Every finding on record at Rivergate Health Care Center

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 06/02/2026 at 8:52 AM observed missing paint from the front edge of the wire rack leaving exposed metal in the two door prep refrigerator in the kitchen. On 06/02/2026 at 9:00 AM observed the three compartment sink drain lines for the wash, rinse, and sanitize basins all connect to a common drain line leading into the grease trap and discharged into the floor with no air gap.On 06/02/2026 at 9:00 AM observed the cap missing from the atmospheric vacuum breaker (AVB) on the water faucet connected by a hose to a chemical dispensing system in the kitchen. An interview with Food Service Director (FSD) A at this time found the hose is used to spray carts down, and indicated they were not sure what happened to the cap.On 06/02/2026 at 9:09 AM observed the drain line from the ice machine discharging into a pump, then travel approximately six feet to the floor drain in the kitchen. [NAME] buildup was visible throughout the clear plastic drain line running from the pump to the floor drain. Further observation found an accumulation of black and brown buildup around the end of the line at the air gap.On 06/02/2026 at 9:15 AM observed the overhead hose hanging below the flood level rim of the counter in the kitchen dish room near the dishwasher. An interview with FSD A at this time was conducted regarding the overhead hose. FSD A indicated a new spring had been installed and that there is normally a handle present to place the hose head.On 06/02/2026 at 9:26 AM observed a can opener with metal shavings accumulated behind the blade. An interview with FSD A at this time found the can opener gets cleaned in the three compartment sink at every shift. FSD A indicated they looked at the can opener this morning and did not see any accumulation. On 06/02/2026 at 9:43 AM observed buildup of juice residue on the upper backsplash of the juice machine in the second floor kitchenette.On 06/02/2026 at 9:45 AM observed an accumulation of white and brown buildup on the interior wall and around the edge of the ice chute of the ice machine in the second floor kitchenette. In an interview at this time, when asked about cleaning of the ice machine, FSD A indicated kitchen staff clean the outside area, and maintenance is responsible for cleaning the ice chute.On 06/02/2026 at 9:50 AM observed the drain line leading from the ice machine extended to the floor drain and terminate below the flood level rim creating an improper air gap in the first floor kitchenette.On 06/03/2026 at 9:02 AM observed the water faucet with a missing atmospheric vacuum breaker in the kitchen. Maintenance Director (MD) C indicated they would need to call to get it fixed. On 06/03/2026 at 9:08 AM observed first floor ice machine drain line terminate below the flood level rim. MD C indicated they would adjust the drain line. Further observation revealed black buildup accumulated on the end of the drain line where it entered the floor drain.On 06/03/2026 at 9:19 AM observed the drain line from the ice machine lead into the adjacent cabinet and extend below the cabinet base in the second floor kitchenette. The drain line was observed resting in the floor drain below the flood level rim creating an improper air gap. Further observation found brown and white buildup in the interior wall of the ice chute where ice is dispensed. MD C acknowledged the buildup and indicated the ice machine would be cleaned this month and would be thoroughly cleaned at the time. According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.According to the 2022 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to LAW; P and (B) Maintained in good repair.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.According to the 2022 FDA Food Code section 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).

Based on observation, and interview the facility failed to maintain general cleanliness and repair of the premises and ensure appropriate backflow prevention was installed at plumbing fixtures. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 06/02/2026 at 2:07 PM an interview was conducted regarding cleaning. Director of Housekeeping and Laundry Services (DHLS) B indicated housekeeping staff clean shower rooms twice a day, and shower equipment is cleaned by Certified Nursing Assistant (CNA).On 06/02/2026 at 2:10 PM observed a floor tile cracked and chipped and the adjacent floor tile missing near the sink in the station one east soiled linen room.On 06/02/2026 at 2:23 PM observed a broken shower head holder and the shower head resting on the handrail in the station four east shower room. DHLS B indicated it had broken.On 06/02/2026 at 2:27 PM observed areas of missing caulk and black accumulation along the floor to wall juncture caulking in the shower stall located in the station four west shower room. DHLS B acknowledged the condition and indicated that occurs because water is frequently in the area. On 06/02/2026 at 2:31 PM observed a mop sink with a chemical pre-dispensing system in place and the hot water faucet left on in the station three west janitor closet. This set up puts undue back pressure on the faucet's internal atmospheric vacuum breaker (AVB), which can compromise the integrity of the mechanism. A sign was observed hanging next to the sink indicating to turn off faucet after use.On 06/02/2026 at 2:34 PM observed areas of black buildup along the floor to wall juncture caulking in the shower stall located in station three west shower room. DHLS B acknowledged the buildup. On 06/02/2026 at 2:37 PM observed an accumulation of clustered black and white buildup on the outside surface and around the base of hose connector on the janitor sink faucet in the station four west janitor closet. DHLS B acknowledged the buildup.On 06/02/2026 at 2:45 PM observed a mop sink with a chemical pre-dispensing system in place and the cold water faucet left on in the first floor janitor closet, creating undue pressure on the faucets internal AVB.On 06/03/2026 at 9:07 AM observed a section of floor tile gouged exposing the wood flooring below and pieces of splintered wood in the south elevator. In an interview at this time, MD C indicated the flooring was somewhat new and electric equipment had caused the damage.On 06/03/2026 at 9:24 AM observed black residue and dirt collected between the slats and around the edges of the air vent register in the station two east shower room. Further observation found evidence of water damage on the ceiling along with peeling paint and chipped plaster in an area approximately one by one foot on the adjacent wall. In an interview at this time, MD C indicated the damage resulted from a previous leak upstairs that had been repaired. On 06/03/2026 at 9:26 AM observed an accumulation of black residue along the floor and floor to wall juncture caulking in the shower stall in the station two west shower room. Further observation found hardened brown residue on the shower bed mat as well as buildup and debris in the creases of the mat. Additional observation found a shower hose with no shower head attached. MD C was unable to run water through the hose.On 06/03/2026 at 9:34 AM observed a mop sink with a chemical pre-dispensing system in place and the hot and cold water faucet left on in the first floor janitor closet, creating undue pressure on the faucets internal AVB.On 06/03/2026 at 11:24 AM observed a mop sink with a chemical pre-dispensing system in place and the cold and hot water faucet left on in the station four west janitorial closet, creating undue pressure on the faucets internal AVB.On 06/03/2026 at 2:02 PM an interview was conducted with DHLS B regarding cleaning of shower rooms. DHLS B indicated deep cleaning of shower rooms should be included on the weekly schedule. DHLS B located deep cleaning of shower rooms on the January 2026 cleaning schedule, and indicated the task needed to be added back to the current schedule. When asked about repairs, DHLS B indicated maintenance is responsible for repairs when notified in their maintenance system.

Based on observation, interview, and record review, the facility failed to remove expired medical supplies (topical lubricating jelly) from the active inventory in the Station 2 medication storage room. Findings include: On [DATE] at 9:19 AM, an inspection of the Nursing Station 2 medication storage room was conducted with Registered Nurse/Unit Manager (RN/UM) H. The inspection revealed fifteen packets of 3g and 5g Lubricating Jelly that were comingled with unexpired stock and had passed their manufacturer expiration dates. Two packets expired [DATE], 3 packets expired [DATE], 4 packets expired [DATE], 3 packets expired [DATE], 1 packet expired [DATE], 1 packet expired [DATE], and 1 packet expired [DATE]. RN/UM H said staff are putting new packets on top of the old packets. There were probably a few of the old packets left, and they threw the new batch in. RN/UM added, We need to change our practice of refilling. On [DATE] at 12:48 PM, the Director of Nursing (DON) said the lubricating jelly was used for dry skin. The DON added, We shouldn't use expired medication. It could have adverse reactions such as skin irritation. A review of the facility policy titled, Storage and Expiration Dating of Medications and Biologicals, dated [DATE] revealed in part the following:- Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.- Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines.- Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. On [DATE] at 4:15 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview and record review, the facility failed to provide restorative services as recommended to maintain range of motion and mobility for one resident (R152) of two residents reviewed for range of motion. Findings include:On 6/02/2026 at 12:45 PM, R152 was observed in a bariatric bed wearing a gown. R152 was interviewed about care in the facility and stated, I'm supposed to be getting restorative services but don't always because they are short staffed.On 6/04/2026 at 9:41 AM, R152 was observed in a bariatric bed wearing a gown. When R152 was asked about restorative services, R152 stated, I haven't had restorative exercises for a week. I want to do my exercises, but I need help. They haven't had the usual person that does restorative and no one else is coming in to help me. On 6/04/2026 at 9:49 AM, Certified Nursing Assistant (CNA) E was interviewed and said she was assigned to R152 but did not perform restorative services.On 6/04/2026 at 11:01 AM, Restorative Aide (RA) F was interviewed regarding restorative services for R152 and said R152 was last seen for restorative on 5/28/2026. RA F further said that the restorative aides frequently get pulled to the floor to work as CNAs, so the residents don't always get restorative services. When RA F was asked how frequently R152 should receive restorative services RA F said when possible.On 6/04/2026 at 11:10 AM, the Assistant Director of Nursing (ADON) I was interviewed and said he oversaw the restorative program. R152's Restorative Nursing Communication Tool signed 3/31/2026 was reviewed with the ADON I. ADON I confirmed the Restorative Communication Tool did not have a restorative frequency and/or duration completed. When asked how staff knew how frequently to perform the restorative program with R152 ADON I did not provide an answer. When asked who determined the frequency and duration of a restorative program, ADON I said the nursing and therapy department worked together to determine the frequency and duration.On 6/04/2026 at 11:33 AM, R152's Restorative Communication Tool was reviewed with the Director of Rehab (DOR) J. When asked how frequently a restorative program should be completed DOR J replied, At least three times per week for a restorative program to be effective.On 6/04/2026 at 12:12 PM, Physical Therapist (PT) K was interviewed regarding R152's restorative program and stated, My recommendation was for R152 to receive restorative services three to six times per week. PT K acknowledged he completed R152's Restorative communication tool on 3/31/26 and was instructed to not fill in the frequency and duration.Record review of R152's Electronic Medical Record (EMR) revealed the most recent readmission to the facility on 1/13/2026 with diagnoses which included Chronic Obstructive Pulmonary Disease, Muscle Weakness, Difficulty in Walking and a History of Falling.Review of the Minimum Data Set (MDS) dated [DATE] for R152 revealed intact cognition. Review of the Restorative Communication Tool signed 3/31/2026 revealed R152 required max assist for transfers and ambulation with a two wheeled walker.Review of R152's care plan revealed, Focus Functional Goal Care Plan: Resident has limited physical mobility r/t (related to) Weakness. Date initiated 4/2/2026. Goal The resident will maintain current level of mobility (with walking 10 to 20 feet with 2 wheeled walker, with gait belt and mod to max assistance, as tolerated through review date, date initiated 4/2/2026. Interventions Nursing Rehab/Restorative Program #1 encourage/assist resident in upper and lower extremity active ROM, with individual or group exercises. Program #2 encourage/assist resident in sit to stand activities, such as standing up with four wheeled walker times 3, with gait belt and mod to max assist. Walking program #1 Encourage assist resident with walking 10 to 20 feet with 2 wheeled walker, with gait belt and mod to max assist. Date initiated 4/2/26.Review of R152's restorative logs revealed no restorative services were documented for the weeks of 4/13/2026, 4/20/2026, and 5/11/2026, with one time completed for the week of 5/18/2026 and one time completed for the week of 5/25/2026. The EMR did not document any refusals of the restorative program.On 6/04/2026 at 12:12 PM, the Director of Nursing (DON) was interviewed and said the expectation is for a Restorative Program frequency to be provided and followed. The DON further said for the restorative program to be effective the program needed to be consistent.Review of the facility policy titled, Restorative Nursing reviewed 9/18/2025 revealed in part.To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident's assessments and indicators. Nursing Assistants must be trained in the techniques that promote resident involvement in restorative activities. Restorative programs may be initiated by nursing and/or therapy. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section Mobility-transfer and ambulation, including walking. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Based on observation, interview and record review, the facility failed to obtain a Level II PASARR (Pre-admission Screening and Resident Review) for one (R16) resident reviewed for PASARRs. This resulted in the potential for care needs being unmet due to the lack of a comprehensive evaluation by the state designated authority. Findings include: Record Review of the Electronic Health Record (EHR) revealed no Level II PASARR since R16's initial admittance date of 06/29/2021. Record review also revealed R16 has a diagnosis of Atherosclerotic Heart Disease, Hemiplegia and Hemiparesis, Factitious Disorder, Hoarding Disorder, Anxiety Disorder, Major Depressive Disorder and Adjustment Insomnia and is prescribed Lexapro Oral Tablet 10mg. On 06/02/2026 at 12:26 P.M., R16 was interviewed at the facility and reported bouts of depression. Record review of The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 -indicating cognitively intact. On 06/04/2026 at 2:09 P.M., Social Worker (SW) D was interviewed regarding PASARR screenings and was unable to provide a Level II PASARR from the state authority. Discussed R16's mental health diagnosis and the referral process for obtaining a Level II PASARR. SW D stated, I've been on leave for 14 weeks and only returned two weeks ago and I plan to do a full audit of PASARR's. SW D also stated, Staffing changes caused the Social Work Department to fall behind on our PASARR processes. I must be honest; we didn't follow up and didn't ensure that we received a Level II evaluation for her. SW D said, to be completely transparent, I didn't follow up. SW D was queried if a Level II PASARR should have been obtained within the last five years that R16 has been a resident within this facility. SW D stated yes, she should have a Level II PASARR. On 06/04/2026 at 2:20 P.M., Nursing Home Administrator (NHA) was queried about the lack of PASARR Level II documentation in the EHR. The NHA stated, I'll have to look into that! Queried as to who is responsible for ensuring PASARR screenings are completed. NHA stated, It's the job of our Social Services Department and we are planning to do a complete audit to ensure compliance. Record review of Care Plan dated 02/08/26 revealed: Focus- [NAME] uses antidepressant medication. Monitor for side effects of anti- depressant medications.Focus- revised date 05/25/2026- At risk for change in mood or behavior due to medical condition. Intervention: Psych consult as indicatedReview of the facility's policy titled Pre-admission Screening and Resident Review (PASARR) Revised: 10/06/2022; Reviewed: 09/26/2025, documented in part: A positive Level I screen necessitates an in-depth evaluation of the individual by the state designated authority, known as PASARR Level II. The Level II PASARR determination and the evaluation report specify services to be provided by the facility and/or specialized services defined by the state.When a Level II PASARR screening is warranted it must be obtained . Record review of the Level I screening criteria completed on 06/24/2025 and again on 06/03/2026, identified 4 of 6 areas that meet the requirement for mental Illness with instruction to contact the local community mental health services program (CMHSP) for Level II screening.1.The person has a current diagnosis of mental illness- yes2. The person has received treatment for mental illness- yes3. The person has taken or been prescribed psychotropic medications within the last 14 days- Yes4. There is presenting evidence of mental illness.yesThere is no documentation of a Level II PASARR or documented follow up on a Level II PASARR for R16 since admittance.

Based on interview and record review, the facility failed to accurately identify incidents of physical harm as abuse by a Resident Representative (RR), for one resident (R501) of three residents reviewed for abuse, resulting in the potential for continued physical harm.Findings include:It was reported to the State Agency that the facility failed to protect a resident from abuse. The complaint revealed the following: Anonymous complainant states on 9/26, last Friday, a. resident (R501) on Station 4 of the facility. was being fed by the (RR), (R501) wouldn't eat (their) food so the (RR) became frustrated and smacked (R501) and grabbed (R501's) jaw . Complainant states the DON and Administrator instructed the nurse to not put a note in the system because it would alert the state. Complainant states the next day, 9/27, the (RR) was observed grabbing (R501's) arm by a dietary aide. On 10/8/25 at 11:35 AM, Licensed Practical Nurse (LPN) A was queried regarding the incident on 9/26/25. LPN A reported she observed LPN C running down the hall. LPN C was screaming, (RR) hit (R501)! According to LPN A, LPN C was typically unhurried, but after this incident moved swiftly down the hall yelling, What should I do? What should I do?. LPN A said that (LPN C) called the Nursing Home Administrator (NHA) and was told not to document in the electronic medical record (EMR) that RR hit R501 because it could alert the state. A review of the clinical record did not reveal documentation of this incident.On 10/8/25 at 12:22 PM, RN D was interviewed and stated, Staff had noticed that (the RR) was getting frustrated with (R501) because (R501) would not eat. RN D said we pulled the RR aside and talked to the RR because the RR was observed grabbing R501's chin while inside of R501's room. On 10/8/25 at 2:47 PM, LPN C was interviewed by telephone and reported witnessing the RR grab R501's jaw to force R501 to eat. LPN C stated to RR, You can't do that! LPN C reported the incident by telephone to the NHA shortly after witnessing RR grab R501's face with force. LPN C stated, The (NHA) determined that it was not abuse and that's why I didn't document it. The clinical record did not reveal that LPN C assessed the R501 for bruising/injury immediately after the incident. On 10/9/25 at 12:30 PM, Social Worker (SW) I was interviewed and reported on 10/7/25 that SW I was informed by LPN A that The (RR) cannot go into (R501's) room because (the RR) slapped (R501). LPN A informed SW I that the NHA was notified of the incident. SW I stated, The (NHA) is the abuse coordinator and did not initiate an investigation. SW I confirmed not being informed of an investigation for this incident as of this date. On 10/9/25 at 12:45 PM, LPN A was interviewed again and confirmed witnessing LPN C being visibly upset after seeing the RR slap and grab R501's face.Physical harm continued to occur as referenced in the complaint. On 9/27/25, the (RR) was observed grabbing (R501's) arm by a dietary aide.On 10/8/25 at 2:15 PM, Dietary Aide (DA) F was interviewed and stated, The (RR) is controlling. When asked to elaborate on controlling, DA F stated, (The RR's) actions are aggressive, even the way (the RR) pushes drinks towards (R501). DA F demonstrated a powerful and aggressive pushing motion with their hand. On 10/8/25 at 2:35 PM, DA B was interviewed and said that approximately two weeks ago they witnessed RR grab R501's arm with force and snatched R501 away from the table where R501 was socializing with other residents. RR then took R501 to another table in the dining room. According to DA B, This made me feel uncomfortable. DA B said with her experience and training, she knows what abuse looks like. DA B said this incident was immediately reported to a group of staff persons at the nurse's desk. Interviews revealed incomplete instructions and rationale were given to staff regarding RR's visitation with R501. 1. On 10/8/25 at 11:43 AM, LPN G who was currently assigned to R501, was asked about supervised intervention. LPN G stated, I was not aware of supervised visitation for (R501).2. On 10/8/25 at 11:50 AM, Certified Nursing Assistant (CNA) H who was currently assigned to R501, was asked about supervised visitation. In response, CNA H stated, I was not aware of any incident.3. On 10/8/25 at 11:55 AM, Registered Nurse (RN) D was interviewed and stated, The (RR) was flustered with (R501), so the (NHA) suggested that the (RR) meet with (R501) in the dining room. RN D was unable to state the purpose of the change. 4. On 10/8/25 at 12:00 PM, CNA's M, N and O were interviewed and reported they did not witness an incident but were told that the RR and R501 were to sit in the dining room during meals. CNA's M, N, and O were unable to state the purpose of the change. A record review of the electronic medical record revealed R501 was admitted to the facility on [DATE] with a diagnosis of Atrial Fibrillation, Alzheimer's with late onset, Hypertension, Obstructive Pulmonary Disease, Anemia, Dementia and Adjustment Disorder. Further review of the clinical record revealed a Brief Interview for Mental Status (BIMS) score of 0/15 denoting a severe cognitive impairment. A review of R501's care plans documented:- resident plans to discharge home- dated 9/15/25-resident has impaired cognitive ability related to dementia- dated 9/15/25-resident is alert with confusion- dated 9/19/25-resident requires set-up assistance for meals- dated 9/12/25-resident has a potential for a nutritional problem - intervention included: provide verbal encouragement/assistance with meals as needed to ensure adequate intake- dated 9/25/25A review of R501's care plans documented the following intervention initiated on 9/28/25- Provide meals to RR when in the facility during mealtime so that RR can eat meals with R501 in the dining room to help promote visual cuing to increase oral intake. Staff to provide assistance when indicated. However, the facility failed to provide care plan interventions for R501 related to the prevention of further physical harm. On 10/8/25 at approximately 1:30 PM, the NHA was requested to provide a complete investigation regarding the alleged abuse of R501. On 10/8/25 at 3:30 PM, the NHA was queried about the incident between the RR and R501. The NHA reported not doing an investigation or reporting this incident due to It not being abuse. The NHA acknowledged being out of the office when they received a telephone call from staff regarding the RR grabbing R501's jaw in an attempt to make R501 eat. When asked, why would they call you for this incident if this was not suspected abuse? NHA stated, They call me for everything. According to the NHA, after receiving the telephone call from the nurse regarding RR grabbing the jaw of R501, the NHA spoke directly to the RR by telephone and educated the RR about dementia. The NHA admitted telling LPN C, (RR) is not trying to hurt (R501). Even though there was not a skin assessment completed on R501, the NHA indicated that it was not abuse.A review of the document titled, Abuse-Inservice Training, dated 5/6/25, revealed the following:- The facility must develop and implement written policies and procedures that prohibit and prevent abuse. -Procedures include staff orientation and training to identify and prevent behaviors constituting abuse.No further documentation related to abuse identification was provided by the facility.

Based on interview and record review, the facility failed to report to the State Agency incidents of physical harm for one resident (R501) by a Resident Representative (RR), for one of three residents reviewed for abuse, resulting in unreported incidents of physical harm.Findings include:The State Agency received an anonymous complaint that a resident was abused at the facility and that it was not reported.The complaint revealed the following: Anonymous complainant states on 9/26, last Friday, a. resident (R501) on Station 4 of the facility. was being fed by the (RR), (R501) wouldn't eat (their) food so the (RR) became frustrated and smacked (R501) and grabbed (R501's) jaw . Complainant states the next day, 9/27, the (RR) was observed grabbing (R501's) arm by a dietary aide. On 10/8/25 at 11:35 AM, Licensed Practical Nurse (LPN) A was queried regarding the incident on 9/26/25. LPN A reported she observed LPN C running down the hall. LPN C was screaming, (RR) hit (R501)! According to LPN A, LPN C was typically unhurried, but after this incident moved swiftly down the hall yelling, What should I do? What should I do?. LPN A said that (LPN C) called the Nursing Home Administrator (NHA) and was told not to document in the electronic medical record (EMR) that RR hit R501 because it could alert the state. A review of the clinical record did not reveal documentation of this incident.On 10/8/25 at 12:22 PM, RN D was interviewed and stated, Staff had noticed that (the RR) was getting frustrated with (R501) because (R501) would not eat. RN D said we pulled the RR aside and talked to the RR because the RR was observed grabbing R501's chin while inside of R501's room.On 10/8/25 at 2:47 PM, LPN C was interviewed by telephone and reported witnessing the RR grab R501's jaw to force R501 to eat. LPN C stated to RR, You can't do that! LPN C reported the incident by telephone to the NHA shortly after witnessing RR grab R501's face with force. LPN C stated, The (NHA) determined that it was not abuse and that's why I didn't document it. The clinical record did not reveal that LPN C assessed the R501 for bruising/injury immediately after the incident.On 10/9/25 at 12:30 PM, Social Worker (SW) I was interviewed and reported on 10/7/25 that SW I was informed by LPN A that The (RR) cannot go into (R501's) room because (the RR) slapped (R501). LPN A informed SW I that the NHA was notified of the incident. SW I stated, The (NHA) is the abuse coordinator and did not initiate an investigation. SW I confirmed not being informed of an investigation for this incident as of this date. On 10/9/25 at 12:45 PM, LPN A was interviewed again and confirmed witnessing LPN C being visibly upset after seeing the RR slap and grab R501's face.Physical harm continued to occur as referenced in the complaint. On 9/27/25, the (RR) was observed grabbing (R501's) arm by a dietary aide.On 10/8/25 at 2:15 PM, Dietary Aide (DA) F was interviewed and stated, The (RR) is controlling. When asked to elaborate on controlling, DA F stated, (The RR's) actions are aggressive, even the way (the RR) pushes drinks towards (R501). DA F demonstrated a powerful and aggressive pushing motion with their hand.On 10/8/25 at 2:35 PM, DA B was interviewed and said that approximately two weeks ago they witnessed RR grab R501's arm with force and snatched R501 away from the table where R501 was socializing with other residents. RR then took R501 to another table in the dining room. According to DA B, This made me feel uncomfortable. DA B said with her experience and training, she knows what abuse looks like. DA B said this incident was immediately reported to a group of staff persons at the nurse's desk.A record review of the electronic medical record revealed R501 was admitted to the facility on [DATE] with a diagnosis of Atrial Fibrillation, Alzheimer's with late onset, Hypertension, Obstructive Pulmonary Disease, Anemia, Dementia and Adjustment Disorder. Further review of the clinical record revealed a Brief Interview for Mental Status (BIMS) score of 0/15 denoting a severe cognitive impairment. On 10/8/25 at approximately 1:30 PM, the NHA was requested to provide a complete investigation regarding the alleged abuse of R501. On 10/8/25 at 3:30 PM, the NHA was queried about the incident between the RR and R501. The NHA reported not doing an investigation or reporting this incident due to It not being abuse! The NHA acknowledged that she was out of the office when she received a telephone call from staff regarding the RR grabbing R501's jaw in an attempt to make R501 eat. When asked, why would they call you for this incident if this was not suspected abuse? NHA stated, They call me for everything. The NHA admitted telling LPN C, (RR) is not trying to hurt (R501). The NHA indicated that it was not abuse.A review of Form Centers for Medicare & Medicaid Services (CMS) 20059 Abuse Critical Element Pathway dated 10/2022 revealed the following: 6) For alleged violations of abuse, did the facility:-Report the results of all investigations within five working days to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency)?No further documentation related to abuse identification was provided by the facility.

Based on interview and record review, the facility failed to thoroughly conduct and document an investigation of incidents of physical harm of one resident (R501) by a Resident Representative (RR), for one of three residents reviewed for abuse, resulting in the potential for continued physical harm.Findings include:It was alleged that RR to resident abuse occurred. The complaint revealed the following: Anonymous complainant states on 9/26, last Friday, a. resident (R501) on Station 4 of the facility. was being fed by the (RR), (R501) wouldn't eat (their) food so the (RR) became frustrated and smacked (R501) and grabbed (R501's) jaw . Complainant states the next day, 9/27, the (RR) was observed grabbing (R501's) arm by a dietary aide. On 10/8/25 at 11:35 AM, Licensed Practical Nurse (LPN) A was queried regarding the incident on 9/26/25. LPN A reported she observed LPN C running down the hall. LPN C was screaming, (RR) hit (R501)! According to LPN A, LPN C was typically unhurried, but after this incident moved swiftly down the hall yelling, What should I do? What should I do?. LPN A said that (LPN C) called the Nursing Home Administrator (NHA) and was told not to document in the electronic medical record (EMR) that RR hit R501 because it could alert the state. A review of the clinical record did not reveal documentation of this incident.On 10/8/25 at 12:22 PM, RN D was interviewed and stated, Staff had noticed that (the RR) was getting frustrated with (R501) because (R501) would not eat. RN D said we pulled the RR aside and talked to the RR because the RR was observed grabbing R501's chin while inside of R501's room.On 10/8/25 at 2:47 PM, LPN C was interviewed by telephone and reported witnessing the RR grab R501's jaw to force R501 to eat. LPN C stated to RR, You can't do that! LPN C reported the incident by telephone to the NHA shortly after witnessing RR grab R501's face with force. LPN C stated, The (NHA) determined that it was not abuse and that's why I didn't document it. The clinical record did not reveal that LPN C assessed the R501 for bruising/injury immediately after the incident.On 10/9/25 at 12:30 PM, Social Worker (SW) I was interviewed and reported on 10/7/25 that SW I was informed by LPN A that The (RR) cannot go into (R501's) room because (the RR) slapped (R501). LPN A informed SW I that the NHA was notified of the incident. SW I stated, The (NHA) is the abuse coordinator and did not initiate an investigation. SW I confirmed not being informed of an investigation for this incident as of this date. On 10/9/25 at 12:45 PM, LPN A was interviewed again and confirmed witnessing LPN C being visibly upset after seeing the RR slap and grab R501's face.Physical harm continued to occur as referenced in the complaint. On 9/27/25, the (RR) was observed grabbing (R501's) arm by a dietary aide.On 10/8/25 at 2:15 PM, Dietary Aide (DA) F was interviewed and stated, The (RR) is controlling. When asked to elaborate on controlling, DA F stated, (The RR's) actions are aggressive, even the way (the RR) pushes drinks towards (R501). DA F demonstrated a powerful and aggressive pushing motion with their hand.On 10/8/25 at 2:35 PM, DA B was interviewed and said that approximately two weeks ago they witnessed RR grab R501's arm with force and snatched R501 away from the table where R501 was socializing with other residents. RR then took R501 to another table in the dining room. According to DA B, This made me feel uncomfortable. DA B said with her experience and training, she knows what abuse looks like. DA B said this incident was immediately reported to a group of staff persons at the nurse's desk.A record review of the electronic medical record revealed R501 was admitted to the facility on [DATE] with a diagnosis of Atrial Fibrillation, Alzheimer's with late onset, Hypertension, Obstructive Pulmonary Disease, Anemia, Dementia and Adjustment Disorder. Further review of the clinical record revealed a Brief Interview for Mental Status (BIMS) score of 0/15 denoting a severe cognitive impairment. On 10/8/25 at approximately 1:30 PM, the NHA was requested to provide a complete investigation regarding the alleged abuse of R501. On 10/8/25 at 3:30 PM, the NHA was queried about the incident between the RR and R501. The NHA reported not doing an investigation or reporting this incident due to It not being abuse! The NHA acknowledged that she was out of the office when she received a telephone call from staff regarding the RR grabbing R501's jaw in an attempt to make R501 eat. When asked, why would they call you for this incident if this was not suspected abuse? NHA stated, They call me for everything. The NHA admitted telling LPN C, (RR) is not trying to hurt (R501).A review of Form Centers for Medicare & Medicaid Services (CMS) 20059 Abuse Critical Element Pathway dated 10/2022 revealed the following: 6) For alleged violations of abuse, did the facility:-Report the results of all investigations within five working days to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency)?- Develop policies and procedures related to ensuring the reporting of suspected crimes, within mandated timeframes (i.e., immediately but not later than two hours if the suspected crime resulted in serious bodily injury, within 24 hours for all other cases) and notifying covered individuals annually of their reporting obligations. No further documentation related to abuse identification was provided by the facility.

Based on interview and record review, the facility failed to thoroughly implement an abuse policy for incidents of physical harm of one resident (R501) by a Resident Representative (RR), for one of three residents reviewed for abuse, resulting in the potential for continued physical and/or psychosocial harm.Findings include:It was alleged that Resident Representative (RR) to resident abuse occurred. The complaint revealed the following: Anonymous complainant states on 9/26, last Friday, a. resident (R501) on Station 4 of the facility. was being fed by the (RR), (R501) wouldn't eat (their) food so the (RR) became frustrated and smacked (R501) and grabbed (R501's) jaw . Complainant states the next day, 9/27, the (RR) was observed grabbing (R501's) arm by a dietary aide. On 10/8/25 at 11:35 AM, Licensed Practical Nurse (LPN) A was queried regarding an incident on 9/26/25. LPN A reported she observed LPN C running down the hall. LPN C was screaming, (RR) hit (R501)! According to LPN A, LPN C was typically unhurried, but after this incident moved swiftly down the hall yelling, What should I do? What should I do?. LPN A said that (LPN C) called the Nursing Home Administrator (NHA) and was told not to document in the electronic medical record (EMR) that RR hit R501 because it could alert the state. A review of the clinical record did not reveal documentation of this incident.On 10/8/25 at 12:22 PM, RN D was interviewed and stated, Staff had noticed that (the RR) was getting frustrated with (R501) because (R501) would not eat. RN D said we pulled the RR aside and talked to the RR because the RR was observed grabbing R501's chin while inside of R501's room.On 10/8/25 at 2:47 PM, LPN C was interviewed by telephone and reported witnessing the RR grab R501's jaw to force R501 to eat. LPN C stated to RR, You can't do that! LPN C reported the incident by telephone to the NHA shortly after witnessing RR grab R501's face with force. LPN C stated, The (NHA) determined that it was not abuse and that's why I didn't document it. The clinical record did not reveal that LPN C assessed R501 for bruising/injury immediately after the incident.On 10/9/25 at 12:30 PM, Social Worker (SW) I was interviewed and reported on 10/7/25 that SW I was informed by LPN A that The (RR) cannot go into (R501's) room because (the RR) slapped (R501). LPN A informed SW I that the NHA was notified of the incident. SW I stated, The (NHA) is the abuse coordinator and did not initiate an investigation. SW I confirmed not being informed of an investigation for this incident as of this date. On 10/9/25 at 12:45 PM, LPN A was interviewed again and confirmed witnessing LPN C being visibly upset after seeing the RR slap and grab R501's face.Physical harm continued to occur as referenced in the complaint. On 9/27/25, the (RR) was observed grabbing (R501's) arm by a dietary aide.On 10/8/25 at 2:15 PM, Dietary Aide (DA) F was interviewed and stated, The (RR) is controlling. When asked to elaborate on controlling, DA F stated, (The RR's) actions are aggressive, even the way (the RR) pushes drinks towards (R501). DA F demonstrated a powerful and aggressive pushing motion with their hand.On 10/8/25 at 2:35 PM, DA B was interviewed and said that approximately two weeks ago they witnessed RR grab R501's arm with force and snatched R501 away from the table where R501 was socializing with other residents. RR then took R501 to another table in the dining room. According to DA B, This made me feel uncomfortable. DA B said with her experience and training, she knows what abuse looks like. DA B said this incident was immediately reported to a group of staff persons at the nurse's desk.A record review of the electronic medical record revealed R501 was admitted to the facility on [DATE] with a diagnosis of Atrial Fibrillation, Alzheimer's with late onset, Hypertension, Obstructive Pulmonary Disease, Anemia, Dementia and Adjustment Disorder. Further review of the clinical record revealed a Brief Interview for Mental Status (BIMS) score of 0/15 denoting a severe cognitive impairment. On 10/8/25 at approximately 1:30 PM, the NHA was requested to provide a complete investigation regarding the alleged abuse of R501. On 10/8/25 at 3:30 PM, the NHA was queried about the incident between the RR and R501. The NHA reported not doing an investigation or reporting this incident due to It not being abuse! The NHA acknowledged that she was out of the office when she received a telephone call from staff regarding the RR grabbing R501's jaw in an attempt to make R501 eat. When asked, why would they call you for this incident if this was not suspected abuse? NHA stated, They call me for everything. The NHA admitted telling LPN C, (RR) is not trying to hurt (R501).No further documentation related to abuse identification was provided by the facility.

Based on observation, interview, and record review, the facility failed to ensure proper disposal of loose medications were conducted for three medication carts (3 West, 2 [NAME] and 2 East) out of four medication carts observed for medication storage. Findings include: On 5/1/25 at 9:01 AM, an observation of the medication cart on unit 3 [NAME] was conducted with Licensed Practical Nurse (LPN) A. Upon inspection of the medication cart on 3 [NAME] a total of two suppositories and one loose pill were scattered on the bottom of the first and second drawers of the medication cart. LPN A could not identify the loose pill. When LPN A was queried regarding the loose medications, LPN A said the suppositories should be in a labelled box and the loose pill should have been discarded. On 5/1/25 at approximately 9:15 AM an observation of the medication cart on unit 2 [NAME] was conducted with LPN C. Upon inspection of the medication cart, a total of 16 loose pills were scattered on the bottom of the second and third drawers of the medication cart. When LPN C was queried who was responsible for cleaning the carts LPNC said all the nurses were responsible. On 5/1/25 at approximately 9:30 AM an observation of the mediation cart on unit 2 East was conducted with LPN D. Upon inspection of the medication cart one loose pill was found on the first drawer. Five loose pills were found in the bottom of the second drawer. When LPN D was asked who is responsible to clean the medication carts LPN D said the pharmacy cleans the carts three to four times a month. On 5/01/25 at 12:15 PM the Director of Nursing (DON) was interviewed and said the midnight shift nurses were responsible for cleaning the medication carts. The DON further said that each nurse was responsible for their own cart, and the expectation was for the medication carts to be clean and not to have loose pills. Review of the facility policy titled, storage and expiration Dating of Medications and Biologicals revision date 8/1/24 revealed in part: Facility should destroy and reorder medications with missing labels. Facility should ensure the medications for each resident are stored in the containers in which they were originally received. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis.

This citation pertains to Intake: MI00151131 Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring to prevent an elopement for one resident (R600) who had severe cognitive impairment and was assessed and care planned as an elopement risk. R600 left a secured unit on the second floor and exited the front door during the time a staff member left the lobby unsecured. R600 exited the building while following an unknown visitor on 03/01/2025 at approximately 6:37 PM, unbeknownst to facility staff. Immediate Jeopardy: The Immediate Jeopardy (IJ) started on 03/01/2025 and the immediacy was removed 04/04/2025 per review of the facility's responding interventions as verified on 4/17/2025. The IJ was identified on 04/17/2025 during an abbreviated survey. The facility was notified of the IJ on 04/17/2025 at 3:20 PM and was asked for a removal plan. The IJ was removed on 04/04/2025, based on the facility's implementation of the removal plan as verified onsite on 04/17/2025. Findings Include: On 4/16/2025 at 11:30 AM, R600 was observed in their room. R600 was lying in their bed, positioned on their right-side, and watching TV. R600 was wearing a sweatshirt, sweatpants, and was well groomed. R600 asked if they remembered leaving the building without staff. R600 said, Sorry I don't. R600 gave a smile and said, Is there anything else you would like to talk about? On 03/01/2025 the State Agency received a Facility Reported Incident that on 03/01/2025 R600 exited the building unsupervised while following a visitor on 03/01/2025 at approximately 6:37 PM. A review of R600's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Alzheimer's Disease, Difficulty Walking, Muscle Weakness, Dementia, Anxiety, and Major Depression. R600 was under the legal care of a guardianship. A review of R600's Brief Interview for Mental Status (BIMS) dated 02/06/2025 revealed a score of 7/15 (severe cognitive impairment). A review of R600's Elopement Risk Evaluation dated 02/05/2025 revealed that R600 was at risk for elopement. A review of R600's care plan revealed the following: Focus: ELOPEMENT: At risk for elopement. Resident states he needs to leave for work, drive his car. Following visitors onto elevators, seeking exit doors. Date Initiated: 2/05/2025. Revision on: 03/06/2025 . Interventions/Task: Monitor for exit-seeking behaviors including pacing around the elevator and doors, following family members/visitors, voicing desire to leave for work/to drive. Date Initiated: 02/05/2025 .Revision on: 03/06/2025 . Focus: (R600) impaired cognitive ability /impaired thought processes r/t (related to) Dementia/Anxiety Date Initiated: 02/05/2025 .Revision on: 02/06/2025 . Interventions/Task: Cue, reorient and supervise as needed. Date Initiated: 02/06/2025 . Focus: (R600) impaired cognitive ability/impaired thought processes r/t Dementia/Anxiety. Date Initiated: 02/05/2025 .Revision on: 02/06/2025 . Focus: (R600) is at risk for communication problem r/t impaired cognitive processes. Date Initiated: 02/13/2025 . Interventions/Task: Observe for residents (R600) ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend. Date Initiated: 02/13/2025 . Focus: (R600) is at risk for falls. Date Initiated: 02/06/2025 . A review of R600's progress note written by Licensed Practical Nurse (LPN)B, dated 03/01/2025 revealed the following: Note Text: At approximately 6:30pm resident (R600) was going to (the) dining room to eat dinner. Aides (Certified Nurse Aide/CNA) exchanged directions on how resident (R600) likes his coffee. At approximately 6:50pm an aide (CNA A) from a different unit brought resident (R600) to med cart and stated (CNA A) found (R600) walking in the back parking lot. Resident (R600) stated (they) didn't know how (they) got outside but (R600) was looking for (R600's) car. Writer assessed resident and took (R600's) vitals. Writer ordered lab work and contacted Guardian and Physician Assistant . On 4/16/2025 at 3:10 PM, a request was made to the Director of Nursing (DON) to view the outdoor cameras. However, the DON stated that they couldn't adjust the camera's date to 03/01/2025. The DON was asked about their observation of R600 walking towards the back of the facility upon viewing of the outdoor cameras. The DON said that R600 walked out of the facility behind a visitor on 3/01/2025. R600 turned left and started walking toward the back of the facility. The DON said that R600 was walking on the driveway, when they reached the back of the facility they turned left towards the back parking lot. The DON said that R600 walked toward the shed behind the facility. On 4/17/2025 at 09:08 AM, an observation was made of the outside of the facility while attempting to follow the steps that the DON discussed as observed on their outside cameras. This writer walked out of the front door of the facility. A major busy street in front of the facility with two lanes going right, two lanes going left, and a middle turning lane was observed. This surveyor walked out the front door and turned left. At the end of the walkway and parking lot, a left turn was made toward a long driveway. To the right side of the driveway was another long-term care facility. To the left were about nine tall trees next to the facility. In addition, the long driveway had several cracks at the side and back of the facility. At the back and left corner of the facility was a diesel fuel container, a generator, and electrical metal boxes, sitting on a block of concrete. There was also a step up to a door with signage that noted Oxygen Room. To the right of the Oxygen Room was a shed. On 4/17/2025 at 10:35 AM, an interview was conducted with CNA A related to R600 being found behind the facility. CNA A said, I picked up a double that day and took a later lunch break around 6:50-6:59pm .I came out of the employee entrance back door .It was dusk, but I could still see. I was parked in the second row of the parking lot. I did not notice anyone outside at that time. I got into my car and the headlights automatically came on. They usually come on at dusk . that's when I saw (R600). CNA A said that R600 was standing near the supply shed (behind the facility and next to the Oxygen Room door). CNA A continued to state that (they) were surprised to see R600 outside in the back of the building. CNA A stated they approached R600 in a calm manner because CNA A did not want to startle R600. CNA A said that it looked as if R600 was looking for something. CNA A continued and asked (R600) what they were doing outside and (R600) said they were looking for their car. CNA A stated to R600, Let's go inside to get your keys. R600 then followed CNA A inside the facility, utilizing the back employee door entrance, and ushered R600 back to the second floor using the elevator. On 4/17/25 at 10:58 AM an interview was conducted with the Lead Receptionist C. Receptionist C explained that receptionist should never leave the desk without having someone cover. Receptionist C stated that during day shift, the receptionist should asked staff that work up front to cover the desk if the receptionist needed to leave the lobby. Receptionist C said, If it's during the afternoon (shift), the receptionist should ask staff at Nurse Station One to cover .the receptionist should not leave the desk uncovered (unattended). On 4/17/25 at 11:34 AM, an interview was conducted via phone with Receptionist D. Receptionist D was asked if they worked the lobby desk as the receptionist on 3/01/2025 around 6:30 PM. Receptionist D said, Yes. Receptionist D was queried if they left the front desk during that time and Receptionist D said, I stepped away from the desk around 6:30pm to get a message from the resident in room (redacted), that's a few doors away from the receptionist desk .The resident started talking about their life and then I told them that I had to leave. I was gone for about 5-10 minutes. Receptionist D was asked if it was within their policies/procedures to leave the desk uncovered and Receptionist D said it was ok if it was less than 15-30 minutes. On 4/17/25 at 11:42 AM, an interview was conducted with the Director of Human Resources (also manager of the receptionists). The Director of Human Resources was queried and asked if it was their policy for Receptionist D to leave the lobby front desk unattended during their shift. The Director of Human Resources stated, When the receptionist needs to leave the desk, they should always have someone to cover .they (Receptionist) should never leave the front desk uncovered. A record review of the facility's investigation, interviews, and statements revealed the following: Facility Executive Director was notified that resident (R600) was observed by the back door of the facility by (CNA A) at approximately 6:45pm. Resident (R600) was escorted back into facility .Resident stated (they) was looking for (their) car. Resident responsible party, physician notified of event . A record review of the facility's interview and statements of CNA A revealed the following: On 3/1/25 at approximately 6:50 pm, (CNA A) exited the facility using the employee entrance to take (their) break. As (CNA A) got to (their) car, which was located in the parking lot behind the building, (CNA A) saw (R600) walking by the exit door near the oxygen supply shed .(CNA A) then redirected (R600) and assisted (R600) back into the facility via the employee entrance and escorted (R600) back to (their) unit and nurse . A record review of the facility's witness statement of LPN B revealed the following: (LPN B) was the nurse assigned to (R600) on the afternoon shift on 3/1/25. At approximately 6:30 pm, (LPN B) observed (R600) come out of (their) room walking towards the dining room. (LPN B) overheard two aides talking about (R600) liking a large cup of coffee. Approximately 20 minutes later, (CNA A) brought (R600) to (LPN B) and informed (LPN B) where (R600) was observed and assisted back into the facility . An attempt was made to contact LPN B via phone on 4/17/2025 at 09:40 AM. A voice message was left with contact number. A record review of the facility's witness statement of Receptionist D revealed the following: Receptionist D was the receptionist on duty the afternoon of 3/1/25. Receptionist D states that around 6:30 pm he had stepped away from the desk to assist a resident. This resident was in 106 whom had called the front desk for assistance and clarification on (their) discharge information. Receptionist D was away from the desk for 5-10 minutes assisting the resident. Receptionist C states that during that time there was no other employee at the reception desk. The facility report of the external cameras documented the following: Review of the external facility cameras indicated that (R600) exited the facility via front door at 6:37 pm, following close behind a visitor. (R600) proceeded around the facility, via the parking lot and was observed by a staff member and assisted back into the facility at 6:45 pm via the back door employee entrance . A review of the facility's interview with Visitor F (R600 followed this visitor out of the front door) documented the following: (Visitor F) remembered being at the facility on 3/1/25 and leaving sometime between 6:30pm and 7:00pm. When asked if (Visitor F) had reached over the high-top counter of the front desk to push the button of security release for the front doors to exit the facility, (Visitor F) did not remember if anyone was at the desk to (get out) or if anyone followed (Visitor F) out of the front door .(Visitor F stated) I do not remember what I did earlier in the day, let alone on the weekend. On 04/17/2025 at 11:56 AM, the DON was interviewed and asked how R600 left the second floor via the elevator (the 2nd floor elevator required a passcode). The DON stated R600 must have followed visitors into the elevator. The DON was asked how R600 exited the front door. The DON stated, (R600) was viewed on the front camera following (Visitor F) out the front door. On 4/17/2025 at 12:28 PM, an interview was conducted with the Nursing Home Administrator (NHA). When queried regarding R600 exiting the facility on 3/01/2025 without staff knowledge, the Administrator explained that (R600) exited the facility behind Visitor F. The NHA stated, We investigated and concluded that (R600) followed a visitor onto the elevator and then followed (Visitor F) out of the front door. The NHA was asked if the second floor was a locked unit. The NHA stated that it was not a locked unit, it was a secured unit that required a passcode to open the elevator on the second floor. The Administrator was asked if residents were given the passcode and the NHA said, No. Residents are not given the passcode. The NHA stated that R600 was let out of the facility by a visitor. The NHA was queried if it was within their policy to maintain staff at the front desk during business hours. The NHA said that receptionists were not used as security. The NHA continued to explain that R600 had been outside for about 10 minutes. The DON stated, (R600) was not in danger because he did not leave the grounds. A review of the facility's policy Area of Focus: Elopement dated 11/19/2024 revealed the following: Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so. A resident who leaves a safe area may be a risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the following: 1. Corrective Action for Affected Individual(s). -A Schedule has been established to monitor the involved R600 15 minutes. -R600 elopement care plan was reviewed and updated to reflect activities of interest including model care that he can design, music, bingo, purposeful wandering. -Notification sent to families/representatives on not letting self out of the building, which is a breach of our security systems. 2. Identification of Residents Affected or Likely to be Affected: -Residents identified at risk for exit seeking, assessment to reduce opportunity to exit facility their care plans will be reviewed, photos updated, if necessary, Medical Director and responsible parties will be notified to be aware of surroundings when on elevator. 3. Identification of Residents Affected or Likely to be Affected: -An ad hoc QAPI meeting was held on 3/7/25 review systematic process enhancements and no further occurrences have been noted. Committee will continue to monitor and perform analysis for any potential root cause to variation in updated systematic process. -Signage has been placed by and in the elevator to remind visitors to be aware of anyone on the elevator without a badge/nametag may be an indication of an unaccompanied resident and to notify a staff member immediately. -All current resident's elopement risk evaluations were reviewed and updated with care plans reviewed and updated as needed. -Front door push button relocated and a protective cover placed over it so visitors cannot reach over the counter and push the button. 3. Systemic Changes to Prevent Recurrence: -Staff educated on elopement, front desk to be attended during business hours. -Education on proper visitor sign in/out process. -Elopement policies were reviewed on 3/05/25. No revisions made to the current policies. -Elopement risk list updated. -Elopement investigation procedure and documentation process were reviewed on 3/05/25. No revisions made to the current procedures and processes. -Elopement drill was from 3/5/25-3/8/25 completed multiple shifts. -Elopement audits last date 4/4/25. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake MI00147167. Based on interview and record review, the facility failed to confirm and document the timely notification of resident representative for one resident (R101), out of four residents reviewed for change of condition, resulting in missed opportunities to participate in medical decisions regarding care and treatment. Findings include: It was reported to the State Agency that the facility staff failed to notify the resident representative of the resident's change in condition in a timely manner. A review of R101's Admission Record documented an admitted [DATE] with diagnoses that included protein-calorie malnutrition, dysphagia, epilepsy, anxiety disorder, and depression. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment. R101's clinical record listed the resident's spouse as the responsible party and emergency contact #1. A review of an Event Note dated 8/1/24 at 12:01 PM for R101 documented the following: Patient observed on the floor next to bed laying on her left side, stated I fell out of bed while I was sleeping. (Two-person) assist with Hoyer transferred patient back to bed. VS (vital signs) obtained, skin assessment completed, PRN (as needed) pain medication administered, cold compress applied to left arm, physician notified, STAT (immediate) X-ray of left arm ordered, neuro checks in place. Patient resting in bed at this time, no c/o (complaints of) pain, sitting up awaiting lunch. All staff documentation completed. A review of a facility document titled, COVID-19 Testing dated 8/14/2024, revealed R101 tested positive for COVID-19 on 8/14/24. This document further indicated, meds ordered by MD (medical doctor). Will notify family. A review of R101's physician orders documented the following: - Tessalon [NAME] oral 100 mg, one capsule by mouth three times a day for COVID-19 for five days beginning on 8/14/24. The Director of Nursing (DON) was interviewed on 12/6/24 beginning at 12:52 PM. The DON provided documentation that R101's Resident Representative (RR) was notified about R101's fall on 8/2/24 at 1:00 PM. When queried if this was timely notification, the DON stated she wanted to see why the notification was 24 hours later. No additional information regarding the delay in notification was provided by the end of the survey. Additionally, the DON was unable to provide documentation that R101's RR had been notified of the positive COVID-19 test result. A review of the facility policy titled, Changes in Resident's Condition or Status, dated 9/5/24, documented in part the following: - This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. - A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) where there is (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment). On 12/6/24 at 3:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review the facility failed to ensure facility staff followed the care plan for transfer assistance for one (R401) of three residents reviewed for falls, resulting in a fall. Findings include: On 10/15/24 at 11:05 AM R 401 was observed in bed with bruising on both arms and stated, I fell in the shower with Certified Nursing Assistant (CNA) A last week. I hurt my left arm. Review of the Electronic Health Record revealed R401 admitted to the facility on [DATE] with diagnoses that included left femur fracture, multiple sclerosis, muscle weakness, and hemiplegia affecting left side. Review of a Minimum Data Set (MDS) assessment for R401, with a reference date of 7/19/24, revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated intact cognition. On 10/15/24 at 1:15 PM Registered Nurse (RN) B was interviewed and said R401 had an X-ray ordered due to complaints of left arm pain after being lowered to the ground during a shower on 10/10/24. The X-ray was negative for a fracture but showed some swelling. Record review of the incident accident report dated 10/10/24 revealed (CNA 'A') was transferring resident from shower chair to wheelchair when resident left leg gave out. I got resident on my knee and gently lowered her to the floor using gait belt and went to nurse station. Got both nurses to help get resident off shower room floor. Record review of the Kardex as of 10/15/24 revealed Resident Care 2 person assist at all times. Record review of Care plan for R401 revealed .Focus .self-care performance deficit r/t (related to) . displaced fracture of left femur .Interventions .2 person assist at all times revised 8/21/24 . On 10/15/24 at 12:15 PM the Director of Nursing (DON) was interviewed and said CNA A did not follow the two persons assist for the shower transfer, There should have been two people to assist. The DON agreed the Kardex states R401 is a two person assist at all times. The DON said the expectation is for CNA's to follow the Kardex for patient care. Review of the facility policy titled Fall Management reviewed 9/25/24 revealed in part .Fall -refers to the unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without an injury is still a fall. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 172 residents who receive meal services. Findings include: 1. On 5/30/24 between 10:12 AM, and 10:40 AM, the following non-food contact surfaces in the kitchen were observed soiled and with visible debris on their surfaces: On the ventilation filters above the fryer. On the grates of the flat top grill. On the sides of the oven On the oven's stainless steel backsplash. Upon observation the surveyor inquired with Dietary Manager, staff A, on if they thought these areas were being cleaned timely and sufficiently to which they replied, not like I thought. These noodles are from a soup made yesterday. I'll talk to the cook about this. On 5/30/24 at 11:25 AM, the surveyor requested a copy of the kitchen's cleaning policy to review. On 5/30/24 at 10:32 AM, the number ten can opener's cutting blade at the cook prep station was observed with visible debris on its surface. Upon observation staff A, commented, I'll set the can opener aside to be cleaned. On 5/30/24 at 11:09 AM, an accumulation of dust and debris was observed on the flooring throughout the walk in freezer. At this time the surveyor inquired with staff A on if they thought the flooring was being cleaned as needed throughout the day to which they replied, usually, but I guess not enough. At the time of the survey team's exit, no additional cleaning schedule documenting verification of the daily cleaning tasks required to be completed was received to review. Review of 2017 U.S. Public Health Service Food Code, Chapter 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, directs that: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2. On 5/30/24 at 9:50 AM, the surveyor asked the Dietary Manager, staff A, how the facility cleans and sanitizes work surfaces to which they stated, we have our red and green buckets. One has soapy water in it, and one has our sanitizer. At this time the surveyor asked staff A if they could test a sanitizing bucket to verify its concentration to which they replied, yes. On 5/30/24 at 9:52 AM, testing of the sanitizer concentration by staff A via a test strip, and comparing its color to the wall mounted chemical manufacturers reference sign, and then to the test strip packaging, revealed a concentration of zero. Upon observation staff A stated, I'll talk to who made it this morning, and I'll remake it now. Let's look at our log. On 5/30/24 at 9:54 AM, record review of a sanitizer verification log with staff A revealed a recorded concentration of 200 ppm taken earlier in the morning. At this time staff A stated, they might not have fully understood what they were doing. Review of 2017 U.S. Public Health Service Food Code, Chapter 7-204.11 Sanitizers, Criteria, directs that: Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)P

Based on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 172 residents and its staff resulting in an increased potential for harm. Findings include: On 5/30/24 between 1:32 PM, and 2:11 PM, during an environmental tour of the facility with Environmental Services Manager, Staff C, the following observations were made: All dryers in the laundry room were observed with a variety of melted/baked on debris varying in color and texture on the interior drums of the units. Upon observation the surveyor inquired with Staff C on the current state of the interior of the dryers to which they stated, it's supposed to be caught when they are being sorted for anything like this. I'll talk to them about this. An accumulation of dust and debris was observed on the flooring in the first and second floor's clean linen storage closets. Upon observation the surveyor inquired with Staff C on the current state of the storage closets to which they stated, we'll get this vacuumed up, and make sure we are looking at these areas more closely during the day.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests, resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 172 residents. Findings include: On 5/30/24 at 11:43 AM, live flies and ants were observed underneath the designated hand washing sink in the first floor's kitchenette. Upon observation the surveyor inquired with Dietary Manager, staff A, if they were aware of a pest issue in the facility to which they replied, no, that's not my department, I'd have to talk to maintenance about this. At this time the surveyor requested the facility's pest control policy to review to which staff A responded, the front desk has a book. On 5/30/24 at 1:23 PM, upon interview with Maintenance Director, staff B, on if they were aware of any pest concerns in the building they stated, no. I usually never see the technician because they arrive before my day starts. I believe it's just preventative maintenance. On 5/30/24 at 4:21 PM, record review of the facility's most recent pest control service record dated, 5/29/24 revealed that the facility is currently being treated around the foundation's perimeter using bait boxes. Additional information listed under the evidence/ treatment notes section of this document were indecipherable by the surveyor and staff B. Review of 2017 U.S. Public Health Service Food Code, Chapter 6-501.111 Controlling Pests, directs that: 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: (B)Routinely inspecting the PREMISES for evidence of pests;

Based on observation, interview and record review the facility failed to ensure that the Pre-Admission Screening and Resident Review (PASSARR) Level I determination (DCH-3877 and/or DCH-3878) was reviewed, revised, and sent to the Local Community Mental Health Services Program (CMHSP) for a Level II OBRA (Omnibus Budget Reconciliation Act) evaluation for one resident (R150) of five residents reviewed for PASSARR, resulting in the potential for unmet mental health services. Findings include: On 5/29/2024 at 2:09 p.m., a review of R150's medical record documented the resident was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included excoriation (skin picking) disorder, undifferentiated schizophrenia, adjustment disorder with mixed disturbance of emotions, and conduct, depression, and attention-deficit hyperactivity disorder. According to the annual MDS assessment dated [DATE], the resident was cognitively intact with a BIMS (brief interview for mental status) score of 15 out of 15. The Preadmission Screening (Level I Screening, 3877) dated 2/21/2024, documented the resident had mental illness which was excoriation disorder , adjustment disorder with mixed disturbance of emotions and conduct, depression, insomnia due to other mental disorder, undifferentiated schizophrenia, attention-deficit hyperactivity disorder, alcohol abuse with alcohol-induced mood disorder, nicotine dependence, and received an antipsychotic and an antidepressant medication. Review of the medical record did not reveal a Level II (3878). The Mental Illness/Intellectual Disability/ Related Exemption Criteria Certification (3878) indicated Hospital Exemption Discharge: . The patient under consideration 1.) is being admitted after a hospital stay, AND 2.) requires nursing facility services for the condition for which he/she received hospital care, AND 3.) is likely to require less than 30 days of nursing services. The two documents indicated a Level II OBRA evaluation is required for R150. On 5/30/2024 at 12:25 p.m., Social Service Designee E was informed a Level II evaluation was not noted in R150's medical record and stated, I am covering for someone else, but I will take a look to see why it's not in the chart. On 5/31/2024 at 10:56 a.m., SSD E was asked during an interview, if R150 had a Level II evaluation completed. SSD E stated, The resident was supposed to have one done because the Level I triggered to have a level II completed. The Level II is not in the chart because the physician has not completed the form yet. The physician must go in the computer to complete the OBRA 3878 form that was automatically generated and sign it. After the physician signs the level II then we place a copy in the resident chart immediately. SSD E said the importance of the having a level II in the resident's medical chart is to show the diagnosis, the mental health plan of care and the treatment for the resident. SSD E said the level II form should have been in R150's chart. Review of the facility's policy titled Pre-Admission Screening and Resident Review PASARR last reviewed date of 9/25/2023 documented: The facility will ensure that potential admission is screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR level I and is completed prior to admission to a nursing facility. A negative level 1 screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. A positive level I screen necessitates an in-depth evaluation of the individual by the 'State designated authority, known as PASARR Level II. A record of the pre-screening should be retained in the resident's medical record. According to the Preadmission Screening (PAS)/ Annual Resident Review (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification Instructions: The DCH-3877 is used to identify prospective and current nursing facility residents who meet the criteria for possible mental illness or intellectual disability .The 3877/3878 must be reviewed and revised annually. Review of the attached directions for completion of these forms documented, The person screened shall be determined to require a comprehensive Level II OBRA (Omnibus Budget Reconciliation Act) evaluation if any of the above items are YES UNLESS a physician certifies on form DCH-3878 that the person meets at least one of the exemption criteria .If any answer to questions 1-6 in SECTION II is YES send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative.

Based on observation, interview, and record review the facility failed to assess a resident (R52) for self-administration of medications resulting in medications left at the resident's bedside. Findings Include: During an observation on 5/29/24 at 10:50 AM, upon entering R52's room, two medications were seen in a clear medicine cup on the resident's bedside table. During an interview on 5/29/24 at 10:51 AM, it was reported by R52 that the nurses sometimes leave the medications on the table if I am sleeping, and I take them when I wake up. Record review of R52's electronic medical record (EMR) revealed no assessment or physician's order to self- administer medications. Further review of R52's EMR revealed admission to facility on 12/6/22 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). According to a Brief Interview of Mental Status (BIMS) dated 3/12/24, R52 had intact cognition with a score of 15/15. During an interview on 5/29/24 at 11:00 AM with Licensed Practical Nurse (LPN) D, it was reported that medications should not be left at the bedside. During an interview on 5/30/24 at 2:10 PM with interim Director of Nursing (DON), it was reported that medication should never be left at bedside, unless the resident has been assessed and has a physician order to self-administer medications. It was further reported that R52 had not been assessed and there was no order for self-administration of medications. When asked the reason medication should not be left at bedside, DON responded, Another resident may accidentally take them. Record review of policy Administration of Medications revised 7/14/21 documented: . All medications are administered safely and appropriately per physician order to address residents, diagnoses and signs and symptoms.

This citation has two deficient practice statements. Deficient Practice Statement #1. This citation pertains to intake MI00142978. Based on interview and record review the facility failed to develop/implement a care plan for one resident (R917) out of three residents reviewed for care interventions for psychotropic medications. Findings Include: Record review of R917's electronic medical records revealed admission into the facility on [DATE] with a pertinent diagnosis of dementia. According to the Minimum Data Set (MDS) dated [DATE], R917 had impaired cognition and required assistance with Activities of Daily Living (ADLS). Record review of Physician orders documented, Seroquel Oral Tablet 25 MG (antipsychotic) Give 0.5 tablet by mouth at bedtime for mood disorder. Start date 8/16/23. Record review of R917's care plans revealed no documentation or implementation of interventions to assess or monitor resident's progress or side effects of taking a psychotropic medication. Further review of Medication Administration Record (MAR) for the month of September 2023 had no documentation of assessment/ monitoring of possible side effects of Seroquel. During an interview on 3/22/24 at 1:45 PM with Director of Nursing (DON), it was reported that facility should have developed and implemented a care plan for R917 when Seroquel was ordered by physician. It was further reported that residents should be monitored when receiving anti-psychotic medications. Record review of policy Comprehensive Care Plans and Revisions reviewed 8/22/23, documented the following: The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. Deficient Practice Statement #2: This citation pertains to intake MI00142978. Based on interview and record review the facility failed to obtain a consent for the use of a psychotropic drug for one resident (R917) out of three residents reviewed for unnecessary medications. Findings Include: Record review of R917's electronic medical records revealed admission into the facility on [DATE] with a pertinent diagnosis of dementia. According to the Minimum Data Set (MDS) dated [DATE], R917 had impaired cognition and required assistance with Activities of Daily Living (ADLS). Record review of Physician orders documented, Seroquel Oral Tablet 25 MG (antipsychotic) Give 0.5 tablet by mouth at bedtime for mood disorder. Start date 8/16/23. Record review of R917's Medication Informed Consent form it was documented with an X for anti- anxiety medication and was signed by daughter of R917. There was no information documented related to the anti- anxiety medication. No other choices for other medications. Form was not completed, and consent or refusal was not marked. Document was not dated. Record review of 917's electronic medical records revealed no evidence that responsible party was informed before receiving Seroquel medication. During an interview on 3/22/24 at 1:45 PM with Director of Nursing (DON), it was reported that facility should obtain consent before administering an antipsychotic medication. It was further reported that R917's electronic medical record had no indication that R917's responsible party was informed or consented to the use of Seroquel. Record review of policy Psychotropic Mediation Informed Consent Policy'' reviewed 8/29/23, documented the following: .The facility will obtain consent or refusal to the use of Psychotropic Medications. This documentation will reflect the intended or actual benefit is understood by the resident and, if appropriate, his/her family and/or representative(s) and is sufficient to justify the potential risk(s) or adverse consequences associated with the selected medication, dose, and duration.

This citation pertains to intake MI00142899. Based on interview and record review the facility failed to prevent the use of inappropriate language during care to one resident (R916) out of three residents reviewed for abuse. Findings include: Record review of Incident Report dated 2/11/2023 (actual date 2/11/2024) documented, On 2/12/24 at approximately 2:56 pm C.N.A. (Certified Nursing Assistant) (E) notified the Executive Director that on the prior shift, while she was working with (CNA F), (CNA E) indicated that she witnessed (CNA F) on last rounds enter into room (XXX) to check on (R916) and see if she was clean and dry. (CNA E) indicated that she witnessed (R916) became combative during care and scratched (CNA F). (CNA F) stated I am tired of you fucking scratching me. I am not doing this shit; I am trying to go home. Further review of the same document noted, . Conclusion: Based on interviews and statements, the facility can conclude that (CNA F) used profane language in front of R916 . Record review revealed R916 was admitted into the facility on [DATE] with pertinent diagnoses of unspecified dementia. According to Minimum Data Set (MDS) dated [DATE], R916 had impaired cognition and required assistance with Activities of Daily Living (ADLS). During an interview on 3/22/24 at 12:30 PM with Director of Nursing (DON), it was reported that it is not appropriate for staff to speak to residents as reported. During an interview on 3/22/24 at 1:15 PM with Executive Director, it was reported that CNA F was terminated related to swearing in front of R916. Record review Termination Form dated 2/22/24 documented, .Reason for Termination -Violation of company policies and procedures.

This citation pertains to MI 270. Based on observation, interview, and record review, the facility failed to provide adequate supervision for 1 of 6 sampled residents (Resident #1) reviewed for supervision, resulting in an Immediate Jeopardy when on [DATE] at approximately 12:10 AM, Resident #1, who was known to wander about the housing unit and try to take food from other residents and from the nurses station and who was on a pureed diet due to dysphagia, obtained a peanut butter sandwich from the nursing station which was left unsupervised and unlocked. Resident #1 aspirated the sandwich, asphyxiated, lost consciousness, sustained an [CONDITION(S)] [CONDITION(S)] and died . Findings include: A review of the Face Sheet for Resident #1 (R1) documented an original admitted [DATE] and readmitted [DATE]. R1 was discharged to the hospital on [DATE]. R1's diagnoses included [CONDITION(S)], [CONDITION(S)], and dysphagia. A Minimum Data Set (MDS) dated [DATE] documented moderate cognitive impairment. R1 also required oversight, encouragement/cueing, and setup help for eating. R1's diet order at the time of discharge was a regular diet of pureed texture. A facility document titled eINTERACT Change in Condition Evaluation, dated [DATE], was reviewed and revealed in part the following: Change in condition: unresponsiveness; Allergies: No Known Allergies; and, Other relevant information: resident aspirated on peanut butter and jelly sandwich. Review of R1's Progress Notes documented in part the following: Nurse's note of [DATE] at 1:20 AM: At the beginning of the shift resident was up and ambulating back and forth between his room and the nurse's station. Writer was passing midnight medication when the CNA passing water notified me the resident was acting strange at about 12:10 AM. Writer went in and noticed the resident slouching over his bed and falling over. Writer asked him was he feeling ok. No response. Writer smelled peanut butter and asked the resident did he eat something and was he choking and he responded yes. Writer began the [MEDICATION(S)] maneuver and encouraged the resident to cough. He was coughing and nothing came up. We got him completely in the bed and he became unresponsive and losing color. Writer told the CNA to call for the other nurse. Writer was able to scoop a chunk of food out the resident's mouth but he was still unresponsive. Treatment nurse notified. He grabbed the crash cart and we began CPR. 911 immediately notified after it was verified that the resident is a full code. The rest of the nurses in the facility arrived and we continued the code protocol. resident remained unresponsive and no pulse was noted. EMT (emergency medical technicians) arrived about 12:20 AM and assisted. Machine hooked up to resident to do CPR. After about 45 minutes of working on the resident, EMT got a pulse and they put the resident on a stretcher and exited the building about 1:05 AM .Resident was taken (to local) hospital. Will follow up. Behavior note of [DATE]: Behavior Management committee meeting: Resident is followed by psych services .(diagnoses) [CONDITION(S)], [CONDITION(S)] .Altered sleep behaviors continue. Resident disrobing and wandering/pacing in public areas. Needs frequent redirection. Noted to take items off of medication carts .Staff to continue to observe and monitor . Nutrition note of [DATE]: Diet: puree (honey thickened liquids) .Resident has been observed drinking thin liquids sometimes taking liquids off of other residents trays . During interviews on [DATE] at 12:18 PM and 2:45 PM, Licensed Practical Nurse (LPN) G said, I came in at 11:00 PM. I was the only nurse on Station 4. I was checking on the residents (on the unit) and was back and forth at the nurse's station. (R1) ambulates and I saw him walking back and forth. CNA (Certified Nurse Aide H) was passing water and saw (R1) in his room stumbling and acting weird. I was across the hall (from R1's room) taking another resident's blood pressure and (CNA H) called for help. (R1) wasn't talking, but he was moving around. I smelled peanut butter and only realized he was choking because I smelled peanut butter. (R1) attempted to cough. I did the [MEDICATION(S)] and scooped what I could out of his mouth. It was a chunk of bread and peanut butter about 2 to 3 sizes of a quarter. When EMT came and tried to get a tube down, they still pulled out more stuff (bread and peanut butter). The peanut butter was in the way. The kitchen made peanut butter and jelly sandwiches. I brought up about five or six sandwiches. The sandwiches were at the nurse's station. They were not locked up in the med room. There was a period of time the sandwiches were left unsupervised. A review of R1's care plans documented in part the following: Focus: (R1) has an ADL (activity of daily living) self-care performance deficit related to weakness/unsteady. Secondary to multiple medical problems .Also has cognitive deficits that impact his ability to care for self. Dated [DATE]. Intervention: Resident wanders without purpose . Dated [DATE]. Focus: Resident noted to refuse medication/care at times. Non-compliant with dietary recommendations at times. Resident is able to be redirected. Dated [DATE]. Intervention: Intervene as necessary to protect the rights and safety of others .Divert attention. Remove from situation and take to alternate location as needed. Dated [DATE]. Focus: Resident benefits from cues and reminders for some ADLs, insight and judgement are poor, safety awareness is poor, a short attention span is evident . Dated [DATE]. Intervention: Cue, reorient and supervise as needed. Dated [DATE]. Focus: (R1) is at risk for oral/dental complication related to missing teeth . Dated [DATE]. Intervention: Diet as ordered . Dated [DATE]. Focus: (R1) is at risk for falls .cognitive deficits, poor safety awareness . Dated [DATE]. Interventions: Resident is at times looking for food when he is wandering. Offer snacks throughout the day. Dated [DATE]. Resident wanders without purpose. Provide supervision with ambulation . Dated [DATE]. In an interview conducted on [DATE] at 11:19 AM, Dietary Manager (DM) I stated a resident on a pureed diet would definitely not receive a peanut butter and jelly sandwich. A peanut butter and jelly sandwich is kind of sticky. If we were to puree it, it would be a mess. We would advise whoever is requesting it, that it's not appropriate for a puree. DM I indicated the facility kitchen is open ,d+[DATE]. In an interview conducted on [DATE] at 12:31 PM, CNA E stated, (R1) was always trying to take food. We would stop him from eating solid food. I saw him grab another resident's cookie. I got it from him and gave him applesauce instead. He was always trying to get his hands on something. In an interview conducted on [DATE] at 12:34 PM, CNA J stated, (R1) walked around a lot. He mostly walked by himself. He would grab a sandwich from the nurse's station so we would have to watch him. Sometimes the sandwiches would be on the front counter but now they put them further back in the nurse's station, so they are not as accessible. In an interview conducted on [DATE] at 12:38 PM, CNA M stated, (R1) would try to grab stuff off the nurses (medication) cart. The previous week, he tried to take food off a resident's tray. I saw it and stopped him before he could get it. In an interview conducted on [DATE] at 3:40 PM, Speech and Language Pathologist (SLP) L said, (R1) was very impulsive. It was hard to do therapy with him. He required lots of cueing. I worked with him a long time. Food above a pureed texture was not safe for (R1) because of his impulsivity. He ate too quickly. He would grab at things and shove them in his mouth. With pureed foods there is no bulk and no texture, so it was much safer. (In terms of safety), he was able to tolerate pureed foods. He would not let other people feed him. He could feed himself, but he would feed himself quickly. He was impulsive. He grabbed a sandwich and look what happened. That was what I was afraid of. He can't handle texture. A peanut butter sandwich has texture. A review of the Rehabilitation Services Multidisciplinary Screening Tool for R1, dated [DATE], written by SLP L revealed the following, The patient must remain on puree with honey thick liquids and cannot be upgraded. At baseline the patient is cognitively impaired (from birth) and has a history of [CONDITION(S)]. He is impulsive when eating and eats too quickly which would make him a choking risk even for mechanical soft solids (and especially for regular solids). He is not a choking risk with puree. In an interview conducted on [DATE] at 3:02 PM, CNA H said, on [DATE] (R1) was in the bathroom and seemed unstable. I asked him if he was okay. He's mobile and I assisted him to his bed. He seemed unstable. I called for the nurse. She did the [MEDICATION(S)]. 911 was called and we got another nurse to assist. Before the choking incident of [DATE] occurred, CNA H stated she observed R1 sitting at the nurse's station. R1 is able to walk independently to the nurse's station. On another occasion, CNA H had previously observed R1 grabbing for a bag of chips. She was able to redirect him and remove the item. On [DATE] R1 resided in the same room as Resident #6 (R6). In an interview on [DATE] at 5:14 PM, R6 said, I don't think they offer me a sandwich at night. But I don't want any. It's not good for the body. It's fattening. During CNA H's interview on [DATE] at 3:02 PM, she said, I never saw R6 with a sandwich for a night snack. A review of the Face Sheet for R6 revealed an admitted [DATE] and readmitted [DATE] with diagnoses that included [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. A MDS dated [DATE] documented intact cognition. An interview was conducted on [DATE] at 1:55 PM with Nurse Unit Manager (UM) F, Infection Preventionist Nurse (IP) K, and Director of Nursing (DON) B. -UM F stated that during the midnight shift of [DATE], sandwiches were at the nurse's station. UM F stated she was aware that R1 sought after food, but normally it was a beverage. UM F said, Another possibility for (R1) being in distress was because he was in AFib ([CONDITION(S)] fibrillation: an irregular and often rapid heart rate) and that very well could have contributed to his choking and unresponsiveness. The results of R1's ECG (electrocardiogram) 12 Lead collected on [DATE] at 1:32 PM was reviewed with UM F and revealed in part the following narrative: [CONDITION(S)] fibrillation; Right bundle branch block; Abnormal ECG . UM F did not provide documentation of medical follow up regarding the ECG findings. -IP K stated she was acting as the DON on [DATE] due to the DON B's absence. IP K said, Nurse G went to the kitchen and got sandwiches and placed them at the nurse's station. The sandwiches were hidden from view but not locked up. IP K indicated they have no proof that Resident #6 (R1's roommate) gave him a sandwich that night. A review of a written statement for LPN G dated [DATE] revealed the following: Writer (IP K) spoke with (LPN G) for follow up on her note for (R1). In the event note, (LPN G) stated she asked, 'was he choking and he responded yes', writer confirmed with (LPN G) that (R1) was still able to verbally express himself. He was verbally able to say 'yes'. Writer asked where the peanut butter and jelly sandwiches were, (LPN G) explained that the sandwiches were just gotten from the kitchen and were at the nurse's station by the computer. Writer asked how she thinks (R1) got the sandwich, (LPN G) stated he would of had to walk around the nurse's station or lean over the counter to get access to the sandwich. -DON B stated that access to the sandwiches could have been prevented if the snacks were in the (locked) med room. DON B acknowledged that when Nurse G was in and out of residents' rooms, she could not see everything going on in the hallway and at the nurse's station. In an interview on [DATE] at 5:05 PM, LPN Q, the treatment nurse, indicated that his shift ended at 11:00 PM on [DATE]. LPN Q was still in the facility charting and reported that he responded when R1 was choking on [DATE]. When he arrived upon the scene (R1's) color had definitely changed from pink to pale. He had no pulse or respiration and was nonresponsive. After determining (R1's) code status, CPR was initiated. In an observation/interview on [DATE] at 5:14 PM, UM F said, the peanut butter and jelly sandwiches were placed on the counter in the front area of the nurse's station behind a computer monitor. UM F pointed to an area at the nurse's station in which the sandwiches would have been only partially hidden from view. In an interview on [DATE] at 10:36 AM, the facility's Medical Director, Physician O, agreed that if a cardiac event occurs and the resident is eating, they can choke, and choking may bring on a cardiac event. Physician O stated, It can happen either way. In an interview on [DATE] at 10:42 AM, R1's Primary Care Physician (Physician P) stated she was told that R1 got access to a peanut butter sandwich, he ate it, and he was choking. They could not clear the throat and the ambulance was called and he was taken to the hospital. Physician P added, He has the habit of grabbing the food from other trays, but staff is always watching to make sure there is no food around him. In the room or outside the room, there should not be any food laying there. Physician P agreed that the stress of choking could cause a cardiac arrest. Physician P stated, If you're choking on something and you cannot breathe, it can cause a lot of problems. The food is in the air pipe, in the lungs, and it can obstruct, causing no oxygen to be given. A review of the hospital records for R1's [DATE] admission received on [DATE] revealed in part the following: - Emergency Department Information: Extensive downtime in the field. Patient did have pulse five minutes prior to transport. Transported to ER. Total downtime was prolonged over an hour. Patient arrives intubated had significant peanut butter in his airway . Radiology Imaging Results of [DATE] at 2:38 AM documented the following: Exam description: Chest 1 View Diagnosis: Asphyxiation (the state of being deprived of oxygen, which can result in unconsciousness or death) due to food .Impression: ET tube (endotracheal tube inserted down the throat and into the windpipe to get air into and out of the lungs) placement with tip 3.3 cm (centimeter) proximal to [NAME] (ridge at the base of the windpipe) .Left basilar subsegmental atelectasis (partial collapse of the lungs). - Physician progress note of [DATE] at 3:34 AM. Assessment and Plan: 1. S/P (status post) Cardiac Arrest - secondary to asphyxiation, roughly one hour of total down time .extremely poor prognosis, unable to reach next of kin, remains full code .2. Cerebral [CONDITION(S)] . - likely secondary to [CONDITION(S)] [CONDITION(S)] 3. Acute Hypoxic [CONDITION(S)] - secondary to asphyxiation on peanut butter . - Hospital Course: .(R1) brought into the ER by EMS unresponsive and pulseless - patient had prolonged down time in the field. Patient was eating peanut butter at the nursing home when he started to choke and went into cardiac arrest. He was given [MEDICATION(S)] and [MEDICATION(S)], and CPR was done en route to the ER. Patient then had CPR in the ER and was shocked two times for V. Fib (ventricular fibrillation - an abnormal heart rhythm) - eventually achieving ROSC (return of spontaneous circulation). He has received multiple doses of [MEDICATION(S)], calcium and [MEDICATION(S)] for prolonged down time .Prognosis is very poor as total down time was over one hour. Also, patient's pupils are fixed and dilated, he is not withdrawing to pain and not breathing over the vent .When patient's DPOA is available in the morning, we will need to discuss change of code status . - End of Life Discussion dated [DATE] at 12:32 PM The summary of the discussion with the patient/family regarding the end of life and patient wishes are as follows .Per family they understand patient has suffered significant damage to his brain during a cardiac arrest caused from choking/asphyxiation while at his nursing home. They are aware he will not recover and is critical at this time requiring a lot of blood pressure support. Family states he would not want to be on machines and they do not want him to suffer. They at this time want to change to DNAR (do not attempt resuscitation) comfort measures. They want all life support removed but are aware he is so critical he may pass before removal of vent and vasopressors. - Patient was unresponsive no detectable vital signs, pupils fixed and dilated .House officer pronounced patient dead at 1:15 PM on [DATE]. - Discharge Diagnoses: Asphyxiation due to food followed by Cardiac arrest associated with [CONDITION(S)] and severe Metabolic acidosis (serious electrolyte disorder) / Lactic acidosis (a form of metabolic acidosis). Acute [CONDITION(S)] with [CONDITION(S)] (deficiency of oxygen to the tissues) and hypercapnia (excessive [MEDICATION(S)] in the bloodstream). Acute renal failure V-tach (heart rhythm disorder) A review of the following facility documents revealed in part the following: -Modified Texture Diets, dated [DATE], These diets (Mechanical Soft, Pureed, and Dysphagia) are designed to provide adequate nutrition for residents who have an impaired ability to chew and/or swallow . The Puree Diet provided foods with a semi-liquid to semi-solid consistency (i.e., applesauce to mashed potatoes). Any food from the Regular Diet is pureed if the quality is acceptable and the food is safe (e.g., coleslaw). Nursing Home Administrator A was notified of an Immediate Jeopardy on [DATE] at 3:23 PM, due to the facility's failure to provide adequate supervision for a resident on a puree diet known to wander about and able to obtain a peanut butter and jelly sandwich from the nursing station. A written plan for removal for the immediate jeopardy was received and verified on [DATE]. - Resident #1 no longer resides at the facility as of [DATE]. - On [DATE] resident snacks were secured immediately by charge nurses' in med rooms or in kitchenette in the dining room. This was evident by observation during onsite survey on [DATE]. - 14 out of 160 residents with pureed diets were reviewed by nurse administration on [DATE], to ensure dietary restrictions are being followed. - Nursing and dietary associates were educated on proper securing of resident snack foods, ensuring current diet is ascertained. This will be provided by the Dietary Director/ADON/designee beginning on [DATE]. Education will be on-going for nursing and dietary associates at start of shift or before they work again. Current total educated 15 out of 18 for the dietary department and 30 out of 110 for the nursing department, which includes PRN (as needed) associates. Staff will not work prior to receiving the education. - The facility Medical Director was called and agreed with the plan for removal of the Immediate Jeopardy on [DATE]. - An adhoc Quality Assurance Performance Improvement (QAPI) team meeting will be held on [DATE] to review the plan for removal. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to all staff had not received the education to ensure resident on modified diets did not receive foods that were restricted and compliance had not yet been verified by the state agency.

This citation has three deficient practices and pertains to intakes MI 612 and MI 625. --Deficient practice #1. Based on observation, interview, and record review, the facility failed to properly maintain infection control practices during a COVID-19 Infection Control Survey by failing to: 1. Consistently ensure residents adhered to proper droplet precautions; 2. Ensure staff adhered to droplet precautions during meal pass. These deficient practices resulted in the high likelihood of spreading coronavirus and harmful pathogens among four residents (R#701, 702, 703, 704), second floor residents that received direct care from staff, second floor residents that interacted with each other, residents that resided on the first floor that received food from the kitchen, and nine residents that transferred to the hospital testing positive for COVID-19, resulting in an immediate jeopardy affecting residents residing in the facility. The total resident census for this facility was 165. The initial Immediate Jeopardy (IJ) was identified on [DATE] at 10:45 AM and began on [DATE]. The facility Administrator was notified of the IJ and a request for a written plan of correction for removal occurred on [DATE] at 2:55 PM. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance with a scope and severity of wide spread, no actual harm with potential for more than minimal harm that is not immediate jeopardy after acceptance and on site verification of the facility's abatement plan. Findings include: The facility document titled, Admission/Discharge To/From Report, dated [DATE] was reviewed and revealed, in part the following: -Nineteen (19) residents expired in the facility. Three (3) residents died between [DATE] and [DATE]. Sixteen (16) residents died in the facility between [DATE] and [DATE]. -Sixteen (16) residents were sent from the facility to an acute care hospital between [DATE] and [DATE]. On [DATE] at 11:24 AM, the facility Administrator revealed that nine of the sixteen residents transferred to the hospital tested positive for COVID-19. The transfer dates of the nine residents that tested positive for COVID-19 occurred between [DATE] and [DATE]. -Resident #705 In an observation on [DATE] at 10:48 a.m., Nurse H opened Resident #705's room door. Nurse H had on a gown with one arm not covered and tied around her neck. When asked if she recognized the gown was not on properly, Nurse H looked down and sighed, then corrected gown placement with gloved hand. In an observation and interview on [DATE] at 10:50 a.m., Resident #705 sat in the hallway and ate a cracker without a mask covering the mouth or nose. A bedside table with a hospital basin which included toothpaste, a toothbrush, lotion and crackers sat in front of Resident #705. Resident #705 reported, I'm doing better. I will feel better when this is all over. In an interview on [DATE] at 10:52 a.m., Nurse J reported Resident #708, Resident #705's roommate had precautions for pneumonia. When asked if Resident #705 should be sitting in the hall, Nurse J then stated, I don't think so, I'll get him back in his room. In an interview on [DATE] at 10:55 a.m., Nurse H reported Resident #705 should always wear a mask when in the hallway. In an interview on [DATE] at 10:56 a.m., the Assistant Director of Nursing (ADON) reported the staff does rounds to ensure Resident #705 wears a mask. The ADON reported all residents should wear a mask when they are in the hall. Review of an admission record revealed, Resident #705 was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment, with a reference date of [DATE], revealed Resident #705 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. Resident #705 required oxygen. -Resident #708 Review of an admission record revealed, Resident #708 was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of a MDS assessment, with a reference date of [DATE], revealed Resident #708 had moderate cognitive impairment with a BIMS score of 11, out of a total possible score of 15. Review of progress notes for Resident #708 with a date of [DATE] at 4:42 p.m. revealed, Note Text: Isolation: Droplet precautions x 14 days . On [DATE] at 3:15 p.m., .Due to changes in condition. Utilizing the Covid-19 wavier per CMS (Centers for Medicare & Medicaid) guidelines. Resident currently on droplet precautions, using O2 (oxygen) via nasal cannula and receiving ATB's (antibiotics) . Review of a physician order for [REDACTED]. -Residents #701, #702, #703, #704 On [DATE] at 11:26 a.m., Nurse P confirmed the resident census for the second floor, Unit 3 as 39, with three nurse aides and two nurses providing direct care services to residents. Nurse P was then asked to give the room numbers of those residents who are on isolation precautions. Nurse P identified fourteen rooms. On [DATE] at 12:10 p.m., CENA Q was observed retrieving a meal tray from the meal cart located in the hall. CENA Q had long pink nails and was not wearing gloves. She did have on a mask and hair covering. CENA Q was then observed going into R#701's room which had a Droplet Precaution sign posted on the door and red containers located by the door. CENA Q was seen placing the meal tray on the bedside table which was located within a couple of inches from the Resident. CENA Q was then observed assisting the Resident with meal set up (removing lids from beverages, removing plate cover, and placing eating utensils within reach) without wearing a gown or gloves. A review of R#701's clinical record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the Resident was severely cognitively impaired and required limited one-person assistance with eating. Review of the Physician's orders dated [DATE] documented: -Droplet precautions r/t (related to) influenza every shift. Effective [DATE]. - XXX[DATE] This Medicare admission meets the qualifications for using the COVID-19 outbreak waiver. It is related to the crisis by the following: (R#701) is currently a resident in our facility requiring Medicare skilled services. Area hospitals are unable to admit as their beds are full due to COVID 19 outbreak. A care plan titled Respiratory Infections, date initiated [DATE] was reviewed and documented as: The resident is at risk for respiratory infection r/t comorbidities. On [DATE] at 12:13 p.m., CENA Q was observed exiting R#701's room, going back into the meal cart, and removing another meal tray. CENA Q was then observed going into R#702's room which was identified as a Droplet Precaution room. CENA Q entered the Resident's room without PPE and was then observed assisting the Resident in room with meal set up which included cutting up the meat that was on the tray. At this time, CENA Q was not wearing gloves or gown and was positioned within inches of the Resident. CENA Q was not observed washing her hands or using hand sanitizer which was in a dispenser within the room before exiting. A review of R#702's clinical record documented the Resident was initially admitted into the facility on [DATE] with the most recent readmission on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the Resident was moderately cognitively impaired and required supervision and set up assistance with eating. Review of the Physician's order dated [DATE], Droplet precautions R/O (rule out) RSV (Respiratory [MEDICAL CONDITION]), Influenza, and [MEDICAL CONDITION] PNA .(Pneumonia). Effective [DATE]. A care plan titled Respiratory Infections, initiated on [DATE], was reviewed and documented as: The resident is at risk for respiratory infection r/t comorbidities. On [DATE] at 12:15 p.m., CENA Q was seen exiting R#702's room, going back into the meal cart, and removing another meal tray. CENA Q delivered that meal tray to room [ROOM NUMBER] which did not have the Droplet Precaution sign on the door nor was the room identified by Nurse P as an isolation precaution room. On [DATE] at 12:17 p.m., CENA Q was seen exiting room [ROOM NUMBER], going back into the meal cart, removing another meal tray, and proceeding to R#703's room which was identified as a Droplet Precaution room. CENA Q was observed entering the room without wearing a gown or gloves with meal tray. CENA Q proceeded to assist the Resident with meal set up. A review of R#703's clinical record documented the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], the Resident was moderately cognitively impaired and required supervision and set up assistance with eating. Review of the Physician's orders revealed the following: -[DATE] documented Droplet precautions r/t influenza every shift. Effective [DATE]. -[DATE] This Medicare admission meets the qualifications for using the COVID-19 outbreak waiver. It is related to the crisis by the following: (R#703) is currently a resident in our facility requiring Medicare skilled services. Area hospitals are unable to admit as their beds are full due to COVID 19 outbreak. Effective [DATE]. A care plan titled Respiratory Infections, initiated [DATE], was reviewed and documented as: The resident is at risk for respiratory infection r/t comorbidities. On [DATE] at 12:19 p.m., CENA Q was observed exiting R#703's room, returning to the meal cart, pouring coffee, and removing a meal tray from the cart. CENA Q proceeded to R#704's room which was not identified as a Droplet Precaution room and assisted with meal set up. Per chart review, R#704 was being monitored and treated for [REDACTED]. A review of R#704's clinical record documented the Resident was initially admitted into the facility on [DATE] with a most recent readmission on [DATE] with [DIAGNOSES REDACTED]. According to the annual MDS assessment dated [DATE], the Resident was severely cognitively impaired and required extensive one-person assistance with eating. Physician's orders for R#704 documented she was currently receiving two antibiotics ([MEDICATION NAME] and [MEDICATION NAME] Solution) for pneumonia. There was no Physician's order for Droplet Precautions. A care plan titled Respiratory Infections, date initiated [DATE], was reviewed and documented as: The resident is at risk for respiratory infection r/t comorbidities. On [DATE] at 12:20 p.m., CENA Q exited R#704's room, returned to the meal cart, poured coffee, and proceeded to enter room [ROOM NUMBER] which did not have the Droplet Precaution sign on the door nor was the room identified by Nurse P as an isolation precaution room. CENA Q assisted with meal set up and was seen exiting the room. On [DATE] at 12:21 p.m. CENAs R and S began to assist with meal pass. CENA R, CENA S, and Nurse P were observed preparing to apply PPEs (gown, gloves, and face shield). On [DATE] at 12:22 p.m., CENA Q was heard asking Nurse P, Should I gown up before going into room [ROOM NUMBER] even if I'm just dropping off a tray? Nurse P was heard saying to CENA Q, Yes. CENA Q was then observed sitting the meal tray on top of the isolation cart and apply a gown and gloves before entering room [ROOM NUMBER], which was identified as a Droplet Precaution room. On [DATE] at 2:50 p.m., CENA Q was interviewed and asked did she receive in-servicing on the proper use of PPEs. CENA Q stated, I received it last week once I returned to work from being off. CENA Q was then asked was she aware that she should wear gloves and gown in addition to wearing mask and hair covering when entering Droplet Precaution rooms during meal pass. CENA Q stated, I truly was not aware that I should gown up, but I know I'm supposed to now. On [DATE] at 2:20 p.m., when the Director of Nursing (DON), who was also the facility's Infection Preventionist, was queried about their current supply of PPE, she said, We are constantly receiving PPE supplies. We are not short now. On [DATE] at 3:49 p.m., the DON was interviewed and asked what the expectation for all staff was to implement proper Droplet Precautions including the use of PPEs. The DON stated, All staff have been in-serviced on 'Droplet Precautions' and should be implementing safe practices at all times. -Meal Cart On [DATE] at 11:25 AM, a food service cart, used for transporting meal trays to resident rooms was observed in the first-floor dining room. When Dietary Aide D was requested to open a stainless-steel meal cart, visible food residue was observed inside the cart. When a clean paper towel was used to wipe the inside of the food cart, food residue and black grime was observed on the paper towel. When Dietary Aide D was queried about her observations of the paper towel, she said, It's dirt; left over food. I'm not sure; I know it looks dirty. On [DATE] at 11:33 AM, when the Dining Services Director E (DSD E) was queried about her expectations for cleaning the meal carts, she said, We wipe them down after every meal using a sanitizer. We deep clean them monthly. When the DSD E was shown the paper towel used to wipe the inside of the stainless-steel food transportation cart, she said, I see dirt. On [DATE] at 1:09 PM, a telephone interview was conducted with the DSD E. When queried if the facility had been using the fiberglass meal trays during [DATE], the DSD E said, Yes. When queried about the importance of cleaning and sanitizing food transportation carts, the DSD E said, We don't want any cross contamination. Whatever comes back on the cart needs to be cleaned up before we put anything clean back on it. Facility Abatement Plan --Immediate Actions taken by the Facility: Meals will be passed to residents who are on isolation precautions by staff wearing appropriate PPE; gloves, gowns and masks; Meal carts used for transporting meal trays will be cleaned and disinfected on [DATE]. --Infection Preventionist Nurse, Director of Nursing, Medical Director, and Executive Director will be educated [DATE] on the following: Infection prevention and control program; Outbreak and/or Pandemic Control and Management policy; -COVID-19 Outbreak Policy. --Facility staff will be educated [DATE] or before working their next shift on the following: Infection prevention and control program; Outbreak and/or Pandemic Control and Management policy; COVID-19 Outbreak Policy; PPE policy; Transmission-based Precautions and Isolation Procedures. --Residents who are on droplet precautions will follow appropriate practices when outside their rooms: Staff will encouraged residents with dementia to utilize masks or cover face with Kleenex in presence of others; Staff will encourage residents with dementia to maintain current social distancing practices. --Medical Director notified of Immediate Jeopardy on [DATE] and agrees with above plan. --Deficient practice #2. Based on observation, interview, and record review, the facility failed to properly maintain infection control practices during a COVID-19 Infection Control Survey by failing to ensure all droplet precaution supplies (container or bags designated for waste or linen) were readily available. This deficient practice resulted in the potential for spreading communicable and harmful pathogens among residents that reside on the second floor. Findings include: On [DATE] at 12:28 p.m., R#707's room was identified to be an isolation room by the Droplet Precaution sign posted outside of the closed door. R#707 was observed resting in bed watching television, and stated she was doing fine. On [DATE] at 12:32 p.m., upon exiting the room, the DON was standing at the nurse's station located directly in front of R707's room and offered the Surveyor new PPEs. The Surveyor stepped back from the room's doorway and further back into the room, looking for the isolation waste containers to discard gown, gloves, and mask before removing them. Isolation waste containers or bags were not in sight within the room. The Surveyor stepped back into the doorway and asked the DON was the removal of PPEs supposed to be done somewhere else because isolation waste containers or bags were not in the room. The DON asked the Surveyor to stand in the doorway as she instructed staff to look for a waste container. On [DATE] at 12:40 p.m., the DON presented a clear plastic bag that looked like a basic large garbage bag in which the PPEs were discarded in. At this time, the DON was asked if R#707 was on Droplet Precautions, why isn't all the supplies readily available for use. The DON stated, We just started monitoring this room for symptoms, so we don't have everything just yet. On [DATE] at 12:47 p.m., a staff member who looked to have been from the Maintenance Department presented two large red containers and placed them in R#707's room. A review of R#707's clinical record documented the Resident was initially admitted on [DATE] into the facility and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the Resident was moderately cognitively impaired and required extensive two-person assistance with activities of daily living. Review of the Physician's order dated [DATE] documented: --Droplet precautions every shift. Effective [DATE]. --This Medicare admission meets the qualifications for using the COVID-19 outbreak waiver. It is related to the crisis by the following: (R#707) is currently a resident in our facility requiring Medicare skilled services. Area hospitals are unable to admit as their beds are full due to COVID 19 outbreak. Effective [DATE]. A care plan titled Respiratory Infections, date initiated [DATE] was reviewed and documented as: The resident is at risk for respiratory infection r/t comorbidities. On [DATE] at 3:45 p.m., the DON was interviewed and asked how soon all necessary PPE supplies should for Droplet Precautions be available for use. The DON stated, As soon as possible. Everything should have been in place. --Deficient practice #3. Based on observation, interview, and record review, the facility failed to properly maintain infection control practices during a COVID-19 Infection Control Survey by failing to consistently monitor the water temperature of a high temperature dishwashing machine, resulting in a potential for the spreading of communicable and harmful pathogens among all 165 residents that received meals from the kitchen. Findings include: On [DATE] at 11:40 AM, when the DSD E was queried about the frequency of testing the temperature of the dish machine, she said, They're supposed to check it before each meal. When the facility document titled, Dish Machine Temperature Log, for [DATE] was reviewed with the DSD E, several instances of temperature documentation were omitted. Dish machine temperatures were not documented on the following dates for the meals as indicated: -Breakfast: [DATE], [DATE], [DATE], and [DATE] through [DATE] -Lunch: [DATE], [DATE], [DATE], [DATE] through [DATE] -Dinner: [DATE], [DATE], and [DATE] The dish machine temperature log indicated the temperature was taken for breakfast on [DATE]. On [DATE] at 1:09 PM, during the telephone interview with the DSD E, she was queried about the importance of testing the dish machine temperature. She said, It's very important to make sure that we keep track and record all temperatures for the dish machine. The DSD E added, It's a high temperature dish machine and that's what sanitizes our dishes. We need to make sure everything is sanitized and ready to go for the residents. The following facility policies and documents were reviewed and indicated, in part, the following: Per review of staff education document titled, Droplet Precautions, undated, revealed: Used for persons known or suspected to be infected with pathogens transmitted by respiratory droplets. A person who is coughing, sneezing, or talking generates such droplets. Personal Protective Equipment: Don a mask, gloves and gown entering the resident's room. Step more than 3 feet from resident then remove and discard contaminated PPE and perform hand hygiene prior to leaving room. Per review of staff education document titled, Sequence For Putting On Personal Protective Equipment (PPE) from the CDC revealed, . 1. Gown: Fully cover torso from neck to knees, arms to end of wrists and wrap around the back. Fasten in back of neck and waist. According to the CDC (Center for Disease Control) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, updated [DATE] documented the following: --Patients and visitors should, ideally, be wearing their own cloth face covering upon arrival to the facility. If not, they should be offered a facemask or cloth face covering as supplies allow, which should be worn while they are in the facility (if tolerated). They should also be instructed that if they must touch or adjust their cloth face covering they should perform hand hygiene immediately before and after. Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. --Mode of transmission: Current data suggest person-to-person transmission most commonly happens during close exposure to a person infected with [MEDICAL CONDITION] that causes COVID-19, primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes. Droplets can land in the mouths, noses, or eyes of people who are nearby or possibly be inhaled into the lungs of those within close proximity. Transmission also might occur through contact with contaminated surfaces followed by self-delivery to the eyes, nose, or mouth. HCP (Health Care Personnel) who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. Gowns: Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. If there are shortages of gowns, they should be prioritized for: aerosol generating procedures, care activities where splashes and sprays are anticipated, high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of HCP. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#Patient_Placement Per review of document titled, Water Temperature Inspection, dated [DATE], revealed: Purpose: to promote patient safety and prevent injury by ensuring that the water supplied to the facility is the correct temperature to [MEDICAL CONDITION] maintain correct infection control techniques. Procedure: The temperature of the wash and rinse cycle will be recorded on a high temperature dish machine. Per review of document titled, Guide to Infection Prevention and Control, undated, revealed: Dishwashers: temperature checks are to be recorded a minimum three times daily, Breakfast, Lunch, and Dinner. Temperatures should be checked at the beginning and end of dish machine use. Per review of document titled, Cleaning Schedule, dated [DATE], revealed: The Director of Food and Nutrition Services develops a cleaning schedule, with assistance from the Registered Dietitian, to ensure that the Food and Nutrition Services department remains clean and sanitary at all times. A review to the 2013 FDA Food Code revealed the following: Section ,[DATE].112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures: (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194 ºF, or less than: (1) For a stationary rack, single temperature machine, 165 ºF; or (2) For all other machines 180 ºF. Section ,[DATE].11. Equipment Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be cleaned (5) at any time during the operation when contamination may have occurred. ,[DATE].13, Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

This citation has two deficient practices. Deficient practice #1: The Bureau of Community and Health Systems, Department of Licensing and Regulatory Affairs, has identified A situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. (See 42 CFR Part 489.3.) Based on observation, interview and record review, the facility failed to follow infection control practices for one (#521) of two sampled residents in contact isolation identified with Clostridium Difficile infection, a potentially life-threatening form of diarrhea that produces toxins, which create spores that can be easily spread from resident to resident, from a total of 31 residents, resulting in immediate jeopardy, potentially affecting the other 22 residents residing on the 1 East nursing unit. The Immediate Jeopardy was identified: On 10/24/17 at 12:30 PM. The Administrator was notified on 10/25/17 at 5:45 PM and a written plan for removal was requested. The immediacy was removed on 10/26/17 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 isolated with the potential for harm that is not immediate jeopardy. Findings include: Facts Supporting Immediate Jeopardy: Nurse 'B' was observed providing care for resident #521 with Clostridium Difficile without use of personal protective equipment (PPE) and proper handwashing, then immediately leaving the resident's room to provide care for other residents on the 1 East nursing unit. (Details to follow.)` On 10/24/17 at 12:30 PM, nurse 'B' was observed preparing medications in the hallway on the 1 East nursing unit for resident #521, who was in contact isolation for Clostridium Difficile (C.diff) and was to receive the medications via gastric feeding tube. There was a sign on the doorway notifying those who wanted to enter the room to first check with the nurse due to isolation precautions being in effect and there were bins outside of the room door containing PPE (gowns and gloves). The nurse entered the room with one crushed pill mixed in water in a medication cup and a vial of liquid nebulizer medication, without donning a gown. Nurse 'B' donned clean gloves from a box in the room without first washing hands and began to search underneath the resident's covers, gown and then underneath the resident's buttocks, covered by an incontinence brief, for the tip of the gastric feeding tube, without success. The bed covers came in contact with the front of the nurses' uniform. The nurse attempted to roll the resident off her back to locate the tip of the tube, but was unable. The resident was totally immobile with both knees permanently flexed (contracted) up to the waist area. Nurse 'B' said that staff had just cleaned the resident causing the tube to become wedged under the resident during turning from side to side. Again, the nurse dug underneath the resident and found the tube, but the cap of the tube had come off and was missing. The uniform contacted the linen. The nurse said, I have to get someone to help me turn (the resident). She went to the doorway, looked down the hall and asked an employee to get a nurse aide to help her. The employee asked nurse 'B' what she needed help with and was told that the resident needed to be turned. The employee entered the room and said, I can help you with that, without donning a gown. The employee and nurse 'B' rolled the resident to the right side. There was a strong, foul odor detected when the resident was turned. The front of the second employee's uniform came in contact with the resident. Nurse 'B' located the cap of the feeding tube, the resident was turned back to a supine position and the second employee left the room. The nurse gave the medications, removed the gloves she had worn the entire time, washed hands and donned new gloves while waiting for the nebulizer to complete. As she was exiting the room, an employee in a resident's room across the hall asked for immediate assistance with that resident. Nurse 'B' was observed entering the room to assist. On 10/25/17 at 11 AM, nurse 'B' was observed entering resident #521's room with medications, without wearing a gown. She lifted the covers and located the feeding tube underneath the resident's gown. After administering the medications, the nurse exited the room and was asked why a gown was not worn on 10/24/17 by herself and the employee who helped turn the resident and why a gown was not worn at that time. Nurse 'B' said, I know I was supposed to wear a gown. I didn't know I was going to be doing all that. When asked who the other employee was, she said, She wasn't an aide. She was from therapy. When asked about not washing hands before donning gloves and not washing hands and changing gloves between looking for the tube and giving the medication, she said, I know. I had gel (hand sanitizer), but that's not good enough. You're supposed to wash your hands. The nurse was not observed using hand sanitizer. When asked about the odor when the resident was turned, nurse 'B' said, She has a lot of wounds (including on the sacral area) and she has C.diff. It (the smell) could be coming from either place. On 10/25/17 at 4:10 PM, when informed about nurse 'B' not wearing a gown during direct care of a resident in isolation for C.diff and immediately providing care to others, the Director of Nursing (DON) said, If a resident is in isolation for C.diff, you should wear a gown if providing care. Regarding hand washing and use of hand sanitizer in that situation, the DON said, No, you have to use soap and water. On 10/25/17 at 4:30 PM and 4/26/17 at 11 AM, the clinical record for resident #521 was reviewed. The resident was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].diff, diabetes, dementia, heart failure and [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted the resident had severe cognitive impairment, was non-ambulatory, required extensive assistance for bed mobility, impaired range of motion to all extremities and had nine wounds. Per hospital records, the resident had a history of [REDACTED].diff. The resident was readmitted into the facility on [DATE], prescribed [MEDICATION NAME] (antibiotic) for 10 days an placed in contact isolation. An order was written on 10/25/17 to obtain a stool sample to test for C.diff toxins. The report noted that C.diff toxins were still detected in the specimen. Orders were written on 10/26/17 for IV (intravenous) [MEDICATION NAME] and for [MEDICATION NAME] (antibiotic), both for 10 days and contact isolation. Per review of [DIAGNOSES REDACTED] Daily Progress Notes: On 10/20/17 midnight shift-one bowel movement (BM), watery diarrhea, foul smelling. On 10/20/17 day shift-one BM, loose stool but not watery, foul smelling. On 10/21/17 day shift-one BM, loose, but not watery, foul smelling. On 10/23/17 afternoon shift-two BMs, watery diarrhea. Per daily BM Monitoring records: On 10/24/17 and 10/25/17-extra large BM on midnight shift and one large BM on the day and the afternoon shifts each day. Per a nursing progress note dated 10/26/17 at 7:36 AM, the resident had one loose stool. Per review of a Complex[DIAGNOSES REDACTED] care plan dated 8/30/17 for resident #521, interventions included: Maintain a clean isolation cart outside the room or just inside if feasible and Staff to wear personal protective equipment when providing direct care with resident at site of infection. A review of the day shift work assignment for nurse 'B' and review of medication records, revealed that nurse 'B' was assigned to a total of 23 residents on the 1 East nursing unit in rooms 101 to 110 and had given medications scheduled for 9 AM, 11:30 AM, 12 noon and 1 PM to those residents on 10/24/17, including resident #521 and the 9 AM medications on 10/25/17. Facility in-service education documents noted that training on C.diff, isolation, PPE and handwashing was conducted in 9/2017. There was no documented indication that nurse 'B' received the training, based on review of staff sign-in attendance sheets. On 10/26/17 at 5 PM, per review of the facility's policy on Transmission-based Precautions and Isolation Procedures dated 11/28/16: Minimize risk of spread of infections between facility patient and/or associates Control spread of infection by intercepting its method of transmission from person to person Contact Precautions are used for diseases transmitted by contact with the patient or the patient's environment by direct or indirect-contact Direct-contact transmission involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized person, such as occurs when personnel turn patients or perform other patient-care activities that require physical contact. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's environment Wear a gown and gloves on room entry gowns/protective apparel-if contact with infectious material is anticipated Materials required for isolation typically include barrier clothing Per review of the facility's policies on Hand Hygiene dated 4/1/2015 and Clostridium Difficile dated 4/2017: -Handwashing/hand hygiene is generally considered the most important single practice for preventing nosocomial infections Note: Because alcohol-based hand rubs do not kill spore-forming organisms, they should not be used by staff when caring for residents with infections caused by spore forming organisms. Examples are Clostridium Difficile Staff will use antimicrobial soap and water -What is different about Clostridium Difficile? .It reproduces by making spores. These spores can live for a long time, outside the body and can live on countertops and other surfaces. The facility submitted the following acceptable Plan of Correction of immediate jeopardy on 10/26/17, including supporting documentation to remove the immediacy related to F441: 1. The infection control nurse immediately contacted the nurse involved after DON met with the state surveyors regarding the breach in contact isolation with cdiff resident on station 1. The nurse was educated on contact isolation with regards to cdiff infections including the use of personal protective equipment when providing direct care and hand washing before and after care per our policy. 2. After notification of immediate jeopardy the nurse in question was suspended pending investigation and to immediately remove the potential for harm. 3. All residents who reside on 1 East hall were assessed for bowl patterns, loose watery stools, and signs and symptoms of cdiff. 4. The medical director was contacted and the DON discussed the situation with him. The medical director determined that the residents residing on the east hallway on station 1 should be monitored for the next 30 days for any signs and symptoms of a cdiff infection. Any residents who show any signs will have their PCP contacted immediately. The resident's Dr. was also contacted regarding the situation and stat blood work was ordered to determine if it was an acute infection. 5. The current policy was reviewed and does not need to be updated. 6. There are no patterns of[DIAGNOSES REDACTED]. There is only one other person in the building with cdiff and it was hospital acquired and admitted with just as the resident in question was. These two residents are on different units of the building. Since the resident in question was admitted on [DATE], there have been no in-house acquired cdiff cases on station one on the east hallway. Reviewing the isolation log, we have only had two in-house acquired cdiff residents in 2017. One was on station 3 after being treated with antibiotics for ESBL in his urine. The other one was on station 2 and treated with two rounds of antibiotics for sepsis and after the second round developed cdiff. 7. Immediate terminal cleaning utilizing bleach of all rooms on 1 east nursing unit including hallway, nurse's station, med carts, and med room was conducted by interdisciplinary team and completed on 10/25/2017. 8. Immediate education was provided to nursing staff currently working in the building by the infection control nurse regarding contact isolation for residents on cdiff precautions and the use of personal protective equipment and proper handwashing. 9. All staff will be educated on contact isolation regarding cdiff and the use of personal protective equipment and proper hand washing by 10/27/17. Deficient practice #2. Based on observation, interview and record review the facility failed to follow proper hand washing procedures during wound care for one sampled resident (# 501), failed to properly clean and store nebulizers (NMT-a drug delivery device used to administer a mist inhaled into the lungs) and gastric feeding tube equipment for one sampled resident (# 521) out of seven residents reviewed for infection control practices out of a total sample of 31 and one supplemental sampled resident (#166), resulting in the potential for spread of infection. Findings include: Resident #501 On 10/25/17 at 9:30 a.m., during wound care for R#501 with treatment Nurses N and O the following observation was made. Nurse N donned a pair of gloves and cleansed the right ischial (lower buttocks region) wound peri area (area surrounding the wound) and with the same, potentially contaminated gloves, Nurse N then layered a barrier cream and an antifungal cream around the wound. Nurse N then removed the gloves, washed his hands, donned a clean pair of gloves and proceeded to cleanse the left ischial (lower buttock) wound. Directly adjacent to the left ischial wound was a brief soiled with drainage from the wounds. Nurse N asked Nurse O to turn R#501 more onto her left side (to move her further away from the soiled brief). Without first removing the soiled brief from the wound care field, Nurse N proceeded to cleanse and change the dressing on the left ischial area. After the wound care, Nurse N and Nurse O removed the soiled brief and put a clean brief on the resident. On 10/25/17 at 10:00 a.m., Nurse N was interviewed and asked about the hand washing with the wound care and stated, I don't remember doing that. On 10/26/17 at 1:00 p.m., Nurse O was interviewed and asked about the soiled brief being in the wound care field to which she responded, I wasn't on that side, I was on her left side. I couldn't see how close the brief was to the wound. Nurse O was asked why the brief was just not removed completely prior to the start of wound care to which she responded, Yeah, it should have. It was changed and removed anyway. Record review for R#501 revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident was cognitively intact and required extensive two person assistance with most activities of daily living (ADL's). Review of the facility's policy titled Hand Washing dated 4/1/15 documented, .Although antiseptics and other handwashing agents do not sterilize the skin, they can reduce microbial contamination depending on the type and amount of contamination, the agent used, the presence of residual activity and the handwashing technique followed. Review of the facility's undated policy titled, Steam Inhalator documented, Procedural Steps: .After treatment is complete, throughly wash and dry inhaltor and return to proper storage. Resident #166 On 10/24/17 at 9:00 a.m., during the initial tour of the Station Four nursing unit, observation was made of an NMT mask sitting on the resident's overbed table next the the resident's breakfast tray. At 9:05 a.m., Nurse E entered the room and was asked about the storage of the NMT mask. Nurse E stated, It (the mask) should have not have been left on the resident's over bed table. It should be bagged up and place in the drawer of the bedside table. Record review revealed that R#166 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the residents cognition was moderately impaired and required extensive assistance with all activites of daily living. Resident #521- On 10/24/17 at 12:30 PM, nurse 'B' was observed preparing medications in the hallway on the 1 East nursing unit for resident #521, who was in contact isolation for Clostridium Difficile (C.diff), a potentially life-threatening form of diarrhea that produces toxins, which create spores that can be easily spread from resident to resident. The resident was to receive the medications via gastric feeding tube and nebulizer (inhaled by mask). The nurse entered the room carrying one crushed pill mixed in water in a medication cup and a vial of liquid nebulizer medication. The nurse placed the medications, a syringe used to deliver the medication through the tube and the syringe plunger directly on the resident's overbed table without cleaning the table or placing a clean field underneath. While wearing gloves, nurse 'B' proceeded to search at length underneath the bed covers, the resident's gown and the resident's body for the tip of the resident's gastric tube. She then began to dig underneath the resident and covers and turn the resident to the right side to search for the cap of the tube that had become disconnected. There was a strong, foul odor detected when the resident was turned. Without washing hands and wearing the same gloves, the nurse replaced the cap on the tube. The tip of the line coming from the tube feeding bag landed on the floor. The nurse picked it up, wiped it off with a dampened paper towel and looped it around the feeding pump. She then administered the crushed pill down the tube. Afterwards, nurse 'B' removed the nebulizer cup from a protective bag, squeezed the liquid medication into the nebulizer cup and placed the connected mask over the resident's face. The nurse removed the gloves that were worn since entering the room, washed her hands and donned new gloves while waiting for the nebulizer to complete. After removing the mask, the nurse used a paper towel to wipe the inside of the mask and a gauze pad to wipe the inside of the nebulizer cup rather than rinsing out the equipment. She removed the gloves, washed hands and exited the room. On 10/25/17 at 11 AM, nurse 'B' was observed entering resident #521's room with medications on a blue plastic tray, a washable surface used to provide a clean field. After administering the medications, the nurse exited the room and was asked about not removing gloves, washing hands and changing gloves between searching for the tube and cap and giving the medication. She said, I know. I had gel (hand sanitizer), but that's not good enough. You're supposed to wash your hands. The nurse was not observed using hand sanitizer. When asked about using the blue tray and not providing a clean field on 10/24/17, the nurse said, I couldn't find my tray. I looked all over for it, but it was under (the resident). Regarding proper cleaning of the nebulizer equipment, the nurse said, You're supposed to wash it. On 10/25/17 at 4:10 PM, the Director of Nursing (DON) was asked about nurse 'B' not properly washing hands for the resident in isolation for C.diff, not establishing a clean field and properly cleaning resident care equipment. He said, regarding use of hand sanitizer in that situation, No, you have to use soap and water. On 10/26/17 at 6 PM, he said that the nebulizer equipment should be washed, cleaned and left in a clean bag to dry. On 10/25/17 at 4:30 PM and 4/26/17 at 11 AM, the clinical record for resident #521 was reviewed. The resident was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].diff, diabetes, dementia, heart failure and [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted the resident had severe cognitive impairment and had nine wounds. An order was written on 10/25/17 to obtain a stool sample to test for C.diff toxins. The report noted that C.diff toxins were still detected in the specimen. On 10/26/17, there were orders written for an antibiotic by IV (intravenous) and a second one via gastric tube for 10 days and for continuation of contact isolation. On 10/26/17 at 5 PM, per review of the facility's policies on Hand Hygiene dated 4/1/2015, Clostridium Difficile dated 4/2017 and Respiratory Medication Administration dated 2/20/15: -Handwashing/hand hygiene is generally considered the most important single practice for preventing nosocomial infections Note: Because alcohol-based hand rubs do not kill spore-forming organisms, they should not be used by staff when caring for residents with infections caused by spore forming organisms. Examples are Clostridium Difficile Staff will use antimicrobial soap and water -What is different about Clostridium Difficile? .It causes diarrhea (colitis) by producing a toxin unlike most bacteria. It reproduces by making spores. These spores can live for a long time, outside the body and can live on countertops and other surfaces. -Correctly disassemble equipment, rinse equipment, dry and place in plastic bag and leave in patient/resident's room to maintain function and to prevent contamination of equipment.

Based on observation, interview and record review, the facility failed to provide documented evidence that restorative range of motion services were provided in accordance with the plan of care for one (#811) of ten sampled Residents reviewed for range of motion/contractures/positioning in a total sample of 29, resulting in Resident #811 experiencing a decline in functional range of motion status to the lower extremity, increased discomfort/pain, and the potential for continued functional deterioration. Findings include: Observations of Resident #811 lying in bed with the left leg flexed (bent upwards towards the torso) were made on 1/24/17 at 12:09 p.m., 2:15 p.m., 4:35 p.m., 1/25/17 at 9:11 a.m., 10:30 a.m., 12:30 p.m., 3:40 p.m., and 5:30 p.m. On 1/25/17 at 3:45 p.m., an interview and observation of the Resident was conducted with the Physical Therapist (Staff R who had previously worked with the Resident while on skilled therapy services from May - September 2016) and the Rehab Manager. When asked about the Resident's functional status upon discharge from skilled therapy on 9/9/16, Staff R reported, He hasn't been on skilled therapy since September 9th. He used to work on the bike. He wasn't walking but he was standing approximately 90 seconds and when he was discharged I set up a restorative program to do standing and range of motion exercises. At that time, when asked if therapy had been informed of any increase in pain or changes to the Resident's range of motion/functional status, both Staff R and the Rehab Manager replied, No. When asked what the process would be if restorative therapy noticed any changes, Staff R reported, The restorative staff would let us know and we would re-assess. At that time with the Resident's permission to assess the range of motion to the lower extremities, Staff R and the Rehab Manager began to move/stretch the Residents legs. Resident #811 was observed to have facial grimacing, wincing and verbalization of extreme pain when the left leg was attempted to be straightened out. The left leg was unable to be fully extended and at that time, Staff R stated, He had tone and was able to get the leg fully extended before (as of 9/9/16). On 1/25/17 at 5:30 p.m., an interview was conducted with the Resident's legal representative (LR) at the Resident's bedside. At that time, the LR was asked if she was aware of the restorative therapy services provided for Resident #811 and stated, None that I'm aware of. That's one of my concerns. He would love to be able to get up. Prior to admission, he was living with my mother and even though the stroke was in 1977 he was functioning. I noticed since stopping (skilled therapy) he's starting to put the leg up and have more pain. Throughout the interview, Resident #811 winced and yelled out each time the LR would attempt to touch the left leg/knee area. Review of the clinical record revealed Resident #811 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS) assessment, Resident #811 exhibited cognitive impairment (scored 8/15 on mental status exam), exhibited no behavior concerns, required extensive assistance with activities of daily living, and transfers, had functional limitations to both the upper and lower extremity and did not receive restorative therapy services during this assessment period. Review of the care plans included, 9/9/16 - Resident is at risk for developing an impairment in functional joint mobility. Interventions to be provided by the Restorative Aide included, Provide active assisted ROM if unable to complete without help and Cue resident to move through tolerated range - LOWE EXTREMITY. Resident #811 was also receiving treatment for [REDACTED]. Review of Resident #811's Care Directive dated 1/19/2017 11:58 AM documented approaches which included, Resident on Restorative - see restorative book for program. Review of the restorative binder included a single form for Resident #811 which identified Restorative Administration Record for the month of [DATE] and documented the following restorative exercises to be provided: Resident to stand from w/c (wheelchair) min assist for 30-80 seconds using hand rail. 3 x wk. There was no documentation (blank entries) for # min (length of time service was provided) and Initial (of staff who provided the service). Some of the entries were noted with an X on 1/1, 1/2, 1/5, 1/9, 1/10, and 1/11. Some of the entries were noted with a P on 1/6, 1/7, and 1/8. AROM (Active Range of Motion) to BLE (bilateral lower extremities). 3 x wk. The supporting documentation on the administrative record included: X on 1/1 and R on 1/4. There were only two documented entries of 15 under minutes provided on 1/2 and 1/11. Documentation on the back of the form noted, 1/2/16 9:55 a.m. Resident is unable to put pressure on feet. He is not permitted to wear shoes due to pain. Nurse notified. *ALSO - Having pain in left leg/hip w/PROM (passive range of motion). There was no other documented evidence included under this section of the form after 1/11/17 to identify restorative therapy services were provided, or that therapy had been notified of the change in status. Additionally, there was no documented evidence of any narrative summary of the Resident's response to each session, nor weekly evaluations by a licensed nurse of the Resident's progress and any changes in the restorative program as indicated per the facility policy. Review of Resident #811's Restorative Assessment forms included: 9/9/16, Standing from w/c .AROM to BLE 3 x weekly for 12 weeks. Resident to stand from w/c with min assist for 30-80 seconds using handrail 3 x weekly x 12 weeks. 12/5/16 Cont current orders. (The section for assessment and findings was left blank.) Review of the current Physician orders [REDACTED].>12/5/2016 Stop: 02/27/2017 Resident to stand from w/c min assist for 30-80 seconds using hand rail. 3 x wk. PRN - 1 times(s) a day 12/14/2016 Stop 03/08/2017 AROM to BLE. 3 x wk. PRN - 1 time(s) a day. Further review of the clinical record (both electronic and hard chart) revealed there was no restorative documentation available for review from September - December 2016. On 1/25/17 at 10:40 a.m., an interview and record review was conducted with Nurse Manager H. When asked about who oversees the facility's restorative program, Nurse Manager H stated, Me and Nurse Manager A oversee the restorative program. We have a team for restorative - two aides, now three do restorative. When asked if changes are noted during restorative sessions, how that information is communicated to the rest of the interdisciplinary team, Nurse Manager H stated, Usually aides communicate to us or the nurse. At that time, Nurse Manager H was asked to provide any additional restorative documentation. (There was no further documentation provided for restorative services by the end of the survey.) Upon review of the Resident's January 2017 Restorative Administration Record, Nurse Manager H confirmed the lack of documentation and when asked about the X entries stated, That would be days treatment not provided. When asked about the R and P entries, Nurse Manager H was unable to offer any explanation. At that time, Nurse Manager H identified that the documentation on the restorative notes had been completed by Restorative Aide M. Nurse Manager H was asked to arrange Restorative Aide M to get in touch for further discussion, however staff did not respond as requested by the end of the survey. On 1/25/17 at 4:05 p.m., an interview was conducted with Social Worker (SW Q) who confirmed she was assigned to Resident #811. When asked about whether Resident #811 exhibited any non-compliant behaviors or refusal of care, SW Q stated, I'm not aware of any non-compliant behaviors or refusal of care. He's very sweet. On 1/26/17 at 12:35 p.m., an interview was conducted with the Director of Nursing (DON). When asked about the concerns regarding the Resident's decline in functional range of motion status and lack of documented evidence that restorative services were provided, the DON acknowledged it was brought to his attention yesterday and reported, Yesterday we did an education with Restorative Aide M and went over providing care and services and documentation. When asked about why the restorative therapy services had not been provided as ordered, the DON was unable to offer any further explanation. At that time, the DON was requested to provide any additional restorative documentation available to review, however there was no further documentation provided by the end of the survey. On 1/26/17 at 3:00 p.m., review of the facility's undated Restorative Nursing Documentation policy provided by Administration included: .The MDS needs to reflect the use of these resources in achieving the beneficiary's functional goals. Therefore, documentation of restorative nursing measures must include the following .Record of the activities provided and the time (in minutes) each activity was provided. A narrative summary of the beneficiary's response to each session. Weekly evaluations by a licensed nurse of the beneficiary's progress and any changes in the restorative program . ( )

This citation has two deficient practices. Deficient practice #1: Based on observation, interview and record review, the facility failed to facilitate a thorough and timely evaluation of a fracture and failed to provide adequate pain management and consistent comfort measures for one (#814) of 14 sampled residents reviewed for pain from a total of 29, resulting in demonstrations of adverse behavior (anxiety, agitation, yelling, rejection of care) and experiencing prolonged pain due to delay in appropriate care and treatment. Findings include: On 1/24/17 at 8:30 AM, resident #814 was observed sitting in a 'wheelchair' near the nursing station. The resident was very agitated, confused, yelling and had noticeable dark bruising underneath the right eye. Staff began to wheel the resident around the unit and attempted to console her, but the yelling continued. She was taken into nurse unit manager 'A's office, but she was observed sitting alone in the room yelling. Staff then transported her to the dining room where the yelling continued. At 1 PM, resident #814 was observed being brought back up to the unit via 'wheelchair' with her daughter and was yelling as she came off the elevator. The daughter was observed immediately asking nurse 'E', Can she get a pain shot? The nurse said, I tried to give her a pill, but she wouldn't take it. She has a pain patch on ([MEDICATION NAME], a weekly 5 milligrams (mg) patch). The daughter said, I know, but we need to do something. Nurse 'E' said, I have to call the doctor. The nurse was observed calling the physician's office and leaving a message with office staff that the resident had breakthrough pain medication in pill form ([MEDICATION NAME] 5/325 milligrams (mg) every 6 hours PRN-as needed), but would not take it, so the daughter requested an injection. After completing the call, the nurse said that she was awaiting a call back with a prescription from the physician. The resident was placed in bed and the daughter stayed at the bedside. The resident could be overheard yelling through the closed door. At 1:30 PM, when asked, the daughter said that resident #814 had not yet received anything further for pain. She said, The pain pills work very well and she settles right down, but she refused to take them. At 4:15 PM, the resident was asleep in bed with the door closed and the daughter present. Nurse 'E' was then asked if she had given the resident any pain medication and she said, Yes. Her daughter talked her into taking a pill. The doctor never called back (with an order for [REDACTED]. A review of the resident's Control Substances Record revealed that a [MEDICATION NAME] tablet had been removed from the narcotic supply that morning at 4:45 AM, but per the resident's Medication Administration Record (MAR), the nurse did not note that it was given to the resident. The Control Substances Record noted that nurse 'E' had removed [MEDICATION NAME] tablets that morning at 11 AM, 1 PM and 1:30 PM, but had to waste (throw away) them because resident #814 refused to take them. Nurse 'E' noted on the MAR that the pill was finally taken at 2:30 PM and noted on the resident's Pain Flow Sheet that the current intensity pain level was 6 when it was given on a scale of 0-10 with 10 being the worse. She noted that in 30 minutes, the pain level was 5, in one hour it was at level 4 and in three hours it was at level 3. (However, at the survey exit, the facility presented a Pain Documentation form where nurse 'E' noted that the resident's pain level was zero that day during her 7 AM-3 PM shift, contradicting what she noted on the Pain Flow Sheet.) On 1/25/17 at 8:45 AM, resident #814 was observed sitting in a 'geri-chair' (a portable reclining chair) in the dining room. The resident was calm, talkative, but confused, smiling and did not appear in pain. The MAR noted that [MEDICATION NAME] had been given that morning at 1 AM and 6 AM. At 10 and 11 AM, the resident's clinical record and an Incident report were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted that the resident had severe cognitive impairment, required extensive assistance for care and had some complaints of pain. The MDS indicated that the level and intensity of pain could not be determined. The resident was prescribed [MEDICATION NAME] (for pain) twice a day. The Incident report noted: On 1/15/17 at 5:40 AM, resident #814 was observed on her right side on the floor in front of the wheelchair. The resident sustained [REDACTED]. Her right head-red-swollen-bruised. Ice was applied to the head and neurological checks were performed. There was an X-ray report dated 1/18/17 noting that the resident had a [MEDICAL CONDITION] clavicle (collarbone). The reason for the X-ray: pain and bruising. Corrective measures to avoid re-occurrence on the Incident Follow-up and Recommendation Form included, a geri-chair for comfort, which was added to the resident's Falls care plan on 1/16/17. On 1/18/17 a right arm sling was added to the care plan for right clavicular fracture healing. However, when observed on 1/24/17 at 8:30 AM and 1 PM, the resident was not in a geri-chair and was not wearing a sling. On 1/25/17 at 4:05 PM, nurse manager 'A' was asked how the resident broke her clavicle and said, from the fall on 1/15(2017). Nursing notes were requested of the incident. There there were no documented notes during the morning of the fall on 1/15/17. When asked why, nurse 'A' said, The incident report is considered a note. Nurses noted the following for resident #814: 1/15/17 at 6:46 PM: Hematoma on right side of forehead. Slight redness noted with no swelling or bruising noted. Resident denies pain at this time. 1/16/17 at 2:20 AM: restless with agitation noted at times. Resident yells out at times Hematoma right side of forehead. No complaint of pain or distress. At 5:02 AM: While resident was being dressed, bruise was noted to right shoulder post fall. Bruising to right side of face/head is worsening also. At 10:48 AM: Bruise to right side of head and eye noted from fall. 1/17/17 at 3:46 AM: Bruises to right side of head and right shoulder remains. At 7:55 AM: Writer called to resident's room by (aide). Right shoulder slightly more red from previous fall No increased pain at site. At 11:24 AM: All 9 AM meds held. Resident refused resident 'yelled' Right shoulder redness and bruise to right eye. At 8:17 PM: Bruises to right side of face and shoulder remain unchanged. 1/18/17 at 2:37 AM: No signs/symptoms of pain No change in bruising or redness At 2:34 PM: Writer assessed right side of eye and bruising remains and right side of shoulder/clavicle bruised and diffused. Resident having facial grimacing. Writer attempted to give medication and resident spit all of medication out notified nurse practitioner about 8:22 AM regarding shoulder from previous fall and new order for stat x-ray to right shoulder obtained results negative. Doctor in to assess resident at bedside ordered new (x-ray) Nursing notes did not indicate that the physician was notified when the shoulder bruising first became apparent on 1/16/17. When asked why, nurse 'A' did not respond. There were no documented physician progress notes [REDACTED]. (During the survey exit, the facility provided the notes which documented that the resident was examined on 1/18/17. The physician noted the clavicle fracture and Large hematoma to right occipital area.) The [MEDICATION NAME] was then ordered. [MEDICATION NAME] was re-ordered on [DATE]. According to medication records, [MEDICATION NAME] was being given multiple times every day since the fracture, whereas before the fracture, it was given infrequently once a day. There was no order observed in resident #814's chart for pain medication by a non-oral route in case she refused to take the breakthrough pain pills again. When asked why, nurse 'A' said, I don't know. She (resident) is being seen by Palliative (Hospice) care (staff) right now and they will address it. Per review of a nursing note dated 1/16/17 at 4:16 PM: Family in support of resident having a palliative care consult with hospice for pain management referral made. The consult was ordered on [DATE]. The was no documented reason why the resident was not seen until 1/25/17 by Hospice staff. On 1/25/17 at 4:30 PM, the resident was observed in the dining room with her daughter. She was alert, confused, calm and appeared comfortable. She was in a wheelchair, not a geri-chair. The Controlled Substances record noted that the resident had previously received [MEDICATION NAME] at 1 PM. On 1/25/17 at 7 PM, a Now order for a [MEDICATION NAME] (antipsychotic) injection for severe agitation was observed in the clinical record when reviewed on 1/26/17 at 9:10 AM. When asked why, nurse 'A' reviewed a nursing note: Resident has extreme increase in agitation. Yelling, discomfort. MD called Nurse 'A' was asked if resident #814 was agitated that evening due to pain and if she had been given another dose of [MEDICATION NAME] after 1 PM on 1/25/17 before the [MEDICATION NAME] injection. Nurse 'A' looked at the resident's MAR and Controlled Substance record. The records noted that the [MEDICATION NAME] and a [MEDICATION NAME] tablet were both given at the same time at 7 PM. When asked how staff could determine if the agitation was pain related or not if the [MEDICATION NAME] and [MEDICATION NAME] were given simultaneously, nurse 'A' did not respond. When asked again if there were orders after the Palliative care consult for pain medication by non-oral routes if pills were refused, especially in lieu of the [MEDICATION NAME] being ordered by injection, nurse 'A' said, no. The 1/25/17 Palliative care Visit Summary was reviewed and revealed: Chronic pain: [MEDICATION NAME] recently started. [MEDICATION NAME] PRN [MEDICATION NAME] 50 mg twice a day. Will discuss with family for greater insight into pain history given patient is a poor historian Discuss with nursing and social worker. There was no mention of the fall and fractured clavicle. Per review of the resident's Pain care plan dated 11/1/16, the resident had arthritis, but no mention of the clavicle fracture. Interventions included: Administer/observe for effectiveness from pain medication, [MEDICATION NAME] PRN; Educate resident/family about pain management and to request pain med early before pain is out of control. There was no mention of the [MEDICATION NAME], the geri-chair or the arm sling. On 1/26/17 at 2 PM, when the delay in the X-ray and examination for the fracture and pain management for resident #814 was discussed with the Administrator, he did not respond and said that he would investigate further. On 1/26/17 at 6 PM, per review of the facility's undated Pain Management policy: the facility must ensure that pain management is provided to residents who require such services must ensure that the patient obtains optimal improvement or does not deteriorate to prevent or manage pain, the facility, to the extent possible: recognizes when the patient is experiencing pain and identifies circumstances when pain can be anticipated manages or prevents pain, consistent with assessment and plan of care ( ) Deficient practice #2: Based on observation, interview and record review the facility failed to consistently ensure Bilateral Palm Protectors were available and consistently applied for one (#823) of 10 residents reviewed for range of motion out of a total of 29 residents, resulting in the potential for further decline and functional ability. Findings Include: On 1/24/17 at 9:40 A.M., during the initial tour resident #823 right hand was observed protruding from under the covers. The resident's right hand was noted to be contracted. There was no assisted device, carrot or towel applied to the resident's hand. During the tour Unit Manager H identified that resident #823 was totally dependent on staff for all Activities of Daily Living and had intellectual/developmental disabilities. On 1/25 at 5:15 P.M., review of the physician Order's dated 12/1/16, documented: Palm Protector to bilateral hands at all times. Remove during bathing/ Activities of Daily Living care (ADL). On 1/25/17 at 5:30 P.M., during an observation both hands of resident #823 were observed contracted. The resident's hands did not have any Palm protectors of devices to prevent or minimize the contractures. On 1/26/17 at the following times resident #823 was observed in her room without the Palm protectors applied: 9:53 A.M., 11:10 A.M., 12: 30 P.M., and 12:40 P.M. During the observation at 12:40 P.M.,Nurse O was escorted to resident #823's room and asked if she knew where the resident's palm Protector were stored when they were not applied? Nurse O searched the resident's drawers, bedside table, wheelchair and closet and stated she could not find the palm protectors and she would check with the other staff on the floor and Unit Manager H. On 1/26/17 at 1:30 P.M., during interview with Unit Manager H she acknowledged The resident's Care Guide printed 1/19/17, did not provide instructions for the application of the palm protectors but she thought the palm protectors were in the Laundry. Unit Manager H later reported another set of Palm Protectors would have to be requested from Therapy along with instructions and clarifications for the staff since the resident's palm protectors were not located. Review of the resident's Admission Face sheet documented, resident #823 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE], revealed resident #823 was severely impaired in cognitive skills for decision making, totally dependent on staff to provide all activities of Daily Living (ADL's) and the resident had impairment of the shoulder, elbow, wrist and hands on both sides of her body. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND SAFETY DEVICES, AND FAILED TO FOLLOW PHYSICAL THERAPY RECOMMENDATIONS TO PREVENT FALLS FOR ONE ( # 714) SAMPLED RESIDENT OUT OF 5 RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 30, RESULTING IN MULTIPLE FALLS AND A FRACTURE. THE FACILITY ALSO FAILED TO ASSURE MEDICATIONS WERE NOT LEFT UNATTENDED AT THE BEDSIDE OF ONE ( # 703) SAMPLED RESIDENT AND ON TOP OF MEDICATION CART WITHIN VIEW OF OTHER RESIDENTS AND VISITORS FOR ONE (# 65) OFF-SAMPLED RESIDENT, RESULTING IN THE POTENTIAL FOR UNAUTHORIZED ADMINISTRATION OF MEDICATION. FINDINGS INCLUDE: ON 5/25/11 AT 8:45 A.M., RESIDENT #714 WAS IN THE DINING ROOM SEATED IN A WHEELCHAIR WITH A PRESSURE SENSITIVE PAD ALARM AND A SELF RELEASING, ALARMING SEAT BELT (SAFETY DEVICES). RESIDENT #714 WAS CONFUSED. ON 5/27/11 BETWEEN 10:10 A.M. AND 11:10 A.M., RESIDENT #714 WAS IN THE HALLWAY IN A WHEELCHAIR IN FRONT OF THE NURSING STATION WITH A PAD ALARM AND AN ALARMING SEAT BELT. THE RESIDENT WAS CONFUSED. THE RESIDENT MADE MULTIPLE ATTEMPTS TO STAND UP WITHOUT ASSISTANCE, CAUSING THE SAFETY ALARMS TO SOUND, AND STAFF TO INTERVENE. WHEN QUERIED, NURSE "D" THE UNIT INTERIM ASSISTANT DIRECTOR OF NURSING (ADON) REPORTED THAT RESIDENT #714 WAS CONFUSED, AND DID NOT REMEMBER THAT SHE COULD NO LONGER WALK UNASSISTED SINCE FRACTURING HER HIP.. ON 5/27/11 AT 12:00 P.M., RESIDENT #714'S CLINICAL RECORD AND FACILITY INCIDENT/ACCIDENT DATA ENTRY QUESTIONNAIRES (I&A) WERE REVIEWED WITH THE DIRECTOR OF NURSING (DON), AND REVEALED THAT THE RESIDENT HAD FALLEN SIX TIMES IN THE FACILITY DURING THE PREVIOUS YEAR, AND HAD SUFFERED A BROKEN HIP ON 4/28/11 AS A RESULT OF A FALL. ON 5/27/11 AT 1:20 P.M., RESIDENT #714'S PHYSICAL THERAPY AND OCCUPATIONAL THERAPY RECORDS WERE REVIEWED WITH THE PHYSICAL THERAPY MANAGER. REVIEW OF RESIDENT #714'S CLINICAL RECORD FACE SHEET, AND AN ACUTE CARE TRANSFER FORM DATED 4/29/11, REVEALED THE RESIDENT WAS admitted to the facility on [DATE], AND REadmitted on [DATE] AFTER A TRANSFER TO ACUTE CARE FOR A TRAUMATIC HIP FRACTURE. [DIAGNOSES REDACTED]. A MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] REVEALED RESIDENT #714 HAD MODERATE COGNITIVE IMPAIRMENT, AND HAD DIFFICULTY UNDERSTANDING INFORMATION AND MAKING HERSELF UNDERSTOOD. THE MDS ALSO REVEALED THAT RESIDENT #714 NEEDED STAFF SUPERVISION FOR MOBILITY IN BED, TRANSFER OUT OF BED, WALKING IN THE ROOM AND ON THE UNIT, AND REQUIRED EXTENSIVE ASSISTANCE FOR TOILETING AND PERSONAL HYGIENE, BUT WAS CONTINENT OF BOWEL AND BLADDER. THE MDS ALSO NOTED THAT RESIDENT #714 HAD SUFFERED FALLS WITHIN THE PAST THREE TO SIX MONTHS. FALL RISK ASSESSMENTS DATED 8/30/10, 10/7/10 AND 10/30/10 REVEALED SCORES OF 16,16, AND 18 RESPECTIVELY, WITH SCORES GREATER THAN 10 CONSIDERED "AT RISK" FOR FALLS. A PHYSICIAN'S ORDER FOR RESIDENT #714 DATED 8/30/10 STATED, "TAB ALARM (SAFETY ALARM) IN BED, DEFINED EDGE MATTRESS." A NURSING CARE PLAN ENTITLED, "POTENTIAL FOR FALLS" FOR RESIDENT #714, DATED 6/7/10, WITH UPDATED 11/30/10, 10/7/10, 10/30/10 REVEALED NO MENTION OF THE DEFINED EDGE MATTRESS OR THE BED ALARM, AND NO INSTRUCTIONS ON THE LEVEL OF SUPERVISION THAT RESIDENT #714 NEEDED FOR AMBULATION (WALKING) AND TRANSFERS. REVIEW OF AN I&A DATED 10/7/10 AT 8:30 P.M., REVEALED THAT RESIDENT #714 WAS FOUND ON THE FLOOR IN THE HALLWAY. THE REPORT DOCUMENTED THAT RESIDENT #714 WAS AMBULATING WITHOUT STAFF ATTENDANCE AT THE TIME, AND THE RESIDENT'S MOBILITY STATUS AS "INDEPENDENT". THE REPORT ALSO DOCUMENTED THAT RESIDENT #714 HAD FALLEN PREVIOUSLY WITHIN THE PAST 61 TO 90 DAYS (TWO TO THREE MONTHS). I&A FOR THESE PREVIOUS FALLS WERE REQUESTED BUT NOT PROVIDED. WHEN QUERIED, THE DON STATED THAT NO NEW SAFETY INTERVENTIONS WERE ADDED AFTER THIS FALL AS RESIDENT #714 WAS INDEPENDENT FOR AMBULATION AND TRANSFERS. THE DON COULD NOT EXPLAIN WHY THE MDS DOCUMENTED THAT RESIDENT #714 NEEDED SUPERVISION DURING AMBULATION, OR WHY A BED ALARM WOULD BE ORDERED FOR A RESIDENT THAT WAS ALLOWED TO GET UP INDEPENDENTLY. THE DON ALSO COULD NOT EXPLAIN WHY A RESIDENT WITH A FALL RISK SCORE OF 16 AND A HISTORY OF PREVIOUS FALLS WOULD BE CONSIDERED SAFE TO AMBULATE WITHOUT SUPERVISION OR STAND BY ASSISTANCE (STAFF STANDING CLOSE ENOUGH TO PHYSICALLY ASSIST THE RESIDENT IF NECESSARY). REVIEW OF AN I&A DATED 10/30/10 AT 7:30 P.M., REVEALED THAT RESIDENT #714 fell WITHOUT INJURY IN THE SHOWER WHILE ASSISTED BY A CERTIFIED NURSING ASSISTANT (CNA). THE WITNESS INTERVIEW FORM DOCUMENTED THE CNA STATEMENT AS, "HAD RESIDENT IN SHOWER ROOM IN LOCKED SHOWER CHAIR. TURNED TO CHECK TEMP OF WATER, HEARD A NOISE AND RESIDENT WAS ON FLOOR." THE INVESTIGATION DOCUMENTED THE RESIDENT'S MOBILITY STATUS AS "UNSTEADY GAIT." INTERVENTIONS TO PREVENT RE-OCCURRENCE WERE DOCUMENTED AS "SHOES ON FEET, AND ORTHOSTATIC B/P (BLOOD PRESSURE)." WHEN QUERIED ABOUT THIS, THE DON WAS UNABLE TO EXPLAIN HOW RESIDENT #714 STOOD UP AND fell WHILE ATTENDED BY A CNA, AND COULD NOT EXPLAIN HOW WEARING SHOES WOULD PREVENT A SIMILAR FALL IN THE SHOWER. A MDS dated [DATE] DOCUMENTED THAT RESIDENT #714 HAD SEVERE COGNITIVE IMPAIRMENT, AND NEEDED SUPERVISION AND OVERSIGHT FOR TRANSFERS AND AMBULATION. THE MDS ALSO DOCUMENTED THAT RESIDENT #714 WAS CONTINENT OF URINE AND WAS UNSTEADY WHEN TRANSFERRING, WALKING, CHANGING DIRECTION AND WHEN STANDING UP FROM A SEATED POSITION.. A WEEKLY REHAB MEETING SUMMARY DATED 2/9/11, AND A PHYSICAL THERAPY (PT) DISCHARGE REPORT DATED 2/11/11, DOCUMENTED THAT RESIDENT #714 "REQUIRED SUPERVISION" AND "STAND BY ASSISTANCE (CLOSE ENOUGH TO REACH PATIENT IF ASSIST NEEDED) WITH VERBAL AND TACTILE CUEING" FOR AMBULATION, AND REQUIRED SUPERVISION FOR STANDING BALANCE. WHEN QUERIED, THE PT MANAGER STATED THAT RESIDENT #714 REQUIRED STAND-BY ASSISTANCE AND SUPERVISION FOR WALKING AND TRANSFERS AT THE END OF SKILLED THERAPY TREATMENT ON 2/11/11. A WEEKLY CARE MANAGEMENT REVIEW, DATED 2/5/11 TO 2/11/11, DOCUMENTED RESIDENT #714'S "FUNCTIONAL STATUS" AS SBA (STAND BY ASSIST) WITH ADLS (ACTIVITIES OF DAILY LIVING) , TRANSFERS AND TOILETING, AMBULATE INDEPENDENTLY WITHOUT ASSISTIVE DEVICE (WALKER OR CANE). GAIT UNSTEADY AT THE TIMES." FALL RISK EVALUATIONS DATED 2/4/11 AND 4/4/11 WERE 20 AND 21 RESPECTIVELY WITH SCORES GREATER THAN 10 INDICATING "AT RISK" FOR FALLS. WHEN QUERIED, THE DON STATED THAT RESIDENT #714 WAS INDEPENDENT FOR AMBULATION DESPITE THE 2/11/11 PT DISCHARGE ASSESSMENT INDICATING THE NEED FOR STAND BY ASSISTANCE AND SUPERVISION, AND A HISTORY OF PREVIOUS FALLS, AND A FALL RISK SCORE OF 20. A NURSING NOTE FOR RESIDENT #714, DATED 4/4/11 (NO TIME INDICATED) NOTED, "RESIDENT HAS BEEN PACING ALL DAY, UNABLE TO REDIRECT RESIDENT TO REST. GAIT GETTING UNSTEADY AND CAUGHT BY STAFF ALMOST FALLING." REVIEW OF AN I&A DATED 4/4/11 AT 8:35 P.M., REVEALED THAT RESIDENT #714 WAS FOUND IN THE HALLWAY WITH A ONE CENTIMETER (CM) BLEEDING LACERATION (DEEP CUT) ON THE BACK OF HER HEAD, AND A FOUR BY TWO CM BRUISE ON HER LEFT FOREARM. THE WITNESS STATEMENT FORM DOCUMENTED, "FOUND PILLOW WITH BLOOD. RESIDENT UNABLE TO GIVE INFORMATION WHAT HAPPENED DUE TO CONFUSION. PRIOR TO EVENT, RESIDENT ASSISTED TO BED AFTER (P) RESISTANCE PER WRITER.". THE INVESTIGATION CONCLUDED THAT RESIDENT #714 HAD FALLEN IN THE ROOM AND BUMPED HER HEAD ON THE BEDSIDE TABLE. INTERVENTION TO PREVENT RE-OCCURRENCE WAS "TAB ALARM APPLIED WHILE IN BED AND IN WHEELCHAIR, REMOVE BROKEN TABLE FROM ROOM." WHEN QUERIED, THE DON WAS UNABLE TO EXPLAIN WHY RESIDENT #714 WAS STILL ALLOWED TO AMBULATE AND SELF TRANSFER WITHOUT SUPERVISION, AND WHY NO SUPERVISION WAS PROVIDED AFTER DOCUMENTATION OF AGITATION AND UNSTEADY GAIT BEFORE THIS FALL. THE DON WAS UNABLE TO EXPLAIN WHETHER THE 8/30/10 PHYSICIAN'S ORDER FOR A BED ALARM HAD EVER BEEN IMPLEMENTED, OR WHEN AND IF IT HAD BEEN DISCONTINUED BY THE PHYSICIAN. RESIDENT #714'S NURSING CARE PLAN FOR "POTENTIAL FOR FALLS" DATED 6/7/10 CONTAINED AN UPDATED INTERVENTION DATED 4/5/11, "TAB ALARM WHILE IN BED AND WHEELCHAIR. REVIEW OF AN I&A DATED 4/28/11 AT 10:15 P.M., REVEALED THAT RESIDENT #714 WAS FOUND ON THE FLOOR BY THE BATHROOM DOOR. THE RESIDENT SUFFERED A 2.5 BY 2 CM HEAD HEMATOMA (BLOOD LEAKING INTO THE TISSUES CAUSING SWELLING) AND A RIGHT HIP FRACTURE (BROKEN), REQUIRING TRANSFER TO ACUTE CARE. THE I&A DOCUMENTED, "BRIEF FOUND LAYING ON BATHROOM FLOOR AND IS SOAKED WITH URINE. BLUE PAD ON BED IS ALSO WET WITH URINE." RECORD REVIEW WITH THE DON REVEALED NO NURSING NOTE DOCUMENTING THE INCIDENT, AND NO INDICATION OF WHEN RESIDENT #714 HAD LAST BEEN TOILETED OR HAD A BRIEF CHANGE. THERE WAS NO DOCUMENTATION OF WHETHER THE BED ALARM WAS IN PLACE AND FUNCTIONING. THE I&A DATED 4/28/11 DID NOT HAVE BED ALARM CHECKED AS A CURRENT OR NEW INTERVENTION AT THE TIME OF THE FALL. WHEN QUERIED, THE DON STATED THAT RESIDENT #714 WAS INDEPENDENT AND DID NOT NEED STAFF SUPERVISION FOR TRANSFERS AND AMBULATION AT THAT TIME. THE I&A LISTED CORRECTIVE MEASURES TO AVOID RE-OCCURRENCE AS "BLADDER PATTERNING, AND CHANGE TAB ALARM TO PRESSURE." THERE WAS NO EXPLANATION FOR THIS RECOMMENDATION AS THE DON CONTINUED TO STATE THAT RESIDENT #714 AMBULATED INDEPENDENTLY WITHOUT SUPERVISION AT THAT TIME. A READMISSION NURSING CARE PLAN FOR "POTENTIAL FOR FALLS" FOR RESIDENT #714, DATED 5/10/11, REVEALED THE FOLLOWING SAFETY INTERVENTIONS, "PRESSURE ALARM TO GERI CHAIR" AND "TAB ALARM TO BED, CHECK FOR PLACEMENT AND FUNCTION EACH SHIFT AND PRN (AS NEEDED)." THERE WAS NO EXPLANATION OF WHY THE 4/28/11 I&A RECOMMENDATION TO CHANGE FROM A TAB ALARM TO A PRESSURE ALARM WAS NOT FOLLOWED. REVIEW OF AN I&A DATED 5/8/11 AT 2:00 A.M., REVEALED THAT RESIDENT #714 WAS FOUND ON THE SAFETY MAT NEXT TO THE BED. THE REPORT INDICATED THAT THE RESIDENT HAD REMOVED THE TAB ALARM. CORRECTIVE MEASURES TO AVOID RE-OCCURRENCE INCLUDED, "PRESSURE ALARM ADDED TO BED". REVIEW OF THE NURSING CARE PLAN REVEALED NO NOTATION INDICATING A PRESSURE ALARM WAS ADDED TO THE BED. REVIEW OF THE FACILITY POLICY TITLED, "FALLS MANAGEMENT" REVEALED THE FOLLOWING: "EACH RESIDENT WILL BE ASSESSED THROUGHOUT THE COURSE OF treatment for [REDACTED]. THE CARE PLAN IS REVIEWED TO ASSURE THE MOST RECENT, UPDATED, AND SPECIFIC FALL REDUCTIONS HAVE BEEN INCORPORATED AS NECESSARY INTO THE PLAN OF CARE." ( ) ON 5/24/11 AT 2:50 P.M., RESIDENT #703 WAS IN BED WITH AN INTRAVENOUS SOLUTION INFUSING AT 70 MILLILITERS PER HOUR VIA INFUSION PUMP. ON TOP OF THE INFUSION PUMP WERE 3 SYRINGES, TWO NORMAL SALINE SOLUTIONS (SALT WATER) AND ONE HEPARIN (BLOOD THINNER) 50 UNITS. AT 3:10 P.M., REVIEW OF RESIDENT #703 CLINICAL RECORD REVEALED RESIDENT #703 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE Minimum Data Set, dated dated [DATE] INDICATED THE RESIDENT'S COGNITION WAS SEVERELY IMPAIRED AND RELIED ON STAFF TO FOR DAILY NEEDS. AT 3:20 P. M., NURSE "F" WAS CALLED TO THE RESIDENT #703'S ROOM AND QUERIED CONCERNING THE SYRINGES LEFT ON TOP OF THE INFUSION PUMP. NURSE "F" STATED "I GRABBED THESE WHEN WE WERE STARTING THE INTRAVENOUS THERAPY (IV) YESTERDAY." WHEN ASKED IF THE SYRINGES HAD BEEN THERE SINCE YESTERDAY, NURSE "F" RESPONDED "YES". THESE SYRINGES SHOULD NOT BE AT THE BEDSIDE" . ON 5/25/11 AT 9:05 A.M., NURSE "G" WAS OBSERVED DRAWING UP A DOSE OF INSULIN FOR RESIDENT #65. AFTERWARDS NURSE "G "PLACED THE VIAL OF INSULIN ON TOP OF THE CART AND WENT TO THE RESIDENTS ROOM TO ADMINISTER THE INSULIN. THE CART AND THE INSULIN BOTTLE WERE IN PLAIN VIEW OF VISITORS AND OTHER RESIDENTS. WHEN ASKED WHY THE INSULIN VIAL WAS LEFT UNATTENDED ON TOP OF THE CART. NURSE "G" RESPONDED "I NORMALLY PUT THE INSULIN IN THE REFRIGERATOR. I SHOULDN'T HAVE LEFT IT ON MY CART." ON 5/26/11 AT 10:00 A.M., THE DIRECTOR OF NURSING (DON) WAS INFORMED OF THE SYRINGES LEFT UNATTENDED AT RESIDENT #703'S BEDSIDE AND THE BOTTLE OF INSULIN LEFT ON THE CART WITHIN REACH OF RESIDENTS AND VISITORS. THE DON STATED " THOSE SYRINGES SHOULD NOT HAVE BEEN LEFT AT THE BEDSIDE AND INSULIN BELONGS IN THE REFRIGERATOR NOT ON TOP OF THE CART WITHIN REACH OF A RESIDENT". ( )