPN B. The following medication was observed throughout the cart unpackaged and without patient identifiers. Compartment labeled 142-2 was observed with two small white half tablets of an unidentifiable medication lying on base of drawer. Compartment labeled 145 was observed storing a loose packaged medication labeled Amlodipine (medication to treat high blood pressure) 5 MG. LPN B acknowledged the medications were not stored properly and did not have patient identifiers. On 5/21/24 at 11: 36 AM, an observation of the Lower Michigan Medication Cart was conducted with LPN I. The following medications were observed throughout the cart unpackaged and without patient identifiers: Compartment labeled 259 one capsule of Omeprazole (medication for excess stomach acid) was observed loose with no patient identifier. LPN I identified in Drawer # 4, two liquid breathing inhalation vials without resident identifiers stored in the back of the cart drawer. One tablet of Lasix (medication to treat fluid retention and/or high blood pressure) 40 mg on the bottom drawer with no patient identifier. The facility policy titled; Medication/Treatment Cart Use 8/15/23 documented: .Medications/Treatment carts are to be kept clean and sanitary. Each shift is responsible for the cleanliness of the cart, including drawers and top of cart . On 5/22/25 at 10:51 AM, The Director of Nursing (DON) acknowledged the concerns of the cleanliness and loose medications without patient identifiers from the four medication carts reviewed.

Based on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent. Four medication errors were observed from a total of 26 opportunities for three (R11, R120, R124) out of four residents reviewed during medication administration, resulting in an error rate of 15.38%. Findings include: R11 On 5/21/25 at 8:47 AM, a medication observation was conducted with Licensed Practical Nurse (LPN) Q for R11 and was observed providing Midodrine 10 milligram (mg) (medication to treat low blood pressure). LPN Qwas ordered to give one tablet by mouth with meals for hypotension hold if Systolic Blood Pressure (SBP) >105. LPN Q administered this medication with R11's SBP of 122. LPN Q was observed instilling four drops into the right eye and two drops into left eye. The order is to instill Artificial tears Ophthalmic Solution one drop in both eyes two times a day for dry eyes. On 5/22/25 at 10:31 AM, an interview was conducted with the Director of Nursing (DON) and acknowledged LPN L should have given the correct medication as ordered by the Physician orders. 39592 R120 On 5/21/25 at 8:14 AM, as part of the medication pass task, LPN A was observed to mix 17 grams (g) of Polyethylene Glycol Powder (a laxative) in water in a small cup. LPN A also prepared two oral medications. LPN A entered R120's room, gave them the two prepared oral medications, then hand R120 the small cup of water with the Polyethylene Glycol Powder mixed into it. R120 put the two oral medications in their mouth, and took two sips of the Polyethylene Glycol Powder mixture, and handed the full cup back to LPN A. LPN A asked R120 if they wanted to finish the cup. R120 explained they only wanted enough to swallow the medication. LPN A then took the full cup with the Polyethylene Glycol Powder mixture in it and dump it into the sink in the bathroom and throw away the cup. On 5/21/25 at 9:15 AM, R120's May 2025 Medication Administration Record (MAR) was compared to the medications observed to have been given. The reconciliation revealed LPN A marked the Polyethylene Glycol Powder as given. R124 On 5/21/25 at 8:29 AM, LPN B was observed to prepare eight medications, including Senna 8.6 milligrams (mg) (a laxative). LPN B entered R124's room and gave them the prepared medications. On 5/21/25 at 9:18 AM, R124's physician orders were compared to the medications observed to have been given. The reconciliation revealed R124 had an order for Senna-S (Sennosides-Docusate Sodium) 8.6-50 mg. It should be noted Senna-S is prepared with a stool softener as well as a laxative. On 5/21/25 at 1:52 PM, the DON was informed of R120's MAR documenting the Polyethylene Glycol Powder as given when R120 did not take all the medication, and R124 being given on Senna when Senna-S was ordered. The DON acknowledged the concern. Review of a facility policy titled, Medication Administration revised 10/17/23 read in part, .Verify the medication label against the medication administration record for resident name, time, drug, dose, and route .Record the result of medications administered as necessary .Record the dose, route, and time of medication on the Medication/Treatment Administration Record. Document if the resident refused .

Based on interview and record review the facility failed to ensure freedom from unnecessary antibiotic therapy for five residents, (R#'s 92, 16, 6, 20, and 91) of five residents reviewed for unnecessary antibiotic use, resulting in the potential for the development of antimicrobial resistance. Findings include: On 5/22/25 at 10:45 AM, a review of the facility's infection control program for the month of March was conducted and revealed the following: R92's facility acquired infection type on the line listing was documented as, Unknown. The line listing did not indicate any signs and symptoms for an infection or any lab results obtained and further documented they had been put on an antibiotic. A progress note in the record dated 3/20/25 read, .resident started on ABT (antibiotics) .no fever. continue having hematuria . R16's facility acquired infection on the monthly line listing documented they had a urinary tract infection. The only documented sign and symptom was, Dark urine, and there was no evidence of urinalysis/culture and sensitivity lab. The report further indicated R16 received an antibiotic for treatment. R6's facility acquired infection on the monthly line listing documented they had a urinary tract infection. The only sign and symptom listed was Dysuria (pain/burning with urination). There was no evidence of a urinalysis/culture and sensitivity lab, and it was documented R6 received an antibiotic for treatment. R20's facility acquired infection on the monthly line listing documented R20 had an Escherichia Coli (E. coli) infection. The report did not indicate the type of infection (urinary tract, gastrointestinal, respiratory, etc), the signs and symptoms listed were Altered mental status, Functional decline. The line listing did not indicate any labs had been completed and it was documented R20 received an antibiotic for treatment. On 5/22/25 at 11:10 AM, a review of the facility's infection control program data for the month of April was conducted and revealed the following: R91's facility acquired infection documented on the monthly line listing documented they had a urinary tract infection. The only documented sign and symptom was the resident saying they had a fever. It was further documented on the line listing R91's infection did not meet McGeer's Criteria (guidelines to help identify signs and symptoms of infection and assist to determine the appropriateness of antibiotic therapies) but they were treated with antibiotics. R20's facility acquired infection documented on the monthly line listing documented they had a urinary tract infection. The only documented sign and symptom was, Fatigue. It was further documented R20's infection did not meet McGeer's Criteria and they were treated with antibiotics. On 5/22/25 at 11:27 AM, an interview was conducted with the facility's Infection Control Preventionist, Nurse 'M'. They were asked about the March data and had no explanation as they had only been overseeing the program for approximately three weeks. They were then asked about the April data and all of the infections that did not meet McGeer's criteria being treated with antibiotics. The said they would soon be working closer with the prescribers to ensure residents had the symptoms and labs to meet McGeer's Criteria either prior to placing them on antibiotics, discontinuing unnecessary antibiotics, or having the prescribers ensure they documented a clinical rationale to continue antibiotics in absence of meeting McGeer's Criteria. A request for a policy on unnecessary medications was requested, however; it was not received by the end of the survey. A review of a facility provided policy titled, Infection Control Antibiotic Stewardship & MDROs (multiple drug resistant organisms) revised 4/2025 was conducted and read, .Antibiotic stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials, by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration .9. Healthcare acquired (nosocomial) infections and use of antimicrobial agents will be tracked and trended The facility has adopted the McGeer's criteria for infection surveillance and definitions .10. The facility will communicate with the physician based on guest/resident history, evaluation, signs and symptoms, and diagnostic tests if applicable of suspected guest/resident infections to determine the best course of treatment .

Based on observation, interview, and record review, the facility failed to ensure a splint/ positioning device (palm protectors) and range of motion were implemented for one (R49) of two residents with hand contractures (hardening of the muscles, tendons, and other soft tissues) reviewed for positioning and range of motion(ROM) resulting in the potential for contracture progression, pain, and further decline in range of motion with compromised skin integrity. Findings include: R49 Record review revealed R49 was a long-term resident of the facility. R49 was originally admitted to the facility on [DATE]. R49 was recently admitted to hospital on 3/13/25 with pneumonia and readmitted to the facility on [DATE]. R49's admitting diagnoses included chronic kidney disease, dysphagia (difficulty with swallowing), anemia, dementia, and heart failure. R49 also had a stage 3 pressure ulcer (Merck manual defines a stage 3 pressure ulcer as a full-thickness skin loss with damage to subcutaneous/fat tissue extending down to [but not including] the underlying fascia. The ulcers are crater-like without underlying muscle or bone exposure) on their coccyx (tail bone area) that they had acquired during the stay the facility. Based on the Minimum Data Set (MDS) assessment dated [DATE], R49 had a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. R49 had contractures in both hands and they were dependent on staff assistance with all their activities of daily living (ADLs) such as eating, dressing, bathing etc. and they were dependent on staff assistance for their mobility in bed and transfers. R49 was receiving hospice services as of 3/25/25, after their recent readmission to the facility. An initial observation was completed on 5/20/25 at approximately 9:40 AM. R49 was observed in bed, laying on their back and had a small pillow of wedge under their upper back on the left side. R49 had a low air loss mattress (specialty mattress) due to the stage -3 pressure ulcer on their coccyx. R49 was lying in bed with both arms on their chest. Both hands were in a clenched position, with both ring and little fingers in contact with the palm of the hands. R49 did have any type positioning device to maintain their range of motion in their hands. R49's family members were sitting next to them and they reported that they regularly visited R49 multiple times every week and they would spend a few hours at each visit. At approximately 10:10 AM, R49 was observed in the same position, laying on their back as before. R49's family member was in the room. The Family member was queried about any braces for R49's hands. The family member reported that R49 used to have some device for their hands so their fingers would not get tight. They have not seen the staff using it recently and they were in the drawer and not sure what happened. They added that when R49 was at the hospital in March, they were using rolled wash cloths on both of R49's hands and was not sure why they were not following it at the facility. Later that day at approximately 5:10 PM, R49 was observed in their bed with their arms on their chest. Both hands were in a clenched position, with their ring and little finger in contact with the palm of the hands. R49 did not have any devices or rolled wash cloths on their hands. When the surveyor asked R49 if they were able to move their fingers, R49 moved their thumb, index, and middle fingers on both hands minimally. Both the ring and little finger were in contact with the palm of hands. On 5/21/25, multiple follow-up observations were completed. At approximately 8:15 AM, R49 was observed in their bed, laying on their back. R49 had a small wedge under their left upper back. They were awake and grimacing moving their arms and trying to reposition themselves. They appeared uncomfortable. R49's arms were resting on their chest with both elbows bent and both hands in a clenched position. R49 did not have any devices on their hands. There were two palm protectors (a device worn on the hand to maintain finger mobility and prevent fingers from digging into the palm, which can cause skin damage or sores) on top of the nightstand, on the left side of the bed. At approximately 10:20 AM, when this surveyor went into R49's room, they were observed in the same position, laying on their back. R49 was grimacing and when asked how they were doing and nodded their head no and did not answer. Their arms were resting on their chest with both hands in a clenched position. The two palm protectors were observed on top of the nightstand. R49 did not appear comfortable. At approximately 12:10 PM, R49 was observed sitting on a Geri-chair (recliner chair with wheels used for patients with impaired mobility that are unable to sit upright in a wheelchair) in the hallway near the nurse's station and a Certified Nurse Assistant (CNA) was pushing the chair. R49 did not have any splints/devices on their hands. Both hands were in a clenched position. At approximately 1:10 PM, R49 was observed in their room, sitting up on their recliner chair. R49 was watching TV. R49 did not have any device on their hands. Both hands were in a clenched position. The palm protectors were on top of the nightstand. Review of R49's Electronic Medical Record (EMR) revealed that they were receiving wound care treatment for the pressure ulcers. Review of R49's mobility care plan did not include any interventions to address the range of motion limitations with risk for further compromise of skin integrity in both hands. Review of R49's EMR revealed that quarterly therapy screening forms. Review of the most recent screening form dated 3/6/25 revealed that a screen was completed, recommendations states no action required. The comments section under range of motion were blank and there was no rationale why there were no recommendations. Review of R49's therapy screen history revealed that interdisciplinary rehabilitation screens were completed on 12/4/24, 9/4/24, and 6/4/24 with recommendations that read no action required with no rationale on why there were recommendations for maintenance programs by nursing staff. Further review of the EMR revealed a restorative referral dated 5/3/24. The plan read Daily for PROM (passive) range of motion (staff performs the range of motion) prior to donning of left palm protector and right palm protector and patient to wear each 4-6 hours per day or as tolerated with skin checks to prevent contractures. The EMR did not have any further documentation about why the plan was discontinued and why quarterly therapy screens did not address R49's contractures or nursing maintenance plan. Review of R49's Kardex (CNA - care plan) did not reveal documentation about splint care. An interview with Licensed Practical Nurse (LPN) EE was completed on 5/21/25 at approximately 1:20 PM. LPN EE was assigned to care for R49 during that shift. They were queried about the plan of care for R49's hand contractures. LPN EE stated that they had seen the braces that staff (CNAs) should be putting them on. They added that R49 holds their hands were tight and they should have it on. After they reviewed the EMR they reported that they did not see it on the care plan and they were not sure why it was not addressed on the care plan. They added that they saw the braces on R49's nightstand. An interview with a Certified Nursing Assistant (CNA) Z was completed on 5/21/25 at approximately 1:25 PM. They reported that they had been working at the facility for approximately 1.5 years and they were very familiar with R49. They were queried about the daily care they were providing for R49. CNA Z reported that they were assisting with basic ADL care, Foley (urinary catheter) care, showers, and they were assisting resident out of bed 4-5 days in their recliner chair. When queried if they were doing any thing for their hands, CNA Z restorative would put the brace on whenever they could and CNAs were not doing anything for R49's hand contractures. An interview with Therapy Director (TD) F was completed on 5/21/25 at approximately 2:40 PM. TD F was asked about the screening and referral process for maintenance program with nursing. They reported that R49 was recently screened after readmission and R49 was receiving hospice services and that did not make recommendations for hospice residents. The recent screen after readmission was not in EMR, most recent screen was dated 3/7/25. They also did not provide any rationale on why R49's maintenance program with nursing was not addressed in their previous quarterly screens from 2024. TD F agreed that R49 would benefit with maintenance program by nursing and use of palm protectors for their hand contractures. An interview with Director of Nursing (DON) was completed on 5/21/25 at approximately 2:25 PM. The DON reported that they were in the process of hiring the assistant director of nursing and they were assisting with the restorative program. They were queried about R49 and what were plans for their bilateral hand contractures. The DON reported that they knew R49 well and they had braces for both hands. They added that nursing staff were aware that they should be using the braces. They reviewed R49's records and reported that they were not sure why there were no orders and a care plan. The surveyor shared the observations with the DON. The DON reported that they understood the concerns and they would follow up. Facility policy for restorative/nursing maintenance program was requested via e-mail on 05/22/2025 at 7:04 AM. The Policy was not received prior to the survey exit.

This citation has two deficient practice. Deficient Practice #1 Based on observation, interview and record review, the facility failed to implement Physician orders for blood pressure monitoring and administration of medication based on ordered parameters for one resident (R11) of two reviewed for medication administration. Findings include: Clinical record review revealed R11 was admitted to the facility requiring long term services on 5/3/24 and had a medical history including heart disease and hypotension (low blood pressure). R11's cognition was intact with a Brief Interview of Mental Status (BIMS) score of 13/15 assessed on 5/13/25. On 5/21/25 at 8:47 AM, a medication observation was conducted with Licensed Practical Nurse (LPN) Q for R11. LPN Q was observed taking the blood pressure and resulted at 122/77 and was observed providing Midodrine (medication to treat low blood pressure). On 5/21/25 at 1:44 PM, a record review was conducted to reconcile R11's medication administration. The Medication Administration Record (MAR) from May 2025 revealed the following Physician Order and parameter to administer Midodrine 10 milligram (mg) give one tablet by mouth with meals for hypotension hold if (Systolic Blood Pressure) SBP >105. The MAR documented from 5/1/25 until 5/21/25 at 8:00 AM, Nursing administered the Midodrine medication 23 times with a documented SBP >105. On 5/22/25 at 2:12 PM, The Director of Nursing (DON) was provided with the MAR documenting administration of the Midodrine outside of the ordered parameters to R11 and acknowledged Nursing did not follow the Physicians Orders. The DON acknowledged the concern, confirmed this was not acceptable and will address the Nursing staff. Review of the facility Policy titled; Medication Administration 10/2023, documented: .Medications are administered in accordance with written orders of the attending physician .The nurse is responsible to read and follow precautionary instructions . 34208 Deficient Practice #2 Based on observation, interview, and record review, the facility failed to ensure scheduled Hospice visits were completed for one resident, (R19), of one resident reviewed for Hospice services, resulting in R19 not receiving their scheduled end of life care visits. Findings include: On 5/20/25 at approximately 10:30 AM, R19 was observed in their room in bed asleep. A review of R19's clinical record revealed they most recently readmitted to the facility on [DATE] with diagnoses that included; dementia, pressure ulcers, osteomyelitis, diabetes, adjustment disorder, and depression. Further review of the record indicated R19 had been signed onto Hospice Services on 5/2/25 by their activated durable power of attorney for healthcare. A review of the Hospice documentation including the plan of care, visit schedule, sign-in logs, and progress notes was conducted and revealed R19 was to have Hospice Aide visits twice a week, scheduled for 5/5/25, 5/7/25, 5/12/25, 5/14/25 and 5/19/24. The sign-in logs and progress notes revealed that of the five scheduled dates the Hospice Aide was to visit R19, an aide visit only occurred on 5/14/25. On 5/21/25 at 2:19 PM, an interview was conducted with Nurse/Social Services Staff 'E' regarding coordination with Hospice care. They were asked specifically who monitors the Hospice contract staff to ensure they are performing the services per the contract and plan of care. They explained the Hospice Social Workers follow up with Social Services in the building and the nurses follow up with resident's assigned nurse on the day they provide services. They further indicated Hospice Staff were expected to document a progress note regarding their visit. They were then asked about who was monitoring the the Hospice Aides and said there wasn't a process in place to follow-up on the aide visits. A review of a facility provided policy titled, Hospice Care revised 8/2023 was conducted and read, When a facility resident elects to receive hospice care, the facility staff communicates with the hospice agency to establish and agree upon a coordinated plan of care that is based on an evaluation of the resident's needs and living situation in the facility .Guidelines .4. Ensure that the plan of care identifies the care and services which the facility and hospice agency will provide in order to be responsive to the unique needs of the resident and their expressed desire for hospice care .Documentation .2. Hospice .notes related to resident's visits and plan of care are to be maintained in the medical record .

Based on interview and record review, the facility failed to implement their abuse policy that requires complete background checks for newly hired staff for one (Certified Nursing Assistant/CNA 'X') of five staff members reviewed for criminal background checks. Findings include: A review of CNA 'X's employee files was completed to ensure the facility completed the appropriate criminal background screening upon hire which was 1/21/25. (The facility had been out of compliance with this regulation during an abbreviated survey on 4/10/25 with an alleged compliance date of 5/8/25.) Review of their personnel file revealed a fingerprint-based criminal history check dated 7/13/18. There was no documentation that this had been completed upon their employment on 1/21/25. Further review of the MICHIGAN WORKFORCE BACKGROUND CHECK CONSENT AND DISCLOSURE dated 1-17-2025 documented the Facility Name as [facility name redacted for another nursing facility not under same ownership]. The section of this document which prompts the employee to complete by initialing and dating was left blank for .Employment Applicant Disclosure Statements .I hereby certify that: a. I have not been convicted of 1 or more of the crimes described in subsection (1) (a) through (g) of MCL (Michigan Compiled Law) 333.20173a, MCL 330.1134a, or MCL 400.734b within the applicable time period described in each subdivision. Initial (left blank) Date (left blank) b. I have never been found Not Guilty by Reason of Insanity. Initial (left blank) Date (left blank) c. I have never been the subject of a substantiated finding of neglect, abuse, or misappropriation of property resulting from an investigation conducted in accordance with 42 USC (United States Code) 1395i or 1396r. Initial (left blank) Date (left blank) If you are not able to certify a, b, or c above, please explain below (left blank) . Further review of the OIG (Office of Inspector General) search results included in CNA 'X's personnel records revealed a search result date of 3/24/25, 4:06 PM. These were not completed prior to employment at the facility on 1/21/25. Further review of the ICHAT (Internet Criminal History Access Tool) search results included in CNA 'X's personnel records revealed a search result date of 4/15/2025 12:32:30 PM. These were not completed prior to employment at the facility on 1/21/25. On 5/22/25 at 12:22 PM, an interview was conducted with the Administrator. At that time, the Administrator was asked about CNA 'X's lack of current fingerprint-based criminal history check, delayed ICHAT and OIG search results and who was responsible for auditing to ensure those were completed. The Administrator confirmed they were recently cited for non-compliance with this exact concern and further reported the HR (Human Resources) Director was responsible for ensuring those were completed, but they were on vacation this week. The Administrator was asked to clarify the incomplete Michigan workforce background check consent and disclosure application, including why another nursing home was listed. They reported they would have to follow-up. The Administrator attempted to contact the HR Director by phone and left a message. The Administrator was also informed this surveyor would like to also interview the HR Director by phone (no further response by the end of the survey). The Administrator reported they had obtained the documentation for the employee criminal history checks from other binders they were kept in and would look again to see if there was any additional documentation. The Administrator confirmed CNA 'X's hire date was 1/21/25 and the Administrator had just pulled up the same result of the fingerprint-based criminal history online and confirmed the only results they had was from 7/13/18 and confirmed none had been completed upon their re-hire in 2025. On 5/22/25 at 1:30 PM, the Administrator reported they think the issue with another nursing home being documented as the requesting facility was due to the employees having the ability to enter this information in manually when completing their applications. The Administrator reported that had since changed to now the employee is not able to enter that information manually. When asked why the facility had not identified the application was completed, especially during their process for auditing compliance since the recent abbreviated survey and alleged compliance date of 5/8/25. The Administrator reported when the facility was completing the audits, they only looked at the name of the facility and staff name, and didn't look at the dates. The Administrator acknowledged CNA 'X' was a previous employee but should've had a new fingerprint-based criminal history completed upon rehire. The Administrator was requested to provide dates of employment. On 5/22/25 at 2:20 PM, the Administrator provided employment dates for CNA 'X' which documented they had previously worked at the facility from 7/17/18-6/21/19 and rehired on 1/21/25-present. Review of the time-punch details and assignment documentation identified CNA 'X' continued to work beyond the facility's alleged compliance date of 5/8/25 on: 5/17/25, 5/18/25, 5/20/25, 5/21/25, and 5/22/25. According to the facility's policy titled, Abuse Prohibition dated 10/14/22: .Screening Employees and Guests/Residents 1. The facility will screen potential new employees for a history of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law (This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries and background checks per state guidelines). The facility will not hire anyone with disciplinary action in effect against a professional license by a state or licensing board. 2. Without exception, all potential licensed and certified candidates must have their status confirmed with the appropriate boards to verify license/certification and to determine if any action has been taken against the license or certification .The facility will assess all new employees during their probationary period to determine the appropriateness of their employment and/or to determine their need for further training .

Based on observation, interview, and record review facility failed to maintain a clean homelike environment with unkempt common/resident areas/hallways and failed to maintain comfortable sound levels in resident areas. This deficient practice had the potential to affect multiple residents including (R102 and R284) with the potential for unsatisfactory living conditions and feelings of frustration. Findings include: During the initial tour of the facility on 5/20/25 at approximately 8:45 AM, there were multiple large brown stains (approximately over 10 inches in diameter) on the carpet in the hallways outside of room #s 170, 171, 180 and multiple areas in common area in front the nurses' station and the hallway leading to rooms 184/187. Some of these stains were over a foot wide. Multiple residents were observed sitting in the lounge/common area front of the nurses' station throughout the day. R102 Record review revealed R102 was a long-term resident of the facility. R102 was originally admitted to the facility on [DATE]. R102's diagnoses included seizures, depression, and history of falls. Based on the Minimum Data Set (MDS) assessment dated [DATE], R102 had a Brief Interview of Mental Status (BIMS) score 15/15, indicative of intact cognition. An initial observation was completed on 5/20/25 at approximately 11:50 AM. R102 was sitting up in their wheelchair. They were asked about the quality of their stay at the facility. R102 reported that they had one ongoing concern that was brought up to the attention of facility's leadership. When queried further, R102 reported that the staff were loud at night times. R102 pointed to the adjoining wall to the clean linen closet and the window and reported that staff were loud, they could hear everything at night from the next room and from outside. They added that door to the linen room was slamming so hard and they had reported that on several occasions and it was recently fixed. When queried further R102, added that they had brought the concerns to the attention of Social Service Director (SSD) E. A follow-up interview was completed on 5/22/25 at approximately 9:25 AM. R102 was laying on their bed and they had their headphones on. They were queried about the noise levels on the night of 5/21/25. R102 reported that they did not hear anything from outside the window, and added it was loud from the room next door/linen closet. The added it was not door; this was staff talking in the next room. On 5/22/25 at approximately 1:40 PM, two staff members were observed sitting at the Oakland nurse's station. There were 2 residents sitting in front of the nurse's station. The staff members were talking loudly about the weekend birthday parties and personal affairs and one staff member had their earphone on. Review of R102's care plan revealed a history of past trauma, insomnia (trouble sleeping), severe anxiety etc. An interview with SSD E was completed on 5/22/25 at approximately 10:15 AM. They were queried if any resident had brought up concerns of staff being loud. They reported that they did not recall and when mentioned about R102, SSD E reported that they remembered. They added that R102 mentioned about the door in the next room was loud and they did not recall anything about staff being loud. They added that they would speak with R102 and follow-up. An interview with the Director of Nursing (DON) was completed on 5/22/25 at approximately 11:10 AM. They were queried if the concern about the noise level at the facility at night times were brought up. The DON reported that it was brought up in resident council before and they had educated the staff. When queried about who was monitoring the staff, they added that they did not have any off-shift managers and added they did not know it was ongoing and they would follow-up. An interview with facility Administrator was completed on 5/22/25 at approximately 12 PM. They were notified of the ongoing concerns of staff being loud at night times. The Administrator reported that the concern was brought up in Resident Council before and they had addressed their team by informal education via their communication application. A facility policy received via e-mail titled Environmental Rounds Policy and Procedure did not address the general cleanliness of resident areas, noise levels, etc. The policy quoted a document titled facility tour audit tool which was not attached with the policy. 39592 R284 On 5/20/25 at 9:43 AM, R284 was observed sitting on their bed. R284 was asked about care at the facility. R284 explained they did not sleep well because the staff were talking and laughing loudly in the hallway at night. Review of the clinical record revealed R284 was admitted into the facility on [DATE] with diagnoses that included: congestive heart failure, end stage renal disease and pulmonary hypertension. According to a Brief Interview for Mental Status (BIMS) exam dated 5/16/25, R284 was cognitively intact. On 5/21/25 at 9:35 AM, R284 was observed lying in bed. R284's door was closed, and staff could be heard talking in the hallway. R284 explained the staff at night were much louder than what could be heard presently, and it kept them awake. 49083 On 5/20/25 at 11:33 AM, a tour of the [NAME] Community/Television area was observed with the entire floor perimeter soiled with crumbs, dirt and unidentifiable debris. The flooring throughout and in front of the furniture was observed sticky. Underneath the sitting chairs and coffee tables were observed with straw wrappers, popcorn kernels, and other unidentifiable debris. The left front corner underneath the window was observed with dead insects and nests. Behind the garbage can, moderate amounts of garbage was observed, and the floor was sticky appearing with debris and wrappers. One resident was observed sitting in one of the chairs watching TV in front of the fireplace. An interview with Certified Nurse Assistant (CNA) CNA FF confirmed residents occupy this area frequently throughout all hours of the day and daily. The common sitting area entrance into the 600 Hallway with chaise lounges and chairs were pulled forward and revealed moderate amounts of unkempt carpeting with food (corn chips and popcorn kernels) straw wrappers, foil wrappers and a smashed medicine cup. The entire perimeter of the carpeted area had noticeable dust and debris. The Exit door labeled #8 was observed with visible dead insects/webs in and around the top and side perimeter of the door. The Exit door labeled #9 was observed with visible dead insects (moth) around the top and side perimeter of the door. The Personal Protective Equipment (PPE) cart stored in the hallway for room [ROOM NUMBER] was wheeled forward exposing moderate amounts of dust, dirt, and debris underneath. On 5/22/25 at 10:17 AM, an Interview and observation tour was conducted with Housekeeping Director (HKD) R at which time they confirmed what roles and timeframes are expected of housekeeping. The observations made on 5/20/25 at 11:33 AM, were still present during this interview/tour. HKD R confirmed the common sitting area entrance into the 600 Hallway should be maintained and vacuumed once a week and was not maintained. Housekeeping is also responsible for pulling PPE carts so the underneath area can be swept and cleaned daily and acknowledged this was not done. The exit doors are to be cleaned weekly. HKD R acknowledged this was not done. The common resident television area is to be maintained by housekeeping daily. Informed the observations made on 5/20/23 were still present, HKD R confirmed the facility had recently terminated three housekeepers. HKD R acknowledged the areas of concern were not cleaned and was not a sanitary environment. HKD R commented they were embarrassed of these observations and would be addressing immediately at the conclusion of our interview.

Based on observation, interview and record review facility failed to demonstrate evidence of follow-up and resolution to resident group concerns related to water pass, follow-up on lost/damaged clothes and personal laundry process for four of eight residents that participated in the confidential resident group interview, resulting in ongoing concerns and dissatisfaction with levels of service and feelings of frustration. Findings include: A confidential Resident Council meeting on 5/21/24 at 11 AM was held with eight anonymous residents. During the meeting, four of eight residents expressed concerns with the facility's personal laundry process and how they did not get their clothes back timely and they got lost and or damaged during the laundry process. When queried if they had discussed the concerns in their prior meetings, all four residents reported that they had brought this during the meetings and they stated yes. Anonymous Resident (AR) A reported that they had been missing 4-night gowns that were sent to the laundry. When queried how long they had been waiting, they reported that it had been almost 2 months. They added that they went to check in the lost and found closet and there were piles of clothes and they were not able to locate their night gowns. They added they had worn the same gown for 3-4 days and they were using the facility provided (hospital) gowns. When asked if they had brought this concern to the facility's attention, they reported that they had discussed the concern with two different staff members from the laundry. They added that they did not have any updates and they were still waiting for their night gowns. Anonymous Resident (AR) B reported that their clothes got damaged in the laundry on multiple occasions. They added that they bought extra-large clothes and they got damaged during the process and when they got their clothes back they were so small and they were not able wear them. AR B reported that the facility had replaced their clothes and they added the issue is ongoing. They added that their family had been buying clothes for them. AR B added that when they notified staff of the ongoing concern and staff had asked AR B to notify the family and buy more clothes. AR B stated how is that fair. Another Anonymous Resident (AR) C reported that the replacement process takes a long time and they were still waiting for one of their pajama pants. All 4 anonymous residents who expressed concern with the personal laundry process reported that they had brought the concerns during the prior meetings. Four of eight anonymous residents also reported that staff had not been passing their water consistently on weekends. They also reported that the concern was brought up in previous meetings. When asked if there had been any change or improvement, all 4 of them reported that the issue was still ongoing. Review of Resident Council minutes from 11/1/2024 to 5/21/24 revealed concerns with water pass on weekends on meeting notes dated 2/19/25, 3/19/25 and 4/16/25. The follow -up note on 4/16/25 read water are more consistent being passed. The follow-up note dated 2/20/25 read managers to audit on weekends. Review of meeting minutes reflect resident who expressed concerns with personal laundry and water pass had attended more than one meeting in the last 4 months. The meeting minutes did not reflect concern about any concerns about the personal laundry process, when all four residents had confirmed that concerns were brought up in the prior meetings. The Facility administrators' signatures were missing on all 4-month meeting minutes. A laundry observation was completed on 5/21/25 at approximately 12 PM. Laundry assistant (LA) S was on duty. They were asked to explain the facility's personal laundry process. They stated that the personal laundry gets washed daily and moved to the cart with room numbers for delivery. Any personal laundry with no name gets moved to the bins (men's or women's) that were kept under the counter and it stayed in the laundry for a week if no staff member/family/resident came to claim it, then gets moved to a lost and found closet in the [NAME] unit. Approximately 10 minutes later an observation of the lost and found closet in the [NAME] unit was completed. The door to the closet had a keypad lock and Registered Nurse (RN) obtained assistance from another staff member to open the closet door. The closet had over 15 boxes/bins of clothes on metal racks. A box that was labeled for men's clothing had a women's top in it. When queried RN M how residents were assisted they reported that staff had to assist them and they were new and not very familiar with the process. The closet had a list on the clip board with some names on it. An interview with the Laundry-Housekeeping Supervisor (HS) R was completed on 5/22/25 at approximately 9:35 AM. They reported that they had been in that role for one year. During the interview they were queried about the personal laundry process. They reported that the laundry staff completed the cleaning and they were sorted and delivered in 24 hours, if they were labeled. When queried about the clothes with no names they added that they were kept in the laundry for a few days and they were moved to the lost and found closet after. They added the laundry had a label maker. When queried about the process they reported that they had to revamp the process. When queried about the lost and found closet with bins of clothes that were not organized and how it is feasible for residents to look through bins that were not organized. HS R reported that they understood the concern with labeling personals timely and keeping the bins organized consistently. They were queried about the list that was on the wall in the linen closet and they reported that was something old and they were going to take it down. An interview with Activities Director (AD) U was completed on 5/22/25 at approximately 9:25 AM. They were queried about the Resident Council Meeting follow up process. They reported that they addressed and followed up on any laundry concerns individually as best as they could and if they were unable to resolve they initiated a grievance form. An interview with the Director of Nursing (DON) was completed on 5/22/25 at approximately 11:10 AM. They were asked about the ongoing concerns by residents about staff not passing water on weekends. DON reported that they had educated and addressed the staff. They were queried about the weekend supervision and they added they had one manager on duty for weekends (non-nursing), to meet with families if any concerns had come up. They were notified of the ongoing concern and they reported they understood the concern and would follow up with their staff. An interview with facility administrator was completed on 5/22/25 at approximately 12 PM. They were queried about the follow-up on the resident council follow up process and the ongoing concerns with water pass and personal laundry. They added that they educate the staff via their messaging application. They added that they had been replacing residents' clothes that were lost or damaged and they maintained the book. They were notified of the ongoing concerns with the process and time frame it takes for the staff to report a lost/damaged item that were shared. Interview with HS R was also shared and they reported that they understood the concern with the process and would follow up. Review of facility provided document titled Guest/Resident Council with a revision date of 6/2/22, read in part, Policy: The Guest/Resident Council provides a formal, organized means of guest/resident input into facility operations . 10. Minutes of the meeting will be recorded and maintained for at least two years. Minutes will not include guest/resident names in regard to issues and complaints. 11. The Guest/Resident Council grievances and recommendations will be documented on the Guest/Resident Assistance Form (Michigan only) or the Guest Satisfaction Concern/ Suggestion form. The completed forms are brought to the attention of the Administrator who will forward the forms to the respective department head for attention and response. 12. Responses regarding resolution are to be documented on the Guest/Resident Assistance Form (Michigan only) or the Guest Satisfaction Concern/Suggestion form, reviewed by the Administrator and a copy of completed forms are sent to [NAME], and kept with the Guest/ Resident Council minutes. 13. Action taken and/or considerations given to issues will be reported back to the Guest/Resident Council at the following meeting and documented within minutes. 14. During each Guest/Resident Council meeting it is recommended to review 2 resident rights and a portion of the Resident Council Critical Element Pathway. An acknowledgement of the receipt will be noted in guest/resident council minutes .

Based on observation, interview, and record review the facility failed to ensure treatment in a dignified manner for four residents, (R#'s 37, 103, 17, and 16) of five residents reviewed for dignity as well as residents who attended the group meeting who wished to remain anonymous, resulting in verbalized complaints, frustration with staff, and decreased feelings of self worth. Findings include: R37 On 5/20/25 at 9:43 AM, an interview was conducted with R37 regarding their stay at the facility. They said this was their third stay in the facility and they expressed disappointment. They said the Certified Nurse Aides (CNA's), do a poor job. When asked for an explanation they said the CNA's don't do their jobs and they are on their phones in the hallway. R103 On 5/20/25 at 10:00 AM, an interview was conducted with R103 regarding their stay in the facility. R103 said, I would like to be treated better, and further said the CNA's did not show respect. When asked for examples, R103 said they knew CNA 'V' and CNA 'Y' did not like them. When asked how they knew, R103 said they overheard them out in the hallway talking about them. R17 On 5/20/25 at 10:36 AM, an interview was conducted with R17 regarding their stay in the facility. R17 said the CNA's were, rude, and rough. When asked how they were rude, R17 said they were short and rushed with care. R17 said staff need to, do better, because we deserve better. R17 then went on to say they reported CNA 'X' and CNA 'Y' and requested they not be assigned to their care. R17 further said they were hesitant to report staff attitudes because staff, make themselves the victim, and we (the residents) are blamed. On 5/22/25 at 3:22 PM, a review of CNA 'Y's personnel file was conducted and revealed an ON THE SPOT IN-SERVICE dated 9/21/24 that indicated CNA 'Y' was witnessed on their personal cell phone at the nursing station. The file additionally contained a DISCIPLINARY ACTION RECORD form that indicated on 11/11/24 CNA 'Y' was asked to provide a sitz bath to a resident. The form further indicated the task was not completed because CNA 'Y' did not know how to perform the task and they did not follow up with the nurse who was going to give them instruction on how to perform the task. 30675 R16 On 5/22/25 at 8:30 AM, upon entering the 600 hall, R16 was observed seated in a wheelchair in the hallway positioned next to two Nurses that were standing next to the medication cart. The Nurses were heard discussing R16's soiled pants and need to be changed. One of the Nurses proceeded to yell down the hallway very loudly, Do you know who his aide is?. A Certified Nursing Assistant (CNA) was observed seated behind the nursing station approximately 50 feet away and was observed to yell loudly back to this Nurse, Who (name of R16)?. On 5/22/25 at 11:27 AM, an interview was conducted with the Director of Nursing (DON). The DON was informed of concerns reported during the resident council meeting regarding whether they felt staff treated them with dignity and respect. The DON was informed of the earlier observation of the nursing staff yelling loudly throughout the hallway and they reported that should not have occurred and would initiate in-service education immediately. According to the facility's policy titled Federal & State - Resident Rights & Facility Responsibilities dated 5//14/2024, .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality or life, recognizing resident's individuality . 47283 During an interview with an anonymous family member on 5/20/25, at approximately 9:50 AM, they reported that they made regular visits to their grandmother who was a resident. The family member reported that during the week of Mother's Day when they were visiting their grandmother, a nurse came to assist the roommate and called her crazy on their way out. A confidential group meeting was conducted on 5/21/25 at 11 AM and 8 residents attended the meeting. During this meeting one anonymous resident reported they kept a water pitcher on their bedside table. They added that staff moved the pitcher too far so they were not able to reach them during the night. They added that the night before they tried to reach for their water and had spilled water all over themselves. They also reported that they had to wait for staff assistance to change their brief for a long time during the night shift. They added that they had to wait all night, until 5:30 AM on multiple occasions. They added that had challenges with the new staff members. Two other anonymous residents when queried about dignity reported that it depended on the staff member. They both reported that they had challenges with the new staff members.

Based on observation, interview and record review the facility failed to ensure dietary interventions were implemented in a timely manner and appropriate dietary monitoring and follow-up were provided for one resident (R89) of four residents reviewed for nutrition, resulting in R89 experiencing severe weight loss (greater than 5% in a month) On 7/25/23 at approximately 10:25 a.m., R89 was observed in their room, laying in their bed. R89 appeared to be frail/thin. On 7/25/23 the medical record for R89 was reviewed and revealed the following: R89 was initially admitted to the facility on [DATE] and had diagnoses including Disease of salivary gland, Hemiplegia and Hemiparesis affecting left side, Cerebral infection. A review of R89's MDS (minimum data set) with an ARD (assessment reference date) of 4/17/23 revealed R89 needed extensive assistance from facility staff with most of their activities of daily living. R89's BIMS score (brief interview for mental status) was nine indicating moderately impaired cognition. A review of R89's plan of care revealed the following: [R89] has Alteration in nutritional and/or hydration status r/t hx NSTEMI (heart attack), CVA (stroke) w/Left-sided weakness and Aphasia, + HIV (Human Immunodeficiency Virus) , and Hyperthyroidism, COVID-19 infection, variable po (by mouth) intake @ times, Hx (history) significant Weight Loss unplanned, likely unavoidable, low BMI (body mass index) .Interventions-Observe and report to physician Significant weight changes: >5% in 1 month, >7. 5% in 3 months, >10% in 6 months .Date Initiated: 05/25/2021 .Provide and serve supplements as ordered. Date Initiated: 05/25/2021 . A review of R89's documented weights for 2023 revealed the following: 5/8/23-155.2 lbs,(pounds) 5/15/23-155.4 lbs, 6/15/23-133.0 Lbs (loss of 14.42% since 5/15), 7/12/23-121.6 lbs (further loss of 9.38% from 6/15). A resident at risk note dated 6/15/23 revealed the following: Reviewed Clinical Indicator: Dehydration, decline, diet down graded, weight loss Action Taken: Reviewed and discussed POC (plan of care) with IDT (interdisciplinary) team. Res (resident) is being followed for dehydration. Res has also shown increased confusion and agitation. Res has also been more combative then usual. Res received 1000ml (milliliters) of 0.9 sodium chloride, tolerated well. Writer down graded diet to mech (mechanical) soft due to difficulty swallowing reported by cna (Certified Nursing Assistant) staff. Awaiting speech eval (evaluation) at this time. Weight loss of 22lbs and 14% within 30days. No further concerns at this time. Response to Previous Actions Taken: Will continue to monitor. A resident at risk note dated 6/22/23 revealed the following: Reviewed Clinical Indicator: Readmit Action Taken: Res (resident) was previously sent to to ER (emergency room ) on 6/18 for unresponsive behaviors, res returned to facility on 6/20 an continues long-term care. [contracted psychiatric provider] will continue to follow as needed as well as NP (Nurse Practitioner). Sw (Social Work) will continue to follow as needed. Res is a weight loss of 22lbs 14% within 30days. No further concerns at this time. Response to Previous Actions Taken: Will continue to follow . A resident at risk note dated 6/29/23 revealed the following: Reviewed Clinical Indicator: Follow up Action Taken: Reviewed and discussed POC with IDT team. Res was recently followed for a return from hospital and weight loss. Res continues long-term care an has declined in transfer status to a hoyer an now using a geri chair. Still being followed by Psych services. Dietary following for previous weigh loss. No further concerns at this time. Response to Previous Actions Taken: Will continue to monitor. A Nutritional evaluation dated 7/12/23 revealed the following: 9. Recent weight change-Significant wt. (weight) loss of 11lbs/8.3% x 30days. Wt. loss related to poor oral intake r/t (related to) medical decline and difficulty swallowing Resident continues on Regular diet, Level 3 Advanced (Mechanical Soft) texture, Thin consistency diet. Noted resident has had decreased meal acceptance since recent hospitalization consuming less than 50% of meals. Noted he takes a few bites and then will refuse staff assistance and not eat any more. Staff reported he at times will pocket food, SLP (speech and language pathologist) made aware. CBW (current body weight)-121.6lbs which reflects a significant wt. loss of 11lbs/8.3% x 30days. Wt. loss undesirable, as resident is below IBW (ideal body weight) with BMI-16. Goal is for resident to have gradual wt. gain. IDT, MD (Medical Doctor), RP (responsible party) made aware of wt. change. Resident has Ensure in place TID (three times a day), will add Hi-cal 120ml BID (twice a day) to provide additional 475kcal, 20g protein. Will monitor acceptance. Skin intact. Medications and labs reviewed. Resident is at increased risk related to inadequate oral intake aeb (as evidenced by) significant wt. loss x 30days. Recommend: Continue diet and Ensure as ordered, add Hi-Cal 120ml BID, monitor wt. trends, encourage intake and assist as resident allows. Goal is for resident to have gradual wt. gain towards UBW (usual body weight) of 140lbs as medically feasible . A Physician's note dated 7/13/23 revealed the following: weight loss .General: Patient has been seen today due to weight loss. Patient has been losing weight month to month. He has an approximate 12 pound weight loss over the last month. He does appear fatigued and weak. He denies any concerns. His vital signs are stable. He does have forgetfulness and confusion and is a poor historian. He does admit to having no appetite. He denies any nausea or abdominal pain .PLANS: Risk of Complications and/or Morbidity or Mortality of Patient Management: MODERATE-Abnormal weight loss: Notified of weight loss by registered dietitian, I reviewed her plan and agree. Will start megestrol 400 mg BID Add Hi Cal 120 mL BID Monitor weights Will check cbc (complete blood count), cmp (complete metabolic panel), prealbumin, TSH (thyroid stimulating hormone) R63.0 - Anorexia: Add megestrol per above. Monitor weights . A resident at risk note dated 7/14/23 revealed the following: Reviewed Clinical Indicator: Significant wt. loss of 11lbs/8.3% in 30days. Action Taken: Resident with decreased meal acceptance. He needs increased assistance with meals however will refuse at times. Resident pocketing food per nursing referred to SLP. Ensure in place TID, added Hi-Cal 120ml BID. Megace started per MD. RP made aware of changes Response to Previous Actions Taken: Resident continues with varied acceptance most meals less than 50%. A review of R89's food acceptance documentation done by the Certified Nursing Assistants for the last 30 days (6/28/23 until 7/27/23) revealed R89 ate less than 26% of their meals 6 times and ate between 26% and 50% of their meals 12 times. Further review of the medical record revealed no dietary progress notes that contained monitoring of interventions/new interventions/assessments from the dietician/dietary department from 6/15/23 until 7/14/23. No nutritional evaluations were observed to have been completed since 5/12/23 until the one noted on 7/12/23. No Physician evaluation for weight loss was noted in the record until 7/13/23 after additional weight loss was noted on 7/12/23 weight documentation. Continued review of the medical record revealed the Hi-cal 120ml BID indicated in the nutritional evaluation on 7/12/23 was never added to R89's orders. On 7/27/23 at approximately 12:15 p.m., Registered Dietician Q (RD Q) was interviewed pertaining to the lack of dietician follow-up/monitoring for R89's weight loss from 6/15/23 until their evaluation on 7/12/23. RD Q indicated that they have had problems getting notified of weight loss at that time and the facility identified the concerns regarding the lack of communicating weight loss to the dietary department which made it hard to assess and implement nutritional interventions. RD Q reported the facility did a past non-compliance pertaining to the weights/nutrition issues. RD Q was queired for documentation of dietician monitoring/evaluations and progress notes when the weight loss was identified on 6/15/23 and they indicated that they did not have any to provide. RD Q was queried why the Hi-cal that was indicated on their evaluation on 7/12/23 was not provided to R89 and they reported that they did not know why it was not added. RD Q was queried if they were made aware of R89's severe weight loss identified on 6/15/23 and they again indicated that they had a communication issue regarding weights and weight loss in the facility during that time period. RD Q was queired if they entered their own dietary orders into the record and they indicated that they did. On 7/27/23 the facility Administrator presented a past non-compliance (PNC) folder that indicated the facility had identified deficient practices on 6/29/23 pertaining to weight monitoring/variances, issues with Physician notification, and implementing care planned interventions to address significant weight loss. The facility implemented a plan of correction including education on obtaining weights and re-weights. Also, the Registered Dietitians were re-educated on the Weight Management Policy including reviewing resident weights weekly for variances, Physician and responsible party notification, implementing interventions to address weight variances and documenting in the medical record. For sustained compliance the RD/DON (Director of Nursing) are conducting random observations of weekly weights for four weeks and the results are to be be brought to the QAPI (Quality Assurance/Performance Improvement) committee for review. The Director of Nursing signed the PNC indicating all evidence of compliance was done on 7/21/23. On 7/27/23 a facility document titled Weight Management was reviewed and revealed the following: Policy-Guests/residents will be monitored for significant weight changes on a regular basis. Guests/residents are expected to maintain acceptable parameters of nutritional status, such as usual body weight and protein levels; unless the guest's/resident's clinical condition demonstrates that this is not possible. Since ideal body weight charts have not yet been validated for the institutionalized elderly, weight loss (or gain) is a guide for determining nutritional status. Therefore, the evaluation of significant weight gain or loss over a specific time period is an important part of the evaluation process .Any guest/resident with unintended weight loss/gain will be evaluated by the interdisciplinary team and interventions will be implemented to prevent further weight loss/gain .5. Guests/residents determined to be at risk or have significant weight changes will be weighed on a weekly basis. Guests/residents at risk are: a. Guests/residents receiving total parenteral nutrition (TPN) for one month or until weights have stabilized b. Newly tube fed guests/residents c. Guests/residents receiving a tube feeding with significant weight changes d. Any tube fed guest/resident that is started on oral trial feedings e. All new admits/re-admits for 4 weeks f. Guests/residents with insidious weight loss and; 5% in one month, 7.5% in three months, 10% in six months .

Based on interview and record review, the facility failed to follow their policy and Centers for Disease Prevention and Control (CDC) guidance to offer and administer pneumococcal vaccinations to residents (R807, R801, R803, R811, R803 R815, R814, administer influenza vaccinations to residents who consented to receive them, screen and assess residents for eligibility of receiving pneumococcal vaccinations, and educate residents on risks versus benefits of the vaccination for any resident who resided in the facility since May 2022, resulting in facility acquired pneumonia for 20 residents between June 2022 and March 2023 and residents who wished to receive the influenza vaccination not being immunized against influenza. The failure to implement these policies following current CDC recommendations for pneumococcal immunizations resulted in an Immediate Jeopardy (IJ) to the health and safety of R807 who developed pneumonia in the facility and subsequently required hospitalization and all other residents in the facility who were not fully immunized against pneumonia. Facility residents, many of whom were at high risk due to age and co-morbidities, had the likelihood of developing pneumonia resulting in serious health complications from the disease including the risk of death due to the systemic failure of not offering an opportunity to be immunized against pneumonia. Findings include: The IJ began 12/7/22. The IJ was identified on 3/14/23. The Administrator was notified of the IJ on 3/14/23 and a plan to remove the immediacy was requested. The immediacy was removed on 3/14/23 based on the facility's implementation of an acceptable plan of removal as verified on-site by the survey team. Although the immediacy was removed the facility's deficient practice was not corrected and remained widespread with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. A review of a facility provided policy titled, Immunizations: Pneumococcal Vaccination (PPV) of Guest/Residents revised 2/25/22 was conducted and read, .A. Each guest's/resident's pneumococcal immunization status will be determined upon admission or soon afterwards, and will be documented in the guest's/resident's medical record .B. All guests/residents with undocumented or unknown pneumococcal vaccination status will be offered the vaccine . A review of a second facility provided policy titled, Immunizations: Influenza (Flu) Vaccination of Guest/Residents revised 1/11/22 was conducted and read, .General Procedure .3. Primary care physicians will be asked that all new admissions be screened and given the influenza vaccine unless specifically ordered otherwise by the Primary physics on admission orders .5. Every admission is screened using the criteria contained within the standing protocol and given the vaccine if indicated .Nursing Procedure .1. Beginning in October, when notified to begin Influenza vaccination by Infection control, review the Standing protocol for Influenza Vaccine. 2. Upon admission, follow the standing protocol to determine the eligibility to receive the vaccine. 3. If the guest/resident is eligible, obtain an order for the vaccine and provide education . On 3/14/23 at 10:30 AM, a review of R801, R803, R807, and R811's influenza (flu) and pneumococcal (pneumonia) vaccination status in the EMR (electronic medical record) was conducted. The records revealed the following: R801 (most recent admission 12/14/22) had no evidence of having been offered, or having received any pneumococcal vaccines. R803 (most recent admission 1/24/23) had no evidence of having been offered, or having received the 2022-2023 influenza vaccine. R807 (most recent admission 2/25/23) had no evidence of having been offered, or having received any pneumococcal vaccines or the 2022-2023 flu vaccine. R811 (most recent admission 5/2/22) had no evidence of having been offered, or having received any pneumococcal vaccines. On 3/14/23 at 12:10 PM, the facility's Assistant Director of Nursing (ADON)/Infection Control Preventionist, Nurse 'A' was asked about the facility's influenza and pneumococcal vaccine program. They said the vaccines would be offered to residents during their first care conference and the MDS (Minimum Data Set) nurses would obtain the consent. When asked how long a resident was in the facility before their first care conference, Nurse 'A' said it was about a week. Nurse 'A' was asked what their facility policy was about offering vaccines and said they did not know. At that time, Nurse 'A' was asked to provide any additional evidence that R#'s 801, 803, 807, and 811 were offered and received or declined their influenza and/or pneumonia vaccines, however; no additional information on those residents was provided by the end of the survey. On 3/14/23 at 12:20 PM, an interview was conducted with MDS Nurses 'B' and 'C'. They were asked about their role in obtaining consents for flu and pneumococcal vaccinations and denied any role. They said they had recently been informed they were going to be offering COVID19 vaccines at quarterly care conferences to residents who remained unvaccinated, but maintained they had no role in obtaining consents for flu and pneumococcal vaccines. On 3/14/23 at 1:41 PM, an interview was conducted with the facility's Administrator and Nurse 'A'. It was reported there was no evidence the facility had offered or administered any pneumococcal vaccines. It was further reported by Nurse 'A', the Director of Nursing (DON) had identified a problem with pneumococcal vaccines when they started their position of DON in the building in November 2022. Nurse 'A' was asked how long they had been in their role of infection Control Preventionist and said they had been in the role since May 2022. They were asked if they followed up or offered pneumococcal vaccines since they began working in the facility and indicated they had not. At that time, they were requested to provide a date of when the last pneumococcal vaccine had been administered in the facility and a list of residents who contracted pneumonia while residing in the building after June 2022. On 3/14/23 at 2:35 PM, an interview was conducted with R815. R815 said they admitted to the facility on [DATE] for skilled wound care and rehabilitation. R815 was asked if the facility assessed them for their flu and pneumococcal vaccination status. R815 reported the facility did not mention anything about flu or pneumococcal vaccines. On 3/14/23 at 2:45 PM, an interview was conducted with R814. R814 said they admitted to the facility on either 3/8/23 or 3/9/23 for rehabilitation for hip surgery. They were asked if any staff had assessed them for their flu and pneumococcal vaccination status and said no one had. R814 said they had their immunization card for COVID19 in their wallet. R814 further said they had been in the facility about a week, and said, Isn't it too late to ask now? On 3/14/23 at 3:05 PM, Nurse 'A' followed up and said the last pneumococcal vaccine administered at the facility was 2/10/22 and they provided the list of residents diagnosed with facility acquired pneumonia since June 2022. A review of the list revealed 22 cases of pneumonia affecting 20 residents from June 2022 until March 2023. The facility was asked to submit a removal plan on 03/14/2023 and submitted the following: [Facility submits the following Credible Allegation of Compliance. Immediate Jeopardy for F883 regarding the facility's alleged failure to not offer, obtain consent, educate about risks and benefits, or administer the pneumococcal immunization to any residents since May 2022. Identified resident R807 continues to reside within the facility. Resident has been evaluated by an Administrative Nurse. Resident R807 does not have any respiratory distress concerns identified. Resident R807 has been educated on the pneumococcal vaccinations and offered. Consent has been updated and vaccination has been ordered from pharmacy. R813 no longer resides at the facility and was discharged from the facility October 15, 2022. On March 14, 2023 the facility conducted a facility wide audit to ensure resident residing within the facility were medically stable and no signs of respiratory distress. On March 14, 2023 the facility educated and offered the pneumococcal vaccination to residing residents. Residents that consented for the vaccination where reviewed by the physician and orders were obtained. The Administrator is responsible for sustained compliance. Facility alleges on March 14th, 2023 the immediacy was removed. 30675 Review of the clinical record revealed R807 was initially admitted into the facility on [DATE], discharged to the hospital from 12/7/22-12/14/22, and 2/19/23-2/25/23 with diagnoses that included: pneumonia, acute upper respiratory infection, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and quadriplegia. According to the Minimum Data Set (MDS) assessment dated [DATE], R807 had intact cognition, speech was unclear but was able to make self understood and able to understand others (with electronic device) and was totally dependent upon staff for all aspects of care. Additionally, the section for resident immunizations (Section O) documented, .Did the resident receive the Influenza vaccine in this facility for this year's Influenza season .No .If Influenza vaccine not received, state reason .Not offered .Is the resident's Pneumococcal vaccination up to date .No .If Pneumococcal vaccine not received, state reason .Not eligible - medical contraindication . Review of the available documentation in R807's clinical record revealed there was no documentation that the pneumococcal vaccine had been offered and/or not eligible with specific medical contraindication. On 3/14/23 at 2:26 PM, an interview was conducted with R807. When asked about whether anyone from the facility had offered the influenza or pneumococcal vaccine, R807 reported no. Further review of the clinical record included a Physician progress note on 12/7/22 by Nurse Practitioner (NP 'I') read, .CHIEF COMPLAINT .Chest x-ray, pneumonia .Patient is being seen today to follow up on results of a chest x-ray. He was suspected of having pneumonia and a chest x-ray was completed. Results to show signs of pneumonia. Patient had Augmentin ordered starting this morning. It has not yet been Administered. Patient is seen also and staff report his oxygen levels are low. They are in the mid 80s. Patient is on supplemental oxygen therapy. Patient is Normally oriented and responsive. He is nonverbal but response through typing on a computer. His is very lethargic, not making eye contact and appears disoriented. His blood pressure is also elevated about 160/100. Symptom onset appears fairly rapid beginning this morning .Lungs: bilateral rhonchi and crackles .ASSESSMENT AND PLAN J18.0 - Pneumonia, unspecified organism: Patient with altered mental status and respiratory distress with Sp02 (pulse oximetry) in the 80?s We will send out to E.R. (emergency room ) For further evaluation and treatment . Additional review of R807's readmission documentation upon 2/25/23 included an admitting diagnoses of pneumonia.

This citation pertains to Intake Number(s): MI00131828. Based on observation, interview and record review the facility failed to ensure a resident was provided safe care according to their comprehensive care plan for one resident (R809) of one residents reviewed for accidents, resulting in R809 sustaining severe left hip pain, forehead contusion, left hand skin tear and subsequent acute transfer to the hospital. Findings include: On 3/15/23, a facility reported incident (FRI) submitted to the State Agency was reviewed which indicated R809 had rolled out of bed while being provided care by Certified Nursing Assistant Y (CNA Y) and sustained multiple injuries. On 3/15/23 at approximately 4:19 p.m., R809 was observed in their room, laying in their bed. R809 appeared to be frail and was not able to answer any questions pertaining to their accident. On 3/15/23, the medical record for R809 was reviewed and revealed the following: R809 was initially admitted on [DATE] with diagnoses including Dementia and Disorder of Bone density. A review of R809's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/26/22 revealed R809 needed extensive assistance from two facility staff with most of their activities of daily living including bed mobility. R809's BIMS score (brief interview of mental status) was 11 indicating moderately impaired cognition. A Nursing progress note dated 9/29/22 at 6:48 a.m., revealed the following: Informed from assigned CNA that the resident fell out of bed during care at 534am. resident was laying on floor Rt. (right) side next to bed, Lt. (left) lateral, faced to bed. Lt. forehead bump, severe Lt. hip pain, Lt. hand skin tear noted. called 911, fire department transferred her to stretcher cart from floor with 4 assistants, left at 543am. notified on call provider, daughter, .and DON (Director of Nursing). An Incident and Accident report dated 9/29/22 revealed the following: .Describe the nature of the Accident/Incident and if injuries sustained, location of injuries: Informed from assigned CNA resident fell out of bed during care, was laying on floor Rt. side next to bed, laying on lf side lateral faced to bed. Bump to Lf. forehead, severe Lt. hip pain, Lf hand skin tear noted .Physician Statement: Transfer to hospital .Interventions implemented-Explain: Educate CNA to follow care plan with two person bed mobility .Describe initial intervention to prevent future falls: Follow Care Plan . A Physician evaluation dated 9/30/22 revealed the following: HISTORY OF PRESENT ILLNESSES-General: Patient is being seen today after having a fall. The fall occurred early yesterday morning. Patient was transferred it to the emergency room after sustaining injuries in the fall. She had bumped her forehead and had swelling and bruising and also complaining of left hip pain. Patient was transferred back from the emergency room after less than 24 hours and resides in her room now. Today, patient is oriented X2 (person, place). She is noted with bruising and Peri orbital swelling .She does have a dressing to her left forearm that she states is uncomfortable but denies any pain or other concerns .HEENT(head, ears, eyes, nose, oral, throat examination): mild swelling to forehead. Small abrasion with scant bleeding to bridge of nose. Small scattered abrasions to nose and forehead. Bilateral periorbital edema and bruising noted . A review of R809's plan of care revealed the following: Focus-[R809] has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility r/t (related to) decreased mobility/weakness, .hx CVA (stroke), hx of LE fx (lower extremity), dementia .Interventions-BED MOBILITY: [R809] is dependent x2 to roll in bed. [R809] is dependent x2 to sit at edge of bed. [R809] is dependent x2 to move towards head of bed . A review of the facility investigation pertaining to R809's fall on 9/29/22 revealed the following: .Date of the Event: 9/29/22 .Was the resident injured? yes .If yes, describe injury: The resident sustained bruising to the face and a skin tear to her left hand .Description of Deficient Practice The CNA [CNA Y] who provided care to resident transferred the resident using 1 person and the resident care plan listed the resident as a 2 person assist with transfers, the CNA did not follow the plan of care .Plan of correction: Indepth analysis of how the deficient practice occurred .Resident's Kardex states the resident is a 2 person assist for transfers. The CNA did not review the resident Kardex prior to providing care and transferred the resident using a 1 person assist .How facility identified residents affected and residents with potential to be affected by the same deficient practice .The Administrative Nursing staff reviewed the residents in the facility to identify the residents that need 2 person assist with transfers .Corrective Action Taken for Resident Affected The resident was sent to the hospital for evaluation and treatment, returned to the facility and the plan of care was reviewed .Measures or systemic changes made to ensure that deficient practice will not occur and affect others .The CNA was educated 1:1 on the Kardex: What information it contains, Where to find it and The importance of following it A state MI-FRI (Michigan-Facility Reported Incident) form with a submitted date of 9/29/22 revealed the following: .Date time incident occurred-9/29/22 at 5:34 AM .Incident Summary-Resident fell from her bed and sustained injuries to face and hand .Investigation Summary/Actions Taken: .Resident requires extensive assistance of two people for bed mobility and toileting .In conversation with [CNA Y] she reported that she was providing care for the resident by herself. When rolling the resident to her side to prepare to use a sling for transfer, the resident rolled off of the bed and onto the floor .A review of the residents care plan and kardex reveals that the resident is documented to require extensive assistance of two people for bed mobility and requires the total assistance of two people for transfers . On 3/15/23 at approximately 3:32 p.m., The Assistant Administrator V (AA V) (who was the facility Administrator around the time of the incident) was queried regarding R809's fall out of the bed and subsequent injuries on 9/29/22. They indicated that CNA Y attempted to assist R809 with the sling with just herself and R809 rolled out of the bed. AA V indicated that in review of the incident, CNA Y should have had another staff member assisting them during the care because R809 required two people for safe bed mobility and transfers. AA V indicated that the facility identified the cause of the fall, re-educated all of the CNA staff on checking the care plans and kardex before providing care. AA V also indicated that CNA Y was provided specific 1:1 inservicing to ensure that the plan of care is followed.

This citation pertains to intake #MI00122959 Based on interview and record review the facility failed to prevent the elopement of one resident (R901) of three residents reviewed for elopement, resulting in immediate jeopardy (IJ) when R#901who was previously identified as an elopement risk and had severe cognitive impairment, exited the building and left the facility premises without staff knowledge or supervision increasing the likelihood of serious injury, serious harm, serious impairment, or death. Findings include: On 10/18/22 a facility reported incident that was submitted to the State Agency was reviewed and indicated that R901 had eloped from the facility without the knowledge of the facility staff on 10/3/22. On 10/18/22 at approximately 1:59 p.m., R901 was observed in their room, standing up and walking around the room. R901 was observed to be confused and unable to follow conversation due to their mentation. R901 was observed to have a wanderguard (safety alert device for residents identified as an elopement risk) on their right ankle. On 10/18/22 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Delusional Disorders. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 8/24/22 revealed R901 needed supervision with most of their activities of daily living. R901's BIMS score (brief interview of mental status) was zero indicating severely impaired cognition. A review of R901's care plans revealed the following: Focus-[R901] is at risk for elopement and/or wandering R/T (related to): Alzheimer's, New Placement, [R901] wanders aimlessly. [R901] has the ability to ambulate independently. Date Initiated: 02/16/2022 .Interventions-Approach in a slow, calm manner and redirect away from exit doors as needed . A progress note dated 10/4/22 revealed the following: Late Entry on 10/3/22 resident was observed outside the facility .Dietary staff member was able to redirect resident back inside the facility . A Physician progress note dated 10/4/22 revealed the following: Elopement-HISTORY OF PRESENT ILLNESSES .General: Resident is seen today after staff report that she had eloped. Patient had left the building. She does have dementia and is confused. She is unable to provide any meaningful information . On 10/18/22 a facility investigation pertaining to R901's elopement from the facility on 10/3/22 was reviewed and revealed the following: On October 3rd, 2022, at approximately 1:17pm the facility received a call from an employee stating that a resident was observed by her outside of the building and off the property Resident is a [R901 demographics] with diagnoses of Alzheimer's disease, Dementia, Essential Hypertension, and Delusional Disorder. Resident has a care plan for elopement and wandering. The care plan states that the resident is at risk for elopement and should wear a wanderguard bracelet .Investigation revealed that the resident exited the facility through fire door by pushing the panic bar until the door opened. Camera footage for the door was reviewed and showed the resident exiting through the door between 1:13 p.m. and 1:14 p.m. Camera footage also showed staff interacting with resident and resident visiting the activity room just prior to her exit .Investigation further revealed that the CNA (Certified Nursing Assistant) assigned to care for the resident, [CNA C] heard the door alarm and thought it was a bathroom call light and responded by checking resident rooms. [CNA C] is a new employee to the facility. [CNA C] was inserviced at the time of her interview by the Director of Nursing regarding appropriate response to the door alarm .The door alarm was reset by a maintenance employee, [Maintenance employee A (ME A). [ME A] stated that he was in the front of the building when he heard the alarm. When he responded to the door, he heard the alarm going off and did not see anyone present. He responded by resetting the alarm. During his interview, [ME A] was inserviced by the Administrator regarding appropriate response to the door alarm . On 10/18/22 at approximately 11:11 a.m., the Administrator was interviewed pertaining to R901's elopement on 10/3/22. The Administrator indicated that R901 went out the exterior door fire door and was found across the street of the facility (a five-lane street) in the parking lot of a closed grocery store by an off-duty staff member on their break. The Administrator reported that R901 pushed panic bar on the fire door and it alarmed appropriately. As R901 went out the door, CNA C came out of a room and heard the alarming door but CNA C was brand new to the facility and thought the door alarm was a bathroom call light indicator and went looking for the bathroom that they thought needed assistance. ME A also responded to the alarming door but did not look outside for anyone and reset the alarm without checking in with anyone. The staff member who found R901 was dietary aide B (DA B). They were in their car coming down the street. DA B got R901 in their car and brought them back to the facility. The Administrator was queried if R901 was safe to be off the facility grounds without any supervision from staff and explained it was not sate due to their dementia and R901 was already identified as an elopement risk. On 10/18/22 at approximately 1:22 p.m., DA B was queried regarding R901's elopement. DA B indicated they had worked that day and went on break around 1:10pm to 1:15pm. DA B reported they were at a corner at a gas station and heard a horn blow. DA B indicated they saw R901 Walking away from the facility across the street on a sidewalk. DA B indicated that they Recognized R901 by their clothing and called the receptionist and informed them that they thought R901 was walking down the sidewalk and asked them if they should follow and they said yes. DA B indicated they pulled over in their car on the side of the street and put their hazard lights on and tried to get R901 into their car and that R901 was mumbling incoherently, got into the car and they drove them to the front of the building. DA B was queried if they asked R901 where they were going and they explained they were not able to get an answer due to their dementia. On 10/18/22 at approximately 1:40 p.m., CNA C was queried regarding R901's elopement. CNA C reported they were in a room with another patient who was being loud and when they came out, they thought they heard a sound that sounded like a bathroom call light but since they were a new CNA to the facility, they did not know the difference of the alert sounds between the door and a bathroom call light and did not think that the sound was an exit alarm going off. CNA C indicated they were educated on the same day about responding to the door alarm and the elopement process was reviewed. On 10/18/22 at approximately 2:29 p.m., ME A was queried regarding R901's elopement and they reported that the receptionist had informed him that the alarm was going off. and they were asked to check it out. ME A indicated they noticed the bolt was engaged and the alarm was going off and they reset the alarm. MA E reported that funeral employees use that door so they did not think anyone had gone out of it and did not think to report that any residents had eloped. MA E indicated that they were given education on the appropriate elopement response when a door alarm sounds such as leaving the alarm engaging and checking to see if a head count was being performed and going outside and checking the area. On 10/18/22 a facility document titled elopement policy was reviewed and revealed the following: Policy-It is the policy of this facility to the extent reasonably possible, the elopement of guests/residents from the facility .Alarm Activation-1. If an employee hears a door alarm, he or she should: A. Immediately go to the site of the alarm. 2. C. If no guest/resident is found to be exiting the facility, the employee should walk outside; conduct a visual observation of the immediate area to ensure that a guest/resident has not already exited the facility. If no guest/resident is observed then the staff member will return into the building .2. In situations where the alarm sounds and a guest/resident is not found to have exited: a. notify the Licensed Nurse immediately, and b. Ensure that a head count is completed to ensure that all guests/residents are accounted for . The IJ began on 10/3/22, it was identified by the survey team on 10/18/22 and the facility was notified of the IJ on 10/18/22, and a removal plan was requested. On 10/18/22, the State Agency completed onsite verification that the Immediate Jeopardy was removed on 10/5/22, however the facility remained out of compliance at a scope of isolated and severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. On 10/18/22 Removal of the immediacy was confirmed onsite when the facility took the following actions: -A skin assessment for R901 was performed and no signs of injury were noted.-10/3/22 -an investigation was immediately commenced with respect to how the incident occurred. 10/3/22 -all exit doors were checked to ensure they were functioning and alarming properly.-10/3/22 -The Risk for Elopement Assessments and care plans for elopement and discharge planning were reviewed and revised and needed.-10/3/22 -re-inservicing of the staff on the facility's Elopement policy and care plan policy was initiated. The CNA who was near the door at the time it was alarming and the maintenance staff member who reset the door received a 1:1 inservice regarding the facility's Elopement policy.-10/3/22 all residents who have an order for a wanderguard device were reviewed to ensure the device was being worn and was functioning properly.-10/3/22 -the facility conducted an elopement drill and staff responded appropriately and were re-inserviced on the facility's Elopement policy.-10/5/22

This citation pertains to Intake Numbers: MI 125, MI 587, MI 888 and MI 019 Based on observation, interview and record review, the facility failed to promptly identify, implement timely interventions to areas of altered skin integrity and prevent pressure ulcers for four (R56, R57, R142 and R143) of 10 residents reviewed for pressure injuries, resulting in the development of multiple facility acquired pressure ulcers. Findings include: R56 On 6/26/22 at 11:37 AM, R56 was observed lying in bed, the covers on the bed were flat, there was no appearance of foam boots on R56's feet. When asked about care at the facility, R56 explained she got tired of lying in bed all the time and would like to get up into her wheelchair more often. Review of the clinical record revealed R56 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R56 had moderately impaired cognition, and required the extensive to total assistance of staff for all activities of daily living (ADL's). The MDS assessment also indicated R56 had one facility acquired Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible) pressure ulcer. Review of a Total Body Skin Assessment for R56 dated 3/18/22 revealed, .Turgor: Good Elasticity . Skin Color: Normal for ethnic group . Temperature: Warm (normal) . Moisture: Normal . Condition: Normal . Enter the # of New Wounds: 0 . Comments: .some blister and redness to BLE (bilateral lower extremities) . It should be noted that a blister would be considered a new wound. Review of R56's record revealed no further mention of a blister or an alteration in skin was documented until 3/23/22 when a Skin & Wound Evaluation documented in part, . Type: Pressure . Stage: Unstageable: Obscured full-thickness skin and tissue loss . In-House Acquired . Location: Left Lateral Malleolus (bony prominence on each side of the ankle) . Exact Date: 3/23/22 . Length: 2.1 cm (centimeters) . Width: 1.5 cm . Slough (non-viable yellow, tan, gray, green or brown tissue . may be adherent to the base of the wound or present in clumps throughout the wound bed): 90% of wound filled . Notes: Left lateral malleolus unstageable wound had a scant amount of serosanguinous drainage. There is 90% yellow and grey slough, no necrosis, no maceration, and no depth due to slough . Review of Skin & Wound Evaluations for R56's left lateral malleolus revealed: 3/30/22, .Unstageable . Length: 2.0 cm . Width: 1.4 cm . 4/6/22, .Unstageable . Length: 3.2 cm . Width: 2.2 cm . Slough: 90% of wound filled . 4/13/22, .Unstageable . Length: 2.1 cm . Width: 1.3 cm . Wounds are likely unavoidable due to multiple comorbidities including multiple [CONDITION(S)] and [CONDITION(S)] as well as other comorbidities and debility . 4/27/22, Unstageable . Length: 1.1 cm . Width: 0.8 cm . Slough: 60% of wound filled . 5/4/22, Unstageable . Length: 0.8 cm . Width: 0.6 cm . 5/11/22, Stage 3 . Length: 1.1 cm . Width: 0.6 cm . 5/18/22, Stage 3 . Length: 1.4 cm . Width: 0.9 cm . 5/25/22, Stage 3 . Resolved . On 6/28/22 at 11:00 AM, an observation of R56's skin was made with Licensed Practical Nurse (LPN) D and LPN E. R56's feet had the appearance of foot drop. The entire length of the foot was in contact with the mattress. Foam boots were not observed, nor were R56's feet floated on pillows. Review of R56's pressure injury care plan revealed an intervention revised 4/14/21 that read, Bil (bilateral) heel protectors as tolerated to (R56's) feet while in bed to float heels. Review of R56's Braden Scale for Predicting Pressure Sore Risk revealed on 1/27/22 and 4/27/22, R56 scored a 16, indicating low risk. It should be noted that R56's pressure ulcer was identified on 3/30/22. On 6/28/22 at 3:08 PM, LPN G, who served as the Wound Care Manager was interviewed and asked about R56's facility acquired pressure ulcer. LPN G explained she was new to the facility and had not been there when the pressure ulcer began. LPN G was asked to verify the facility provided documentation that there were 13 pressure ulcers, and nine of those were facility acquired. LPN G confirmed there were nine facility acquired pressure ulcers. LPN G was asked who had deemed R56's pressure ulcer Unavoidable. LPN G explained it had been the wound doctor. When asked since the pressure ulcer had progressed to a Stage 3 and healed in two months, was it truly unavoidable, LPN G had no answer. On 6/29/22 at 9:45 AM, Nurse Practitioner (NP) H, who served as the contracted Wound Consultant was interviewed and asked about R56's left lateral malleolus pressure ulcer. NP H explained R56 had a lot of comorbidities and had chronic wounds and those were unavoidable. NP H was asked if having a chronic unavoidable wound made every other wound unavoidable. NP H explained she just wrote one note for all wounds. When asked since the pressure ulcer had progressed to a Stage 3 and healed in two months, was it truly unavoidable, NP H explained it would not have healed so fast if it was unavoidable. On 6/29/22 at 2:57 PM, the Director of Nursing (DON) was interviewed and asked about R56's left lateral malleolus pressure ulcer not being identified until it was an Unstageable pressure ulcer. The DON explained it should have been discovered before it became an Unstageable pressure ulcer. The DON was asked about the Total Body Skin assessment dated [DATE] that documented no new wounds, but then said there was a blister. The DON explained the blister should have been listed as a new wound, and a treatment put in place. When asked if the blister had been treated, would the injury have progressed to a Stage 3 pressure ulcer. the DON had no answer. R57 On 6/26/22 at 11:23 AM, R57 was observed lying in bed. R57 was asked about care at the facility. R57 explained he had not been out of bed for a week, since Father's Day. A wheelchair was observed next to the dresser in R57's room. Review of the clinical record revealed R57 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R57 was cognitively intact and required the extensive to total assistance of staff for all ADL's. Review of R57's Skin & Wound Evaluation dated 6/22/22 read in part, .Type: Pressure . Stage: Unstageable . Location: Lateral Right Foot . Acquired: In-House Acquired . Exact Date: Unknown . Length: 4.5 cm . Width: 2.1 cm . Eschar (dead or devitalized tissue that is hard or soft in texture): 100% of wound filled . Review of R57's Braden Scale for Predicting Pressure Sore Risk dated 5/5/22 revealed a score of 13, indicating moderate risk. On 6/28/22 at 11:15 AM, an observation of R57's skin care was made with LPN D and LPN E. R57 kept his right leg bent out to the side so the lateral aspect of the right foot was in contact with the mattress. No foam boots were observed. There was black Eschar along the lateral side of the right foot from the base of the pinkie toe to approximately 1.5 to 2 inches down the foot. On 6/28/22 at 3:08 PM, LPN G was interviewed and asked about R57's wounds. LPN G explained R57's right leg was not contracted, but he kept it bent out so the side of the foot would lay on the bed. LPN G was asked about R57 stating he had not been out of bed for a week. LPN G explained R57 should be up in the chair, she had even acquired a low air loss cushion for his wheelchair. On 6/29/22 at 9:34 PM, NP H was interviewed and asked about R57's wounds. NP H explained she had discovered that morning a new pressure injury to R57's left posterior thigh. When asked if getting up to a chair would help R57's wounds, NP H explained R57 should be getting up to a chair daily. NP H was asked if foam boots would help R57's lateral foot. NP H explained foam boots would help take the pressure off R57's foot as he kept his leg bent out. R142 A complaint was filed with the State Agency on 3/14/22 that alleged in part, .the resident developed a bedsore that needed to be packed and debrided due to the facilities lack of care . Review of the closed record revealed R142 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R142 had moderately impaired cognition and required the extensive to total assistance of staff for all ADL's. The MDS assessment also indicated R142 had a facility acquired Stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) pressure ulcer. Review of R142's left buttock Skin & Wound Evaluations revealed: 1/27/22, .Type: Pressure . Stage: Stage 2: partial-thickness skin loss with exposed dermis . Location: Left Buttock . Acquired: In-House Acquired . Exact Date: 1/26/22 . Length: 4.1 cm . Width: 2.2 cm . Slough: 10% of wound filled . 2/2/22, .Stage 2 . Length: 4.1 cm . Width: 1.1 cm . 2/9/22, .Unstageable . Length: 5.7 cm . Width: 1.6 cm . Slough: 70% of wound filled . Notes: Left buttock stage II wound is now an unstageable wound . 2/16/22, .Unstageable . Length: 6.1 cm . Width: 2.4 cm . Slough: 80% of wound filled . 3/16/22, .Stage 4 . Length: 4.0 cm . Width: 2.5 cm . Slough: 10% of wound filled . 3/23/22, .Stage 4 . Length: 5.5 cm . Width: 3.4 cm . Notes: Sacrum (previously left buttock) stage IV wound has a moderate amount of serosanguinous and purulent drainage. The site has 10% slough, 20% necrosis . a depth of 1.3 cm, and circumferential undermining of 39 cm . There is palpable bone today . 3/30/33, .Stage 4 . Length: 5.3 cm . Width: 3.4 cm . Slough: 40% of wound filled . Review of R142's progress notes revealed a note dated 4/6/22 by NP H that read in part, .Sacrum (previously left buttock) stage IV wound has a large amount of serosanguinous and purulent drainage. The site has 30% slough, 20% necrosis, no maceration, a depth of 2.2 cm, and circumferential undermining of 5.0 cm . There is palpable and visible bone today . On 6/29/22 at 10:20 AM, NP H was interviewed and asked about R142's wound. NP H explained she had last seen R142 on 4/6/22 and remembered the sacrum wound was bad. Resident #143 Review of a complaint submitted to the State Agency for indicated that R143 did not receive appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/27/22 The medical record for R143 was reviewed and revealed the following: R143 was initially admitted to the facility on [DATE] and discharged on [DATE]. R143 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R143's BIMS score was six indicating severely impaired cognition. A review of R143's Nursing Comprehensive Evaluation dated 5/18/22 revealed the following: Section K-Skin: 23)Coccyx- dark pink areas slow to blanche .23) Coccyx-light colored scab. A Nursing note dated 5/19/22 revealed the following: Second Skin Assessment: [R143] presented as A&O x name, unable to make her needs known as she seems to have a lack of sensory perception due to the fact that she did not know she needed to be changed. She has thick discolored toenails bilaterally, a small skin tear to her right forearm general spots of discoloration to bilateral arms and a small open area to her coccyx area. Further review of the medical record revealed no Physician orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . every day and night shift for Skin protection Nurse to complete tx (treatment) after shower and/or Weekly Skin assessment. A review of the May and June 2022 TAR (treatment administration record) revealed no documentation that R143 received their chamosyn treatment on their coccyx for the morning shift of 6/2/22. A review of R143's care plan revealed the following: Focus-[R143] is at risk for impaired skin integrity/pressure injury R/T (related to): decreased mobility, OA ([CONDITION(S)]), [CONDITION(S)] (Hypertension), dementia. Date Initiated: 05/18/2022 .Interventions-Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/22 at approximately 3:09 p.m., Wound care manager G (WCM G) was queried regarding the timeliness of the implementation of the coccyx treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . For buttocks/coccyx impairments the Nurses should make sure to implement the Chamosyn treatment immediately upon identification of a new area. At that time, R143's medical record was reviewed with WCM G and they indicated that the Chamosyn should have been ordered immediately to prevent opening of the scab on R143's coccyx on 5/18/22. WCM G was queried if it was their expectation that an identified impairment on a resident's coccyx go untreated and they indicated it was not and that was the purpose of the standing Chamosyn order that the Nurse can implement. Review of a facility policy titled, Skin Management revised 7/14/21 read in part, .Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan . The interdisciplinary team considers whether the guest/resident exhibits conditions or is receiving treatments that may place the guest/resident at higher risk of developing [NAME] injury or complicate their treatment. Such conditions may include cognitive impairments . Impaired/decreased mobility and decreased functional ability . Co-morbid conditions . Guest/resident refusal of some aspect of care and/or treatment . A resolved injury .

This citation pertains to intake #'s MI 411, MI 565, and MI 597 Based on interview and record review, the facility failed to immediately report a resident's complaint of a broken Hoyer sling and ensure an appropriate and safe transfer with a mechanical Hoyer lift for one resident (R902), of two residents reviewed for Hoyer lift transfers, resulting in R902 falling and fracturing their left femur and their right femoral neck requiring hospitalization and surgical intervention. Findings include: Two complaints and a Facility Reported Incident were received by the State Agency that alleged R902's Hoyer lift sling broke, they fell and fractured their left femur and right femoral neck. A facility provided policy titled, Transfer with a hydraulic lift dated [DATE], was reviewed and read, .Although most hydraulic lift models can be operated by one person, it's better to have two staff members present during a transfer .Make sure the sling and straps are not frayed, stressed at the seams, or otherwise damaged. if the device, sling, or straps are defective or have compromised integrity, remove them from patient use . A review of R902's clinical record was conducted on [DATE] and revealed R902 admitted to the facility on [DATE] with diagnoses that included: heart failure, [CONDITION(S)], diabetes, muscle weakness, [CONDITION(S)], muscle wasting and atrophy, and a history of falls. R902's most recent Minimum Data Set assessment dated [DATE] indicated R902 had intact cognition, was non-ambulatory, and required extensive assistance from two staff members for transferring. R902's Kardex (care guide) read, .TRANSFER: Resident requires Mechanical lift x2 (staff) dependent assist for transfers . R902's care plans were reviewed, and an intervention initiated [DATE] indicated R902 required a mechanical lift and two staff members for transferring. A review of R902's weights was conducted and revealed they were in excess of 300 pounds. Review of a nursing progress note dated [DATE] at 7:46 PM entered into the record by Licensed Practical Nurse (LPN) 'A' was reviewed and read, .Aid <sic> came and got writer and he said that the sling broke. Writer walked into the room with aid <sic> and seen guest laying on his back on top of the hoyer lift on the floor .Guest left hip appear <sic> to look dislocated and his left knee was flat and facing the wall .guest was taken to (Hospital Name) . A review of a facility reported incident investigation file was conducted. The file contained a typed document summarizing the incident that read, .On [DATE], Administrator/Abuse Coordinator .was notified that the resident had fallen from the Hoyer lift during transfer at approximately 11am. The resident was sent to the hospital for evaluation .One hour prior to the fall, the resident notified his Social Worker (Social Worker 'B') that he believed his sling needed to be replaced. (Social Worker 'B') promptly brought it to the attention of the management team in the morning meeting. Administrator .gave the directive to have the sling replaced right away. As the new sling was being brought down to the resident's room, the resident fell from his Hoyer lift .The CNA (certified nursing aide) assisting the resident during the transfer was (CNA 'C) .She went to his room to set up the Hoyer lift and let down the assist bars on his bed. She went back to the floor to find assistance but was not able to locate another staff member. She stated she was going to wait until a co-worker was free, but the resident kept insisting that she go ahead and put him to bed .She proceeded to hook the purple straps of the sling onto the top and bottom to attach it to the lift. She didn't notice any issues with the sling .As she began to move him, a strap on the sling broke causing the resident to fall on top of the Hoyer lift and hit his head . Continued review of the investigation file included a statement signed by CNA 'C' and CNA/Union Steward 'D' obtained by the facility's Director of Nursing (DON) on [DATE] that read, .I proceeded to get the Hoyer lift ready for (R902) .I went to get someone to help, but nobody was around .I was going to wait for someone to help me, but (R902) kept insisting that I go ahead and put him to bed .After I adjusted the sling under him, I looked the sling over. I noticed the black strap was torn .As soon as I began to move him, the Hoyer strap broke . The file contained a second statement from CNA 'C' dated [DATE]. The statement did not indicate who obtained the statement and was not signed. That statement read, .I hooked the purple straps on the top and bottom to attach it to the hoyer lift and didn't notice any issues with the sling .As soon as I began to move him, the strap broke on the sling . The file contained a statement from R902 dated [DATE] that said CNA 'C' was putting him back to bed and, .the strap broke. I fell out of the Hoyer. It was further noted the investigation file contained a document titled, ON THE SPOT IN-SERVICE for CNA 'C' that read, .Employee transferred (R902) without following Kardex (care guide) appropriately, resulting in a fall .Employee will follow Kardex for transferring. Will always use 2 persons when using a hoyer with the legs in the open position, slings to be inspected for wear prior to use . On [DATE] at 1:00 PM, an interview was conducted with Social Worker 'B' about their knowledge of R902's broken Hoyer lift sling. Social Worker 'B' said on the morning of [DATE], R902 reported to her his Hoyer lift sling was broken. When asked what she did with the knowledge of the broken sling and whether they reported it immediately to someone such as R902's nurse, Social Worker 'B' reported that since it was time for the morning meeting, they reported the information during the meeting. On [DATE] at 1:20 PM, an interview was conducted with the facility's administrator regarding their investigation into R902's fall. The administrator was queried if they knew the extent of R902's injuries from the fall. The administrator said they had not received any hospital documentation but said staff present at the time reported that R902's legs appeared injured. The Administrator also said that R902's family had reported to the facility that he had broken his leg and his hip and required surgery. On [DATE] at 10:05 AM, a telephone interview was conducted with CNA 'C' regarding the incident involving R902. CNA 'C' acknowledged they did perform a one person Hoyer lift transfer with R902 and did not wait for a second available staff person to assist. During the interview, CNA 'C' was asked about their conflicting statements on [DATE] where they said R902's Hoyer sling was .torn . and on [DATE] where they, .didn't notice any issues with the sling . During the interview, CNA 'C' was hyperverbal and said when they wrote the first statement they were, confused, out of my mind, and nervous. CNA 'C' was difficult to re-direct through the interview but when asked if the sling was damaged in any way, CNA 'C' stated, It was damaged. CNA 'C' was asked to describe the damage and said the black part of the sling looked like it had been bleached. CNA 'C' stated, It was miscolored, old and worn. CNA 'C' said it appeared it had been washed many times. On [DATE] at 10:25 AM, an interview was conducted with the facility's DON regarding R902's fall from the Hoyer lift. The DON said they had been made aware of the fall right away and when they reported to the unit, CNA 'C' was distraught. The DON said they went in the room and observed R902 on the floor lying on top of the legs of the Hoyer lift. When asked if R902 appeared to have any injuries, the DON reported R902's legs did not look right and said his left leg was, in a very bad position. The DON said emergency medical personnel responded and took R902 to the local hospital. The DON was then asked about the statement they obtained from CNA 'C' on [DATE]. The DON said when they began the investigation CNA 'C' came to their office with CNA/Union Steward 'D' and said she wanted to give her statement. The DON said after she typed the statement, she read it aloud back to CNA 'C' and both CNA 'C' and CNA/Union Steward 'D' signed and dated the statement. The DON was queried if they obtained the unsigned statement from CNA 'C' on [DATE] and said they did not, the Administrator did. During the interview, the DON was asked about Social Worker 'B' reporting R902's complaint of a broken Hoyer sling during the morning meeting. The DON explained the format of the morning meeting and what topics were discussed during the meeting and said the sling was brought up at the end of the meeting when they staff in attendance went around voicing any additional concerns. The DON said after it was reported they immediately addressed it. The DON said the transfer took place and sling broke as Housekeeper 'F' was delivering the new sling to the resident. The DON was asked if the broken sling should have been brought to someone's attention prior to the morning meeting and said it should have. On [DATE] at 11:00 AM, a follow-up interview was conducted with the facility's Administrator regarding the conflicting statements obtained from CNA 'C' on [DATE] and [DATE]. The Administrator acknowledged the inconsistencies between the statements and said they even had CNA 'C' perform a demonstration using the Hoyer lift to clarify the inconsistencies; however, CNA 'C' demonstrated additional inconsistencies when performing the demonstration. At that time, the Administrator was made aware of additional inconsistencies obtained during the telephone interview on [DATE] at 10:05 AM. As the interview continued, the Administrator acknowledged CNA 'C' should not have transferred the resident in the Hoyer lift by herself and reported that more urgency should have been put on the knowledge of the sling being damaged. On [DATE] at 4:00 PM, R902's records were received from the acute care hospital they were transferred to after the fall on [DATE]. The records read, Hospital Course .He (R902) was brought to the hospital via EMS when he was seen evaluate <sic> by emergency room and activated as a trauma. X-rays were obtained of the left lower extremity which sowed a subtrochanteric (anatomic description) femur fracture .pelvis showed a right femoral neck fracture and possible right greater trochanteric (anatomic description) fracture .Orthopedic was consulted for management of these injuries . Continued review of the hospital record read, .Discharge Diagnosis and Plan: 1. Displaced subtrochanteric fracture of left femur, initial encounter for closed fracture 1.<sic> Fracture of femoral neck, right 2. Fall 3. Closed head injury 4. Contusion of right forearm [CONDITION(S)], Leg Injury-Major, Shock. Patient Discharge Condition: deceased .

Based on observation, interview, and record review, the facility failed to assist residents with feeding, accurately assess weight loss, consistently document residents' intake, and ensure residents were evaluated by a physician after a significant weight loss occurred for three (R#s: 90, 70, and 113) of seven residents reviewed for nutrition, resulting in the potential for continued weight loss and physical decline. Findings include: Resident #113 On [DATE] at 11:15 AM, R#113 was observed sleeping. The resident appeared thin. On [DATE] at 3:05 PM, R#113 was observed seated in bed, not wearing a shirt, and attempting to feed themself potato chips from a bag. R#113's chest was covered in broken potato chips and they appeared to be having difficulty eating the chips. An overbed table was positioned in front of the resident that contained a plate of spaghetti with tomato sauce, bread, and vegetables, and two plastic cups with a clear beverage that appeared to be juice. R#113 was observed from 3:05 PM until approximately 3:30 PM and no assistance was provided by staff. The plate of spaghetti was untouched by the resident and potato chips remained on the resident's chest. When spoken to, R#113 did not respond and only made eye contact. On [DATE] at 12:31 PM, R#113 was observed lying in bed sleeping. Staff were observed passing lunch trays in the hallway until approximately 1:00 PM. At 1:15 PM, R#113 was observed in the common area seated at a table with a plate of meat, potatoes, a green vegetable, a roll, two cups of juice, and a yogurt that had a spoon in it. R#113 was not observed to eat any of the food independently. At that time, Restorative Aide I sat next to R#113 and physically assisted the resident with eating. R#113 was observed to accept food with assistance. R#113's meal ticket was observed at that time and it documented, .Alerts: 1:1 (one to one) feeding . On [DATE] at 2:59 PM, Restorative Aide I was interviewed. When queried about the level of assistance R#113 required for eating, Restorative Aide I stated, She has to be fed for all meals. Restorative Aide I reported R#113 was supposed to be brought out to the common area for meals due to being a high fall risk. R#113's clinical record was reviewed and revealed the following: R#113 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #113 had severely impaired cognition, indicated by a Brief Interview of Mental Status score of 00 (0 to 7 indicated severe impairment), no behaviors, and required set up only for eating. The MDS documented R#113 had weight loss greater than five percent in the last month or loss of 10 percent or more in last six months and was not on prescribed weight-loss regimen. Review of aNutritional Evaluation dated [DATE] and a Nutritional Re-Evaluation assessment dated [DATE] documented R#113's usual body weight was between 132 and 141 lbs. A review of R#113's Weights Summary documented R#113 lost 20 pounds between [DATE] and [DATE]. On [DATE], R#113's recorded body weight was 140 pounds (lbs). On [DATE], R#113's recorded body weight was 120 lbs. This indicated R#133 had a severe weight loss of 14.2 in one month. R#113's recorded weight on [DATE] was 137.4 lbs. R#113's recorded weight on [DATE] was 122.2 lbs. This indicated R#113 had severe weight loss of 11.06 percent in six months. A review of R#113's care plans revealed the following: A care plan initiated on [DATE] and revised on [DATE] documented, (R#113) has alterations in nutrition and hydration status aeb (as evidenced by): Cannot understand or speak English. Oral intake of meals is variable. H/o (history of) significant weight loss .Requires feeding assistance, but is able to feed self at times . Interventions initiated on [DATE] documented, Monitor and record oral intake on food acceptance record and report any changes in ability or intake to dietitian .Offer substitution if refuses or consumes < (less than) 50% of meals .Provide assistance at meals as needed: provide 1:1 assistance and encouragement with meals; provide 1:1 feeding if needed, depending on (R#113's) ability for the day . A review of the POC Response History (documentation by the Certified Nursing Assistants - CNAs when care is provided) for Amount Eaten and Eating (which documented the level assistance provided by staff) for R#113 for the past 30 days revealed the following: On [DATE] at 1:24 PM and 1:25 PM Not applicable was documented for Amount Eaten (food acceptance at each meal) and Eating assistance. There was no food acceptance or assistance with eating documented for that day. (Note: An observation of R#113 was made at 3:05 PM eating lunch unassisted which was after the recorded time of Not applicable. Further review of the POC Response History for Amount Eaten and Eating assistance was conducted and revealed the following: On [DATE], one meal was documented. On [DATE], two meals were documented. It was documented R#113 ate ,d+[DATE]% of their meal at 10:28AM. It was documented R#113 received set up help only at that time. On [DATE], two meals were documented. On [DATE], two meals were documented. it was documented R#113 ate ,d+[DATE]% of their meal at 10:00 AM. It was documented R#113 received set up help only at that time. On [DATE], no meals were documented. On [DATE], no meals were documented. On [DATE], two meals were documented. On [DATE], two meals were documented. It was documented R#113 ate ,d+[DATE]% of their meal at 9:55 AM. It was documented R#113 received set up help only at that time. On [DATE], one meal was documented. On [DATE], two meals were documented. It was documented R#113 ate ,d+[DATE]% of their meal at 9:30 AM. It was documented R#113 received set up help only at that time. On [DATE], there was two documentations at12:35 PM that noted R#113 refused and ate ,d+[DATE]% of their meal. On [DATE], two meals were documented. On [DATE], one meal was documented. On [DATE], two meals were documented. On [DATE], two meals were documented. On [DATE], one meal was documented. It was documented R#113 ate ,d+[DATE]% of their meal at 10:18 PM. It was documented R#113 received set up help only at that time. On [DATE], no meals were documented. On [DATE], one meal was documented at 11:58 PM. On [DATE], no meals were documented. On [DATE], one meal was documented at 10:36 PM. On [DATE], no meals were documented. On [DATE], one meal was documented as refused at 11:44 AM. On [DATE], two meals were documented indicating R#113 ate ,d+[DATE]% at both meals. On [DATE], two meals were documented. It was documented R#113 ate ,d+[DATE]% of their meal at 12:09PM. It was documented R#113 received set up help only at that time. On [DATE], no meals were documented. A Nutritional Evaluation dated [DATE] and a Nutritional Re-Evaluation assessment dated [DATE] documented R#113's usual body weight was between 132 and 141 lbs. A Nutritional Re-Evaluation dated [DATE] documented R#113's usual body weight was between 120 and 125 lbs which was lower than the previous assessment. The assessment documented, .Weight is stable x 2 months, however UBW range is lower than previous review and is triggering for significant loss x 3 & 6 months . (Note: If the usual body weight range was lower it would reduce the trigger for significant weight loss). On [DATE] at 3:05 PM, Registered Dietician (RD) C was interviewed. When queried about how resident weight loss was monitored, RD C reported she reviewed the Weight and Vitals list which showed any triggers for significant weight loss. When queried about what the protocol was when a resident triggered for weight loss, RD C reported a reweigh should be done, preferably the next day, and if weight loss occurred, it should be discussed in the clinical meeting to figure out what was going on. In addition, RD C reported they made observations of the resident eating. RN C further reported that the physician would be notified to evaluate the resident to rule out any underlying medical issue or identify any medical issue contributing to the weight loss. When queried about how a resident's intake was monitored, RD C reported the CNAs documented the amount of food eaten at each meal. RD C reported they reviewed the CNA documentation, as well as attempted to observe the residents during mealtime. RD C was queried about how the nursing staff would know the level of feeding assistance a resident required. RD C reported it would be documented on the resident's meal ticket. RD C was further interviewed regarding R#113. When queried about the level of assistance the resident required with eating, RD C reported it depended on how her day was going. RD C reported sometimes R#113 would let people assist her and sometimes she would not. When queried about R#113's meal ticket documenting 1:1 feeding, RD C reported there was a training conducted recently, and all feeding assistance was changed to 1:1 feeding. The CNAs are to decide based on their judgment whether the resident required assistance for each meal. When queried about whether CNAs were able to assess residents as part of their scope of practice, RD C did not offer a response. At that time, RD C was asked to provide any information about what contributed to R#113's significant weight loss and what interventions were put in place after it was identified. On [DATE] at 4:19 PM, RD C followed up with the following information. RD C reported R#113's weight was in the 130s and 140s (lbs) in [DATE]. RD C stated, On [DATE] her weigh was 140 (lbs) and on [DATE] it went down to 126 (lbs). I'm not sure the 140 was a correct weight. When asked why she thought that RD C did not offer a response. RD C reported the Physician's Assistant saw R#113 on [DATE]. Upon review of the note written by the Physician Assistant, there was no mention of weight loss or that the resident was evaluated for that reason. When queried about how usual body weight was determined and how it was used to calculate weight loss, RD C confirmed that usual body weight was used to determine percentage of weight loss. When asked why R#113's usual body weight was decreased from ,d+[DATE] lbs on [DATE] to ,d+[DATE] on [DATE], RD C reported R#113's weight had been stable at that range, but that she typically would not change that unless at least 6 months had passed. RD C did not offer an explanation as to why R#113's usual body weight was changed after she had a significant weight loss. RD C reported the Physician Assistant saw R#113 on [DATE]. A review of progress notes from [DATE] and [DATE] revealed no progress notes from a medical practitioner that included evaluation for significant weight loss until [DATE]. On [DATE] at 1:06 PM, an interview with the DON was conducted. When queried about how facility staff and nursing staff contracted through a staffing agency knew whether a resident required feeding assistance or not, the DON reported it would be documented on the meal ticket or the Kardex. When queried about what 1:1 feeding meant, if documented on the meal ticket, the DON reported it meant someone had to sit with the resident and physically feed them throughout the meal. The DON was queried about the training mentioned by RD C where it was determined CNAs could assess whether a resident required assistance with eating at each mean. The DON reported she was unaware of that training and CNAs would not determine the level of assistance required. When queried about how residents' intake was monitored, the DON reported it would be documented by the CNAs for each meal in the food acceptance record (CNA Task for Amount Eaten). The DON was asked to clarify when usual body weight would change for a resident. The DON reported she was not sure but would look into it. No additional information was provided prior to the end of the survey regarding usual body weight. R90 On [DATE] at 8:19 AM, R90 was observed in their room, in bed attempting to eat their breakfast. A review of R90's meal tray ticket was conducted and read, .Alerts: 1:1 feeding . Staff were not observed to be present in the room assisting R90 with their meal. On [DATE] at 12:10 PM, R90 was observed in their room in bed attempting to consume their lunch meal. Review of the lunch tray ticket was conducted and read, .Alerts: 1:1 feeding Staff were not observed to be present in the room assisting R90 with their meal. It was further observed R90 was attempting to remove the paper lid from their nutritional treat ice cream supplement, however; due to the [CONDITION(S)] on their right side, R90 was not able to remove the lid. It was further observed R90 was to have their beverage served in a 2-handled cup. It was observed there was a cup of thickened cranberry juice with foil lid peeled back, and a 2 handled cup on the bedside table, however; the 2 handled cup was empty. On [DATE] at approximately 8:20 AM, R90 was observed in their room attempting to eat their breakfast meal. Staff were not present in the room to assist R90 with eating. On [DATE] at approximately 12:40 PM, R90 was observed in their room seated in their wheelchair attempting to eat their lunch meal. Staff were not observed in the room to assist R90 with eating. On [DATE] a review of R90's clinical record was conducted and revealed an admitted [DATE] and a re-admitted [DATE]. R90's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R90's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R90 had severely impaired cognition, was non-ambulatory, and required extensive assistance from one staff member for all activities of daily living, including eating. A review of R90's care plan for alteration in nutrition was conducted and an active intervention initiated [DATE] read, Provide assistance with meals as needed: provide 2-handle cup per OT (Occupational Therapy) recommendations . A review of R90's documented weights was conducted and revealed the following: [DATE] 177.5 lbs, the first weight documented upon re-admission on [DATE]. [DATE] 155.0 lbs [DATE] 155.0 lbs [DATE] 153.6 lbs [DATE] 152.6 lbs [DATE] 151.0 lbs [DATE] 152.6 lbs [DATE] 152.6 lbs [DATE] 152.5 lbs [DATE] 152.6 lbs [DATE] 150.8 lbs [DATE] 153.2 lbs [DATE] 152.6 lbs. It was noted there was a 22.5 lb documented weight loss between [DATE] and [DATE]. It was further noted there was no re-weight obtained at that time. A review of a Reentry Nutritional Evaluation dated [DATE] was reviewed and had R90's weight documented as 174.6, however; it was noted on the evaluation the date the weight was obtained was [DATE]. A review of a second assessment titled, Nutritional Re-evaluation dated [DATE] indicated R90 showed a significant weight loss at 3 and 6 months. The assessment further read, .16. Ability to Feed Self: independent with cueing to eat slowly . A review of R90's Certified Nursing Assistant (CNA) tasks for Eating and Amount Eaten was reviewed and revealed: [DATE]: Of the 93 times staff should have documented assistance with meals for R90, 39 times the documentation was left blank. It was further noted that of the 93 meals that a percentage of the meal consumed should have been documented, 38 meals (breakfast, lunch, dinner) were left blank. February 2021: Of the 84 times staff should have documented assistance with meals for R90, 32 times the documentation was left blank. It was further noted that of the 84 meals that a percentage of the meal consumed should have been documented, 32 meals were left blank. [DATE]: Of the 93 times staff should have documented assistance with meals for R90, 30 times the documentation was left blank. It was further noted that of the 93 meals that a percentage of the meal consumed should have been documented, 30 meals were left blank. [DATE]: Of the 27 meals staff should have documented percentage of meal eaten, 11 meals were left blank. On [DATE] at 4:10 PM, an interview with Registered Dietician 'C' was conducted. Dietician 'C' indicated R90 had some weight loss and indicated he was supposed to have 1:1 feeding assistance from staff because he eats fast and needs cueing to slow down. When queried how staff would know what R90's needs are with dining and assistance, Dietician 'C' indicated it would be on the meal ticket. R#70 On [DATE] at approximately 10:13 AM, R#70 was observed lying in bed. The resident was alert, but not able to answer any questions asked. On [DATE] at approximately 8:00 AM, Nurse Q reported that the resident expired in the middle of the night. A review of the resident's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Addition diagnosis (creation date [DATE]) indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .) Further review of the MDS indicated that the resident weighed 182 lbs. and needed extensive one-person physical assist. Hospital records reviewed documented, in part, the following: Nursing Plan of Care .Problem(S) .Multiple wounds .tolerated small amount of breakfast 1:1 feed. Emotional support provided .1:1 feed for lunch . A review of the weights obtained by the facility documented: [DATE]: Weight 182.2 lbs. [DATE]: Weight 152.2 lbs. [DATE]: Weight 150.0 lbs. [DATE]: Weight 136.2 lbs. A Nutritional Evaluation (dated [DATE]) and authored by RD B documented, in part, .Most Recent Weight: 182.2 date [DATE] .Usual Weight: 150 .Weight from Nursing Comprehensive Evaluation .159.2 [DATE]: 182.2 #. If facility weights are accurate, weight gain could possibly be from [CONDITION(S)] Able to self-help with set up .She was a 1:1 assist with feed at hospital and reports she is able to feed herself with her good arm .Will monitor weight, oral intake will further intervene as needed. A Dietary Note ([DATE]) at 2:02 PM documented, Reviewed amount eaten and intake has decreased .Already has order or 120 ml Hi-Cal TID, will continue and start Nutritional Treat supplement TID . There were no further dietary notes found in the clinical record after [DATE]. A physician Encounter note ([DATE]) documented, .History of Present illness: Patient is being evaluated this morning after being noted to have 18-pound weight loss in 1 month, and 46-pound weight loss in the past two months. Of note patient was recently signed with hospice. She is noted with a poor appetite and extensive wounds . An additional diagnosis (creation date [DATE]) Unspecified Severe Protein-Calorie Malnutrition was added to the resident's clinical record. R#70's Care Plans documented, in part,: Focus: (name redacted) R#70 has an ADLSelf Care Performance Deficit .Eating: R#70 requires x1 assist to feed all meals (date initiated [DATE]) .Focus: R#70 has alterations in nutritional status .Hospice as of [DATE] .Interventions: Weigh per facility protocol and notify physician and RD (registered dietician) of any significant weight changes ([DATE]) .Regular diet, Level 1 Puree texture, 2 handled cup, 120 ml (milliliter) Hi-Cal (a protein supplement general used for those with pressure sores) TID (3X per-day), Nutritional Treat TID ([DATE]) .Monitor for and report any s/sx (signs/symptoms) of fluid imbalances such as [CONDITION(S)] .recent/sudden weight loss([DATE]) .Monitor and record oral intake on food acceptance record and report any changes in ability or intake to dietician ([DATE]) .1:1 feeding at meals ([DATE]) . The Resident's POC Response History for the month of February 2021 indicated the resident was to receive three meals per day (breakfast, lunch, and dinner) for a total of 84 meals for the month. The resident's care plan for Nutrition (dated [DATE]) indicated that the resident was to receive 1:1 assist with feeding and that the resident's percentage of meals, alternative offerings and fluid intake were to be noted in the POC. The Intervention/Task that documented support provided during meals and the amount eaten revealed that 22 Meals were BLANK with no indication that the resident was being assisted with meals and the amount eaten (including fluid intake) as follows: [DATE]: [DATE] (lunch), [DATE] (dinner), [DATE] (breakfast, lunch, dinner), [DATE](dinner), [DATE] (dinner), [DATE] (breakfast and lunch), [DATE] (dinner), [DATE] (dinner), [DATE] (breakfast, lunch, dinner), [DATE] (dinner), [DATE] (breakfast, lunch), [DATE](breakfast, lunch, dinner), [DATE] (dinner), [DATE] (dinner). On [DATE] at approximately 3:18 PM an interview was conducted with RD B with respect to R#70's decline in weight. RD B indicated that she could not recall the resident and would need to view the resident's clinical record. When queried as to the facility protocol for weight management, RD B reported that all new admits should be weighed weekly for the first four weeks and then once per month. She also indicated that if there were any decrease in weight it should be reported to her. RD B indicated that nutritional assessments were to be completed quarterly. On [DATE] at approximately 4:30 PM, RD B returned to discuss R#70's weight decline. RD B reported that R#70 should have been weighed weekly for four weeks following admission. With respect to R#70's, 17.67 % weight decline from 182.2 lbs. ([DATE]) to 150 lbs. ([DATE]), RD 'B reported that the decline was most likely due to [CONDITION(S)] and indicated the resident stated her weight was usually 150 lbs and noted that . When queried as to the 9.33% weight decline from 150 lbs. ([DATE]) to 136.2 ([DATE]), RD 'B indicated that she was not certain. When asked about the significant number of non-documented 1:1 food assists and lack of documentation of food acceptance for the month of February 2021, RD B indicated that she was not able to look back past 30 days to review the POC record. On [DATE] at approximately 1:32PM an interview was conducted with the DON. When queried as to R#70, the DON indicated that if a resident requires 1:1 assist with food intake the CNA's are implement the task, record that it was completed and enter the percentage of food consumed. If there is any decline in consumption and weight, it should be reported to a nurse and the RD. A review of the facility policy titled, Weight Management (revised ,d+[DATE]) documented, in part, the following: Policy: Guests/residents will be monitored for significant weight changes on a regular basis. Guest/residents are expected to maintain acceptable parameters of nutritional status .Anticipated Outcome: Any guest/resident with unintended weight loss/gain will be evaluated by the interdisciplinary team and interventions will be implemented to prevent further weight loss/gain .The Dietary Manager/RD and DON are responsible for coordination of an interdisciplinary approach to managing the processes for prediction, prevention, treatment, monitoring and calculation of unintended weight loss/gain .Guest/residents will be weighed upon admission/readmission; weekly x4 then monthly or as indicated .Guest/residents determined to be at risk or have significant weigh changes will be weighed on a weekly basis. Guest/residents at risk are .Guests/residents with insidious weight loss and; 5% in one month, 7.5% in three months, 10% in six month .Dietary Manager, Unit Manager and/or RD are to communicate weight changes to the IDT, attending physician and guest's/resident's responsible party. Once an insidious weight loss is identified, the RD further assesses the guest/resident and makes recommendations .

This citation pertains to intake: MI 114. Based on interview and record review the facility failed to accurately complete the residents weekly skin assessments, promptly implement interventions (care plan) for a resident who was assessed as high risk for developing a pressure ulcer and identify and report worsening of coccyx wound for one (R#804) of three residents reviewed for pressure ulcers, resulting in Immediate Jeopardy (IJ) when R#804 developed an unstageable pressure ulcer (Full - thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) to the coccyx area (within 12 days of admission) and worsened to a stage IV (stage 4 - Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) with bone visible and palpable that required multiple debridement's, hospitalization s and required IV (Intravenous) antibiotics for an infected pressure ulcer and [CONDITION(S)]. This deficient practiced placed all residents at risk for skin breakdown and those residents with pressure ulcers at risk for serious complications, harm, injury and/or death. Findings include: The IJ began on 1/8/21 and was identified by the survey team on 3/16/21. The Administrator of the facility was notified of the IJ on 3/16/21 at 11:27 am and a plan to remove the immediacy was requested. On 3/16/21 the State Agency completed onsite verification that the IJ was removed on 3/11/21, however the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. A complaint submitted to the state agency stated the resident developed a bed sore at the facility that progressively got worse. The resident had to undergo three different debridement's. On 3/10/21 an onsite investigation was conducted into the complainant's allegations. A review of the clinical record revealed the following: R#804 was admitted into the facility on [DATE] and discharged to hospital on 2/24/21. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 00 indicating severely impaired cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of the admission MDS dated [DATE], revealed the resident did not have any pressure ulcers. A Braden Scale For Predicting Pressure Sore Risk dated 1/10/21 documented a score of 12 (High Risk), however a review of the resident care plans revealed the facility failed to implement a care plan or interventions timely to prevent pressure ulcers (Care Plan Implemented on 2/17/21). Review of the Skin & Wound - Total Body Skin Assessment (a weekly skin assessment completed by Registered Nurse (RN) D) dated 1/20/21 revealed, Turgor- Good Elasticity, Skin Color- Normal for ethnic group, Temperature - Warm, Moisture - Normal, Condition - Normal, Enter the # of New Wounds - 0. A Wound note (completed by the Wound Nurse Practitioner (WNP) E) dated 1/20/21 documented in part, . Plan: Abdomen and right flank may be left open to air. Nursing may check with surgeon's recommendations about staple removal. Coccyx: Santyl daily covered with border foam . Recommend frequent repositioning, specialty bed, offloading boots . This is the first documentation of any skin concerns to the coccyx area, identified by the Wound Practitioner, not the facility staff. A Skin & Wound Evaluation dated 1/20/21 (completed by Licensed Practical Nurse (LPN) A who rounded with WNP E ) documented in part, . Pressure . Unstageable: Obscured full-thickness skin and tissue loss . Due To: Slough and/or eschar . Location: Sacrum . Area - 13.5 cm2 (centimeters squared), Length - 6.8 cm, Width - 2.8 cm .Slough . 50% of wound filled . , Prior to the Wound consult, the facility staff failed to identify the skin changes to the resident coccyx area. On 3/11/21 at 11:53 am, RN D was queried regarding why they failed to identify the resident's coccyx wound when they completed the 1/20/21 weekly skin assessment, RN D stated in part . I thought it was a stage two. I don't remember. I probably assumed that the facility knew about it . RN D acknowledged their error and stated the facility did educate them on the correct protocol when completing weekly skin assessments, identification of a wound and obtaining treatments. On 3/11/21 at 9:32 am, Licensed Practical Nurse (LPN) A (the nurse that rounded with the wound team on 1/20/21) was queried regarding the identification of the resident's coccyx wound and stated in part, . I round with them (Wound Practitioner) . we do a thorough head to toe assessment for every new admission. He was already on the list due to having surgical incisions, so we were initially going to close him out (close the need for wound care). We did a full head to toe and the unstageable was discovered to the coccyx . LPN A was queried on why the facility staff failed to identify the resident's coccyx area prior to the wound care visit and stated they were unsure because they didn't work that unit, they only rounded with the practitioner. LPN A was then asked how the facility ensured the recommended frequent repositioning of the resident and stated that all of the residents' in the facility is turned every two hours. When asked again how the facility ensured that this resident with a wound was repositioned more frequently to aid in wound healing, LPN A again stated all residents are turned every two hours. The resident entered the facility with no concerns to the coccyx area and within 12 days developed an unstageable to the coccyx, which the facility staff failed to identify timely. On 1/27/21 a Wound note documented in part, . Nonviable tissue of coccyx was debrided aggressively with #5 curette scalpel down to the epithelium epithelial subcutaneous tissue . Healthy amount of bleeding was achieved with some good granulation tissue in wound bed after the debridement . Area was 17.0 cm . A Skin & Wound Evaluation dated 1/27/21 documented in part, . Pressure . Unstageable: Obscured full-thickness skin and tissue loss . Due To: Slough and/or eschar . Acquired: In-House Acquired . Wound Measurements . Area 19.8 cm2, Length 6.0 cm, Width 4.5 cm . Slouch 69% of wound filled . A Skin & Wound weekly nursing skin assessment dated [DATE], documented in part . Turgor- Good Elasticity, Skin Color- Normal for ethnic group, Temperature - Warm, Moisture - Normal, Condition - Normal, Enter the # of New Wounds - 0 . On 2/3/21 a Wound note documented in part, . Coccyx has an unstageable wound has a large amount of malodorous serosanguineous drainage, Total depth is 3.3.cm with circumferential undermining measuring 2-1/2 cm. The wound bed itself is significantly worse today and covered with 100% yellow and brown eschar after aggressive debridement with a #10 scalpel. Bone is palpable. Left buttock has a new wound today which appears to be associated with moisture . Coccyx Dakin's daily covered with border foam. Left buttock: [MEDICATION(S)] covered with border gauze daily . Nonviable tissue of coccyx was debrided aggressively with #10 scalpel . down to epithelium epithelial subcutaneous tissue. Patient did not require anesthesia. Healthy amount of bleeding was achieved with some good granulation tissue in wound bed after the debridement . Area was 11.8 cm . Despite the worsening of the wound noted on 2/3/21 the facility staff failed to identify and report worsening of the wound to the physician. A Skin & Wound Evaluation dated 2/3/21 documented in part, . Pressure . Unstageable: Obscured full-thickness skin and tissue loss . Due To: Slough and/or eschar . Location - Coccyx . In-House Acquired . Wound Measurements . Area 11.8 cm2, Length 5.2 cm, Width 3.2 cm, Depth 3.3 cm, Undermining 2.5 cm . Slough 60% of wound filled . A Skin & Wound weekly nursing skin assessment dated [DATE], documented in part . Turgor- Good Elasticity, Skin Color- Normal for ethnic group, Temperature - Warm, Moisture - Normal, Condition - Normal, Enter the # of New Wounds - 0 . On 2/10/21 a Wound note documented in part, . Coccyx has an unstageable wound has a large amount of malodorous serosanguineous drainage. Total depth is 2.6 cm with circumferential undermining measuring 3.4 cm. The wound bed itself is significantly worse today and covered with 100% yellow and black eschar. Bone is palpable. Left buttock moisture associated wound is completely closed . Recommend sending out for surgical debridement of coccyx wound. This has been discussed with DON (Director of Nursing) and nursing . Due to poor intake, I would expect to see continued delayed wound healing. Continue frequent repositioning and specialty bed. Dietary is following. Also recommend restarting PEG (percutaneous endoscopic gastrostomy) tube when readmitted back from (hospital name redacted) for surgical debridement of coccyx wound . Despite the worsening of the wound noted by the wound team on 2/10/21, a clinical review of the record revealed the facility staff failed to identify and report worsening of the wound to the physician. A hospital Operative Report dated 2/10/21, documented in part, . Preoperative Diagnosis- Infected sacral decubitus ulcer . Procedure Incision and Drainage Rectal Abscess, I & D (irrigation and debridement) sacral stage IV decubitus ulcer excisional debridement . The patient will undergo serial wound care on the floor, and may be a candidate for a wound VAC. He may need additional debridement's . Findings - Stage IV sacral decubitus ulcer 8x7x1cm with 4 cm of tunneling in the L Lower area of the wound . A Skin & Wound weekly nursing skin assessment dated [DATE], documented in part . Turgor- Good Elasticity, Skin Color- Normal for ethnic group, Temperature - Warm, Moisture - Normal, Condition - Normal, Enter the # of New Wounds - 0 . The resident was hospitalized and was not in the facility for staff to have completed this skin assessment. A hospital Discharge Summary dated 2/17/21 documented in part, . Hospital Course - Sacral decubitus ulcer, stage IV, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . IV antibiotics - [MEDICATION(S)] + [MEDICATION(S)] + done finished course of abx (antibiotics) . Patient finished course of antibiotics patient is doing okay . recommended the patient goes to subacute . On 2/17/21 an initial care plan titled . at risk for impaired skin integrity/pressure injury . is implemented in part, . Goal - Minimize risk in an effort to reduce likelihood of pressure injury development through next review date . Interventions: . Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician . low air mattress provided (02/19/2021) . Turn/reposition Frequently and PRN . Observe location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician . These interventions were implemented after the resident was already diagnosed with a Stage IV coccyx. A 2/24/21 Wound note documented in part, . Coccyx has an unstageable wound has a large amount of malodorous serosanguineous drainage. Total depth is 3.1 cm with circumferential undermining measuring 3.8 cm. The wound bed itself is significantly worse today and covered with 90% yellow and black eschar. Bone is visible and palpable. This wound has worsened since the last time patient was seen prior to inpatient I&D . Coccyx: Recommend sending patient out for surgical debridement. Recommend frequent repositioning, specialty bed, offloading boots . Despite the worsening of the wound noted by wound on 2/24/21, a clinical review of the record revealed the facility staff failed to identify and report worsening of the wound to the physician. A Skin & Wound Evaluation dated 2/24/21 documented in part, . Pressure . Stage 4: Full thickness skin and tissue loss . In-House Acquired . Wound Measurements . Area 20.1 cm2, Length 6.7 cm, Width 4.3 cm . The resident was then transported to the hospital for a higher level of care for the coccyx wound. A hospital Emergency Documentation dated 2/24/2021 documented in part, . sent . for worsening sacral decubitus ulcer . WBC (white blood cell) 12.38 (High) . Wound was examined with surgery at the bedside . plan is for excisional debridement of the wound today . Empiric antibiotics were started with Vanco and [MEDICATION(S)] . Plan was to five [MEDICATION(S)] for patient's fever . Assessment/Plan: Sacral decubitus ulcer, [CONDITION(S)] Decubitus Ulcer . On 3/10/21 at 4:17 pm, the Director of Nursing (DON) and Administrator was queried on the inaccurate documented skin assessments completed by the nurses, the delayed implementation of a care plan to prevent the development of a wound and the delayed implementation of a care plan to prevent worsening of the coccyx wound (prior to 2/17/21) and the DON stated in part . I am still in the process of working on this . and assured they would follow up. The DON and Administrator was asked to provide all of the resident care plans that were implemented to prevent the development of a wound (based off of the resident's Braden score) and any care plans implemented to prevent worsening of the resident's wound prior to the implemented 2/17/21 care plan and no further care plans were provided by the end of survey. On 3/11/21 at 11:18 am, the Medical Director (MD) B was queried regarding the inaccurate weekly skin assessments, delayed implementation of interventions and the development and worsening of the coccyx wound and acknowledged that all of the findings were concerning for sure and assured they would look into the case and follow up. A facility policy titled Skin Management (Revision date 10/2019) documented in part, . It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries . those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes . Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan . Appropriate interventions implemented to promote healing . An initial care plan is developed upon admission The licensed nurse will monitor, evaluate, and document changes regarding skin condition . in the medical record . residents with pressure injury and lower extremity ulcers will be evaluated, measured, and staged weekly . The licensed nurse will notify the attending physician with any changes as needed .

This citation pertains to intake: MI 114. Based on interview and record review the facility failed to timely complete nutritional evaluations for one (R#804) of three residents reviewed for nutrition, resulting in unmet nutritional needs, severe weight loss of 11.55% of body weight (from January to February of 2021), which played a contributing factor in delayed wound healing of the resident's Stage IV coccyx wound. Findings include: A complaint submitted to the State Agency documented concerns of R#804 not being fed resulting in weight loss. An onsite investigation into the complainant's allegations was conducted. A review of the clinical record revealed the following: A hospital Discharge/Transfer Summary (from transferring hospital to the admitting facility) dated 1/8/21 at 5:30 pm documented in part, . Diagnosis . [CONDITION(S)] blockage/ perforation . Peg Tube . A&Ox1 (Alert and Oriented times one) development delay . dementia . ADL (Activities of Daily Living) full assist . Diet, Feeding - [MEDICATION(S)] 1.2 at 60 ml/hr/ 20 ml/hr water . A&OX1, pulls at lines, cords, confused . R#804 was admitted into the facility on [DATE] and discharged to the hospital on 2/24/21. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 00 indicating severely impaired cognition and required staff assistance for eating and all Activities of Daily Living (ADLs). A Nursing Summary note dated 1/9/21 at 7:55 am documented in part, . Resident arrived to Regency [NAME] at 6:45 pm. Vitals stable . Resident is here for rehab on IV (Intravenous) ABT (antibiotic) therapy dx (diagnosis) lung infection . Resident is on an NPO (nothing by mouth) diet at this time and has a peg tube (Percutaneous Endoscopic Gastrostomy) in place for tube feeding . A review of the resident's census report revealed the resident was admitted into the facility on [DATE], with a PEG tube for enteral feeding. Further review of the clinical record revealed no documentation that the facility provided enteral feeding to the resident on the date of admission 1/8/21. A Physician Assistant Note dated 1/12/21 at 2:52 am documented in part, . Notified by staff that resident pulled out his PEG tube. According to staff, they do not have his type of PEG tube at the facility available to attempt replacement. Therefore, resident sent to hospital for replacement. A hospital Consultation Note dated 1/12/21 documented in part, . Reason for Consult: Patient pulled out G (gastrostomy) tube . Baseline mental impairment . presents to the ED (Emergency Department) after pulling out his G tube at facility. Patient has a significant history of a food bolus on 12/31/20 with attempted EGD resulting in [CONDITION(S)] perforation. Patient was taken emergently to the OR (Operating Room) . for a right thoracotomy, right thoracostomy, [CONDITION(S)] injury with intercostal flap, exploratory laparotomy, gastrotomy w/removal of food bolus, gastropexy, and g-tube placement. Patient had an uncomplicated hospital stay afterwards and was subsequently discharged on [DATE]. Patient was sent to a facility. Overnight patient pulled out his G tube and was sent to the ED for further evaluation. 1/12/21: Attempted to replace G tube in the ED - a pegogram was ordered which showed that the G tube was not intraluminal. G tube subsequently removed. Plan to monitor patient at this time. Will discuss with facility if the patient is able eat. Patient previously had passed his swallow studies in the hospital and was tolerating a diet on 1/7/21. If the patient is able to eat - may consider not replacing G tube and just monitoring the patient for now. Further recs (recommendations) to follow . Plan to continue to monitor patient now . Will discuss with patients currently living facility if he is currently eating food by mouth . A hospital Emergency Department Transition Record dated 1/13/21 documented in part, . Patients initial complaint/Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . R#804 was transferred back into the facility on [DATE], without a PEG tube and with orders to eat food by mouth. Review of R#804's medical recored revealed there was no implementation of a PO (by mouth) diet until 1/14/21, revealing that no nutrition was given to R#804 on the day of readmission into the facility on [DATE]. A review of R#804's weight summary documented in part the following: 1/20/21 at 4:15 pm, 142 lbs. 2/4/21 at 12:06 pm, 127.6 lbs. 2/10/21 at 8:42 am, 125.6 lbs. The review of the weights revealed a -11.55% body weight loss from January to February 2021. An Encounter note documented by the Physician Assistant (PA) dated 1/18/21, documented in part . Date of Service: 01/19/2021 . Visit type: Acute . Patient is being evaluated this morning for follow-up of appetite. Of note, patient is resting comfortably . poor historian, and is noted to be nonverbal upon encounter today . patient with history of PEG tube which he had removed himself. Upon evaluation in the emergency department, it was not replaced, noting that patient had been eating without difficulty . No pain or discomfort. No nausea, vomiting or difficulty swallowing . Weight 140 pounds . Dysphagia . Patient to continue with mechanical soft diet. Patient is noted to be eating varying amounts throughout the day. Dietitians to continue to follow and evaluate. Of note, patient with PEG placement in the past. Continue with supportive care monitor patient closely for acute changes . Cognitive developmental delay, Continue to monitor patient closely for acute changes in condition. Continue with supportive care per staff . Despite the PA documenting Dietitians to continue to follow and evaluate the dietician had not consulted with the resident since admission into the facility. A Nutritional Evaluation dated 1/20/21 (12 days after admission) documented in part, . weight: 142.0 (lbs.) . IBW (Ideal Body Weight) 154 . Weight has ranged between 134-142 % since 1/11/2021 . Energy Needs, Estimated . Calories - 1614 - 1935 . Grams protein - 65-77 . Fluid - 1935 . Current Diet Order - Regular diet, Level 3 Advanced (Mechanical Soft) texture, Thin consistency . Is the resident receiving enteral feedings? No . Own Teeth - No . Dentures - None . 1:1 assist . Clinical Observations - Unstageable PI (pressure injury) to sacrum (coccyx) (6.8 x 2.8 cm) . admitted [DATE] NPO with PEG which he pulled out. He was sent to hospital and PEG was not replaced and readmitted on oral diet . Intake of meals has been charted as variable since staring <sic> an oral diet. He must be fed at meals and is a slow eater. Is edentulous per hospital records. Receives mechanical soft diet and is receiving ST. Weight is showing an 8% gain x 9 days, unsure of accuracy of weight on 1/11/2021 . Plan: d/t (due to) variable intake of meals, will start 120 ml Hi-Cal TID (three times a day) (720 kcal/30 g PRO). Will monitor weight, oral intake, skin condition and labs as drawn. Will further intervene as needed. An Encounter note documented by the Physician Assistant (PA) dated 1/29/21 documented in part, . Patient is being evaluated swing <sic> for follow up appetite . poor historian . stable appetite, denying feelings of increased hunger or discomfort. He was noted to have recent discontinuation of PEG tube per hospital evaluation . Staff denies any additional changes in patient's condition at this time . Developmental delay . Skin . Coccyx wound . Patient is noted with intermittently fluctuant appetite, although is noted to be eating 76-100% of meals, with sporadic refusals of meals. Patient had received enteral feeding in the past, which was recently discontinue by surgeon. We will continue with use of high Cal 3 times a day. Dietitian to continue to follow on recommendations appreciated . Cognitive developmental delay - Continue to monitor patient closely for acute changes in condition. Continue with supportive care per staff . Despite documented concerns with appetite and the need for dietary consultation, the facility dietician did not follow up until the day of the resident's discharge on 2/24/21. A Resident At Risk note dated 2/4/21 at 11:31 am, documented in part . wound continues to degrade . Labs are being drawn to determine better nutritional support. Currently on Hi-Cal TID and started on Prostat for wounds BID . continues the need to be fed and does not eat well . A Wound consultation note dated 2/10/21 documented in part, . Coccyx has an unstageable wound . Recommending sending out for surgical debridement of coccyx wound . Patient was admitted with a peg tube which has since been DC' d (discontinued); he has had poor nutritional intake since the PEG tube was removed . I would expect to see further skin breakdown. Due to poor intake, I would expect to see continued delayed wound healing. Continue frequent repositioning and specialty bed. Dietary is following. Also recommend restarting PEG tube when readmitted back from [NAME] for surgical debridement of coccyx wound . Despite the Wound Practitioner documenting the recommendation for reinsertion of PEG tube to promote better nutrition for wound healing, the recommendation was never followed up by the facility staff or discussed with the physician and/or IDT (Interdisciplinary team). The resident's clinical record did not have any documentation of the Wound Practitioner recommendation to reinsert the resident's PEG tube for nutrition. A Resident At Risk note dated 2/19/21 at 10:57 am, documented in part . readmitted into the facility for short term rehab . has a stage IV coccyx wound . Nutritional supplements received 3 times a day, prostat and hi Cal . No social work concerns . A Encounter note documented by the Physician Assistant (PA) dated 2/23/2021 documented in part, . Patient is being evaluated this morning after most recent review of chart indicates weight loss. Of note, patient is minimally verbal upon exam . denies feelings of excessive hunger/thirst/urinations. Of note, patient currently receives p.o. diet, although had PEG tube placement in the past, which was removed during hospitalization . Weight loss - Patient is noted with 2-pound weight loss over the last week, and approximately 17-pound weight loss over the past month. Of note, when patient initially presented to facility, he had PEG tube in place, although after self-removal, it was not replaced per surgeon due to patient's p.o. intake. Patient is generally noted to be eating approximately 51 to 75% of meals, with intermittent refusals as well as slight fluctuations. Patient is also receiving high count 3 times a day, prostat 3 times a day, and is noted with an extensive ulceration to his coccyx, which all could be contributing to patient's continued weight loss. New order has been placed for CBC, BMP, TSH at this time. We will continue with recommendations per dietitian and further adjust plan of care as needed . A Nutritional Evaluation dated 2/24/21 (the day of the resident's transfer to the hospital/discharge) documented in part, . Weight: 125.6 (lbs.) Date 2/10/2021 . Recent weight change . -6.4% x 30 days. Weight has fluctuated between 125.6 - 142% x past 30 days. Weight from hospital records: 124.96% . Current Diet Order - Regular diet, Level 1 Puree texture, Thin consistency . Is the resident receiving enteral feedings? No . Own Teeth - No . Dentures - None . Fed at meals . Chewing Problems - No . Clinical Observations - Stage 4 PI (6.7 4.3 cm) Has wound vac . Sources of information - Resident, Chart . readmitted from hospital with s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . [NAME] can only say minimal words and does not provide much hx (history). Intake of meals has been charted as variable and several refusals charted prior to d/c (discharge) to hospital. He is fed at meals and is a slow eater. Is edentulous. Receives pureed diet and is receiving ST. Weight is showing a significant weight loss x 30 days . Has increased needs to promote skin healing . Plan: increase Hi-Cal dose from 120 ml to 8 oz TID (1440 kcal/60 g PRO) & continue 30 ml Prostat AWC TID. Will monitor weight, oral intake, skin condition and labs as drawn. Will further intervene as needed. Documentation Survey Report (Certified Nursing Assistant - CNA) documentation of tasks (amount consumed by R#804) for the months of January and February 2021 revealed the following: January- Amount Eaten 1/14- breakfast and lunch 0-25%; dinner (blank), 1/15 (blank), 1/16 lunch and dinner (blank), 1/17 lunch 26-50%; dinner (blank), 1/18 breakfast and lunch (blank); dinner refused, 1/19 dinner (blank), 1/20 & 1/21 (all blank), 1/22 breakfast- refused; dinner (blank), 1/23 lunch and dinner (blank), 1/24 dinner refused, 1/26 breakfast and lunch (blank); dinner 26-50%, 1/27 dinner refused, 1/28 lunch and dinner refused, 1/29 breakfast and dinner refused; lunch (blank), 1/30 dinner (blank) and 1/31 lunch 0-25% and dinner (blank). The eating assistance level provided documented multiple blanks, refusals, Independent, supervision and limited assistance; despite the resident requiring one on one assistance with meals. February- Amount Eaten 2/1- lunch refused, 2/2 breakfast and dinner 26-50%; lunch (blank), 2/3 breakfast 26-50%; dinner (blank), 2/5 (blank) for all meals, 2/6 dinner (blank), 2/7 breakfast and lunch refused; dinner (blank), 2/8 breakfast refused; dinner (blank), 2/9 breakfast and lunch (blank), 2/10 breakfast refused,(2/10-2/17 hospitalized ) 2/17 dinner (blank), 2/18 breakfast refused; lunch 26-50%; dinner (blank), 2/19 dinner (blank), 2/20 lunch and dinner (blank), 2/22 breakfast 0-25%, lunch (blank), 2/23 and 2/24 (blank) for all meals. The eating assistance level provided documented multiple blanks, refusals, and supervision assistance; despite the resident requiring one on one assistance. The resident was transferred to the hospital on 2/24/21, further review of the record revealed the facility failed to obtain any further weights from 2/10/21 until transferred on 2/24/21. On 3/11/21 at 9:14 am, Registered Dietician (RD) C was queried regarding the resident's delayed initial nutrition evaluation, RD C stated in part . I do their evaluation based off the day they were admitted . When queried on the facility's policy which documented in part, .All guests/residents will have a baseline assessment of their nutritional status within 7 days of admission . and the initial consultation being completed on 1/20/21 when the resident was admitted on [DATE] with a PEG tube initially, which changed upon their return to the facility on [DATE], RD C stated they thought they could go from the resident's readmitted [DATE] instead of going by the resident's admitted [DATE]. RD C was queried regarding their observations with R#804 and admitted to never observing and/or evaluating the resident in person. When asked how they obtained their data for the nutritional evaluations, RD C stated by the chart and CNA documentation. RD C was then queried on how that was possible with the lack of CNA documentation regarding R#804's meals and the documented weights that revealed consistent weight loss and RD C was unable to provide any further explanation. RD C was then asked about the many notations from the physician assistant (regarding concerns with appetite and meal consumption) and the need for dietary follow up, as well as the Wound Practitioner recommendation for the reinsertion of the PEG tube (to aid in nutrition and wound healing) and the consistent delay on following up with these concerns, as well as the missing weights from 2/11 until 2/24 and RD C did not offer an explanation. RD C was then asked to review their records and to provide any additional information regarding R#804 (nutritional plan of care or interventions implemented to meet the resident's nutritional needs) and no further information and/or documentation was provided by the end of survey. R#804's care plans was reviewed and revealed the following: . has alterations in nutrition and hydration status r/t (related to): significant weight loss x 30 days. Weight fluctuations up and down. Originally admitted NPO with PEG for nutrition/hydration, pulled out PEG and it was not replaced, started on oral diet per hospital d/c orders. Variable oral intake of meals. He must be fed at meals and is a slow eater. Is edentulous. Receiving ST (Speech Therapy). Has increased needs for wound healing . Goal . will consume 75-100% of estimated needs, will not have significant weight changes as medically feasible will not have s/s (signs/symptoms) of fluid imbalances as medically feasible, and skin will show healing by next review . Interventions . 1:1 (one on one) feeding . Encourage food and fluids served on the tray and between meals within dietary limits . Monitor and record oral intake on food acceptance record and report any changes in ability or intake to dietitian . Monitor for and report any s/sx . recent/sudden weight loss . Offer substitution if refuses or consumes <50% of meals . Provide assistance at meals as needed . Regular diet, Level 1 Puree texture, Thin consistency . Weigh per facility protocol & notify Physician and RD of any significant weight changes . . actual impairment to skin integrity r/t (related to) debility, malnutrition (date initiated 2/17/21) documented in part, . Encourage good nutrition and hydration in order to promote healthier skin. Provide dietary supplements as ordered . A care plan titled has an ADL Self Care performance deficit and requires assistance with ADL's and mobility r/t (facility left this part blank) . Eating . requires dependent assistance x1 for eating . (date initiated 2/20/21) The eating assistance requiring one on one staff assistance was initiated 38 days after returning back from the hospital without a PEG tube for nutrition. On 3/11/21 at 11:18 am, the Medical Director (MD) B was queried regarding the resident's nutrition concerns and acknowledged the issues found were concerning and assured that they would follow up. On 3/11/21 at 5:09 pm, the Director of Nursing (DON) and Administrator was queried regarding the concerns on the delayed nutritional evaluations and reassessments (for documented concerns and recommendations), the resident's weight loss, lack (and inaccurate) CNA documentation for meals, the fact that weights were not being followed up on timely and the skipped weeks of no weights documented; both the DON and Administrator acknowledged all concerns and stated they would follow up on it. When asked about when the initial and follow up nutritional assessments should have been completed both the DON and administrator acknowledged that the assessments should have been completed timely and per the facility policy and both assured that they would follow up on the concerns. A facility policy titled Weight Management (revised 10/2019) documented in part, . Guests/residents will be monitored for significant weight changes on a regular basis. Guests/residents are expected to maintain acceptable parameters of nutritional status . the evaluation of significant weight gain or loss over a specific time period is an important part of the assessment process . Any guest/resident with unintended weight loss . will be evaluated by the interdisciplinary team and interventions will be implemented to prevent further weight loss . The Dietary Manager/RD and DON are responsible for coordination of an interdisciplinary approach to managing the processes for prediction, prevention, treatment, monitoring, and calculation of unintended weight loss .All guests/residents will have a baseline assessment of their nutritional status within 7 days of admission/readmission . Re-weights are initiated for a five-pound variance if the guest/resident is > than 100 lbs. Re-weights will be done within 48-72 hours . Guests/residents determined to be at risk or have significant weight changes will be weighed on a weekly basis .

This citation pertains to intake #MI 524. Based on observation, interview, and record review, the facility failed to ensure resident safety and appropriate meal set-up assistance for one resident (R901), of one resident reviewed for safety, resulting in R901 sustaining second [MEDICAL CONDITION](a burn which often looks wet or moist, affecting the first and second layers of skin where blisters may develop, and pain can be severe) on their left shoulder, arm, and left chest wall and increased pain with the sustained burns. Findings include: On 1/27/21 an onsite investigation was conducted for a facility reported incident that indicated R901 had sustained a burn. On 1/27/21 at approximately 10:55 AM, R901 was observed in bed. R901 appeared sleepy and did not engage in attempts at verbal communication. On 1/27/21 at approximately 11:00 AM, a review of R901's progress notes was conducted and revealed a note dated 12/7/21 at 8:01 AM that read, CENA (Certified Nurse Aide) entered resident's room at 0430 (4:30 AM) .when she noticed 'something with her skin' on her upper left arm and asked resident about it .Writer entered room and noted skin peeling and redness with blistering on the left upper arm and left upper ribs .Resident was unable to recount any details of the incident . On 1/27/21 at 11:10 AM, a review of a facility reported incident investigation file was conducted. The file contained a form titled, Incident and Accident Report that read, .CENA (Certified Nurse Aide) assigned to resident notified writer of redness located on resident's upper left arm. Writer entered resident's room at approx. 4:30 AM and noted second [MEDICAL CONDITION] resident's upper left arm, shoulder to elbow and around upper left rib area. Resident unable to explain what occurred . A second form in the file titled Incident and Accident Investigation Form was reviewed and under the Investigation section, question #3 indicated R901 had been examined by a physician after the incident and the Physician Findings: read, Second degree burn with ruptured blisters with pain and discomfort . The Conclusion section of the form read, The overhead cameras were reviewed and no hot liquids were observed being brought into room. Through investigation (R901) spilled soup during dinner. This was confirmed through a reenactment <sic> with resident . A review of an interview with R901 read, Is your bedside table usually on your left side? Yes, that's where I like it . A typed account of the re-enactment of the incident was also reviewed and read, (Director of Nursing, DON) entered (R901's) room and the bedside table was observed on the left side of the bed. (DON) had (R901) reach for a bowl on the bedside table and (R901) reached across her body with her right hand to the bedside table on the left side of the bed. (R901) was very unsteady with the bowl. A review of a typed summary contained in the file read, .Outcome: The overhead cameras were reviewed and no hot liquids were observed being brought into (R901's) room. (R901) does have left upper extremity impairment since 019. A thorough investigation has determined that (R901) had spilled her soup during dinner. Through a re-enactment, (R901) was observed reaching across with her right arm to pick up a bowl. It was determined that (R901) spilled the soup on herself and did not remove the hot/wet clothing which prolonged the burning effect and resulted in a second degree burn . It was noted the investigation file did not contain any interviews with the staff member who served the dinner meal containing the hot soup in the room on 12/5/20, nor were any attempts to identify whether a staff member discovered spilled soup in the bed or on the linens. A second review of R901's progress notes after sustaining the burn was conducted and revealed the following: A Physician's Assistant's (PA) note for a date of service on 12/7/20 that read, .Chief Complaint .Burn to left arm .History of Present Illness: Patient is being evaluated this morning after being observed with a new burn to her left arm .increased pain to her left upper extremity .Patient notes that the area is very painful, and states that when the area touches anything, causes her more pain. Patient states that she is able to move her arm, although it is painful .Assessment .Patient noted with second-degree burn of arm now with ruptured blisters. Patient notes increased pain/discomfort to the area . A Nurse Practitioner (NP) note for a date of service on 12/9/20 that read, .Chief Complaint .Wound care consulted for evaluation and treatment of [REDACTED].General .Left upper extremity has a moderate amount of serosanguineous drainage. Wound bed itself is red and yellow in appearance with gray skin peeling at multiple areas .Patient does have complaints of pain to the site. Left axillary also has a second-degree burn. There is 1 on the left blister to this area. The surrounding skin is red and erythemic .Patient also has complaints of pain to this area . An NP note for a date of service on 12/11/20 that read, .General .Skin: Warm and dry, pink. Large area of ruptured blister area over her left shoulder extending to distal upper arm laterally. Appears as though ruptured blister with tissue at outlines . A PA note for a date of service on 12/12/20 that read, .Assessment .Second degree burn of arm. patient to continue with current wound care orders. We will need to monitor patient closely due to increased risk of fluid loss with [MEDICAL CONDITION]. An NP note for a date of service on 12/16/20 that read, Chief Complaint .Wound care following up [MEDICAL CONDITION] left arm, left shoulder, left axillary .General .Left upper extremity has a moderate amount of serosanguinous drainage. Wound bed itself is red with approximately 50% slough .patient does have complaints of pain to the site . A PA note for a date of service on 12/28/20 that read, History of Present Illness: patient is being evaluated this morning by request due to pain. Patient has burn on left arm. She states it is painful all the time. Dressing changes worsen the pain. Patient requests pain medication .Assessment .Second degree burn of Arm. We will add [MEDICATION NAME] 5/325 (narcotic pain medication) every 8 H (hours) as needed, to be given 30 to 60 minutes prior to dressing changes . An NP note for a date of service on 12/30/20 that read, .Chief Complaint . wound care following up [MEDICAL CONDITION] left arm, left shoulder, left axillary .History of Present Illness: .being seen by wound team today for evaluation [MEDICAL CONDITION] hot soup past few weeks still painful at times .General .Left upper extremity has a moderate amount of serosanguineous drainage. Wound bed itself is red with approximately 50% slough .patient does have complaints of pain to the site . A review of R901's clinical record was conducted and revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. R901's most recent completed Minimum Data Set (MDS) assessment dated [DATE] indicated R901 had severe cognitive impairment, (Brief interview for mental status score of 6/15) and was able to feed herself but required set-up assistance for eating. A review of R901's care plans was conducted and revealed the following interventions for Activity of Daily Living Deficits: .LUE (left upper extremity) ROM (range of motion) Impairment . initiated 3/8/19. .EATING: (R901) is SET UP at all meals . initiated 5/14/20. On 1/27/21 at 12:45 PM, an interview with Occupational Therapist (OT) 'A' was conducted regarding R901's assessment and safety with hot liquids/foods, meal set-up, and ability to feed themselves. OT 'A' explained that R901 needed an adaptable cup (handles and a lid) for hot liquids, but they were able to safely spoon feed themselves soup from a bowl. OT 'A' indicated R901 needed assistance with setting up their meal and had left sided weakness, but after set-up was able to safely feed themselves their meals, including soup from a bowl. On 1/27/21 at 3:20 PM, an interview with CNA 'B', an assigned CNA on the Huron unit was conducted regarding how they set up a resident for a meal. CNA 'B' explained they would ensure the resident was properly positioned, place their meal in front of them, open any containers and cut up any food if the resident needed the set-up assistance. On 1/27/21 at 3:35 PM, an interview was conducted with the facility's Administrator and DON regarding meal set-up and R901's burn from the hot soup. It was explained that to properly set up a meal for a resident the meal should be placed in front of them. At that time, they were queried if they interviewed the staff member who delivered R901's meal tray with the hot soup on 12/5/20, and whether they set up the meal, or whether they just dropped it off in the room on the bedside table. They indicated they did not interview that person and they do not know if it was properly set up. It was queried if they knew the location of the bedside table at the time the meal tray was delivered, and they indicated they did not. When further queried as to why then the re-enactment was performed with the resident's table on the left side of their bed, there was no explanation. They were then asked if they interviewed any other afternoon or midnight staff who may have witnessed the sheets being soiled with the spilled soup and they indicated they did not. A review of a facility provided document titled, Feeding ADL Deficit revised October 2020 was reviewed and read, .Interventions .Assist with meal setup, making sure that the tray is close enough to the patient; . A review of a second facility policy titled, Hot Liquids and Foods was reviewed and read, .2. The facility will provide supervision to residents who receive hot food and beverages in an attempt to prevent hot liquid/food spills which may result [MEDICAL CONDITION].

This citation pertains to intake(s): MI 690 and MI 678 Based on observation, interview, and record review the facility failed to prevent the development and worsening of avoidable pressure ulcers, promptly identify and obtain treatment for [REDACTED].#702 and 709) of four residents reviewed for wounds, resulting in an Immediate Jeopardy when R#709 developed a facility acquired stage 4 (full thickness skin and tissue loss) pressure ulcer of the sacral area, resulting in hospitalization , septic shock requiring admission into ICU (Intensive Care Unit), surgical debridement, osteo[DIAGNOSES REDACTED] and placement of a [MEDICAL CONDITION] due to the wound tunneling to the rectal area and an observation of R#702's reopened sacral wound, requiring further medical intervention. This deficient practice placed all residents at risk for skin breakdown and those residents with pressure ulcers at risk for serious harm, injury, and/or death. Findings include: The IJ began on 1/22/20 and was identified by the survey team on 8/11/20. The Administrator of the facility was notified of the IJ on 8/11/20 at 1:02 PM and a plan to remove the immediacy was requested. On 8/12/20 the State Agency completed onsite verification that the IJ was removed on 2/26/20, however the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. R#709 On 8/11/20 at 9:25 am, a phone interview with the complainant was conducted and the complainant stated in part, . When I looked at his sore, I seen a sore that I've never seen in my [AGE] years as a nurse. It was already at a stage 4 . I looked at it and raised hell . He was seen by the wound physician assistant (PA) the next day and she called and told me that he needed debridement at the bedside. I said no way is that going to happen there, send him to the hospital He would tell me that they're not turning or changing me . (complainant starts to cry) He had to go through so much . He doesn't want to live. I am fighting with him every day to live now . They destroyed a human being . They didn't call and tell me . I had to find it . Why do I have to pay the Nursing home for almost killing my dad? . On 8/10/20 a onsite survey was conducted at the facility regarding the complainant's allegations. A review of the resident's clinical record revealed the following: R#709 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating intact cognition). R#709 required assistance from staff for all Activities of Daily Living (ADL's). An admission skin assessment dated [DATE] at 22:40 (10:40 PM) documented in part, . Resident has a closed red area to the buttock area . Further review of the R#709's clinical record revealed the following inaccurate Braden and Skin assessments: An admission Braden Scale For Predicting Pressure Sore Risk (a tool to assess a resident's risk of developing a pressure ulcer) assessment dated [DATE] at 22:40 (10:40 PM) documented in part, . Moderate Risk, Score: 14.0 (moderate risk) . (Sensory Perception) No Impairment . (Moisture) Occasionally Moist . (Activity) Bedfast . (Mobility) Completely Immobile . (Nutrition) Adequate . (Friction & Shear) No apparent problem . A Braden assessment dated [DATE] at 21:54 (9:54 PM) documented in part, . Low Risk, Score: 19.0 . (Sensory Perception) slightly limited . (Moisture) rarely moist . (Activity) walks occasionally . (Mobility) slightly limited . (Nutrition) Adequate . (Friction & Shear) Potential problem . R#709's MDS assessment dated [DATE] documented in part, . ADL activity itself did not occur . for the Walk in room and Walk in corridor sections. A Braden assessment dated [DATE] at 13:45 (1:45 PM) documented in part, . Low Risk, Score 15.0 . (Sensory perception) No impairment, (Moisture) Occasionally Moist, (Activity) Bedfast, (Mobility) Very Limited, (Nutrition) Adequate, (Friction & Shear) Potential Problem . All weekly skin assessments for R#709 were requested from the Director of Nursing (DON) on 8/11/20 at 8:46 am. The DON provided weekly skin assessments for the dates of: 12/27/19, 1/3/20, 1/10/20 and 1/17/20. All assessments were reviewed and revealed no abnormal findings or newly identified wounds. A Skin/Wound Progress Note dated 1/8/20 at 14:46 (2:46 PM) documented in part, . Writer attempted to call residents daughter (name redacted) to update about new areas of skin breakdown. Voicemail was left. Will attempt to call again. A Skin/Wound Progress Note dated 1/9/20 at 14:22 (2:22 PM) documented in part, . Writer spoke with residents daughter (name redacted) in regards to new areas of skin breakdown. Writer explained stages of wounds, notified (R#709's family member name redacted) of new treatment orders entered, soft boots provided to resident, foam wedge and new mattress provided. Updated . that wound PA wound <sic> be in to see resident on 1-10-2020 and writer will update (R#709's family member name redacted) after visit with wound PA . A Wound consultation note dated 1/10/20 at 9:04 PM, documented in part . Chief Complaint . Evaluate sacral pressure ulcer . Patient does complain of significant pain 6 out of 10 localized to the gluteal area . does not ambulate . Patient has been otherwise stable without fevers . Patient does have a stage II left gluteal pressure ulcer appears uninfected edged are pulled pink granulation tissue and adjacent with deep pressure injury deep purple in color, additionally patient does have a stage I right gluteal pressure ulcer exacerbated likely from friction from transfer in and out of bed to wheelchair . continue local wound care and offloading. Discussed wound care with honey and moisture barrier with frequent turning discussed with wound care nurse managers at bedside wound measurements reviewed . On 8/12/20 at 8:40 am, the DON was queried on why R#709 was not seen by the wound physician for worsening of their sacral wound between the dates of 1/10/20 and 1/22/20 and provided a Skin & Wound Evaluation dated 1/15/20 at 13:19 (1:19 PM) completed by a Licensed Practical Nurse (LPN) that documented in part, . Pressure . Unstageable: Obscured full-thickness skin and tissue loss . Slough and/or eschar . Sacrum . In-House Acquired . Exact Date 01/08/2020 . Area- 75.8 cm (centimeters) 2, Length- 11.9, Width- 10.4 cm, Depth- Not Applicable, Undermining- Not Applicable, Tunneling- Not Applicable . Eschar . % Eschar- 100% of wound filled . Evidence of Infection- None, Exudate- None . Edges: Non-Attached: Edge appears as a cliff . Progress: Deteriorating . Resident seen by wound care for UTD (unstageable) to sacrum. Scant amount of serosang drainage noted with no odor . Enter name of practitioner notified: (medical practitioner name redacted) . The DON was unable to provide a consultation from the wound PA or any other physician that assessed the resident's sacrum wound on 1/15/20. The DON was asked to provide all consultations from the wound PA and/or physician regarding the assessment of the sacrum wound and no further documentation was provided by the end of survey. On 1/14/20 at 7:00 am, a physician order [REDACTED]. Cleanse UTD to coccyx/R (right) buttock w (with)/NS (normal saline), pat dry. Apply [MEDICATION NAME] and [MEDICATION NAME] to wound base, apply zguard to surrounding tissue and large foam dressing QD (every day) and PRN (as needed) . Although a new order treatment order was started on 1/14/20, a review of the clinical record revealed no indication/assessment/consultation or progress note from the PA, physician, or nurse on why the new order was implemented. A Wound consultation note dated 1/23/20 at 10:14 am, documented in part . Chief Complaint . Evaluate sacral pressure ulcer as well <sic> ulcerated wound to left hip and to evaluate heels . Asked to see patient regards to sacral pressure ulcer (After R#709's family member observed the wound on 1/22/20 and informed the staff of their shock and concern regarding the wound, per family) . Patient does complain of significant pain 6 out of 10 localized to the gluteal area . Patient has been having daily wound care but does not ambulate . Patient has not had drainage or redness . Patient has been otherwise stable without fevers or chills nursing staff reported patient does have a wound on his left hip that is been evaluated . Patient also has had a small skin tear in his right leg as well . Patient does have stage IV (4) sacral pressure ulcer with necrosis and foul odor. Does track approximately 12 o'clock position proximal 5 cm and 2 9 o'clock position. Bone and muscle aches bruised and palpable additionally patient does have left hip pressure ulcer with some deep pressure injury unstageable but appears uninfected right heel skin is peeling but no redness patient is <sic> a small skin tear right lateral leg superficial does not appear infected . Pressure ulcer of sacral region, stage 4 . Debridement performed of some necrotic tissue will likely need further debridement will change wound care over to (treatment name redacted) after nursing nurse manager at bedside. Clinically bone exposed and labs to be ordered including [MEDICATION NAME] . Despite the wound physician documenting that the resident was stable without fevers the resident's temperature log documented otherwise as evidenced by R#709's medical record which revealed the following temperatures: 12/31/19 at 13:39 (1:39 PM)- 100.9 F (Fahrenheit- scale of temperature) and 17:43 (5:43 PM)- 100.5 F 1/1/20 at 20:10 (8:10 PM)- 100.7 F 1/2/20 at 20:26 (8:26 PM)- 99.6 F 1/5/20 at 1:02 am- 99 F 1/16/20 at 20:25 (8:25 PM)- 102.7 F and 21:20 (9:20 PM)- 100.2 F 1/17/20 at 16:50 (4:50 PM)- 100.5 F, 17:57 (5:57 PM)- 99.9 F and 18:57 (6:57 PM)- 100.2 F 1/19/20 at 8:32 am- 99.3 F 1/22/20 at 19:02 (7:02 PM)- 99.7 A facility's Toilet Use and Continence and Shower/Bathing documentation forms for December 2019 and January 2020 was reviewed and revealed R#709 was assisted by the Certified Nursing Assistants (CNA's) and/or facility staff, three times a day on most days for toilet use/continence care and showers/bath. Despite the many documented opportunities for the facility staff to identify the worsening of the resident's sacral wound, a review of the clinical record revealed no documentation of the facility staff identifying the worsening of the wound or prompt notification to the PA and/or physician of the wound worsening. A care plan titled (R#709 name redacted) has actual impairment to skin integrity r/t (related to) decreased mobility and weakness secondary to cervical fracture with anterior repair . (created on 12/20/19) documented in part . UTD to coccyx/R (right) buttock . (date initiated 1/8/20) . Goal . UTD to coccyx/R buttock . will show signs of healing by review date . (revised 1/8/20) . will have no complications r/t UTD to coccyx/R buttock . Interventions . report abnormal findings to the physician . Observe for s/sx (signs/symptoms) of infection of area (i.e. temperature increases, increased drainage, odor or redness etc. and report to physician as needed . Observe location, size and treatment of [REDACTED]. to physician . Turn and Reposition frequently throughout the shift as tolerated . On 8/17/20 at 2:04 PM, the DON was asked how often dependent residents are turned and repositioned and the DON stated, every two hours. When queried how the facility is ensuring that staff are turning and repositioning the residents, the DON stated, by doing rounds and supervisor oversite. The DON confirmed that the facility does not require the staff to document the turning and repositioning of dependent residents. A care plan titled Actual impairment to skin integrity r/t decreased mobility and weakness secondary to cervical fracture with anterior repair . (Initiated on 1/8/20) documented interventions in part . Administer medications as ordered. Observe for ineffectiveness and side effects, report abnormal findings to the physician . Observe for s/sx of infection of area (i.e. temperature increases, increased drainage, odor or redness etc and report to physician as needed . Observe location, size and treatment of [REDACTED]. to physician . Provide incontinent care and use moisture barrier treatment as needed after incontinent episodes . Turn and reposition frequently throughout the shift as tolerated . Further review of R#709's skin care plans revealed no new and/or modified interventions implemented to prevent worsening of the sacrum wound between the dates of 1/10/20 to 1/22/20. A Nurses Notes dated 1/23/20 at 12:00, documented in part . Late Entry: . Writer and unit manager called and spoke with (R#709's family member name redacted) via a phone conversation . (R#709's family member name redacted) said I was headed to see you because I seen his wounds the day before . Writer explain to (R#709's family member name redacted) that he had a reddened area on his buttock upon admission and that when it's undetermined how deep the tissue damage goes sometimes ones can rear themselves (sic) . (R#709's family member name redacted) was concerned with repositioning . Writer explained that the wound care nurse attempted debridement at the bedside but due to the extent of the wound the PA was making a decision on sending him out for further debridement. (R#709's family member name redacted) stated she wanted them sent out because she knows that they will be more aggressive at the hospital versus what we could do at the bedside for the wound. Writer and unit manager updated the PA on the unit in regards to the daughters request she agreed . An ED (Emergency Department) Physician Note dated 1/23/20 at 20:47 (8:47 PM) documented in part, . presenting from (nursing home name redacted) for bedsores . There was a call ahead from an RN (Registered Nurse) and bedside report from EMS (Emergency Medical Services) stating that patient and his daughter were concerned for this worsening bedsore . Patient is complaining of pain from his buttocks . Sacrum has a 10 cm ulceration (affected by an ulcer) at the proximal side of gluteal cleft. Large eschar (dry, black, non-viable tissue due to reduce blood supply) present with pus and discharge escaping beyond it . Tunneling (wounds that extend from the initial injury deeper into the surrounding tissues) towards rectum . we did [MEDICAL CONDITION] (a life threatening complication of an infection) at this time . known decubitus ulcer (bed sore) source of infection . We did a rectal temperature was so <sic> was found to be 105 . At this time, we did make the decision to admit the patient to ICU (Intensive Care Unit) . A hospital Wound Consult dated 1/24/20 at 10:28 am, documented in part . chief compliant of worsening sacral pain with concern for worsening sacral ulcers. Sacral stage 4 pressure injury . L (length) 13cm x W (width) 10cmx D (depth) 4cm, 80% soft black eschar, 20% granulation tissue (healthy), able to palpate bone, foul odor, mod sang purulent drainage (milky appearance), partial thickness skin loss around the area. Very close to rectum. Wound just debrided. Surgery planning on [MEDICATION NAME] more A Discharge Summary Note dated 2/18/20 at 4:40 pm, documented in part . Final diagnosis,[MEDICAL CONDITION] present on admission, Septic shock secondary to infected decubitus ulcer . Infected sacral decubitus ulcer stage IV present on admission . Treatment and procedures performed- Multiple debridement of the sacral wound, Divergent [MEDICAL CONDITION] (an opening for the colon and/or large intestine, through the abdomen, with a pouch covering the opening and drain stool from the colon into the [MEDICAL CONDITION] pouch) . Upon arrival to ED patient was septic with temperature of 100.8, [MEDICAL CONDITION] (increased) heart rate up to 130's, tachypneic (increased respirations) with respiratory rate of 25. Patient was hypotensive (low blood pressure) with blood pressure 86/48. Blood work was remarkable for leukocytosis (white blood cells above normal range) with WBC (white blood cells) of 14 . Patient is being transferred to ICU for management of septic shock. Surgery has been consulted . Patient had a very foul-smelling future (sic) decubitus ulcer present on admission, Surgery was consulted, Patient was taken for the surgery, Part of the bone was removed as part of the debridement, Bone was positive for osteo[DIAGNOSES REDACTED] (Inflammation of bone cause by infection) . Because the patient decubitus ulcer was near the rectal area it was recommended to get the divergent [MEDICAL CONDITION] done, patient underwent diverting [MEDICAL CONDITION] . Suprapubic catheter was placed . Couple of times we thought we can discharge the patient but patient's infection could worsen need more debridement . Overall patients <sic> came in with a infected decubitus that was extremely bad and because of the location with a diverting [MEDICAL CONDITION] and a suprapubic catheter (tube that drains urine from bladder, inserted into the bladder from a small hole in the stomach), Patient has a wound VAC (vacuum assisted closure that aides in wound healing) at this time . Patient needs very close supervision for his wounds . Patient will continue IV (intravenous) antibiotics for according to (doctor name redacted) for 42 days . patient was stable with infected decubitus ulcer at the time of the discharge that will require long term IV antibiotics and wound care before he can get he <sic> well . Medically stable at the time of discharge patient has a long recovery ahead of him . On 8/11/20 at approximately 2:04 pm, the DON acknowledged the facility's deficient practices (Nursing comprehensive noted concern with no follow up by wound nurse, Braden's were not consistent) and presented a plan of correction that was initiated by the facility on 1/23/20. The facility staff were re-educated with the facility's Skin Management policy, by the confirmed date of 2/26/20, per the DON. A facility policy titled Skin Management (dated 10/2019) documented in part, . the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries . Guests/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. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes . The Braden Scale will be completed upon admission, weekly for 4 weeks, quarterly and with a significant change of status by a licensed nurse to determine the risk of pressure injury development. Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan . the licensed nurse will document on the skin and wound evaluation for pressure injury and vascular ulcers, Document weekly until the area is resolved, Photos may be taken of pressure injury and vascular ulcers . The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complication and pain) in the medical record . each guest/resident on a weekly total body skin evaluation that is completed by the licensed nurse. The licensed nurse will document findings of the skin evaluation. The CNA's will report any new skin impairment to the licensed nurse that is identified during daily care . The licensed nurse will notify the attending physician with any changes as needed . R#702 A complaint was submitted to the State Agency (July 2020) regarding a concern of bed sores on R#702's buttocks. An onsite survey was conducted to look into the reported concern. A review of the resident's clinical record revealed the following: R#702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. An MDS assessment dated [DATE] documented a BIMS score of 15 (indicating intact cognition) and required assistance from staff for all ADL's. On 8/11/20 at 3:58 pm, the resident was observed in their bed lying on their back with their eyes closed. Initially, the resident did not respond to verbal stimuli, however when verbal stimuli was attempted closer to the bedside the resident responded. When queried regarding if the resident had any open areas on their body the resident responded in part . just my butt, because I be wet so long . At that time, the Registered Nurse (RN) N who was assigned to the resident was asked to assess the resident's buttocks. At 4:08 pm, RN N assessed the buttock area which revealed . two small open areas, with some discharge . A small open area was noted with reddish/brown discharge noted on the resident's brief. A Change in Condition note dated 8/11/20 at 17:10 (5:10 pm) documented in part . The Changes In Condition/s reported on this . Evaluation are/were: Skin wound or ulcer . Nursing observations . The area is small with scant drainage. Open area is from an old pressure injury that reopened . Primary Care Provider responded with the following feedback . Recommendations: Triad to area cover with foam dressing . A skin assessment dated [DATE] at 15:51 (3:51 pm), was reviewed and documented no abnormal findings or new wounds for R#702. On 8/12/20 at 11:29 am, the DON was queried regarding the wound on R#702's buttock and the documented normal skin assessment from 8/10/20 and referred the question to Nurse Unit Manager (NUM) O who stated in part, . I didn't get notification from the floor nurses that (R#702's name redacted) had any opening areas. I had her on Sunday night, so I know for sure that she didn't have anything then .

This citation pertains to intakes # MI 496 and MI 597 and has two deficient practice statements. Deficient practice #1 Based on interview and record review, the Facility failed to provide safe bed mobility assistance per the resident's care needs for one (R#715) out of three residents reviewed for falls/accidents, resulting in R#715 rolling out of bed and sustaining a fracture to the left femur, pain and a hospital stay. Findings include: R#715 A complaint was filed with the State Agency (SA) that alleged that R#715 was provided care by only one staff person and should have been cared for by at least two people resulting in the resident rolling out of bed as they were being turned, landing on the floor and sustaining a fracture to the left femur. A review of R#715 clinical record documented that resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the R#715's Minimum Data Set ((MDS) dated [DATE] documented R#715 was cognitively intact and required extensive assitance of two or more staff for bed mobility and bed transfers. An MDS dated [DATE] also indicated R#715 required extensive assistance of two or more for bed mobility. A progress note dated 1/23/20 documented, in part: Resident was being moved in their bed by the CNA (certified nursing assistant) at approximately 2:20 PM and rolled out of L (left) side of bed .Resident states her L knee was developing a bruise .order to send to Hospital to obtain x-ray . An Incident and Accident (I/A) Report dated 1/23/2020 documented, in part, the following: Person involved: (R#715) .Time of Day: 2:30 PM .Location of Injury: Abrasion of R(right) great toes and bottom of foot, bruise on L knee. Activity Before: Bed .Describe the nature of the accident: Resident was being moved in her bed while being assisted by CNA and resident rolled out of bed onto her knees she has a bruise and pain one L knee and abrasion to R great toe .Witness: CNA L .Physician Statement: Send to Hospital to obtain x-ray for L Hip, L knee, L tibia, L foot and L ankle. Also x-ray of R foot and R ankle .Re-Creations: .Resident was in bed .CENA gave the resident a bed bath .CNA was applying creams and asked R#715 to lift up and resident started to roll .CNA was unable to stop the fall. New Interventions: 2 person bed mobility. Review of R#715 Hospital records, including X-ray results, documented the resident had an Acute oblique, impacted and comminuted [MEDICAL CONDITION] left femur with mild posterior placement Hospital physician progress notes [REDACTED].having pain in bilateral extremities, excruciating pain .had some nausea .Assessment .Active Problems: Femoral fracture .admitted with traumatic left distal femur fracture . A Nursing Comprehensive form dated 1/22/20 (one day prior to incident/fall), documented, in part, the following: .G. ADL (activities of daily living) status .1. Transfers-Able to Transfer .Total assist 2. Weight Bearing .Non-weight bearing .3. Bed Mobility 2 person assist .6. Non-ambulatory .Mechanical Lift . Review of R#715's Care Plans documented the following: (R#715) has an ADL Self Care Performance Deficit and requires assistance with ADL's and mobility .Interventions (date initiated 8/24/19) Bed Mobility: Resident requires extensive assistance x2 to reposition and turn in bed. A second care plan intervention (date initiated 8/24/19) documented: Resident requires extensive assistance x1 to reposition and turn in bed. An interview with CNA L was conducted on 8/12/20 at approximately 8:50 AM. When queried about the incident that lead to R#715's fall, CNA L reported that she was assigned to the resident and was performing a bed bath. Following the bed bath, CNA L attempted to put cream on the resident and lifted the residents hip and asked the resident to lift the hip and hold the assist bar, then the resident rolled out of bed onto the floor. When queried as to R#715's bed mobility status, CNA L stated that she believed that at the time of the fall the resident was a one person assist. When asked if she would have completed the task had she known the resident was a two person assist, CNA L stated, If I knew R#715 was a two person assist, I would not have worked by myself. On 8/12/20 at approximately 9:15 AM an interview and record review was conducted with Physical Therapist (PT) M. PT M was queried as to how resident's care plans regarding bed mobility are determined. PT M reported that residents, including R#715 are assessed by PT upon admission, re-admission and continued screening per physician orders. Following assessments PT will communicate with nursing staff and recommendations will be placed in the resident's care plan. When queried about PT's recommendation per bed mobility prior to the fall on 1/23/20 , PT M reviewed a PT Evaluation and Plan of Treatment (1/8/20) and reported that R#715 functional assessment was determined to be total assist and thus required two person assist for bed mobility. On 8/12/20 at approximately 10:30 AM an Interview was conducted with the Director of Nursing (DON) regarding the incident that occurred on 1/23/20. The DON reported that it was determined that R#715 who was a one person assist for bed mobility rolled out of bed during care provided by one CNA and follow-up interventions were implemented to ensure the resident received two or more assist for bed mobility. The DON was informed that the resident's care plan (8/24/19) indicated that the resident required two person assist, PT assessments required two person assist, the MDS documented the resident was a two person assist and a nursing assessment prior to the fall also documented the resident was a two person assist for bed mobility. The DON reported that there also was a care plan that indicated R#715 was a one person assist and indicated that had CNA known the resident was a two person assist she would not have performed the care on her own. The DON reported that she was going to review the care plan and would provide further information. It should be noted that no further information regarding R#715's care plan was provided prior to the end of the survey and the DON reported that no documents could be found. A Facility Policy titled Physical Function (revised 10/2019) documented, in part, the following: Guests/residents abilities in activities of daily living do not diminish .These activities include the .residents ability to transfer and ambulate .move freely in bed .residents with limited range of motion receive appropriate treatment and services to increase/and or to prevent further decrease .Guidelines .residents are evaluated .to determine their ability to perform .ADLs using the MDS . A Facility Policy title Care Planning (revised 11/2017) documented, in part, the following: Purpose: Every resident in the facility will have a person centered Plan of Care developed and implemented that is consistent with resident's rights, based on comprehensive assessments .and prepared by an interdisciplinary team that includes, but not limited to; attending physician, a registered nurse ., a nurse aide ., therapy staff . Procedure: .7. The care plan must be specific, resident centered, individualized and unique and may include .How to manage risk factors .Involve and communicate the needs of the resident with direct care staff (i.e. CNA, kardex) .The care plan and resident kardex will be updated .this includes adding new focuses goals and interventions . Deficient Practice #2 Based on observation, interview and record review the facility failed to implement interventions to prevent falling for one resident (R#718) of three residents reviewed for accidents/hazards, resulting in the increased potential for R#718 to fall. Findings include: On 8/11/20 at approximately 3:55 p.m., R#718 was observed in their room, up in their wheelchair. R#718 was queried how the care in the facility was and they indicated they had fall a month ago when showering. R#718 was queried how they fell in the shower and reported they had slipped. R#718 was queried if facility did anything to help them from slipping again in the shower and they reported they were unsure. R#718 was observed without any grip-strips (tracking material placed on the floor to prevent slipping) in their bathroom. On 8/12/20 at approximately 9:50 a.m., R#718 was observed in their room up in their wheelchair. R#718's bathroom was still observed to not contain any grip-strips. On 8/11/20 the medical record for R#718 was reviewed and revealed the following: R#718 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#718's MDS with an ARD of 7/21/20 revealed R#718 needed extensive assistance from facility staff with most of their activities of daily living including bathing. R#718's BIMS score (brief interview of mental status) was 13 indicating intact cognition. An incident and accident (I/A) report dated 5/5/20 was reviewed and revealed the following: Type of A/I: Fall .Observed on floor .Describe the nature of the accident/incident: I stood up to turn and sit on the w/c (wheelchair), I slipped to the groud .Interventions implemented-Explain (corrective measure taken to reduce repetition of accident or incident)-Grip-Strips in front of shower . A Post fall evaluation dated 5/5/20 revealed the following: New interventions after IDT (interdisciplinary team)review: Grip-Strips to be applied to floor outside of shower stall . A review of R#718's current care plan revealed the following: Focus-((R#718) is at risk for falls r/t (related to)co-morbidities .[MEDICAL CONDITION] ([MEDICAL CONDITIONS](hypertension, decreased safety awareness r/t dementia .Non-compliant with call light. Will attempt to self-transfer without assistance Interventions-Grip-Strips to floor in front of the shower . On 8/13/20 at approximately 9:30 a.m., during a conversation with Nurse Unit Manager O (NUMO), NUM O was queried regarding R#718's fall on 5/5/20 and the Grip-Strips that were supposed to be in R#718's bathroom per their care plan. NUM O indicated the grip-strips were supposed to be in place but weren't. NUM O indicated they had put in a new work order (that day) for maintenance to put them in R#718's bathroom per their plan of care.

This citation pertains to intake #MI 773. Based on interview and record review, the facility failed to provide adequate and appropriate care to prevent and/or treat pressure ulcers for one (#802) of four sampled residents reviewed for pressure ulcers, resulting in the deterioration of an unstageable facility acquired pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) which became infected, and required surgical intervention at the hospital. Findings include: A complaint was submitted to the State Agency that alleged the resident Got a big bedsore on her backside and the toxicity from it killed her. 6 inches wide in diameter .She did not have it when she went in (to the facility) .She was incontinent. They let her lay there for hours in a wet diaper and it got toxic. Then she started defecating on herself and they let her lay there for hours . On [DATE] at 5:10 PM, a phone interview was conducted with the complainant who reported, She went in on the 20th of (MONTH) last year, she was there six days short of a year. Three to four months before she got sick, she developed a bedsore. I believe when she decided to stay in bed she was sick with [MEDICAL CONDITION] cause she was getting very confused. The bedsore was about six inches, she went back and forth to the hospital and this last time, the necrotic tissue (non-viable, black, dead tissue) took her whole backside. When asked if the facility had involved the complainant who was R#801's emergency contact and responsible party, to discuss changes with the wound, and possible alternate interventions to encourage wound healing, the complainant reported, Never said anything about having the pressure ulcer to me. She was getting confused. She was incontinent and always wet. I was always asking them to reposition her and change her but they didn't listen. Review of R#801's hospital records from [DATE] to [DATE] included in part, the following documentation: A record of death dated [DATE] documented, in part: .Diagnosis: [REDACTED].Infection: Yes . An Emergency Physician record dated [DATE] documented, in part: .time of Recognition of [DIAGNOSES REDACTED].Source of infection: Sacral decubitus .arrived from (name of facility) Pt (patient) is bedridden here for wound in sacral area and to R/O (rule out)[MEDICAL CONDITION] . A discharge summary report dated [DATE] documented, in part: .On [DATE], sharp excisional debridement of right sacral and gluteal decubitus ulcer measuring 21 x 11 x 3.0 cm (centimeters) .Discharge [DIAGNOSES REDACTED].Wound culture, Providencia stuartii and Streptococcus agalactiae group B (antibiotic resistant bacteria) .Toxic metabolic [MEDICAL CONDITION], likely secondary to above .The patient deceased after terminal wean and comfort measures . An onsite investigation into the above complaint was conducted on [DATE]. R#801's clinical record was reviewed and revealed the following: R#801 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], R#801 had moderately impaired cognition (scored ,[DATE] on brief mental status exam), exhibited verbal behaviors towards others, required extensive assistance of two people for bed mobility, transfers, bathing, and toilet use, was incontinent of bowel and bladder, did not have a stage 1 or greater pressure ulcer, was at risk for developing pressure ulcers, and had pressure reducing device for chair, bed, and application of ointments/medications other than to feet. On [DATE] at 1:26 PM, an interview and record review was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). At that time, the DON reported the wound care nurse was not here today and they would be able to answer any questions regarding R#801. When asked when the wound was first identified, the DON confirmed the documentation available in the clinical record and reported [DATE]. The DON was requested to provide any documentation of R#801's wound (census information, care plans, wound assessments, physician orders, consultations, and treatments provided). Review of R#801's interdisciplinary care plans included: Date Initiated: [DATE], Revision on [DATE]: (name of R#801) has Actual impairment to skin integrity .Resident is non-compliant at times with allowing resident to reposition while in bed. Resident frequently declines wound care treatments .UTD to R buttock Interventions included: Encourage and assist resident to reposition while in bed as tolerated (initiated [DATE]) Notify nurse if dressing comes off or becomes soiled (initiated [DATE]) Roho cushion to w/c (wheelchair) (initiated [DATE]) Roho mattress (initiated [DATE]) Turn and Reposition frequently throughout the shift (initiated [DATE]) Date Initiated: [DATE], Revision on [DATE]: (Name of R#801) is at risk for skin breakdown/pressure injury r/t (related to) weakness and limited mobility .Incontinent of bowel/bladder .UTD to R buttock Interventions included: Administer treatments as ordered and observe effectiveness. (initiated [DATE]) (name of R#801) requires Pressure relieving/reducing device on bed/chair (initiated [DATE]) Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Inform resident/family/caregivers of any new area of skin breakdown. (initiated [DATE]) Provide incontinence care as needed and apply moisture barrier cream/ointment per facility policy/orders (initiated [DATE]) Turn/reposition resident frequently throughout the shift and PRN (as needed) (initiated [DATE], revised [DATE]) Date initiated: [DATE], Revision on [DATE]: (name of R#801) is incontinent of bladder & bowel r/t (related to) decreased mobility Interventions included: Resident uses disposable briefs. Change frequently and prn. (initiated [DATE]) Date initiated: [DATE], Revision on [DATE]: (name of R#801) is at risk for fluctuation in cognitive thinking r/t Dementia Interventions included: Communicate with resident/family/caregivers regarding residents capabilities and needs & discuss concerns about confusion, disease process, NH (nursing home) placement as needed. (initiated [DATE]) Review of R#801's census information revealed multiple hospitalization s and readmissions into the facility which included: Actual Admission - [DATE]; hospitalization - [DATE]; Readmission - [DATE]; hospitalization - [DATE]; Readmission - [DATE]; and hospitalization [DATE]. Review of R#801's physician orders [REDACTED]. [MEDICATION NAME] dressing to right buttocks, wipe area with skin prep and apply dressing qday (every) and PRN (as needed). As needed for PI (pressure injury) (started [DATE]) [MEDICATION NAME] dressing to right buttocks, wipe area with skin prep and apply dressing qday and PRN. Every shift for PI (started [DATE]) [MEDICATION NAME] dressing to right buttocks, wipe area with skin prep and apply dressing qday and PRN. One time a day for PI (started [DATE]) [MEDICATION NAME] then foam dressing to R (right) buttock; Cleanse with NS (normal saline), pat dry, apply [MEDICATION NAME] and then foam dressing as needed for PI (pressure injury) (started [DATE]) [MEDICATION NAME] then foam dressing to R (right) buttock; Cleanse with NS (normal saline), pat dry, apply [MEDICATION NAME] and then foam dressing every shift for PI (pressure injury) (started [DATE]) Daily and prn wound tx (treatment) to right buttock. Cleanse with NS and pat dry. Apply triad wound paste and cover with gauze and then large foam dressing as needed for wound care (started [DATE]) Daily and prn wound tx to right buttock. Cleanse with NS and pat dry. Apply triad wound paste and cover with gauze and then large foam dressing every day shift for Wound care (started [DATE]) [MEDICATION NAME] solution reconstituted 1 GM inject 1 gram intramuscularly one time only for infection for 1 day (started [DATE]) [MEDICATION NAME] sodium solution reconstituted 2 GM (grams) use 2 gram intraveneously one time a day [MEDICAL CONDITION] for 5 days (started [DATE], ended [DATE]) [MEDICATION NAME] sodium solution reconstituted 2 GM (grams) use 2 gram intraveneously every shift [MEDICAL CONDITION] for 5 days (started [DATE], ended [DATE]) Review of R#801's physician orders [REDACTED]. Zgaurd <sic> to buttocks as needed every 12 hours as needed for excoriation (started [DATE]) apply large foam dressing to coccyx/buttoc <sic> area after cleansing with n/s (normal saline). qd (every day) and prn (as needed) every day shift for wound (started [DATE]) apply large foam dressing to coccyx/buttoc <sic> area after cleansing with n/s. qd and prn every night shift for wound (started [DATE]) Santyl Ointment 250 Unit/GM apply to coccyx topically every day shift for pressure injury Cleanse PI to coccyx w/NS, pat dry. Apply santyl, gauze and cover with foam dressing QD and PRN (started [DATE]) Santyl Ointment 250 Unit/GM apply to R (right) buttock topically every 8 hours as needed for pressure injury (started [DATE]) Santyl Ointment 250 Unit/GM apply to R buttock topically every 8 hours as needed for pressure injury (started [DATE]) Santyl Ointment 250 Unit/GM apply to R buttock topically every evening shift for pressure injury Cleanse PI to R buttock w/NS, pat dry. Apply santyl, gauze and large foam dressing QD and PRN (started [DATE]) Review of R#801's physician orders [REDACTED]. Santyl Ointment 250 Unit/GM apply to R buttock topically every 8 hours as needed for pressure injury (started [DATE]) Santyl 250/gm (grams) applied to right buttock pressure injury, cleanse with NS and apply thin layer, cover with foam dressing every shift (started [DATE]) Santyl Ointment 250 Unit/GM apply to R buttock topically every 8 hours as needed for pressure injury (started [DATE]) Santyl Ointment 250 Unit/GM apply to R buttock topically every day shift for pressure injury Cleanse PI to R buttock w/NS, pat dry. Apply santyl, moist gauze and cover with large foam dressing QD and PRN (started [DATE]) Review of the actual Treatment Administration Records (TARs) from (MONTH) to (MONTH) 2019 documented R#801 received the scheduled wound/skin treatments as ordered, however the section of the TAR to document whether there were any PRN treatments administered as ordered were left blank. Review of the nurses note dated [DATE] at 10:16 PM documented, in part: .CNA (certified nursing assistant) also alerted writer to a pressure injury on the right buttocks. Pressure injury is about 5 inches in diameter, purple in color and nonblanchable <sic> and non stageable .put a wound consult in for the pressure injury. Writer notified son .Will begin TX (treatment) to right buttocks with [MEDICATION NAME] dressing qday . Review of R#801's Skin & Wound Evaluation assessments provided by the facility from [DATE] to [DATE] included: On [DATE] at 11:24 AM, .Bruise .Location (left blank) .In-House Acquired .Exact Date [DATE] .Wound Measurements .Area 59.9 cm2 .Length 9.2 cm .Width 9.8 cm .Depth Not Applicable .Exudate (fluid) None .Odor noted after cleansing None .Periwound .Edge appears flush with wound bed or as a sloping edge .Surrounding Tissue .Intact: Unbroken skin .Pain Frequency .None .Orders .Goal of Care .Healable .Treatment .Dressing Appearance .Intact .Normal Saline .Primary Dressing .Foam .No secondary dressing .Additional Care .Repositioning device(s) .Resident seen by wound care for discolored area to right buttock, no drainage, foam dressing applied, will observe for changes . On [DATE] at 7:38 AM, .Bruise .Location Right Buttock .In-House Acquired .Exact Date [DATE] .Wound Measurements .Area 33.3 cm2 .Length 7.5 cm .Width 6.3 cm .Depth Not Applicable .Exudate (left blank) .Odor noted after cleansing None .Edge appears flush with wound bed or as a sloping edge .Surrounding Tissue .Intact: Unbroken skin .Pain Frequency .None .Orders .Goal of Care .Healable .Treatment .Normal Saline .Dressing Appearance .Intact .Cleansing Solution .Soap & Water .Primary Dressing .Foam .no secondary dressing .Additional Care .Repositioning device(s) .resident seen by wound care physician for discolored area to right buttock no drainage foam dressing applied . On [DATE] at 10:55 AM, .Pressure .Unstageable: Obscured full-thickness skin and tissue loss .Location Right Buttock .In-House Acquired .Exact Date [DATE] .Wound Measurements .Area 11.5 cm2 .Length 5.8 cm .Width 2.9 cm .Depth Not Applicable .Wound Bed .Slough .100% of wound filled .Exudate .light .Serosanguineous .Odor noted after cleansing None .Non-Attached: Edge appears as a cliff .Surrounding Tissue .Fragile: Skin that is at risk for breakdown .Pain Frequency .None .Orders .Goal of Care .Healable .Treatment .Normal Saline .Dressing Appearance .Intact .Cleansing Solution .Normal Saline .Primary Dressing .Other .Secondary Dressing .Foam .Additional Care .Mattress with Pump .Resident seen by wound care for UTD (unable to determine) to R buttock. Scant amount of serosang <sic> drainage noted with no odor. Area cleansed w/NS, pat dry, Santyl, gauze and foam dressing applied. Resident tolerated well. Treatment orders in place. Will continue with current plan of care . On [DATE] at 7:27 AM, .Pressure .Unstageable: Obscured full-thickness skin and tissue loss .Location Right Buttock .In-House Acquired .Exact Date [DATE] .Wound Measurements .Area 21.0 cm2 .Length 7.2 cm .Width 3.9 cm .Depth Not Applicable .Wound Bed .Eschar .100% of wound filled .Exudate .light .Serosanguineous .Odor noted after cleansing None .Edges .Attached: Edge appears flush with wound bed or as a sloping edge .Surrounding Tissue .Fragile: Skin that is at risk for breakdown .[MEDICAL CONDITION] .Non-[MEDICAL CONDITION] extends > 4 cm around wound .Pain Frequency .Intermittent .Orders .Goal of Care .Healable .Treatment .Normal Saline .Dressing Appearance .Intact .Cleansing Solution .Normal Saline .Primary Dressing .Other .Secondary Dressing .Foam .Additional Care .Cushion .Incontinence management .Mattress with Pump .Turning/repositioning program .Resident seen by wound care physicians service for UTD to right buttock, 100% necrosis with small amount of serosang <sic> santyl and foam dressing applied .Education: Resident educated on importance of offloading pressure to area, resident states understanding but also states she does not want to be repositioned and wants to lay flat on her back with head of bed elevated . On [DATE] at 8:05 AM, .Pressure .Unstageable: Obscured full-thickness skin and tissue loss .Location Right Buttock .In-House Acquired .Exact Date [DATE] .Wound Measurements .Area 14.4 cm2 .Length 6.4 cm .Width 3.1 cm .Depth Not Applicable .Wound Bed .Slough .30% of wound filled .Eschar .70% of wound filled .Exudate .light .Serosanguineous .Odor noted after cleansing None .Edges .Attached: Edge appears flush with wound bed or as a sloping edge .Surrounding Tissue .Normal in color .No swelling or [MEDICAL CONDITION] .Pain 2 .Pain Frequency .Intermittent .Orders .Goal of Care .Healable .Treatment .Normal Saline .Dressing Appearance .Intact .Cleansing Solution .Normal Saline .Primary Dressing .Other .Secondary Dressing .Foam .Additional Care .Cushion .Incontinence management .Mattress with Pump .Repositioning device(s) .Resident seen by wound care physician services for unstageable pressure wound to right buttock. 30% granulation and 70% necrotic tissue with small amount of serosang <sic> discharge. Roho cushion and mattress in place and checked for proper inflation. Santyl and foam applied, will observe for changes . On [DATE] at 8:29 AM, .Pressure .Unstageable: Obscured full-thickness skin and tissue loss .Location Right Buttock .In-House Acquired .Exact Date [DATE] .Wound Measurements .Area 20.4 cm2 .Length 4.8 cm .Width 4.0 cm .Depth Not Applicable .Wound Bed .Eschar .100% of wound filled .Increased drainage .Exudate .Moderate .Serosanguineous .Odor noted after cleansing Faint .Edges .Attached: Edge appears flush with wound bed or as a sloping edge .Surrounding Tissue .Fragile: Skin that is at risk for breakdown .Scarring .No swelling or [MEDICAL CONDITION] .Periwound Temperature .Warm .Pain 3 .Pain Frequency .At Dressing .Orders .Goal of Care .Healable .Treatment .Normal Saline .Dressing Appearance .Intact .Cleansing Solution .Normal Saline .Primary Dressing .Other .Secondary Dressing .Foam .Additional Care .Cushion .Incontinence management .Mattress with Pump .Repositioning device(s) .Resident seen by wound care physicians services for UTD PI to coccyx extending to right buttocks, 100% necrosis which is starting to separate, slight odor noted, medium amount of drainage, santyl and foam dressing applied, wound NP states suspected abscess which needs surgical debridement, PCP (primary care physician) contacted and ordered resident to be sent to hospital, roho mattress checked for proper inflation . Review of Wound Nurse Practitioner (Wound NP L) documentation provided by the facility included the following Wound Care Consults for R#801: On [DATE], .Unstageable pressure injury site to right buttock that extends to coccyx .Today's initial wound consult requested by medical physician for evaluation and treatment of [REDACTED]. Patient recently acquired a large unstageable wound .She is currently on contact isolation for shingles and has very limited mobility. Comorbidities also include obesity, dementia, depression. Patient also has very moist skin. This wound was noted by staff in the past week or so, patient complains of mild tenderness at site which is relieved by offloading pressure, local wound care and PRN pain medication .Patient has very moist skin and is debilitated .She does tend to stay in a supine position in bed and becomes easily anxious and unable to follow instructions at times. Currently the wound measures 9 cm in length by 10 cm in width with a depth UTD. Wound base is 100% dark maroon in color with sloughing noted to [MEDICATION NAME] layer with minimal serosanguineous drainage. Tissue damage may be evolving .currently no sign of infection .Alert x,[DATE] with confusion .Plan .She has chronically moist skin begin daily and as needed wound treatment to this site cleansing with normal saline and pat dry. Apply thick layer of Triad wound paste to the wound region and cover with gauze fluffs and large foam dressing. She has grab bars in place to her bed to assist with turning. She will receive a bariatric Roho wheelchair cushion for her chair. Strict offloading pressure protocol should be performed including not sitting up for long periods of time . On [DATE] (R#801 was in the hospital during the Wound NP Ls last visit to the facility), .Patient was seen by me on (MONTH) 8 then went to the hospital. Patient has since returned and today's a follow-up evaluation of very concerning unstageable decubitus ulcer to the coccyx that extends to the right buttock. Patient complains of pain at wound site, she is medicated per orders. She continues to be debilitated most recent weight is 333 pounds and she is incontinent .resting in bed no acute distress noted she is confused .Patient's wound shows a decline since I seen her earlier in the month. This wound is evolving and I anticipate it will open eventually be a stage IV decubitus ulcer .Today the wound measures 10 cm in length by 5 cm in width with a depth UTD. Wound base is 100% necrotic tissue with minimal serosanguineous drainage .no odor. Currently there is no sign of infection. Nursing reports patient refuses to participate in turns in bed to properly offload pressure to this area .Alert X,[DATE] with confusion .Plan: I spoke with patient regarding the necessity for turning offloading protocol. Patient refused to have us reposition her in a side-lying position today. She is high risk for this wound declining, monitor closely for any onset of infection. Continue daily. Wound treatment apply topical Santyl nickel thickness for enzymatic debridement cover with gauze fluffs and large foam dressing. Recommended patient receive a bariatric Roho mattress as soon as possible . On [DATE], .Patient returns from the hospital, follow up evaluation of coccyx/right buttock PI site. Patient states she does not have any pain at site today. She has Roho mattress and cushion now .she is confused .Coccyx to right buttock PI is still concerning and measures 9cm in length by 5cm in width and depth of UTD. New granular tissue noted, 30% with 70% dark necrosis, minimal serosang <sic> drainage, positive induration to periwound area. Patient very resisting to be turned to her side to off load pressure .Alert X,[DATE] with confusion .Plan: Continue daily and prn santyl wound tx to coccyx/right buttock PI site, cleanse with NS. Apply nickel thickness, covered with gauze and foam. Maintain off loading equipment and manage incontinence . On [DATE], .Today's follow-up evaluation of a concerning large unstageable pressure injury to coccyx that extends to her right buttock. Patient is complaining of increased pain at the site and she does appear ill today .The wound measures 10.5 centimeters in length by 6 cm in width with a depth to UTD. Wound is 100% moistened necrotic with edges that are beginning to separate. Currently this wound has a mild odor and there is onset of fluctuance at the center and minimal to moderate serosanguineous drainage. Periwound area is moist. Patient currently has abnormal vital signs and most recent white count slightly elevated. She is hot to touch and confused .Plan: Patient will need a surgical debridement of this wound and treatment for [REDACTED].Patient will be sent to (name of local hospital) for further work-up and treatment and debridement of this wound . On [DATE] at 2:40 PM, an interview was conducted with the DON and ADON. At that time, the DON was asked about R#801's facility acquired pressure ulcer and the DON confirmed the onset date of [DATE]. The DON further reported R#801 had a specialty mattress in place and that the resident was resistive to repositioning and offloading. When asked about the documented weekly skin assessments that identified the goal was to heal, and other options of wounds that might be considered unavoidable were not identified, the DON confirmed the goal as documented was to heal. When asked about what alternate wound interventions had been attempted, such as involving the family given the fluctuation in the resident's cognition, other incontinence management (such as an indwelling catheter as implemented for another sampled resident due to incontinence) given the resident's incontinence status, severity of the wound, and description of the wound being constantly moist, the DON reported she would investigate and get back. When asked if she felt it was appropriate that the facility documented re-educating the resident about repositioning and why the family had not been included to assist with encouraging compliance with repositioning or alternate interventions given the resident's fluctuating cognition and mental status exam score, the DON offered no further response. When asked about the lack of documented PRN wound treatments given the resident's incontinence, the DON confirmed the lack of PRN treatments as blank entries and offered no further response. The DON was requested to provide any other documentation to support the facility had provided any alternate wound care interventions, however there was no further documentation provided by the end of the survey. On [DATE] at 5:00 PM, a phone interview was conducted with Wound NP [MI] When asked about R#801's facility acquired pressure ulcer, Wound NP L reported, I look at risk factors that are medical co-morbidities, lack of mobility and cognition. After I met her, red flag for me was psych .I personally wanted to reposition her and she didn't allow. That's a problem .She was heavy, resistant biggest risk factor was her psych .It was a large DTI .May have had some underlying issue cause temp to spike that week. I felt she was at high risk, contacted attending and sent out . When asked if she had any discussion with the family in regards to the wound, and/or alternate interventions, Wound NP L reported it would be the facility who would do that. Review of the facility's Skin Management policy dated Revised: ,[DATE] documented, in part: It is the policy of the facility that a resident does not develop pressure injury unless clinically unavoidable .Appropriate preventative measures will be implemented .and the interventions are documented on the care plan .

Based on observation, interview, and record review, the facility failed to ensure appropriate catheter care, assessment, and maintenance for one Resident (R#66) of four residents reviewed for urinary catheters, resulting in catheter occlusion, [MEDICAL CONDITION], pain, and a five day hospitalization for intravenous antibiotic therapy for treatment of [REDACTED]. Findings include: care On 03/18/19 12:07 PM, R#66 was observed in bed. At that time, an interview with R#66 was conducted regarding his indwelling urinary catheter. R#66 was asked if staff perform peri-care and catheter care (washing of the peri-area and cleaning of the catheter) and if the nurses assess the catheter, the peri-area and insertion site. R#66 stated, Some of them do, but not all of them. I just got back here not to long ago because I went to the hospital for a urinary infection. I spent five or six days there. An observation of the catheter drainage bag was conducted and revealed yellow urine with some cloudiness in the bag and tubing. A review of R#66's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R#66 was discovered to have re-admitted on [DATE] with an added [DIAGNOSES REDACTED]. A review of R#66's Minimum Data Set assessment dated [DATE] indicated intact cognition, non-ambulatory and extensive assistance of one to two staff members for activities of daily living. A review of R#66's physician's orders [REDACTED]. A review of the electronic Treatment Administration Records (eTAR)'s was conducted for (MONTH) 2019 thru (MONTH) 2019 and did not include any evidence that R#66 had catheter assessment or care performed including peri-care cleaning or catheter cleaning. A review of the Certified Nursing Assistant (CNA) tasks for a 30 day look-back period was conducted and revealed that CNA's documented urinary catheter care for only three days, 2/19/19, 2/20/19 and 3/20/19. Further review of R#66's record revealed one care plan with an initiation date of 3/6/19 (despite R#66 originally being admitted on [DATE]) that read, Focus: (R#66) is at risk for urinary tract infection and catheter-related trauma .Interventions .Provide Catheter care per policy . A review of R#66's progress notes was conducted and indicated that R#66 had admitted to the facility with a catheter in place. Further review of the progress notes revealed: A nursing note on 2/21/19 that read, Note text: Resident gave unmeasurable <sic> amount of urine during shift. Was irrigated during day shift due to same problem. Was told by nurse manager to change foley cath (catheter). Was unable to change due to the amount of pain the resident was in, also the site was red with a thick amount of greenish, yellow pus at the urethral. On call physician was called, order was given to send the resident out .EMS was called, arrived shortly after . A nursing note by the Registered Nurse and Unit Manager 'K' dated 2/21/19 that read, Assigned nurse contacted writer regarding concerns of leaking foley catheter with possible bladder distension. Writer assessed resident and noted that resident's bladder was distend and tender to palpation. Penile [MEDICAL CONDITION] noted. Copious amounts of thick yellow discharge draining from urethra. Bladder scanned for >900 (milliliters). On Call NP for Dr. (name redacted) notified . A review of R#66's hospital documentation for the admission from 2/21/9 thru 2/26/19 was reviewed and read, .Hospital Discharge Diagnosis: [REDACTED]. A review of the hospital attending physician's notes dated 2/21/19 was conducted and read, .Patient brought in after providers at his nursing facility noticed purulent drainage from his penis around Foley catheter insertion site. On evaluation patient does have purulent drainage with [DIAGNOSES REDACTED] (redness) to penis [DIAGNOSES REDACTED] extends down and also involve scrotum .however his scrotum is also tender to palpation. He does have a lot of purulent drainage from his urethra. His urine is very cloudy colored. His catheter was obstructed initially .Suspected UTI .he will be admitted for IV (intravenous) antibiotics and further management . A review of the hospital's infections disease physician's consult was conducted and read, .Problem 1: Urinary tract infection, [MEDICAL CONDITION], bilateral hydro[DIAGNOSES REDACTED] (swelling of the kidneys) Plan 1: Patient was seen .Low-grade fever .Leukocytosis (elevated white blood cell count, frequently a sign of an [MEDICAL CONDITION] response) present with current WBC (white blood cell) at 14.5 (normal range 5.0-10.0). Patient was brought to the ED from extended care facility due to [MEDICAL CONDITION] .Foley catheter present at time of arrival was occluded with pus noted around insertion site. Urinalysis was grossly positive with urine culture currently pending. Culture obtained from penis showing mixed infection .Catheter was changed and urine still appears cloudy . It was noted that in the hospital discharge paperwork, R#66 was provided with discharge instructions that went back to the facility that read, .3. Cleaning Your Skin and Tubing: Clean the skin near the catheter with soap and water .Wash the catheter tubing. Always wash the catheter in the direction away from your body . On 3/19/19 at 2:01 PM, an interview with Licensed Practical Nurse (LPN) 'H', was conducted regarding the nurses responsibility for catheter care, assessment, and documentation. LPN 'H' explained that nurses were supposed to assess the catheters every shift. LPN 'H' stated, We monitor for the leg straps, patency, and insertion site. When queried where it would be documented in the record, LPN 'H' said, There is supposed to be an order for [REDACTED]. LPN 'H' further explained that when CNA's change a resident's brief they should be cleaning the catheter as well. LPN 'H' stated, I don't think I have anyone assigned to me with a catheter today. On 3/20/19 at 11:45 AM, an interview with the facility's Director of Nursing (DON) was conducted regarding nurses responsibility and the facility policy for catheter care. The DON indicated that catheter care should be done daily and more often as needed. When queried where nurses would document catheter care or assessment the DON indicated that the nurses could document it in the CNA task on the electronic medical record. When queried if there should be a physician's orders [REDACTED]. At that time, it was brought to the DON's attention that other residents with indwelling catheters had physician's orders [REDACTED]. The DON had no explanation why R#66 did not have an order for [REDACTED]. On 3/20/19 a review of a facility provided document titled, Indwelling urinary catheter (Foley) care and management with a revision date of (MONTH) 14, (YEAR) was reviewed and read, .Inspect the urinary catheter system .Provide routine hygiene for meatal (peri-area) care .Inspect the periurethral area for signs of inflammation and infection .Document the procedure . The facility was asked if they had any additional policies or information to provide regarding documentation and assessment of urinary catheters, none was provided by the end of the survey.

This citation pertains to intake #MI 696. Based on observation, interview and record review, the facility failed to ensure an effective elopement system was in place for a resident who required supervision and exited the facility through the main doors for one (#701) of six residents reviewed for elopement, resulting in an Immediate Jeopardy (IJ) when R#701 who had impaired cognition, been identified as a risk for elopement, exited the facility unattended without knowledge of the staff, and accessed an unlocked vehicle of a contracted lab technician which had the additional potential likelihood of exposure to bloodborne pathogens that were stored within the vehicle. This had the likelihood to result in serious injury, harm, and/or death. Findings include: This IJ was identified on 10/29/18 at 2:45 PM. The IJ started on 10/3/18 at 5:15 AM. The Administrator was notified of the IJ on 10/29/18 at 3:40 PM and a plan of removal was requested to remove the immediacy. The IJ was removed on 10/30/18 based on the provider's implementation of an acceptable plan of removal as verified onsite by the surveyor on 10/30/18 at approximately 2:15 PM. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with the likelihood for harm that is not immediate jeopardy. On 10/29/18 at 8:45 AM, the Administrator and Director of Nursing (DON) were interviewed about a facility reported incident (FRI) submitted to the State Agency regarding R#701 exiting the facility without supervision on 10/3/18 at approximately 5:15 AM. At that time, the Administrator reported R#701 was not currently at the facility and was in the hospital for an unrelated issue. The Administrator further reported that their investigation revealed that although the facility's alarm system for the main entrance was functional as verified via the electronic logs, facility staff did not respond as required and R#701 was able to exit the building, then entered a visiting lab technician's (Lab Staff H) unlocked car without their knowledge. Review of the documentation provided by the Administrator of their investigation into R#701's elopement from the facility confirmed the above information discussed with the Administrator and DON. Review of the facility's investigation summary included: On 10/13/18 at approximately 5:15 am, (R#701) self-ambulated to the front door and exited the building and placed himself in the passenger seat of a parked, non-running vehicle that was outside the front door approximately 2 feet from the curb. He played with the radio (as seen on the camera) and listened to music while sitting in car. The Director of Nursing (DON) and Administrator reviewed the camera and confirmed time he left (5:15 am) and was observed by technician at 5:24 am sitting in her car. (There is an approximately 3.5 min (minute) time discrepancy between door report and camera.) Investigation was immediately started .(R#701) has a BIMS (brief interview for mental status) of 4 (severely cognitively impaired) and has no recall of the event. The following is determined based on the code alert door report review and reviewing the camera feed. The statements made by the EMS technicians and Lab Technician confirmed the time lines and presumptions made after a thorough and comprehensive investigation. (R#701) was seen sleeping in his room at 4:30 by his nurse (Licensed Practical Nurse/LPN I). (R#701) was seen in his room on the unit heading toward his rest room at approximately 4:45 am by Lab Staff H. A couple minutes after 5am, EMS arrived to pick up a resident for a scheduled appointment. EMS let themselves into the facility and (R#701) was not seen at the time of their arrival. (Timeline per the Door Code Alert Report) 5:11:04a (R#701) walked near door. The wander guard sounded the door. 5:11:34 (R#701) let himself out. The door alarm continued to sounded. 5:20:46 Lab Staff H cleared door alarm prior to exiting building. 5:21:42 Lab Staff H entered the building setting off the alarm after observing (R#701) sitting in her car. She cleared the alarm at 05:22:07 She locked him in her car which had been unlocked (and not running) and came back into building to get assistance to bring (R#701) back in. At 5:28:05, (R#701) reentered the facility being escorted by three CENAs (Certified Nursing Assistants/CNA J, K, and L). EMS was exiting the building during the time (R#701) was in the car waiting for the CNAs to come escort him back into building .A Code Search was implemented to ensure no other residents had exited building during the alarm and all current residents were accounted for .It is determined, after extensive investigation, that (R#701) left the building after reading the notification on the door that reads, Keep Pushing. Door Will Open in 15 Seconds. The Alarm will Sound. When viewing the cameras, he walked directly to the car, sat in car, closed door, began playing with the radio . On 10/29/18 at 2:08 PM, observation of the video footage (external camera facing the front entrance under the awning) with the Administrator confirmed the reported timeframes as documented in the facility's investigation. At 5:15:17, R#701 was observed walking without any assistive device as he approached the vehicle parked just in front of the curb at the entrance. (An ambulance was also observed parked on the left side of the vehicle. Both vehicles were observed not running as there were no visible lights lit up on them.) R#701 then opened the door on the front passenger side, move something from the front passenger seat, sit down and close the door. At approximately 5:17:50, there was a flash of light observed from the interior of the car (further identified as a radio that was functional despite the lack of running vehicle). At approximately 5:23:39, Lab Staff H was observed walking from the facility's entrance toward her vehicle and upon approach of the driver door, observed R#701 in the front passenger seat. Lab Staff H appeared to then lock the vehicle (tail lights lit up) and re-enter the facility. At approximately 5:27, EMS staff were observed exiting the building with another resident by stretcher and did not appear to be aware of R#701 seated in Lab Staff H vehicle. Review of the staff interviews conducted by Administration with the nursing staff on duty on 10/3/18 at the time of R#701's elopement from the facility revealed there were no staff that recalled hearing any alarms, but some did acknowledge hearing the overhead announcement to begin the facility wide check to ensure other residents were accounted for. On 10/29/18 at 3:18 PM, Lab Staff H was interviewed by phone. When asked to recall the incident with R#701 on 10/3/18, Lab Staff H reported, I go there Monday through Friday just to draw blood. I keep them (blood pathogens and supplies) in my car. When I got there (facility) I went through the door. Someone had to let me in. I had to call the facility to let me in. I usually go to the left and work my way around to the end of the other nursing station. I started and went around. Normally I go to second station which is where that resident (R#701) was. I went to the back and came back through and seen that patient on way into bathroom. No sure what he's able to do (walk with an assistive device or not). I kept going down to the next nursing station. As I was walking down that way heard an alarm. Normally (door) alarm is cause EMS will hold door until alarm goes off (to be able to enter the facility). I witnessed it before. Made way down and I seen them EMS go into someone's room. I think I had three residents to draw (obtain blood sampled from). There were three aides at the nursing station not going to the door to check the alarm. I got the three blood draws and the alarm was still going off. I went to the front door and cut alarm off (turned off alarm) and it resetted <sic> itself. As I was walking outside I saw them (EMS) outside. I was beside my car and saw my radio lights on and that particular morning I forgot to lock my (car) door. I went to door and scared me. (R#701) said hi. I locked him in my car and I made alarm go off and resetted <sic> it again. I went to nursing station and didn't see anyone so I went to Michigan I think and told them to come get their patient out of my car. I went to find the nurse . (The statements obtained from Lab Staff H conflicted with interviews obtained from facility staff, as well as observation of video footage that EMS staff were not visible until after Lab Staff H re-entered the facility.) Lab Staff H was asked how she obtained the code to shut off the alarm to exit and how she re-entered the facility and reported facility staff had provided the code at one time and that she had pulled the door until it opened (after 15 seconds for fire safety). On 10/30/18 at 10:59 AM, a phone call was placed to LPN I but there was no return call prior to the end of the survey. On 10/30/18 at 11:02 AM, a phone call was placed to CNA J but there was no return call prior to the end of the survey. On 10/30/18 at 11:03 AM, a phone interview was conducted with CNA K. At that time, CNA K confirmed she was one of the staff that had assisted with bringing R#701 back into the facility on [DATE]. When asked to recall the events, CNA K reported, I was working Waterford/Telegraph unit. I didn't hear any alarms going off. Lab Staff H approached the whole unit and said she couldn't find anyone on Oakland to assist so she asked us to help. There's supposed to be an alarm to go off. That night I didn't hear anything at all. Review of the clinical record revealed R#701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Medicare/5 Day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/11/18, R#701 scored a 4/15 on brief interview for mental status (BIMS which indicated severe cognitive impairment) and had wandering behavior for one to three day during this assessment period of seven days. The elopement risk care plan was initiated on 2/13/18 and revised on 10/3/18 to include frequent checks on resident throughout the day as tolerated. Review of the Risk for Elopement assessments included an assessment dated [DATE] which documented a score of 17 (which indicated at risk for elopement). Review of the physician orders [REDACTED]. On 10/30/18 at approximately 1:30 PM, an audible alarm was heard while at the Michigan nursing station. At that time, Nurse QQ was observed seated at the desk and CNA QQ was observed standing at a computer on the wall in the hallway. Neither staff which were in proximity to the audible alarm responded. At that time, observation of the identified alarm area on the computer showed the alarm was for the front door. On 10/30/18 at 1:33 PM, the DON and Corporate Clinical Staff SS were informed of the observation of multiple staff's lack of response to an activated door alarm. On 10/30/18 at 2:15 PM, Administration reported they had completed an immediate in-service with all staff currently on duty to re-educate on the facility's elopement policy, to stop what they are doing and respond to the alarm. Review of the facility's Elopement Policy dated Revised: 5/2017 documented: .Unsafe wandering may occur when the resident at risk enters an area that is physically hazardous or that contains potential safety hazards .Elopement occurs when a resident who needs supervision leaves a safe area without authorization .and/or any supervision to do so .If an employee hears a door alarm, he or she should: a. Immediately go the site of the alarm . The facility submitted the following acceptable plan including supporting documentation to remove the immediacy on 10/30/18. IJ REMOVAL PLAN 10-29-18 Element 1 1. Resident #701 was assessed for injury upon his return on 10-03-18, by the Nurse and the Physician and has had no ill effects from leaving the facility unattended. R#701 care plan was reviewed and updated 10-03-18. R#701 wanderguard was checked for placement and function on 10-03-18, and was in place and functional. Element 2 2. All residents previously identified at risk for elopement had their wanderguards checked for placement and function and then were rechecked by the DON/designee on 10-03-18. All were in place and functional. Care plans were reviewed and updated as needed. 3. All of the wanderguard equipped doors were checked for function by the Director of Maintenance on 10-03-18, at 9:00 AM, and were found to be functional. 4. Elopement books on all units and the reception desk were reviewed by the Social Work on 10-03-18, and were accurate. Elopement books will be updated weekly by the Social Worker. Element 3 5. Education on the elopement policy and procedure was immediately started on 10-03-18, and as of 2:25pm 10-07-18, 200 of 202 employees were educated on the elopement policy and procedure, with the remaining employees on LOA to be educated prior to returning to work. All new employees will be educated during the new orientation program. 6. Elopement drills continue to be completed every shift every quarter by the Maintenance Director. 7. An ad hoc QA meeting was held on 10/3/2018, which included the DON, LNHA, AR Coordinator, Wound Care Nurse, Restorative Nurse, ADON, Unit Managers (3), Staff Development Coordinator, Social Work Director, Social Workers (2), MDS Coordinator, MDS Nurses (2), Activity Director, Rehabilitation Director, Medical Records Coordinator, Registered Dietitian (2), Maintenance Director, Environmental Director, Payroll Coordinator and Human Resources. The P[NAME] was reviewed and approved by the committee. Element 4 8. Random elopement drills will be conducted for the next 4 weeks, then monthly. Drills will be completed by the Maintenance Department and results of drills will be forwarded to the QAPI committee for review and recommendation. Any identified issues will be addressed immediately. 9. Audits of new admission elopement assessments will be completed weekly x 1 month, then monthly x 3 by the DON/designee with all results forwarded to QA committee. 10. Audits of the elopement books will be conducted weekly by the Administrator/Designee to ensure weekly updates are being conducted with all results forwarded to QA committee. Allegation of compliance 10-07-18 Administrator and DON responsible for sustained compliance.

This Citation Pertains to Intake Number MI 303. Based on interview and record review, the facility failed to provide adequate assessment, monitoring, and timely emergency medical treatment and transfer for one (# 701) of two Residents reviewed for assessment and monitoring, of a total sample of three, resulting in a delay in emergency medical treatment for [REDACTED]. decline. Findings include: On [DATE] at 8:20 AM, an interview was conducted with Confidential Witness A and Confidential Witness B. When queried regarding Resident #701, Confidential Witness A stated, I got a call (Resident #701) needed to go to the ER and they (facility) wanted to know where I wanted (the Resident) to go. At this time, Witness B stated, I called up there (to facility) and talked to (Nurse C). (Nurse C) said they were gonna take (Resident #701) to the hospital because (the Resident) was real lethargic and their INR was eight (normal range is 0XXX,[DATE].2 for a person not taking [MEDICATION NAME] and typically 2XXX,[DATE].0 for someone taking [MEDICATION NAME]). With further inquiry, Witness B stated, (Nurse C) said the day shift nurse got the INR results and gave (Resident #701) Vitamin K but their INR didn't go down. (Nurse C) told me (Resident #701) was incontinent of urine and stool and that was not normal. (Resident #701) hated that (being incontinent), it was not normal. (The Resident) usually put themselves on the commode. Witness B then said, I asked (Nurse C) what color the stool was and she said dark. I asked if it was black and (Nurse C) said yes. I said (Resident #701) is bleeding and you need to get them out of there. With further inquiry, Witness B stated, I'm a critical care nurse, have been for [AGE] years. (Resident #701) needed some FFP (Fresh Frozen Plasma - Blood product that can be utilized to reverse elevated INR levels). When queried, Witness B stated, I want to know how it (INR) got that high and why (the Resident) was not sent to the hospital sooner. I don't know what they were waiting for. When queried what happened when Resident #701 got to the hospital, Witness A stated, I never made it up there to see (the Resident). I was getting ready to go and the Doctor from the hospital called me around 2:00 AM and told me (Resident #701) was gone. The Doctor said they revived (the Resident) once but they lost (the Resident) again and couldn't get them back. With further inquiry, Witness A stated, The death certificate said the cause of death was from a Cerebral Hemorrhage. Record review on [DATE] at 9:30 AM revealed Resident #701 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, a full code (indicating they wanted all measures taken to preserve their life), and required limited to extensive assistance of one person to perform Activities of Daily Living (ADL's). Review further revealed the Resident was transferred to the hospital and discharged from the facility on [DATE]. Record review on [DATE] at 9:44 AM revealed the following documentation within Resident #701's medical record: -Nurses Note: Dated [DATE] at 6:51 AM: PT/INR 8XXX,[DATE].0 -MD paged, awaiting call back. -EMAR (Electronic Medical Record) Note: Dated [DATE] at 9:15 PM: [MEDICATION NAME] 2.5 mg (milligrams) . INR elevated 8.1, hold until [MEDICATION NAME] levels therapeutic. -Nurses Note: Authored by Nurse C and dated [DATE] at 11:03 PM: Resident transferred to (hospital), mental status change, possible rectal bleed, elevated INR 8.0, Resident is usually A & O X 3 (Alert and Orientated to person, place, and time), continent of bowel and bladder. Changed to lethargy, incontinent of bowel and bladder. On-call doctor notified, New orders to transfer out to hospital. Family notified- want Resident transferred to (hospital), (Ambulance) transferred Resident out at approximately 11:00 PM. Review of Health care provider documentation within Resident #701's medical record revealed a note dated [DATE], authored by Physician D indicating, Continue [MEDICATION NAME], monitor INR- goal ,[DATE]. An interview was conducted with Nurse F on [DATE] at 12:20 PM. When queried regarding facility policies and procedures pertaining to INR monitoring for Resident's receiving [MEDICATION NAME] therapy, Nurse F replied, They (staff) give and check the [MEDICATION NAME] on nights. With further inquiry regarding monitoring and follow up of abnormal results, Nurse F stated, The results are in a log book. Review of the unit log book with Nurse F at this time did not reveal documentation for Resident #701. On [DATE] at 12:25 PM, an interview and record review was completed with Unit Manager Nurse E. When queried regarding monitoring and documentation of PT/INR results for Resident #701, Nurse E stated, It should be scanned into the record. Nurse E reviewed Resident #701's medical record and located the document entitled, [MEDICATION NAME] Flow Sheet. Documentation on Resident #701's [MEDICATION NAME] Flow Sheet revealed the following PT/INR testing dates and results: -[DATE]: Current [MEDICATION NAME] Dose: 3 mg; Current INR result: 3.7, Current PT result: 44.5; Additional information: (blank); Next INR Date: [DATE]; S/S (signs/symptoms of Bleeding/Bruising): none . -[DATE]: Current [MEDICATION NAME] Dose: Held; Current INR result: 3.7, Current PT result: 44.0; Additional information: Holding dose; Next INR Date: [DATE]; S/S (signs/symptoms of Bleeding/Bruising): none . -[DATE]: [MEDICATION NAME] Dose: 3 mg; Current INR result: 3.7, Current PT result: 37.6; Additional information: lower dose, recheck ,[DATE]: Next INR Date: [DATE]; S/S (signs/symptoms of Bleeding/Bruising): none . -[DATE]: Current [MEDICATION NAME] Dose: 2.5 mg; Current INR result: 4.6, Current PT result: 55.5; Additional information: (blank); Next INR Date: [DATE]; S/S (signs/symptoms of Bleeding/Bruising): none . -[DATE]: Current [MEDICATION NAME] Dose: 2.5 mg; Current INR result: 8, Current PT result: 96; Additional information: MD paged awaiting call back; Next INR Date: (blank); S/S (signs/symptoms of Bleeding/Bruising): possible rectal . -[DATE]: Current [MEDICATION NAME] Dose: 2.5 mg; Current INR result: 8.1, Current PT result: (blank); Additional information: Hold until INR therapeutic. Transfer to hospital; Next INR Date: (blank); S/S (signs/symptoms of Bleeding/Bruising): (blank) . A review of Resident #701's Medication Administration Record [REDACTED] -[DATE]: INR 3.1 -[DATE]: INR 3 -[DATE]: INR 3 When queried regarding documentation on Resident #701's [MEDICATION NAME] log on [DATE] indicating, MD paged, awaiting call back and if documentation should be present in the medical record of physician response to page, Nurse E stated, Yes. There should be a (nurses) note. A review of nursing note documentation occurred with Nurse E at this time. Review revealed a Nurses Note, dated [DATE] at 6:51 AM, indicating PT/INR 8XXX,[DATE].0 -MD paged, awaiting call back. No further documentation was present within the Resident's medical record. When queried regarding follow up care by the physician and facility staff, Nurse E reviewed Resident #701's medical record and stated, It ([MEDICATION NAME]) was held. There is a note that it was not given on [DATE] at 9:15 PM. When queried regarding the goal for Resident #701's INR level and if there was a health care provider order, Nurse E indicated there was not a health care provider order to maintain the Resident's INR level within specific parameters. When queried regarding a policy and/or procedure regarding PT/INR monitoring and [MEDICATION NAME] therapy, Nurse E replied, I'm not sure if we have one. I don't think so. When queried how staff are aware of therapeutic goal of PT/INR levels for Resident's receiving [MEDICATION NAME] therapy, Nurse E stated, It's different for everyone. Nurse E then stated, Therapeutic (INR) is usually between 2 and 3. When queried regarding the Resident's mental status changes and if neurological assessments were completed, Nurse E replied, No, there aren't any. An interview was completed with the Director of Nursing (DON) on [DATE] at 12:50 PM. When queried regarding facility policy/procedure related to INR monitoring and [MEDICATION NAME] therapy, the DON stated, I will have to look. When asked for Incident and Accident Reports for Resident #701, the DON stated, There aren't any. When asked what is considered a critical INR value per facility policy, the DON stated, We just notify the doctor. A facility policy/procedure pertaining to lab monitoring and critical lab values was requested at this time. On [DATE] at 1:30 PM, an interview was completed with Nurse G. When queried regarding Resident #701, Nurse G stated, I remember (Resident #701's) INR was elevated. I paged the doctor and they didn't call back by 7:00 AM when I go home. When asked, Nurse G stated, I don't remember what the day shift nurse's name was but I would have told them in report. When asked if the Resident had any signs/symptoms of bleeding or other abnormal assessment findings, Nurse G replied, I don't think so. I don't remember. When queried regarding documentation on the Resident's [MEDICATION NAME] Flow Sheet of possible rectal (bleeding), Nurse H indicated they were unable to remember. At 1:45 PM on [DATE], an interview was conducted with Nurse C. When queried regarding Resident #701, Nurse C stated, I transferred (the Resident) out. I got in report that their INR was elevated and the Doctor had ordered Vitamin K. When I was doing my checks, (Resident #701) had a bowel movement and it was dark and tarry. When queried if the Resident had other signs/symptoms of bleeding prior to the dark and tarry bowel movement, Nurse C indicated they were unable to recall. When queried regarding documentation of Resident #701's mental status change, Nurse C replied, I documented it. When queried if neurological assessment or neuro checks were completed, Nurse C stated, No. An interview was completed with Nurse H on [DATE] at 2:24 PM. When asked about Resident #701, Nurse H stated, (Resident #701) had a high INR, eight I think. I called the Doctor and they told me to give (the Resident) Vitamin K. I reported it to (Nurse C) when I left that night. When asked if the Resident had any signs/symptoms of bleeding or other abnormal assessment findings, Nurse H stated, I don't remember. When queried regarding documentation on the Resident's [MEDICATION NAME] Flow Sheet of possible rectal (bleeding), Nurse H indicated they were unable to remember. On [DATE] at 2:40 PM, an interview was conducted with Physician D. When queried regarding treatment for [REDACTED]. With further inquiry regarding Resident #701 including documentation of an INR of 8, possible rectal (bleeding) in the early morning on [DATE], and treatment with Vitamin K, Physician D stated, I do not remember if they (facility staff) called me. With further inquiry regarding why the Resident was not sent to the hospital for evaluation earlier related to signs and symptoms of bleeding and INR results, Physician D did not provide an explanation and stated, I don't remember specifically. Record review on [DATE] at 2:50 PM of Nursing Assistant Toileting Schedule documentation for Resident #701 revealed the Resident had loose bowel movements on [DATE], [DATE], [DATE], [DATE], and [DATE]. The documentation did not reveal the color of the bowel movements. An interview was conducted with Nursing Assistant J on [DATE] at 3:00 PM. When queried regarding documentation of bowel movement color for Residents, Nursing Assistant J stated, It (documentation system) doesn't give us (nursing assistants) that option but it would be nice. We are the ones that see it. When queried regarding Resident #701's bowel movements, Nursing Assistant J was unable to recall. On [DATE] at 3:05 PM, an interview was conducted with Nursing Assistant K. When queried regarding meaning of Large, loose bowel movement in documentation, Nursing Assistant K stated, It could be diarrhea or it could be like the consistency of hair mousse. It could mean different things to different people. When queried regarding Resident #701's bowel movements, Nursing Assistant K was unable to recall. An interview was completed with Nursing Assistant J on [DATE] at 3:10 PM. When queried regarding Resident #701, Nursing Assistant J stated, I notified the nurse that (Resident #701's) bowels were loose and dark on the day (the Resident) got transferred. With further inquiry, Nursing Assistant J stated, I don't think (the Resident) had a bowel movement when I took care of them the day before. An interview was conducted with Nursing Assistant I on [DATE] at 3:15 PM. When queried regarding Resident #701, Nursing Assistant I stated, (The Resident) was doing good when they first got here and then something changed and they started to go downhill. They weren't doing so much for themselves. When queried when they noticed the decline in the Resident's condition, Nursing Assistant I replied, It wasn't long before they left, probably a couple of days. When queried if Resident #701 had any bleeding and/or dark bowel movements, Nursing Assistant I indicated they were unable to remember. On [DATE] at 3:45 PM, an interview was completed with the facility Administrator and the DON. When queried regarding Resident #701's elevated INR on [DATE] at 6:51 AM, documentation of possible rectal bleeding at that time on the [MEDICATION NAME] Flow Sheet and why the Resident was not transferred to the hospital until approximately 11:00 PM on [DATE], the DON indicated facility staff followed doctor orders and administered oral Vitamin K to Resident #701. With further inquiry regarding the Resident's death shortly after arriving at the hospital due to a cerebral hemorrhage, the Administrator and DON indicated they were unaware Resident #701 had died . Record review of the [MEDICATION NAME] Flow Sheet occurred with the DON and Administrator. After review, the Administrator stated, I cannot say anything except maybe it (possible rectal bleed) was written on the wrong line. When queried regarding handwriting on the [MEDICATION NAME] Flow Sheet, the Administrator stated, It looks the same. I can't say that it isn't. When queried regarding the lack of neuro assessment related to the Resident's mental status changes, the Administer and DON were unable to provide an explanation. Record review of facility policy entitled, Lippincott Procedures: Anticoagulant Therapy (Dated 2017) on [DATE] at 4:45 PM revealed, Effectively monitoring Residents receiving anticoagulant therapy and reduce the risk of bleeding by maintaining therapeutic blood levels in accordance with physician orders [REDACTED]. Document lab results, current dosage, and physician orders [REDACTED]. Documentation: Physician order [REDACTED]. Record review of facility policy entitled, Lippincott Procedures: Change in status, identifying and communicating, long-term care (Revised [DATE]) on [DATE] at 4:50 PM revealed, A change in status can happen rapidly in minutes or slowly over hours or days. The condition may manifest as a change in cognition . or a physical change . Policies and/or procedures pertaining to critical lab values and nursing assessment/documentation were requested but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to send one sampled resident (#505) to the hospital after a fall with injury out of one resident reviewed for hospitalization out of a total sample of 8 residents resulting in a delay in diagnosing and treating Resident #505's injuries. Findings include: Resident #505 was admitted to the facility on [DATE] and readmitted after a hospitalization on [DATE] with the following Diagnoses: [REDACTED]. On 10/25/17 at 10:00 AM, a record review of the incident and accident (I & A) report revealed Resident #505 was observed laying on the floor on 9/14/17 at 3:00 AM. Resident #505 was described as laying in the left lateral position, right side next to bed, faced (sic) to bed. Abrasion to the nose, forehead noted. According to the I & A, the resident stated he sat on bed, tried to check cath (catheter) then fell on floor. Root cause was cath. (catheter) malfunction. New intervention after IDT (interdisciplinary team) review: urology consult, ensure Foley (catheter) secure to leg. On 10/25/17, an SBAR Communication Form, dated 9/14/17 at 4:00 PM, (thirteen hours after Resident #505 was found lying on the floor of his room), the patient #505's pain was getting worse. The pain was documented as located in the right and left antecubital region. The neurological evaluation indicated weakness. The recommendation was to send Resident #505 to the local hospital via stretcher and c-collar to have cervical spine assessed. On 10/26/17 at 12:40 PM, an interview with the Director of Nursing (DON) was done. According to the DON, Resident #505 fell in the middle of the night because he was having pain due to his Foley catheter. The Foley catheter was changed. X-rays were done in the facility and were negative. However, Resident #505 continued to complain of pain. The physician gave orders to transfer Resident #505 to the local hospital emergency room to evaluate Resident #505's cervical spine. On 10/26/17 at 2:00 PM, a record review of the physical's order, dated 9/14/17 at 16:01, stated send to ER to have cervical spine assessed r/t (related to) fall . On 10/26/17, a record review of the History and Physical (Final Report) from the local hospital documented: The patient states that he was attempting to get out of bed when he fell over striking his head at his nursing home. He states he was feeling somewhat weak prior to the event. Per ems and nursing staff, the right side of his body is generally extremely weak due to a [MEDICAL CONDITION](stroke) and his left side is usually stronger. Per EMS staff, the patient was not following commands when they arrive and was unable to communicate with them. The patient complains of pain from abrasions on his head. The patient appears to have purulent material voiding from his catheter. Further documentation indicated CT scan of the C-spine demonstrates anterior [MEDICAL CONDITION] at C6. Maxillofacial CT demonstrates displaced [MEDICAL CONDITION] nasal bone. Resident #505 was also diagnosed with [REDACTED]. An Addenda to the final report stated Nursing home staff uncertain what time the patient fell . Right forehead abrasion. Multiple abrasions on nose. On 10/26/17 at 2:30 PM, a record review of the Fall Management Policy, released on 5/2010 and revised on 8/2016, was done. There was no verbiage describing when a resident was to be sent to a local hospital for evaluation.

This Citation refers to intake numbers MI 01 Based on observation, interview and record review, the facility failed to ensure one (#804) of four residents reviewed for accidents, from a total sample of seven, were free from injuries when a staff member ran into the resident with a food cart, resulting in a fracture with loss of use of the dominant hand. Findings include: On 11/2/16 at 0930, a facility reported incident for resident #804, occurring on 10/12/16 at approximately 0850, was reviewed. The incident was investigated and reported by the facility on 10/13/2016. It revealed resident #804, was leaving the dining room when a dietary employee, (dietary employee G ) accidentally ran into his right hand with the food cart which resulted in a minimally displaced acute oblique fracture of the distal second metacarpal (a bone in his right hand). The physician was contacted and the resident was transferred to the hospital on [DATE] at 1635 and returned to the facility on [DATE] at 2320 with a splint on his right hand. A record review on 11/2/16 at 1000 reveals Resident #804 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment ((MDS) dated [DATE] indicates severe cognitive dysfunction and the resident needed 1 person assist with all activities of daily living (adl ' s). Resident #804 was observed in their room lying in bed on 11/2/16 at 1120. The resident was asked if they injured their hand and responded, Yes . When asked if it hurts, Resident #804 responded, a little bit . When further asked if the surveyor could see their right hand (it was under the blanket) the response was, No . On 11/2/16 at 1230 Resident #804 was observed sitting in a wheelchair in the dining room, using their left hand to eat. The right hand was discolored with a darkened bruise across his hand and knuckles and resting on the arm of the wheelchair. A splint was not in place to the right hand. The resident was asked if he was left handed and he responded, Not usually. A staff member was observed assisting him with cutting his food. A record review on 11/2/16 at 1300 reveals an Occupational Therapy Evaluation dated 10/13/16 stating, .due to recent [DIAGNOSES REDACTED]. Upon further assessment,: Patient exhibits exacerbation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced functional activity tolerance, pain, reduced ADL participation and increased need for assistance from others placing patient at risk for anxiety, compromised general health, cardiac insufficiency, falls and muscle atrophy. Per staff resident is removing splint and choosing not to wear it (purpose and benefits explained to resident). The Administrator was interviewed at 1400 on 11/2/16 and asked what preventive measures were put in place to ensure another resident was not bumped with the dietary cart and he stated, We provided education to the employee pushing the cart. She was just helping out that day and doesn ' t usually push them. All of the aides know how to push them and we have never had an incident before. When asked how someone else who doesn ' t normally push the dietary carts, but is helping out for the day, as was dietary employee G , know how to safely push the cart, he responded, I see what you are saying, but we ' ve never had an issue before. Documented education was observed for dietary employee G , be more careful of residents in the path of the carts while pushing them. There was no documented education for dietary employees on how to safely push the food carts. There was no education provided for other staff to prevent future occurrences of injury to residents. ( )

This citation refers to M 8035. Based on observation, interview and record review, the Facility failed to provide fully functioning GERI chair support devices for one (Resident #702) of three Residents reviewed for falls out of a total sample of five residents resulting in a preventable fall and injury to right humerus. Findings include: On 3/15/16 at 9:00 a.m., Resident #702 was observed in the physical therapy room. The Resident was reclined in a Broda Chair ( a non-self propelled chair that ensures protection and lateral support) with a helmet on her head, her eyes were closed and she did not respond to questions asked. Physical Therapist A stated She is very sleepy. We are doing limited therapy with her. When queried as to why the therapy was limited, PT A stated, We are not able to do any therapy on her Right shoulder, my understanding is that her hardware she had from a prior fracture, dislodged On 3/15/16 at 9:30 a.m., Resident #702's clinical record was reviewed and revealed that Resident #702 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) (a tool used to assess a resident and help determine the amount/level of care they need), dated 2/9/16 revealed that the Resident had a Brief Interview for Mental Status (BIMS) (a tool used to measure a resident's cognitive ability) score of 0 (severely cognitively impaired). In addition, Resident #702 required extensive assistance two person assist for transfers and was totally dependent on staff for locomotion. On 3/15/16 at 11:00 a.m., a Facility Incident and Accident (I&A)Report dated 2/4/16 was reviewed and revealed, in part, the following: Person Involved: Resident #702 Date of Occurrence: 2-4-16 Location: Nursing Station Type of Injury: No injury Other: Gerichair (Geriatric Chair used used to provided more substantial seating - designed to enable a person to sit comfortably in a variety of ways while being fully supported.) Describe Nature of the Accident/Incident: Resident leaning to the right side of chair fell over the side arm to the floor. Interventions Implemented: PT (physical therapy) notified to assess gerichair. Lateral support (prevents lateral leaning in a geri chair) fixed - it was broke. A Post Fall Evaluation dated 2/4/16 included with the I&A report revealed, in part, the following: 1. What did the resident say they were trying to do just before they fell ? Did not Respond 6. What was the resident doing during or just prior to the fall? leaning to right side of chair. On 3/15/16 at 11:30 a.m., and I & A dated 2/22/16 was reviewed and revealed the following: Resident involved: #702 Brief Description: When in therapy for OT (occupational therapy) Resident's daughter states she observed a green/yellow area of discoloration on right upper arm. Physician findings: Resident transferred to Hospital for further evaluation. Additional Interviews: Additional Interviews: Interviewees (#1-5) signed that they had been interviewed and did not give a written statement Conclusion: After investigation writer unable to determine how area of discoloration happened. On 3/15/16 at 1:28 p.m., a phone interview was conducted with Resident #702's daughter/responsible party concerning the incident that occurred on 2/4/16 and 2/22/16. The daughter stated, As for the fall on 2/4/16 the Facility did contact me. I was a bit confused as to how she could fall out of the Geri chair. I do know that she has random movements, but I thought that is why they put her in that chair instead of a wheelchair. After the fall I was on vacation for a few weeks. When I came back, I received notice that she was not progressing with therapy. I was surprised because prior to the fall she seemed to be doing fairly well. That was one of the reasons we selected the Facility. I came to the facility on [DATE] to discuss some concerns about PT and mom was in the therapy room. She was having therapy to her arms. I noticed that she was wincing when they asked her to lift her right arm. She was wearing a short sleeve shirt and I noticed large yellow bruising on her right shoulder. I told the staff and they ordered an x-ray and sent her to the hospital. I spent all night with her at the hospital and they told me that all her hardware from a former fracture about 6 years ago had come loose. They attributed it to her fall and possibly lifting and transferring her. When she came back from the hospital the ortho discontinued her therapy form the arm. They also changed her care plan for transfer to a Hoyer lift. My mom just seems like she is declining. Continued review of the Resident's clinical record revealed the following: 2/25/16 (Hospital Emergency Note): PT (patient) with PMH (past medical history) of dementia who presents to ER (emergency room ) with complaints of R (right arm pain).PT fell approx 1 week ago. PT's family noticed a bruise to PT's RUE (right upper extremely). PT's family also reported noticing that PT refused to raise her RUE and appeared more agitated today than normal abnormal study with hardware failure of plate and screws which does not appear to be adequately stabilized across fracture of R (right) proximal humerus. Screw in soft tissue. Old fracture R proximal humerus shaft and region- including mild displacement over acute fracture On 3/15/16 at 12:10 an interview was conducted with Nurse B who noted as an interviewee on the 2/4/16 I & A. Nurse B was queried as to the fall that occurred on 2/4/16 and stated, I did not see her actually fall, but I came after. She was sitting by the nurses station. I remember that at the time the strap was broken and then therapy fixed it. She was given a Broda chair after that. Certified Nursing Assistant CNA C was interviewed at 12:15 p.m. on 3/15/16 regarding the incident that occurred on 2/4/16. CNA C stated, I remember that she was sitting near the Nurses station on the Unit. I saw her leaning over to her right, I tried to catch her, but I couldn't. I remember that there was something broken with the strap. I do know that she is a very wiggly person and is always moving from side to side. On 3/15/16 at 3:30 p.m., an interview was conducted the Physical Therapist Director, Staff D, regarding the broken lateral support referenced in the I&A. Staff D stated, We did have to fix the clasp in the back of the support. I am not sure if that would have prevented the fall, but I do know that it was broken. She now uses a Broda chair and a Hoyer lift for transfers. Her PT for her right shoulder has been discontinued per physician order [REDACTED]. On 3/15/16 at 3:45 p.m., an interview was conducted with the Director of Nursing (DON) regarding the fall that occurred on 2/4/16 and the subsequent identification of bruising on the right shoulder. The DON was queried as to the cause of the bruising to Resident #702's right shoulder. The DON stated, I'm not sure of the cause. It obviously was an old bruise. Maybe her hardware got giggled around too many times while lifting her. When further queried as to whether any bruising or pain were identified prior to 2/22/16 when the Resident's daughter identified the bruise, the DON stated, I don't think any bruising was identified on the skin assessments or by any other staff. When queried regarding the I & A report dated 2/22/16 regarding the lack statements from the interviewees, the DON was not able to provide explanation or further documentation. The DON and Administrator were asked to provide any additional information pertaining to the fall on 2/4/16 and the bruising and subsequent dislodging of hardware and fracture of right humerus. No additional documentation was provided prior to the exit. On 3/15/16 at 4:00 p.m., the Facility's policy titled Fall Management was reviewed and revealed, in part, the following: Policy: The Facility will identify hazards and resident risk factors and implement interventions to minimize falls. 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 of falls. ( )

THIS CITATION PERTAINS TO INTAKE #MI 811 BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO ENSURE EACH RESIDENT BE PROVIDED WITH ADEQUATE SUPERVISION TO PREVENT ACCIDENTS IN 1 OF 4 SAMPLED RESIDENTS REVIEWED FOR ACCIDENTS (#101), FROM A TOTAL SAMPLE OF 4, RESULTING IN PAIN, SWELLING, DISCOLORATION AND A FRACTURED LEFT THUMB WITH THE POTENTIAL FOR FUTURE INJURIES. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED 5/22/2012, RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO LIVED AT THE FACILITY SINCE 5/06/2012. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SET assessment dated [DATE], RESIDENT #101 HAD MODERATELY IMPAIRED DECISION MAKING WITH BOTH LONG AND SHORT TERM MEMORY LOSS. RESIDENT #101 HAD DIFFICULTY FOCUSING, DISORGANIZED THOUGHTS AND DELUSIONS THAT IMPACTED NOT ONLY HER CARE, BUT THE CARE OF OTHERS. SHE WANDERED AND WAS DEPENDENT ON ONE STAFF MEMBER FOR LOCOMOTION THROUGHOUT THE FACILITY. REVIEW OF CARE PLANS DATED 5/22/2012, REVEALED STAFF WERE TO REMOVE/LIMIT ALL CAUSES OF PAIN FOR RESIDENT #101, WHO REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH WHEELCHAIR LOCOMOTION. PHYSICIAN ORDERS [REDACTED]. THE physician progress notes [REDACTED].#101'S RIGHT THUMB. A "LATE ENTRY" IN THE NURSING NOTES FOR 6/06/2012 AT 8:45 P.M., WAS WRITTEN BY LICENSED PRACTICAL NURSE (LPN) #1, ON 6/07/2012 AT 11:15 A.M. LPN #1 DOCUMENTED THAT RESIDENT #101 HAD A RED DISCOLORATION TO HER RIGHT THUMB. ON 6/07/12, AT 7:15 A.M., STAFF DOCUMENTED THE RESIDENT #101'S RIGHT THUMB WAS DISCOLORED AND SWOLLEN. physician progress notes [REDACTED]. ON 6/07/2012, HER PHYSICIAN ORDERED A STAT X-RAY OF THE RIGHT HAND. THE X-RAY REPORT DATED 6/07/2012 REVEALED RESIDENT #101 HAD AN "INCOMPLETE NON-DISPLACED FRACTURE OF (THE) PROXIMAL PHALANX OF FIRST DIGIT (ON THE RIGHT HAND) AGE INDETERMINATE..." DURING OBSERVATIONS MADE ON 6/25/2012 AT 11:30 A.M. RESIDENT #101 SAT IN THE DINING ROOM AND REPORTED HER RIGHT THUMB WAS SWOLLEN AND BLACK BECAUSE "THEY CRUSHED IT." SHE DECLINED TO ANSWER ANY FURTHER QUESTIONS RELATED TO THE INJURY. RESIDENT #101 DID NOT REPORT ANY PAIN AND COULD MOVE THE DIGIT FREELY, BUT HER RIGHT THUMB WAS STILL SWOLLEN AND DISCOLORED. IN A TELEPHONE INTERVIEW ON 6/26/2012 AT 12:20 P.M., LPN #2 SAID SHE WAS REQUIRED TO USE FORCE ON 6/06/2012, TO PULL A USED FORK FROM RESIDENT #101'S RIGHT HAND. LPN #2 SAID, WHEN SHE (#2) REFUSED TO LET RESIDENT #101 EAT, THE RESIDENT BECAME MAD AND RESISTED STAFF AS THEY MOVED HER IN A WHEELCHAIR DOWN A "75 FOOT" HALLWAY. LPN #2 SAID RESIDENT #101 WAS THROWING HER ARMS AROUND TO RESIST BEING WHEELED BACK TO HER OWN UNIT AND HER RIGHT HAND WAS CAUGHT IN THE WHEEL AS IT TURNED. LPN #2 SAID SHE NOTED IMMEDIATELY RESIDENT #101'S RIGHT THUMB WAS RED FROM THE INJURY. IN AN INTERVIEW ON 6/25/2012 AT 1:15 P.M., THE ASSISTANT DIRECTOR OF NURSING (ADON) SAID THE INCIDENT WAS NOT REPORTED TO THE STATE LICENSURE AND CERTIFICATION AGENCY, BECAUSE THERE WAS NO ABUSE AND THE CAUSE OF THE FRACTURE HAD BEEN DETERMINED. THE ADON SAID THE RIGHT THUMB INJURY SUSTAINED BY RESIDENT #101 OCCURRED ON 6/06/2012, AS THE RESULT OF THE APPROACH TAKEN BY LPN #2. THE ADON SAID RESIDENT #101 PHYSICALLY RESISTED LPN #2 TWICE THAT NIGHT AND THOUGH IT WAS UNCLEAR WHICH EVENT CAUSED THE INJURY IT WAS CLEAR LPN #2 "LACKED THE EXPERIENCE AND EXPERTISE TO DEAL WITH RESISTIVE RESIDENTS."

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE DISHES WERE PROPERLY SANITIZED FOR RESIDENTS IN THE FACILITY, RESULTING IN IMMEDIATE JEOPARDY TO 91 OUT OF 99 RESIDENTS SERVED MEALS DUE TO THE HIGH POTENTIAL FOR FOOD BORNE ILLNESSES AND SERIOUS GASTROINTESTINAL (GI) DISCOMFORT. THE IMMEDIATE JEOPARDY (IJ) WAS IDENTIFIED ON 7/09/11. THE FACILITY'S ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 7/12/11 AT 5:35 P.M. A PLAN OF CORRECTION WAS REQUESTED TO REMOVE THE IJ. THE IMMEDIATE JEOPARDY WAS REMOVED ON 7/13/11 AT 12:10 P.M., BASED ON THE PROVIDER'S IMPLEMENTATION OF CORRECTIVE ACTIONS AS VERIFIED ONSITE ON 7/13/11. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 7/13/11, THE DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINS AS WIDESPREAD WITH NO ACTUAL HARM WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ON 7/12/11 AT 9:30 A.M., DURING THE INITIAL TOUR OF THE KITCHEN, AND DURING THE TESTING OF THE FACILITY'S HIGH TEMPERATURE DISH MACHINE REVEALED THAT THE TEST STRIP DID NOT TURN BLACK TO INDICATE THE INTERNAL TEMPERATURE REACHED PROPER RANGE (160-180 DEGREES FAHRENHEIT) TO SANITIZE THE DISHES. ON 7/12/11 AT 12:00 NOON, THE DISH MACHINE WAS tested AGAIN AND REVEALED THAT THE INTERNAL TEMPERATURE REGISTERED AT 138 DEGREES FAHRENHEIT (F). THE NORMAL TEMPERATURE RANGE IS BETWEEN 160-180 DEGREES (F). AT THIS TIME, COOK "H" WAS ASKED IF THERE WAS ANOTHER SET OF DISHES IN THE FACILITY TO SERVE THE RESIDENTS. COOK "H" STATED, "THESE ARE ALL OF OUR DISHES, WE DON'T HAVE ANYMORE." THE RESIDENTS WERE SERVED ON GLASS CHINAWARE, SILVERWARE AND REGULAR GLASSWARE/CUPS. ON 7/12/11 AT 9:35 A.M., RESIDENT #504 COMPLAINED OF NAUSEA AND VOMITING ON 7/12/11. AT 11:10 A.M., LICENSED PRACTICAL NURSE (LPN) "G", STATED RESIDENT #100 WAS SENT TO AN ACUTE CARE FACILITY FOR NAUSEA AND VOMITING ON 7/10/11. ON 7/12/11 AT 11:55 A.M., DURING THE LUNCH MEAL OBSERVATION IN THE MAIN DINING ROOM, GLASSES AND SILVERWARE HAD WATER STAINS, SPLATTERS AND WHITISH SPOTS (LIKE SNOW). THE RESIDENTS WERE SERVED JUICES/BEVERAGES USING THOSE GLASSES. DURING THE OBSERVATION, STAFF POURED BEVERAGES INTO THE GLASSES. RESIDENT #503 WAS INTERVIEWED AND STATED, "THE CUPS HAVE DARK BROWNISH RINGS". RESIDENT #34 AND A VISITING FAMILY MEMBER STATED, "IT'S BEEN LIKE THIS FOR TWO WEEKS NOW." RESIDENT #508 STATED, "THE GLASS IN WHICH THE LEMONADE WAS SERVED HAD WHITISH SPLATTERS." A VISITING FAMILY MEMBER STATED, "THE SILVERWARE STAINS CAN BE WIPED OFF WITH THE CLOTHING PROTECTOR SOMETIMES." FURTHER OBSERVATIONS REVEALED RESIDENTS PICKING UP GLASSES AND LOOKING AT THEM WITH A LOOK OF DISGUST ON THEIR FACES. ON 7/12/11 AT 12:40 P.M., DURING AN INTERVIEW WITH EXECUTIVE CHEF "A" REGARDING THE PROCEDURE, OR SYSTEM IN PLACE TO ENSURE THE DISHES WERE SANITIZED, REVEALED NO DOCUMENTED EVIDENCE OF LOGS OR MANUFACTURER INSTRUCTIONS TO ENSURE THE TEMPERATURES REACHED ADEQUATE RANGES FOR A HIGH TEMPERATURE DISH MACHINE. ON 7/12/11 AT 1:55 P.M., DURING AN INTERVIEW WITH THE INFECTION CONTROL NURSE AND THE DIRECTOR OF NURSING STATED THERE WERE NO RESIDENT COMPLAINTS OF NAUSEA AND VOMITING. HOWEVER, REVIEW OF RESIDENT # 503 NURSE'S NOTE DATED 7/9/11 AT 2:45 P.M., DOCUMENTED RESIDENT #503 "COMPLAINED OF STOMACH DISCOMFORT AFTER MEALS X 2. DENIED NAUSEA AND VOMITING. RESIDENT #503'S NAME WAS PUT ON THE DOCTOR'S LOG." THE PHYSICIAN ORDERED MEDICATION FOR RESIDENT #503 ON 7/12/11. ON 7/12/11 AT 2:40 P.M., DURING AN INTERVIEW WITH THE CORPORATE DIETITIAN "I" AND EXECUTIVE CHEF "A" STATED THAT THE TEMPERATURE OF THE DISH MACHINE HAD BEEN "FLUCTUATING" FOR THE PAST THREE DAYS AND THE REPAIR COMPANY HAD IDENTIFIED A PART THAT NEEDED TO BE REPLACED. BOTH WERE NOT CERTAIN WHICH PART HAD BEEN ORDERED OR WHAT IT WAS USED FOR. ON 7/12/11 AT 2:40 P.M., THE FACILITY'S POLICY WAS REQUESTED. HOWEVER, IT WAS NOT AVAILABLE AT THAT TIME. WHEN ASKED TO PRODUCE THE DOCUMENTATION TO SUPPORT THE TEMPERATURE LOGS, CHEF "A" STATED, THEY WERE NOT ON THE PREMISES, BUT RATHER CORPORATE HAD THEM. REVIEW OF THE FACILITY'S POLICY TITLED "DIETARY STANDARD OPERATING PROCEDURES, DISH MACHINE SANITATION", DATED 7/12/11 AND PROVIDED ON 7/13/11 AT APPROXIMATELY 11:00 A.M., DOCUMENTED "HIGH TEMPERATURE DISHWASHER (HEAT SANITIZATION): WASH 155-160 DEGREES (F) WASH; AND FINAL RINSE MUST BE 180-195 DEGREES (F)." REVIEW OF THE FACILITY'S IMMEDIATE JEOPARDY PLAN OF CORRECTION WHICH WAS SUBMITTED ON 7/13/11 AT APPROXIMATELY 9:00 A.M., REVEALED THE FOLLOWING INTERVENTIONS: 1. RESIDENT IDENTIFIED TO BE AFFECTED BY THE ALLEGED DEFICIENT PRACTICE. RESIDENT #503 WAS ASSESSED FOR PAIN AT APPROXIMATELY 3:00 P.M. ON 7/12/11. THE RESIDENT HAS A HISTORY [MEDICAL CONDITION] STATED THAT SPICY FOOD CAUSES DISCOMFORT, RESIDENT'S DIET CHANGED TO BLAND. RESIDENT #100 REMAINS hospitalized WE CONTACTED THE HOSPITAL, NO INFORMATION WAS PROVIDED, BUT WE DID HAVE A PHONE CONVERSATION WITH THE RESIDENT'S WIFE/RESPONSIBLE PARTY, AND SHE INDICATED THAT THE RESIDENT IS BEING WORKED UP FOR GALL STONES. RESIDENT #92 WAS ASSESSED BY THE NURSING STAFF AND HAD NO COMPLAINTS OF NAUSEA. 2. RESIDENTS WITH THE POTENTIAL TO BE AFFECTED BY THE ALLEGED DEFICIENT PRACTICE. ALL RESIDENTS (99 RESIDENTS) WERE REVIEWED FOR SIGNS AND SYMPTOMS OF FOOD BORNE ILLNESSES AND GI DISCOMFORT, NO ISSUES WERE IDENTIFIED. THIS REVIEW WAS COMPLETED 7/12/11. THE FACILITY SWITCHED TO PAPER PRODUCTS DURING LUNCH SERVICE ON 7/12/11. 3. SYSTEMIC MEASURES. JACKSON REPAIR WAS CONTACTED ON 7/12/11. ON 7/13/11, THE NECESSARY REPAIRS WERE MADE TO ENSURE THAT APPROPRIATE TEMPERATURES ARE MET CONSISTENTLY IN THE DISHWASHER. THE DISHWASHER WAS REPAIRED AT 10:25 A.M. THE DISH MACHINE WAS CHECKED BY SURVEY TEAM LEADER AND DEEMED APPROPRIATE FOR USE. DIETARY STAFF BEGAN TO WASH DISHES AFTER SIX LOADS WERE DONE THE MACHINE TEMPERATURE AGAIN DROPPED BELOW THE MINIMUM REQUIRED TEMPERATURE. THE DISH MACHINE WAS TAKEN OUT OF SERVICE AND THE DISH MACHINE USAGE POLICY POLICY WAS FOLLOWED. A NEW DISH MACHINE WAS ORDERED TO REPLACE THE DEFECTIVE MACHINE AND WE ARE AWAITING INSTALL. DISH MACHINE TEMPERATURE LOGS ARE LOCATED IN A NOTE BOOK ON THE COOKS TABLE. THE FACILITY DEVELOPED THE POLICIES ON DISH MACHINE SANITATION, THREE COMPARTMENT SINK AND DISH MACHINE USE AND REVIEWED WITH CORPORATE REGISTERED DIETICIAN, ADMINISTRATOR AND DON. ON 7/12/11, A MANDATORY INSERVICE FOR DIETARY STAFF WAS COMPLETED ON DISH MACHINE SANITATION, THREE COMPARTMENT SINK AND DISH MACHINE USE. 5 OF 15 DIETARY EMPLOYEES WERE INSERVICED ON 7/12/11. AS OF 7/13/11, 10 OF 15 DIETARY EMPLOYEES HAVE BEEN INSERVICED. THE REMAINING DIETARY STAFF WILL RECEIVE EDUCATION ON THE ABOVE POLICY/PROCEDURE UPON REPORTING FOR DUTY ON THEIR NEXT SCHEDULED DAY AND WILL NOT BE ALLOWED TO WORK UNTIL THE EDUCATION IS COMPLETED. AS OF 7/13/11, 46 OF 88 NURSING EMPLOYEES WERE INSERVICED ON SIGNS AND SYMPTOMS OF FOOD BORNE ILLNESSES AND GI DISTRESS. THE REMAINING NURSING STAFF WILL RECEIVE EDUCATION ON THE ABOVE POLICY/PROCEDURE UPON REPORTING FOR DUTY ON THEIR NEXT SCHEDULED DAY AND WILL NOT BE ALLOWED TO WORK UNTIL THE EDUCATION IS COMPLETED. 4. QUALITY ASSESSMENT AND ASSURANCE. THE THREE COMPARTMENT SINK WILL BE CHECKED PRIOR TO EACH SERVICE TO ENSURE PROPER LEVELS ARE MAINTAINED FOR SANITIZING DISHWARE. ONCE THE NEW DISH MACHINE IS INSTALLED, TEMPERATURES WILL BE RECORDED PRIOR TO EACH USE AND THEY WILL BE RECORDED ON THE TEMPERATURE LOG. ADMINISTRATOR/DESIGNEE WILL AUDIT THE LOGS WEEKLY AND REPORT AUDIT FINDINGS TO THE QA COMMITTEE ON A MONTHLY BASIS AND CONTINUE UNTIL THE COMMITTEE DETERMINES THAT COMPLIANCE WITH THIS PLAN HAS BEEN MAINTAINED. THE ADMINISTRATOR IS RESPONSIBLE FOR OVERALL SUSTAINED COMPLIANCE. ( ) ( ) ( ) ( ) ADDITIONALLY, BASED ON OBSERVATION AND INTERVIEW, THE FACILITY FAILED TO MAINTAIN POTENTIALLY HAZARDOUS FOOD AT THE APPROPRIATE TEMPERATURE FOR 1 (# 510) SAMPLED RESIDENT AND 2 (#'S 4 AND 92) OFF SAMPLED RESIDENTS, AND ENSURE PROPER HANDLING OF EATING UTENSILS, RESULTING IN THE POTENTIAL OF FOOD BORNE ILLNESSES. FINDINGS INCLUDE: ON 7/13/11 AT 9:05 A.M., RANDOM TEST TRAYS OF FOOD TEMPERATURES OF POTENTIALLY HAZARDOUS FOODS WERE tested AT THE POINT OF SERVICE. THE FOLLOWING TEMPERATURES WERE RECORDED: 1. RESIDENT #510 - MILK REGISTERED AT 62.6 DEGREES (F) 2. RESIDENT #4 - MILK REGISTERED AT 57.5 DEGREES (F) 3. RESIDENT #92 - MILK REGISTERED AT 61.3 DEGREES (F) ON 7/12/11 AT 12:25 P.M., DURING THE LUNCH MEAL OBSERVATION, STAFF IN THE MAIN DINING ROOM WERE OBSERVED OBTAINING SILVERWARE THAT HAD BEEN STORED IN CYLINDERS WITH THE EATING PORTION POSITIONED UPWARDS. STAFF USED THEIR BARE HANDS TO OBTAIN FORKS, SPOONS, AND KNIVES TOUCHING THE EATING PORTION OF THE SILVERWARE. ( ) ( ) ( )