Every finding on record at The Orchards at Big Rapids

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. Findings Include:On 04/20/2026 at 9:50am, observed in the residents' refrigerator located in East Hall nursing station, a 32-ounce container of Greek yogurt, that was half full, without a resident name or room number and without a date as to when the container was received or opened. When asked who was responsible for labeling the food with resident's information and the date, Dietary Manager (DM) N replied, if the food does not come from the kitchen, it is the responsibility of the staff, who placed the food in the refrigerator.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . On 04/20/2026 at 10:12AM, observed the drain line for the ice machine does not have an air gap. The drain line opening was below the grate of the drain in the floor. 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.

Based on observations, interviews, and record review, the facility failed to properly clean 1 Residents (R36's) BiPap (Bilevel Positive Airway Pressure) machine (equipment use to assist in breathing), properly clean a facility glucometer (meter used to test blood sugar) after use and fully operationalize the facility legionella prevention plan and failed to follow Enhanced Barrier Precautions during wound care.Findings included:During an observation on 4/20/26 from 4:30 PM to 4:45 PM, Licensed Practical Nurse (LPN) K was observed checking R74's, R18's, R39's and R4's blood sugar levels with a glucometer machine. LPN K was observed cleaning the glucometer monitor machine with [name brand of germicidal wipes] for 10 seconds prior to and following each blood sugar check. LPN K would wipe the machine with the germicidal wipe and then immediately dry it with a gauze pad. LPN K was also observed putting the glucometer machine in his scrub pocket after he used it on R74 and pulled it out of his pocket at the medication cart to clean it. During an observation on 4/21/26 at 8:00 AM, Licensed Practical Nurse (LPN) F was observed checking R32's blood sugar level with a glucometer machine. After checking R32's blood sugar level, LPN F cleaned the glucometer machine with an alcohol pad. LPN F stated she was taught not to use the [name brand] germicidal wipes because they can be harsh on the glucometer machines. She stated, I always use an alcohol pad. During an interview on 4/21/26 at 1:00 PM, LPN K stated he uses the purple wipes [color of the lid to the container of the [name brand] germicidal wipes) to clean glucometer machines. He stated the machine needs to be wet for 10 seconds in order for the wipe to disinfect it. During an interview on 4/22/26 at 1:50 PM, LPN H stated he cleans the glucometer machine with an alcohol swab after each use. LPN H also stated staff cannot carry the glucometer machines in their pockets. He stated they have to transport them either in a cup or on a barrier, such as a tissue. During an interview on 4/22/26 at 3:00 PM, the Director of Nursing (DON) stated staff are not supposed to carry glucometers in their pockets. She also stated the nurses are supposed to clean the glucometer machines with the [name brand] germicidal wipes and the wait time for the wipe to disinfect the machine was two (2) minutes. A review of the label on the [name brand] germicidal wipes revealed it takes 2 minutes for the wipe to disinfect an object. A review of the user's manual for the brand of glucometer that the facility uses, dated 2/16, revealed, To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below. The meter should be cleaned and disinfected after use on each patient. The [name brand of glucometer machine] may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. Cleaning and Disinfection The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. A variety of the most commonly used EPA (Environmental Protection Agency)-registered wipes have been tested and approved for cleaning and disinfecting of the [name brand of glucometer machine]. The disinfectant wipes listed below have been shown to be safe for use with this meter. Please read the manufacturer's instructions before using their wipes on the meter. two disposable wipes will be needed for each cleaning and disinfecting procedure: one wipe for cleaning and a second wipe for disinfecting. The user's manual lists the [name brand] germicidal wipes that are located in the facility's medication carts as an approved disinfection/cleaning product for their machines. The manual also lists the contact time for the [name brand] germicidal wipes that the facility uses as 2 minutes. However, the user's manual does not list alcohol pads/wipes as an approved product for disinfecting their machines. BIPAP EQUIPMENT Review of R36's admission record revealed she was admitted to the facility on [DATE] and pertinent diagnoses included: chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, sleep apnea, lymphedema, and peripheral vascular disease. R36 was her own responsible party. During an observation on 4/21/26 at 2:35 PM R36's BiPap machine was observed on her nightstand (not in use) R36's was sleeping. No cleaning equipment or supplies were observed in the room. Review of R36's Treatment Assessment Record (TAR) for April 2026 revealed, After resident remove CPAP/BIPAP (breathing equipment) in AM cleanse mask and reservoir with soap and water every day shift related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA; CHRONIC OBSTRUCTIVE PULMONARY DISEASE, OBSTRUCTIVE SLEEP APNEA. All the boxes were marked as completed from April 1 to April 21. Licensed Practical Nurse (LPN) K's initials were noted to be in the boxes dated 4/20/26 and 4/21/26). During an interview on 4/21/26 at 2:46 PM, (LPN) K reported he cleans the face part of R36's BiPap equipment and dumps the water reservoir and he had marked the box on R36's Treatment Assessment Record (TAR) this morning (4/21/26) indicating he had cleaned the equipment. LPN K said he was not aware there was more to cleaning the equipment. He denied cleaning the water reservoir and did not know anything about cleaning the hose to the equipment. During an interview with the Nursing Home Administrator (NHA) on 4/21/26 at 3:13 PM the NHA confirmed that they were getting more residents with C-Pap (Continuous Positive Airway Pressure) device used to treat sleep apnea, and BiPap (Bilevel Positive Airway Pressure) device used to assist breathing by delivering pressurized air through a mask) and did not currently have a respiratory therapist service available. She did not have records to indicate when R36's BIPAP machine was last checked by a Respiratory Therapist or when the mask/hoses were replaced. The NHA was not aware staff were not cleaning the water reservoir daily. There was no indication anyone had ever cleaned the hose to R36's BIPAP machine. The NHA said they did contact a respiratory care company that would start next month and they would be reviewing all residents' equipment needs and would be starting training. Review of the facility Cleaning Respiratory Equipment policy no date did not mention CPAP or BIPAP equipment. According to the American Thoracic Society, Patient Education/Information series. www.thoracic.org. What happens if I don't clean my PAP device? If you do not clean your PAP device and supplies, bacteria and mold may begin to grow. This may put you at higher risk of getting sick. Your device and supplies may be more likely to break down earlier if not kept clean. You may notice the device or mask starting to smell bad as well. Author: [NAME] Schotland. Enhanced Barrier Precautions During a wound dressing observation for R36 on 4/21/26 at 10:30 AM, LPN K did not use a gown. There was a sign posted above R36's bed that read Enhanced Barrier Precautions. Instructions included using gloves and gowns during wound care. LPN K was asked if he needed to use a gown and he said he did not because the resident did not have an infection. There were no gowns visible in R36's room or in the hall. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 4/22/26 the observations of no gown being used during wound care and no gowns being visible in the room or hall were reviewed. They confirmed that staff should be using gowns during wound care. On 04/20/2026 at 10:15AM, observed plumbing with an overhead sprayer and open spot for garbage disposal equipment, adjacent to the three-compartment sink. The drain line was capped off and water connections for garbage disposal equipment were coming out of the wall. On 04/20/2026 at 2:00PM, Maintenance Director (MD) O was asked for the facility's water management plan, at that time the CDC Toolkit: Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, was provided. During review of the document, it was noted that the Identifying Buildings at Increased Risk page was not completed and a building water system diagram or written descriptions were not available for review. On 04/21/2026 at 7:40AM, during interview with Dietary Manager (DM) N, DM N was asked if maintenance staff came into the kitchen to flush the lines in the area where the garbage disposal used to be located, DM N asked to be shown the area they had been asked about. Upon viewing the area DM N stated that they had not seen maintenance staff flushing the lines in this area. On 04/21/2026 at 8:20AM, several documents were requested from MD O, a word description and diagram of water system for the facility, as mentioned in the water management plan document provided on 04/20/2026 and a copy of the Legionella Prevention Policy. MD O provided a copy for review, of the facility's Legionella Prevention Policy at time of request, MD O was unable to provide a copy of either a word description or diagram of the water system for the facility at time of request. On 04/21/2026 at 8:30AM, interview with MD O regarding the plumbing in the kitchen that was observed on 04/20/2026; MD O was asked if the plumbing in the area where the garbage disposal had been removed, was being flushed and if so, how often. MD O replied that the water was turned off at the site, and they were not flushing the lines. MD O then proceeded to turn on the faucet to the overhead sprayer and a small but steady flow of water came out of the sprayer. MD O further indicated the facility had hard water and that might have been a contributing factor to the valve not being fully closed and allowing water through.

During observation, interview, and record review, the facility failed to provide privacy for 2 of 10 residents (R3 and R39) observed during medication administration.procedures. Findings include:R3 A review of R3's admission Record, dated 4/21/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's admission Record revealed they had multiple diagnoses that included diabetes, dementia, post-traumatic stress disorder (PTSD), and anxiety. A review of R3's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/24/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 6 which indicated R3 was severely cognitively impaired. During an interview on 4/22/26 at 3:00 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated that it was acceptable to give a resident insulin in public areas if the resident was care planned that they did not object. Some residents don't care. The NHA and DON were asked if they considered whether other residents in the vicinity would care if they saw a resident receiving insulin and the NHA stated that as long as the resident receiving the insulin did not care it was alright to administer the insulin in a public setting. A review of R3's care plans, dated 4/1/25 to 4/22/26, failed to reveal any documentation that R3 preferred, or did not object to, receiving insulin (or any other injection) in a public area. R39 A review of R39's admission Record, dated 4/22/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R39's admission Record revealed multiple diagnoses that included diabetes and Alzheimer's Disease. A review of R39's MDS, dated [DATE], revealed they had a BIMS score of 5 which indicated they were severely cognitively impaired. During a medication administration observation on 4/20/2026 from 4:30 PM to 4:40 PM, Licensed Practical Nurse (LPN) K was observed performing blood glucose checks for R74, R18, and R39. When LPN K performed R39's blood glucose check using a lancet to draw blood, place the drop of blood on a test strip, and insert it into a portable monitoring machine, he did so in the hallway outside of the dining room while R39 was in line to get into the dining room prior to dinner. There were other residents in line and in the hallway in the vicinity of the dining room at the time of the observation that were able to observe the procedure. A review of R39's care plans, dated 4/14/25 to 4/22/26, failed to reveal any documentation that R39 preferred, or did not object to, receiving her blood glucose checks in a public area. A review of the facility's Blood Glucose Tests Nursing SOP (Standard Operating Procedures), undated, revealed, Procedure 1. Identify resident, provide privacy, and explain procedure. A review of the State Operations Manual Appendix PP, dated 7/23/25, revealed, Personal privacy includes accommodations, medical treatment, Each resident has the right to privacy and confidentiality for all aspects of care and services. A nursing home resident has the right to personal privacy of not only his or her own physical body, but of his or her personal space, including accommodations and personal care.

This citation refers to Intake 2724753 and Intake 2793094.Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.and did not report an allegation of abuse and a potential crime to law enforcement for 2 of 5 residents (R77 and R85) reviewed for abuse.Findings include:According to the State Operations Manual (SOM), Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.According to the SOM, section S483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) inaccordance with State law through established procedures.R77 A review of R77's admission Record, dated 4/22/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R77's admission Record revealed multiple diagnoses that included dementia and cognitive communication deficit. A review of R77's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 4/10/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which indicated R77 was severely cognitively impaired. R85 A review of R85's admission Record, dated 4/22/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R85's admission Record revealed multiple diagnoses that included bipolar disorder, dementia, and paranoid schizophrenia. A review of R85's MDS, dated [DATE], revealed they had a BIMS score of 15 which indicated R85 was cognitively intact. A review of the facility's Summary of Incident, undated, revealed on 1/19/26, R85 stated R77 entered her room without permission. R85 stated she threw a pudding cup at R77. The next day, R85 told staff that she had previously warned them that if anyone came in her room, she would hit them. She stated when R77 entered her room she pushed him back out. Staff interviews confirmed that R77 had entered R85's room but did not see any physical contact between them. When R77 had a physical assessment after the incident, he had a skin tear to his arm and bruising to his back. Appropriate treatment to R77's skin tear was performed. Staff stated they redirected R77 from R85's room and R77 was easily redirectable. The facility concluded it is probable that an unobserved physical interaction occurred between [name of R77] and [name of R85], as [name of R85] acknowledged pushing [name of R77] out of her room. A review of R77's Illustration of Documentation and Measurements of Skin Areas form, dated 1/19/26, revealed R77 had a skin tear to the outer left upper arm above the elbow and bruises to his outer left upper back between the elbow and armpit area. The skin tear and bruises in the illustration appear to be in line with each other. A review of R77's Weekly Head-To-Toe Assessment- Licensed Nurses form, dated 1/13/26 (6 days before the incident occurred), revealed, There are no skin concerns at this time and the illustrations did not show any bruises or skin tears on R77's body. A review of the [Name of County] Sheriff's Office Primary Report (police report), dated 1/26/26, revealed on 1/23/26 a deputy responded to a complaint by Adult Protective Services (APS) that stated (name redacted but identified through other documents as R85) claimed that while she was in the bathroom an unknown male entered the bathroom and she shoved him out of the bathroom. The deputy reported that he went to the facility and spoke with the Nursing Home Administrator (NHA). The NHA stated that R85 was no longer a resident at the facility and she had been transferred to another facility. The deputy asked the NHA what had occurred on 1/19/26 which was when the alleged incident had occurred. The NHA told the deputy that a male resident (R77) had walked into R85's bathroom and she had thrown a pudding cup at him. The NHA told the deputy that R77 had an open wound on his arm and they asked R85 if she had hit him or shoved him. The NHA stated that R85 initially denied that she had, but the next day she told them that she had shoved him out the door. During an interview on 4/21/2026 4:45 PM, the NHA stated they did not call the police for the incident on 1/19/26. She stated the police just showed up on 1/23/26 (4 days after the incident). The NHA stated R85 or APS must have called them. She stated they do not usually call the police, unless they can prove an actual physical altercation occurred or unless a resident has a bloody nose, a wound, or bruising. She also stated that R77 may have sustained his skin tear and bruises to his back from falling backwards. The NHA implied that R77 had a fall prior to the incident that caused R77's injuries because no one saw a physical altercation between R77 and R85. A review of R77's incident reports, dated 12/19/25 to present, failed to reveal that R77 had a fall immediately prior to the incident on 1/19/26. R77's last fall prior to 1/19/26 was on 12/21/25. R77 was not noted to have any injuries from that fall. A review of the facility's Facility Suspected Crime Report- Elder Justice Act Policy and Procedure, dated 2/17/20, revealed, The facility will comply with the Federal Elder Justice Act by ensuring that any reasonable suspicion of a crime against a resident is reported to the appropriate agency and the State Survey Agency within required timeframes. 1. The Administrator or designee, in collaboration with the Director of Nursing and appropriate facility leadership, will review the available information to determine whether there is reasonable suspicion of a crime. 2. The review may include resident statements, witness interviews, staff observations, physical assessment findings, injury type or pattern, cognitive status, behavioral history, prior allegations or patterns, and any other relevant information. 3. If reasonable suspicion of a crime is identified, the facility will report to law enforcement and/or the State Survey Agency within required timeframes. 4. If the initial information does not clearly establish reasonable suspicion of a crime, the facility will continue to investigate, monitor, reassess, and document findings. If new information later creates reasonable suspicion, reporting will be completed within the required timeframe from the point reasonable suspicion is identified. Reports will be made within the following timeframes: a. Immediately, but not later than 2 hours, if the suspected crime resulted in serious bodily injury. b. Not later than 24 hours, if the suspected crime did not result in serious bodily injury. A review of [Name of State] Criminal Law & Procedure- A Manual for [Name of State] Police Officers- Fourth Edition, dated 2019, revealed battery is A forceful, violent, or offensive touching of the person or something closely connected with the victim. A review of [Name of State] Criminal Law & Procedure- A Manual for [Name of State] Police Officers- Fourth Edition, dated 2019, revealed assault and battery is a misdemeanor offense (a crime) where 1. The defendant committed a battery on the victim. The touching must have been intended by the defendant, that is not accidental, and it must have been against the victim's will. It does not matter whether the touching caused injury. 2. The defendant intended either to commit a battery upon the victim or to make the victim reasonably fear an immediate battery.

Based on observations, interviews, and record review, the facility failed to assess, monitor and properly treat a wound and medical condition, lymphedema for 1 resident (R36) of 3 residents reviewed for wounds and medical care.Findings included:This citation pertains to intake number 2698828Findings included:Review of R36's admission record revealed she was admitted to the facility on [DATE] and pertinent diagnoses included: chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, sleep apnea, lymphedema, and peripheral vascular disease. R36 was her own responsible party.During an observation and interview with R36 on 4/20/26 at 9:47 AM, R36 was in bed. Her lymphedema pump (a device that attaches to the residents' legs to provide intermittent pressure to reduce edema) was on a chair in her room with blankets over and the pump portion the leg tubing was visible. R36 said staff do not consistently put the pump on her and they do not always have time to do all her care.During an interview with Unit Manager (UM), Registered Nurse (RN) K, on 4/21/26 at 10:09 AM, UM K said she did not know anything about R36's lymphedema pump. UM K reviewed R36 Electronic Medical Record (EMR) and found a physician order for R36 to use her lymphedema pump twice a day at 45 for 45 minutes. When Reviewing R36's Treatment Administration Record (TAR) for April 2026 it was discovered there were several refusals documented and some blank areas which indicated R36 did not receive the treatment as ordered. UM K reviewed the EMR and could not locate any information on why the treatments were not given or any explanation or reason for R36's refusal to have her lymphedema treatment done. UM K said the nurse should document the reason for R36's refusals. RN Q had documented on 4/20/26 at 11:48 PM that R36 refused her lymphedema treatment. There was no documentation indicating why R36 did not want the treatment at that time.During an interview with R36 with UM K in the room on 4/21/26 at 10:27 AM, R36 denied refusing to have her lymphedema pumps on 4/20/26 at 23:48 (11:48 PM). R36 said her preferred times to use the lymphedema pumps was after lunch and between 11:00 PM and midnight daily.Review of R36's Treatment Administration Record (TAR) dated 4/1/26 to 4/30/26 revealed a treatment, leg pumps BID (twice a day) at 45 for 45 minutes every shift related to lymphedema. Each date had a day and night box. From 4/1/26 to 4/21/26 (21 boxes were coded refused and 2 boxes were blank. R36's record revealed she received the lymphedema pump treatment 18 times (treatment should have been provided 41 times). There was no explanation found in R36's EMR for the missing or refused treatments. Upon exit, the facility did not provide any additional information on R36's refusals to use her lymphedema pumps.R36 was observed during a wound treatment on 4/21/26 at 10:47 AM. R36's right lower extremity was wrapped with gauze and dated 4/20/26. Licensed Practical Nurse (LPN) K said he was the one that did the treatment on 4/20/26. When the dressing was removed approximately 1/3 of the front of R36's right leg had approximately 9 open areas (all bright red) with small amounts of healthy skin tissue between the open areas. LPN K applied a full sheet of xeroform over part of the wounds and 2 partial sheets over the rest of the wound area. The xeroform was approximately 3 inches by 4 inches. The xeroform was also applied over the healthy skin tissue. After the treatment was completed LPN K was asked if the wound was getting better. LPN K said it looked better today than it was yesterday. The surveyor explained that the last note with a description and size indicated there was only one wound and it was very small. LPN K was not aware of this and said he does not document the wound appearance when he does wound treatments or review the last note that describes the wound.Review of R36's Treatment Administration Record (TAR) dated 4/1/26 -4/30/26 revealed a treatment for, Right lower extremity: wash with wound cleanser, pat dry, apply xeroform cut to size of open areas, cover with ABD pad, wrap with roll gauze. Change daily and prn. The boxes indicating the treatment was completed were marked from 4/8/26 to 4/21/26 except for 4/16/26 which was left blank. (blank indicates the treatment was not done)Review of R36's progress noted, Late Entry dated effective 4/15/26 at 17:10 (5:10 PM) and created on 4/19/26 at 3:10 AM revealed, Wound care provided to right lower extremity, scant serosanguinous (watery wound discharge with blood) drainage noted, total area measures 6cm x 8cm x 0.1 cm, multiple small open areas noted within the measurement, no signs or symptoms of infection noted. Wound showing signs of improvement, 100% granulation tissue, small open are decreasing in numbers.During an interview with the facility wound nurse, Licensed Practical Nurse (LPN) R and UM K on 4/21/26 at 2:21 PM, a photograph of R36's wound taken that morning was shown to LPN R in addition to a review of the last wound documentation for 4/15/26. LPN R confirmed that R36 only had one wound when she treated her on 4/15/26 and it was much smaller than the open areas today. LPN R said that it can change a lot in a week. When asked if putting xeroform over healthy skin tissue could cause it to open again LPN R responded, yes. UM K confirmed staff are not documenting the condition of the wound after each treatment and she was not able to determine when the wound declined in condition. UM K said R36's medical record did not have the wound description from 4/15/26 in it until 4/19/26 as LPN R keeps wound measurements in a book in her office and does not enter them in the medical record until she has time. UM K confirmed staff cannot assess whether a wound is improving or declining if they are not entering a description in the medical record every time a wound is observed.

Based on interview and record review, the facility failed to properly transport a resident in a wheelchair for 1 of 21 sampled residents (R39). Findings include:A review of R39's admission Record, dated 4/22/25, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R39's admission Record revealed multiple diagnoses that included diabetes and Alzheimer's Disease. A review of R39's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/8/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 5 which indicated R39 was severely cognitively impaired. During an observation on 4/20/26 at 4:40 PM, Licensed Practical Nurse (LPN) K was observed pushing R39 in her wheelchair down the hallway from the Therapy Services Occupational Physical Speech Room to R39's room without foot pedals. LPN K just told R39 to raise her feet while she was being pushed down the hallway. During an interview on 4/22/26 at 1:50 PM, LPN H stated when staff transport a resident down the hallway, the resident is supposed to have foot pedals on their wheelchair. LPN H stated no way should a staff member transport a resident without foot pedals, even if the resident can follow instructions and raise their legs while being pushed. During an interview on 4/22/26 at 3:00 PM, the Director of Nursing (DON) stated that staff are not supposed to transport residents in wheelchairs without foot pedals. She stated she does not think the facility has a policy that covers transporting residents in wheelchairs, but it's basic nursing practice that for safety if staff push residents in wheelchairs, then they must ensure the residents have foot pedals on them.

Based on observations, interview, and record review, the facility failed to have ongoing respiratory assessments and documentation of use of a BiPap (Bilevel Positive Airway Pressure) machine for 1 Resident (R36) of 1 Resident reviewed for respiratory equipment use.Findings included: Review of R36's admission record revealed she was admitted to the facility on [DATE] and pertinent diagnoses included: chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, sleep apnea, lymphedema, and peripheral vascular disease. R36 was her own responsible party.Review of R36's physician orders dated 3/8/26 revealed, BiPap at HS (night) with the following settings: EPAP Breath rate: Min IPAP: 9Max IPAP; volume: Flex Pressure relief: on Oxygen bleed.During an interview with Unit Manager (UM) K on 4/21/26 at 2:40 PM, UM K reported that R36 frequently refuses to us her Bipap machine. The Surveyor reported that R36 had been sleeping on and off during the day and did not have the Bipap machine in use when observed today. UM K reviewed R36's Electronic Medical Record and could not locate any documents that tracked when R36 used the BiPap machine or when she was refusing it. She could not locate any BiPap assessments. There was no documentation to show when the BiPap machine was last assessed or when the BiPap therapy was reviewed for effectiveness. There was information to assist R36 with putting the BiPap on at night and for cleaning. There was no indication she should be assisted with the BiPap during the day if she was sleeping.Review of R36's Oxygen assessments revealed her Oxygen was only assessed one time in March 2026, 3/1/26 at 17:23 (5:23 PM) and was 94 with oxygen on via nasal cannula. R36's Oxygen was only assessed one time in April 2026, 4/18/26 at 17:03 (5:03 PM) and was 93 % with oxygen on via nasal cannula.Review of R36's respiratory care plan dated 2/4/26 revealed, I have altered respiratory status/difficulty breathing and potential for alteration in my respiratory status due to COPD (Chronic Obstructive Pulmonary Disease). The interventions did not include respiratory assessments, equipment assessments, amount of assistance needed or when the equipment was to be replaced or evaluated for effectiveness.During an interview with the Nursing Home Administrator (NHA) on 4/21/26 at 3:13 PM the NHA confirmed that they were getting more residents with C-Pap (Continuous Positive Airway Pressure) device used to treat sleep apnea, and BiPap (Bilevel Positive Airway Pressure) device used to assist breathing by delivering pressurized air through a mask) and did not currently have a respiratory therapist service available. The NHA said they did contact a company that would start next month and they would be reviewing all residents' equipment needs and would be starting training.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (5%) for 2 of 7 residents (R2 and R3) observed during the medication administration task. Findings include:Resident #2 (R2) A review of R2's admission Record, dated 4/21/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R2's admission Record revealed multiple diagnoses that included diabetes. During an observation on 4/21/26 at 8:15 AM, Licensed Practical Nurse (LPN) F administered ten medications to R2, including one tablet of metformin 500 milligrams (mg) (a medication for diabetes). LPN F verbalized the medications and the doses as she was preparing them and placing them in a medication cup. A review of R2's April 2026 Medication Administration Record (MAR) revealed R2 should have received two tablets of metformin 500 mg, not one. Resident #3 (R3) A review of R3's admission Record, dated 4/21/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's admission Record revealed they had multiple diagnoses that included diabetes with diabetic neuropathy (nerve pain), post-traumatic stress disorder (PTSD), and anxiety. During an observation on 4/21/26 at 7:45 AM, Registered Nurse (RN) J administered nine medications to R3, including one tablet of potassium 20 mEq (milliequivalents) (a medication for potassium replacement) and one capsule of gabapentin 100 mg (a medication for neuropathy). A review of R3's April 2026 MAR revealed R3 should have received potassium 40 mEq, not potassium 20 mEq. In addition, R3's MAR revealed R3 should have received two capsules of gabapentin 100 mg, not one. During an interview on 4/21/26 at 4:51 PM, the Nursing Home Administrator and Director of Nursing were notified of the medication errors that had been observed immediately after all the medications observed during the medication observation task were reconciled with the individual residents' physician orders and MAR's.

Based on observation, interview, and record reviw, the facility failed to secure medications in 1 of 5 medication carts (200 Hall Medication Cart) or a medication room. Findings include:During an observation on 4/20/26, Licensed Practical Nurse (LPN) K was observed walking away from the 200 Hall Medication Cart to deliver medications to another unit (LPN K had just received and signed for a pharmacy delivery for the facility). LPN K left a 30- count medication card of trazadone 50 milligrams (mg) (a medication for depression) for R15 and a 60-count medication card of acyclovir 400 mg (an antibiotic) for R76 on top of the controlled substances book on the medication cart unattended. LPN K returned to the 200 Hall Medication Cart, moved the two medication cards from on top of the controlled substances book on the right-hand side of the medication cart to the left-hand side on top of the medication cart. LPN K then continued to prepare and administer medications to residents while leaving the trazadone and acyclovir medication cards, unattended on and off, on top of the 200 Hall Medication Cart when he would leave to find the residents. This continued until 4:50 PM when LPN K saw a nurse that was assigned to another medication cart and delivered the trazadone and acyclovir to her. These two medications were then secured in another medication cart. During the entire time that the trazadone and acyclovir were left unattended and out of the sight of staff, residents were observed ambulating up and down the hallway past the medication cart and one resident was observed sitting in the vicinity of the medication cart. During an interview on 4/21/26 at 08:25 AM, LPN F stated that the nurses cannot leave medications unattended on top of the medication carts because someone might grab them and take them. During an interview on 4/21/26 at 1:00 PM, LPN K stated that you can never leave medications on the medication cart unattended because someone could come by and take them. A review of the facility's Medication Storage in the Facility policy and procedure, dated 2024, revealed that only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed unsupervised access to medications.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 21 sample residents (R85). Findings include: R77 A review of R77's admission Record, dated 4/22/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R77's admission Record revealed multiple diagnoses that included dementia and cognitive communication deficit. A review of R77's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 4/10/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 0 which indicated R77 was severely cognitively impaired. R85 A review of R85's admission Record, dated 4/22/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R85's admission Record revealed multiple diagnoses that included bipolar disorder, dementia, and paranoid schizophrenia. A review of R85's MDS, dated [DATE], revealed they had a BIMS score of 15 which indicated R85 was cognitively intact. A review of the facility's Summary of Incident, undated, revealed on 1/19/26, R85 stated R77 entered her room without permission. R85 stated she threw a pudding cup at R77. The next day, R85 told staff that she had previously warned them that if anyone came in her room, she would hit them. She stated when R77 entered her room she pushed him back out. Staff interviews confirmed that R77 had entered R85's room but did not see any physical contact between them. When R77 had a physical assessment after the incident, he had a skin tear to his arm and bruising to his back. Appropriate treatment to R77's skin tear was performed. Staff stated they redirected R77 from R85's room and R77 was easily redirectable. The facility concluded it is probable that an unobserved physical interaction occurred between [name of R77] and [name of R85], as [name of R85] acknowledged pushing [name of R77] out of her room. A review of R85's electronic medical record (EMR), dated 12/19/25 to 4/21/26, failed to reveal any information that R85 was involved in any incident on 1/19/26. During an interview on 4/21/26 at 4:45 PM, the Nursing Home Administrator (NHA) confirmed that there was not any documentation in R85's medical record that stated an incident had occurred on 1/19/26. She stated her Social Services Director was off at the time and they had someone filling in. The NHA stated that even though the other social worker did wellness visits, the documentation did not specify if the visits were from an incident or were just visits by the social worker to check on R85's general welfare. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care. High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care- Assessments; Clinical problems; Communications with other health care professionals regarding the patient; Communication with and education of the patient, family, and the patient's designated support person and other third parties. Patient responses and outcomes, including changes in the patient's status. Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org, retrieved on 7/27/25).

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment potentially effecting 64 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 03/11/25 between 9:15 AM and 10:20 AM during the initial tour with Dietitian (B) the following concerns were observed: The hand sink basin was observed visibly soiled from a build-up of grime and scale. Further observation of the hand sink revealed a leak in the plumbing fixture. The drain boards, the backsplash and inside sink basins of the 3-compartment sink (located across from the hand sink) was observed to be soiled and had build-up scale, grime and debris. Walk In Cooler's door (including door handle, ledge, and opening), the shelving and fan compressor grate were visibly soiled with a build-up of dust, food residues/debris, mold and mildew. Walk in Freezer's door, (door handle, ledge, opening) and the flooring were visibly soiled. Kitchen shelving units (located on wall between hood system and the hallway door) had build-up of residues/debris. The flooring in the dry storage area beneath the shelving and along the floor/wall junctures had an accumulation of dirt and debris. The flooring in the hallway (leading to the outside/dumpster area) had an accumulation of rock salt, dust and debris. According to the 2017 FDA Food Code section 6-501.18 Cleaning of Plumbing Fixtures, PLUMBING FIXTURES such as the HANDWASHING SINKS, toilets, and urinals shall be cleaned as often as necessary to keep them clean. According to the 2017 FDA Food Code section 5-205.15 System maintained in Good Repair, A PLUMBING SYSTEM shall be: (A) Repaired according to LAW and (B) Maintained in good repair. According to the 2017 FDA Food Code section 4-501.14 Warewashing Equipment, Cleaning Frequency, A WAREWASHING machine; the compartments of sinks, basins, or other receptacles used for washing, and rinsing EQUIPMENT, UTENSILS, or raw FOODS, or laundering wiping cloths; and drainboards or other EQUIPMENT used to substitute for drain boards or specified under 4-301.13 shall be cleaned: (A) Before use; (B) Throughout the day at a frequency necessary to prevent recontamination of EQUIPMENT and UTENSILS and to ensure that the EQUIPMENT performs its intended function; and (C) If used, at least every 24 hours. According to the 2017 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 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.

Based on observation, interview, and record review, the facility failed to follow standards of practice for medication administration for two of six residents (Resident #1 and Resident #17) reviewed for professional standards. Findings: Resident #1 (R1) Review of a Face Sheet revealed R1 was a 69 tear old male, last admitted to the facility on [DATE], with pertinent diagnoses of seizure disorder, muscle weakness, cognitive communication deficit, glaucoma, and mild cognitive impairment. During an observation on 03/11/25 at 9:09 AM, R1's morning medications sat on the bedside table in a plastic medication cup. R1 stated that he would take the medications in a bit. During a review of R1's electronic health record (EHR) revealed that there was not an assessment completed for R1 to self administer medications. During an interview on 03/11/25 at 12:17 PM, the Administrator indicated that none of the residents has been successfully assessed to self administer their medications. Resident #17 (R17) Review of a Face Sheet revealed R17 was a [AGE] year old male that admitted to the facility on [DATE]. During an observation on 03/11/25 at 9:46 AM, R17's morning medications sat on the over-bed table in a plastic medication cup. R17 stated that they usually leave my medications for me to take. During a review of R17's EHR revealed that there was not an assessment completed for R17 to self administer medications. During an interview on 03/12/25 at 1:51 PM, Registered Nurse (RN) I indicated that leaving medications bedside for a resident without an assessment for the resident to safely administer the medications, was not a standard of practice at this facility. Review of the facility policy Self-Administration of Medication reflected .Each resident is offered the opportunity to self administer his or her medications during a routine assessment by the facility's interdisciplinary team . If the resident wishes to self administer medications, the interdisciplinary team must assess the resident's cognitive, physical, and visual ability to administer his or her own medications.

Based on observation, interview, and record review, the facility failed to maintain sanitary oxygen supplies in 3 (R19, R29 and R115) of 4 residents reviewed for respiratory care from a total sample of 17 residents. Findings: Resident #19 (R19) Review of a Resident Face Sheet reflected R19 admitted to the facility on [DATE]. Review of a Nursing progress note dated 2/19/25 reflected R19 was having low oxygen saturations of 79%-80% and oxygen at 2 liters per nasal cannula was applied by the nurse. On 2/20/25 R19 was diagnosed with bronchitis and prescribed an antibiotic. Review of a General Administration History: 02/01/2025 - 02/28/2025 reflected Change Oxygen tubing, humidification, all oxygen supplies, date new supplies, every Sunday and as needed. Order As Needed Frequency Special Instructions Diagnosis 02/25/2025 - Open Ended Start/End Date 2/25/2025 - open ended. During an observation on 3/12/25 at 7:58 AM, oxygen tubing was draped over the handle to the portable oxygen tank, a clean plastic bag was not present to secure the oxygen tubing. During an observation on 3/12/25 at 12:51 PM, oxygen tubing draped over the handle to the portable oxygen tank, a clean plastic bag was not present to secure the oxygen tubing. Resident #29 (R29) Review of a Resident Face Sheet reflects R29 admitted to the facility with pertinent diagnoses that included chronic respiratory failure with hypoxia (low blood oxygen), sleep apnea and (severe) obesity with alveolar hypoventilation (a breathing disorder that affects some people with obesity). Review of a Care Plan initiated 4/10/2024 indicated R29 has the potential for alteration in respiratory function related to chronic obstructive pulmonary disease (COPD), chronic respiratory failure (CRF) did not reflect any directions for staff care of oxygen supplies. During an observation on 3/11/25 at 9:46 AM, R29's nasal cannula and oxygen tubing is draped over a fan on the resident over bed table, a clean plastic bag was not in the vicinity of the supplemental oxygen tubing. During an observation on 03/12/25 at 2:35 PM, R29's oxygen tubing is draped over a fan on the resident over the bed table. Additional oxygen tubing, detached from any oxygen supply, was on a blue plastic storage bin in front of the resident dresser, not secured in a clean plastic bag. Resident #115 (R115) Review of a Resident Face Sheet reflected R115 admitted to the facility on [DATE] with pertinent diagnoses that included acute on chronic diastolic (congestive) heart failure, Sarcoidosis (a chronic inflammatory disease characterized by the formation of granulomas, which are small clusters of immune cells, in various organs of the body) and chronic obstructive pulmonary disease (COPD). During an observation and interview on 3/11/25 at 9:23 AM, R115 reported she only wears the oxygen at night. R115's oxygen nasal canula which was connected to tubing attached to the oxygen concentrator is resting in the garbage can and does not appear dated. During an observation on 3/12/25 at 12:47 PM, R115's oxygen nasal canula is resting on top of the oxygen concentrator next to the trash bin, a clean plastic bag is not observed near the oxygen tubing. Review of a Treatment Administration History: 03/01/2025 - 03/12/2025 reflected Change oxygen tubing once a week on Sunday, and PRN (as needed) Order as Needed Frequency Special Instructions Diagnosis 03/11/2025 - open ended. The order does not indicate a requirement for any additional supplies or date marking requirement. During an interview on 03/13/25 at 8:23 AM it was reported by Registered Nurse (RN) F the resident oxygen tubing should be held in a clean plastic bag which is changed weekly. Review of a facility policy Respiratory Treatment Oxygen updated 5/19/21 reflected To provide supplementary oxygen to the respiratory system through oxygen therapy while maintaining appropriate infection control measures to reduce the risk of transmission of infectious agents. The policy specified 4. Date all equipment being used (oxygen tubing, nasal canula, mask, plastic storage bag and humidification bottle if indicated). 10. When oxygen is not in use store in dated plastic bag. 11. Change oxygen tubing, nasal canula, mask, humidification bottles and plastic storage bag every (7) days and as needed.

Based on interview and record review, the facility failed to 1.) involve the resident representative in the psychotropic medication management process for 2 residents (Resident #3 and #45) and 2.) failed to monitor laboratory studies for 1 resident (Resident #33) out of 6 residents reviewed for psychotropic medication use. Findings: Resident #3 (R3) Review of an admission Record revealed R3 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: anoxic brain damage, anxiety, depression, major depressive disorder, and seizure disorder. Review of R3's Psychiatric Consultation Note dated 4/21/25 revealed, .Anoxic brain damage .Plan: He can be impulsive at times. He is on 17.5mg Zyprexa daily, no GDR (Gradual Dose Reduction) have been done per wife's wishes .would recommend to continue to discuss with wife about GDRs . Review of R3's Pharmacy Recommendation signed by the provider 2/28/25 revealed, (R3) is currently taking .olanzapine (Zyprexa) 15 mg .(R3) is due for a dose reduction evaluation at this time .Please evaluate if a dose reduction would be appropriate at this time. If a GDR is contraindicated, please consider writing a risk vs. benefit statement documenting the clinical rationale for no reduction . Agree was circled below indicating a GDR would be attempted and was signed by the provider. During an interview on 03/12/25 at 01:07 PM, Resident Representative (RR) H reported that she received a phone call by a facility staff member and was told that the State of Michigan was forcing them to reduce his (psychotropic) medications. RR H reported that his behaviors were stable, and he was doing well and therefore felt the dose reduction of R3's Zyprexa would result in a decline in R3's psychosocial wellbeing. RR H reported that R3 was not over sedated and was appropriately interacting with other staff and residents. She was concerned that any changes in his medication regimen would result in increased behaviors and outbursts and wanted to keep the regimen as it was because he was psychologically stable and doing well. RR H also reported that R3's Zyprexa was not just for behavior but also for neurological issues. RR H stated, I told them his psych meds were not to be touched, and they said it's forced by the State, and it has to be done. RR H stated she felt forced into consenting to the medication change because the State regulations were threatened. Review of R3's Progress Note dated 03/05/2025 at 05:22 PM revealed, Received recommendation from pharmacy to perform GDR on one of (R3's) psychoactive medications. We have attempted to discuss this change with (RR H), who declined changes. (Contracted psychiatric consultant) also saw resident and recommended changes. On 3/4/25, we were able to discuss with (RR H) the fact that as a resident here, and subject to the rules and regulations set by the State of Michigan, resident does require a GDR of antipsychotic. (RR H) acknowledged that this is what must happen, but states, you guys have fun with that. He was a bear last time they messed with his meds. He was angry and mean and then would just cry, just sob. Staff offered support and reassurance and explained that we will monitor resident closely and make changes as necessary. Order placed to decrease Zyprexa to 7.5 nightly. Resident #45 (R45) Review of an admission Record revealed R45 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with psychotic disturbances. Review of R45's Order Summary dated 02/07/2025-03/05/2025 revealed, Depakote (divalproex) tablet, delayed release (DR/EC); 125 mg; amt: 125mg; oral Special Instructions: psychotic disturbance within Unspecified Dementia Twice A Day Review of R45's Progress Note dated 03/04/2025 revealed, Per (psychiatric consultants) recommendation, Depakote level increased to 250 (mg) BID (twice a day) .Provider agreed. Order placed. Will monitor for changes to behavior and report to provider as necessary. Review of R45's Progress Note dated 03/05/2025 revealed, Received recommendation from pharmacy to GDR resident's Lorazepam (antianxiety medication). Resident has continued to have anxious behaviors, crying, moaning, repetitive vocalizations, pacing. IDT (interdisciplinary team) and Provider made determination to decline recommendation at this time. Recommendation received from (psychiatric consultant) to increase resident's Depakote. Will re-evaluate resident's response to medication change and determine if GDR is appropriate at that time. Review of R45's Order Summary dated 03/05/2025 revealed, Depakote (divalproex) tablet, delayed release (DR/EC); 250 mg; amt: 250mg; oral Special Instructions: Psychotic disturbance within unspecified dementia Twice A Day. Review of R45's Electronic Medication Record revealed no documentation that R45's responsible party was involved in the decision to increase R45's depakote on 3/4/25-3/5/25. Review of R45's Progress Note dated 03/10/2025 revealed, Resident continues to be agitated, restless, tearful. She paces up and down halls with repetitive vocalizations, will break out into moments of screaming and crying, completely inconsolable. Discussed behaviors with IDT and reviewed meds with (unit name omitted) Hall Coordinator, Provider, and resident's family. Reviewed resident's (psychotropic medication genetic testing) and determination was made that Xanax may be a better medication to try to address resident's anxiety. Provider gave order for 0.5mg twice daily, PRN every 8 hours as needed. Order written, nurse notified, family aware of change. Will monitor and report changes to provider as necessary. During an interview via email on 03/12/2025 at 6:41 PM, Nursing Home Administrator (NHA) stated, On 03/10/25 DON (Director of Nursing) met with guardian on unit and completed medication review due to behaviors. Confirming R45's guardian was not made aware of the increase in depakote at the time the order was changed. Resident #33 (R33) Review of an admission Record revealed R33 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: paraphilia. Review of the National Library of Medicine revealed Paraphilias are persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature. (https://www.ncbi.nlm.nih.gov/books/NBK554425/) Paraphilias are persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature. Review of R33's Order Summary dated 3/16/24 revealed, Provera (medroxyprogesterone) tablet; 5 mg; amt: 10 mg; oral. Special Instructions: paraphilia Once A Day. Review of R33's Electronic Health Record revealed no documentation that R33 was followed by the contracted psychiatric consultant following the diagnosis of paraphilia and the subsequent order for Provera. R33's records did not reveal that he had had a liver function tests (LFTs), serum testosterone, LH, or FSH labs completed since the initiation of the Provera. During an interview via email on 03/12/2025 at 6:41 PM, NHA reported the facility physician was responsible for the management of R33's Provera order and monitoring. R33's physician did not order any labs due to the indication of use for the Provera. Review of the National Library of Medicine research article titled Medroxyprogesterone (Provera) last updated 02/29/2024 revealed, .If patients are currently prescribed medroxyprogesterone for paraphilia/hypersexuality, liver function tests (LFTs), complete blood count (CBC), serum testosterone, LH, FSH, and glucose require regular monitoring. Also, consider an annual bone scan if serum testosterone markedly decreases . [NAME] A, [NAME] P, Gerriets V. Medroxyprogesterone. [Updated 2024 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559192/ During an interview on 03/13/2025 10:11 AM, Nursing Home Administrator (NHA) reported that the Behavior Management Team follows the resident and/or resident representatives' direction when it comes to the GDR process and ensure all parties are educated on the process and the risk versus benefits of the psychotropic medications prior to any medication changes. During an interview on 03/12/25 at 02:27 PM, Social Services (SS) G reported that she had been the Social Services staff member for the facility for approximately 3 years until she transitioned to a different position the end of January 2025. SS G reported that the psychiatric consultation group assesses all residents prescribed a psychotropic medication and the facility Behavior Management Team would follow their recommendations for treatment. SS G reported the Behavior Management Team also followed the guidelines in the State Operations Manual regarding the GDR process and the team would try to respect their wishes. SS G stated that the facility was required per State guidelines to attempt a GDR for residents on psychotropic medications that were not exhibiting any behaviors to ensure residents were not overmedicated. SS G reported that RR H had previously refused all GDR attempts for R33 due to her fear that he would decline, and his behaviors would increase. SS G reported that R33's behavior documentation (lack of behaviors) didn't support his use of psychotropic medications and therefore a GDR was required to take place despite SS G's confirmation that R33 was not over sedated, and his representative was against the recommendation. SS G reported that RR H was concerned that R33 would have increased behaviors with any changes to his medications. SS G reported that she had not discussed with R33's representative the recommendation of increasing the depakote. Review of the facility policy Medication Management (A) (no date) revealed, .Procedure-The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis (quarterly) .2. The resident is evaluated before initiating, withdrawing, or withholding medication(s), or using non-pharmacologic approaches. A. The extent of the evaluation will vary according to the resident's current condition, but may include .ii. Resident's goals and preferences .iv. History of prior and current medications .vi. Refusal of care and treatment, including the basis for declining it and the identification of pertinent alternatives. vii. An evaluation of medication risk vs. benefits will include/summarizing the rationale for necessary for (sic) medication therapy. 3. Information gathered during the initial and ongoing evaluations are incorporated into a comprehensive care plan that reflects appropriate medication-related goals and parameters for monitoring the resident's condition and ongoing need for the medication(s) .a. The care planning team defines quantitative and qualitative monitoring parameters using a variety of resources .clinical practice guidelines or clinical standards of practices; medication references; and clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals .9. When a resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, and/or non-pharmacological interventions, including behavioral interventions, have been effective in reducing the sumptoms (sic), the resident is evaluated for the appropriateness of a taper or gradual dose reduction (GDR) of the medication. A. Antipsychotics. If a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated .2. The continued use is in accordance with relevant current standard of practice and the physician documents the clinical rationale of why any additional attempted dose reductions would likely impair the resident's function, increase distressed behavior, or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder . Medroxyprogesterone Last Update: February 29, 2024. If patients are currently prescribed medroxyprogesterone for paraphilia/hypersexuality, liver function tests (LFTs), complete blood count (CBC), serum testosterone, LH, FSH, and glucose require regular monitoring. Also, consider an annual bone scan if serum testosterone markedly decreases . [NAME] A, [NAME] P, Gerriets V. Medroxyprogesterone. [Updated 2024 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559192/

Based on observation, interview, and record review the facility failed prevent a facility-acquired pressure ulcer, and measure, assess and promote the healing with an appropriate dressing change for one resident (Resident #63) of 1 resident reviewed for pressure ulcers. This deficient practice resulted in Resident #63 developing an unstageable pressure ulcer on the heel. Findings include: The facility provided a policy for Pressure Injuries: Assessment, Prevention and Treatment (undated and unsigned) for review. The policy reflected, 2. Skin will be assessed routinely for the presence of developing pressure injuries and documented on the Nursing Skin Tool .12. Float heels - keep heels off the bed .15. Check placement of splints, casts, and positioning devices to assure they are not causing friction on the resident's skin . Resident #63 (R63): Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R63 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represents R63 had severe cognitive impairment. The MDS reflected the R63 required 2 staff assistance with all activities of daily living. According to the MDS dated [DATE], R63 was identified as risk for ulcers/injuries and had no unhealed pressure ulcers/injuries upon admission to the facility. The facility provided a copy of the policy for Wound Care undated and unsigned for review. The policy reflected, Steps in the Procedure 1. Clean hands. 2. Establish clean field. Place all items to be used during procedure on the clean field . During an observation and interview on 3/12/24 at 9:38 AM, Registered Nurse (RN) R was observed while she changed the dressing to R63's heel wound with the assistance of State Trained Nursing Assistant (STNA) U who held her leg and assisted with positioning. RN R opened her dressing supplies at the corners and placed them on the stand next to the TV without preparing a clean dressing field. RN R removed the blue cushioned bootie from the left foot and the inside of the bootie was heavily soiled, which was in direct contact with the outer portion of the wound dressing. RN R stated she would see about replacing the soiled bootie. RN R removed the dressing, and an open area was visible to the bottom of the heel. The wound was cleansed, redressed with a clean dressing and the soiled blue cushioned bootie was reapplied. According to the policy the staff will establish a clean field to use for the procedure and the dressing supplies. The facility provided a copy of the Orthopedic consult for review dated 1/10/24 signed by the physician on 1/11/24. The note reflected, Non communicative. X-rays: fracture healed (to left leg) .large unstageable posterior heel pressure ulcer. A/P (assessment and plan) = Bimalleolar (type of fracture) ankle fracture healed. Posterior heel pressure ulcer. (Name of boot that protects heel from all pressure) provided today - only needed for her pressure sore. She no longer requires bracing (splint to entire left left) for her fracture. Wound care for ulcer. No f/u (follow up) needed. The facility provided all wound measurements for review. The first wound measurements were done on 1/19/24 (9 days after the Orthopedic made note of the pressure ulcer). The assessment reflected, Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed .Original wound onset date 1/19/24 .Size (Length X Width X Depth) 3.4 cm x 5.2 cm x 0.3 cm. The facility provided a copy of Etiology of Skin Breakdown 1/19/24 for review. The document identified risk factors that contributed to the pressure ulcer development as significant weight, loss since admission, a full leg immobilizer, and residents shifting and scooting while her leg was in the brace. The document reflected, On 1/19/24 the staff reported heel breakdown and was noted to have an unstageable heel pressure injury. A (name of boot that protects from pressure) was implemented by her Orthopedic Physician. According to the Orthopedic note dated 1/10/24, R63 presented with a new pressure ulcer to the left heel and the protective boot was provided at the time of the consultation evaluation (1/10/24). There was no evidence the facility took action with interventions and treatment orders on the day the pressure ulcer was first noted by the Orthopedic. The following weekly measurements were provided for review from 1/19/24 - 3/6/24: 1/19/24 3.4 x 5.2 x 0.3 1/31/24 3.3 x 4.2 x unable to determine. 2/7/24 2.1 x 1.7 x unable to determine. 2/14/24 1.6 x 1.3 x unable to determine. 2/21/24 0.7 x 0.3 x 0.4 2/28/24 0.8 x 0.3 x 0.3 3/6/24 1.9 x 0.5 x 0.8 (decline in healing noted) According to the Medication Administration Record (MAR) for January 2024 reflected, Skin prep (a medication that creates an invisible layer on the skin to protect it from friction) to bil (both) heels Q (every) shift as preventative 12/4/23 - Open Ended, and an order for, Left Heel: Cleanse with NS (normal saline) and pat dry. Apply medi honey (wound healing agent) gel to the wound and cover with bordered foam. Change daily and prn (as needed) started on, 1/19/24 - Open Ended. The MAR reflects 2 different treatments to be applied to the left heel, one dressing daily and a skin treatment every shift. According to the January MAR, the healing agent was not started until 9 days after the Orthopedic noted the wound and recommended wound care for the ulcer. The weekly skin assessment from 2/1/24 to 3/11/24 were requested for review for R63. The facility provided copies of the Nursing Skin Tool dated 2/19/24, 2/26/24, and 3/4/24 for review. The Nursing Skin Tool was incomplete and did not reflect the signature of any nurse for over 5 weeks. During an interview on 3/13/24 at approximately 11:00 AM and a follow-up interview at approximately 1:00 PM, the Director of Nursing (DON) stated that R63 was admitted on [DATE] and wore an immobilizer to the left that extended from her upper thigh to just above the ankle for a leg fracture. The DON stated that R63 wore the splint until it was discontinued on 1/22/24 (12 days after seeing the Orthopedic Physician who directed to discontinue it on 1/10/24). The DON stated the staff first noted the pressure ulcer to the left heel on 1/19/24 which was the first time it was assessed, measured and a new treatment was put into place to facilitate the healing. The DON stated that a blue offloading boot was added to the care plan on 2/5/24. The DON identified other causative factors that contributed to the development of the pressure ulcer such as weight loss, the leg immobilizer that would slip down her leg and frequent scooting and shifting of her leg. The DON stated it was the expectation that a nurse assess residents weekly and document the findings on the Nursing Skin Tool sheet.

Based on interview and record review, the facility failed to 1.) Accurately document administration of controlled substances and 2.) Ensure that narcotic medications were administered following the physicians' orders for 4 residents (Resident #5, Resident #7, Resident #9, and Resident #54), reviewed for controlled substances, resulting in medication errors. Findings include: Resident #5 (R5): Review of an Admission Record revealed R5 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: peripheral vascular disease. Review of R5's Physician Order revealed, gabapentin capsule; 100mg; once a day to be administered at 10:00 AM. Review of R5's Physician Order revealed, gabapentin capsule; 300mg; once a day to be administered at 10:00 PM. Review of R5's Controlled Substance Proof of Use Form for gabapentin 100mg revealed that on 3/4/24 at 9:12 AM and on 3/4/24 at 9:26 PM a dose of gabapentin was administered. Indicating the incorrect dose of gabapentin was administered on 3/4/24 at 9:26 PM. Review of R5's Controlled Substance Proof of Use Form for gabapentin 300mg revealed that on 3/4/24 (no time documented) a dose of gabapentin was administered. Indicating 400mg of gabapentin was administered instead of 300mg). Review of R5's Controlled Substance Proof of Use Form for gabapentin 100mg revealed that on 3/8/24 at 9:00 AM a dose was administered, on 3/9/24 at 8:14 PM a dose was administered, and on 3/9/24 at 9:12 AM a dose was administered. Review of R5's Controlled Substance Proof of Use Form for gabapentin 300mg revealed that on 3/8/24 there was no dose administered. Indicating R5 received a dose of gabapentin 100mg instead of 300mg at that time. Resident #7 (R7): Review of an Admission Record revealed R7 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: seizures. Review of R7's Physician Order revealed, Briviact; 10mg/ml; 8ml via peg tube; twice a day. Review of R7's Medication Administration Record revealed both doses of Briviact were administered on 3/11/24 with a note Given by previous shift, per night shift RN (registered nurse). Review of R7's Controlled Substance Proof of Use Form for Briviact 8ml (80mg) revealed a dose was administered on 3/11/24 at 8:48 PM. Indicating there was no morning dose of Briviact administered. Resident #9 (R9): Review of an Admission Record revealed R9 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain. Review of R9's Physician Order revealed, tramadol; 50mg tablet. Administer 25mg twice a day. Review of R9's Controlled Substance Proof of Use Form for Tramadol revealed that on 3/8/24 a dose was administered at 9:01 AM. There was no evening dose of tramadol documented as administered. Review of R9's Medication Administration Record revealed that both the morning and evening dose of tramadol were documented as administered on 3/8/24. Resident #54 (R54): Review of an Admission Record revealed R54 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: neuropathic pain (nerve pain). Review of R54's Physician Order revealed, Neurontin; 100mg capsule. Amount to administer: 200mg twice a day. Review of R54's Controlled Substance Proof of Use Form for gabapentin revealed that on 3/10/24 a dose was administered at 8:47 AM. There was no evening dose of tramadol documented as administered. On 3/11/24 a dose was administered at 11:56 AM. There was no evening dose of tramadol documented as administered. Review of R54's Medication Administration Record revealed that both the morning and evening doses of tramadol were documented as administered on 3/10/24 and 3/11/24. During an interview on 3/13/24 at 1:30 PM, Nursing Home Administrator confirmed that there were discrepancies with the above narcotic medications and reported the Director of Nursing would be completing licensed nurse education and disciplinary action. Review of the facility policy, Administering Medications (no date) revealed, .Administration .2. Medications are administered I accordance with written orders of the attending physician .Documentation: 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented . Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition.

This citation has 2 separate Deficient Practice Statements A and B. Deficient Practice Statement A: Based on observation, interview, and record review the facility failed to routinely assess, monitor, and respond to new skin breakdown for 3 of 4 residents, (Resident #23) R23, (Resident #47) R47 and (Resident #63) R63. This deficient practice resulted in R47 impaired skin integrity to go unassessed, unmonitored and untreated. Findings include: The facility provided a policy for Pressure Injuries: Assessment, Prevention and Treatment (undated and unsigned) for review. The policy reflected, 2. Skin will be assessed routinely for the presence of developing pressure injuries and documented on the Nursing Skin Tool . The facility provided a policy for Alteration in Skin Integrity (partial thickness) undated and unsigned for review. The policy reflected, The facility will identify residents with alteration is skin integrity and implement appropriate measures to promote healing. Upon first assessment the clinician is expected to document the following in the medical record: underlying condition contributing to the scab, scab edges and wound bed, location, shape, and condition of surrounding tissues. Procedure: 1. Upon identification of a new alteration in skin integrity, a Licensed nurse will assess the area and enter documentation in the clinical record to reflect the appearance of the wound . R47: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R47 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represents R47 was cognitively intact. During an initial tour on 3/11/24 at approximately 8:20 AM, R47 was observed in his room seated in a wheelchair with a dressing to the right lower leg that did not contain a date nor initials. When asked about the dressing to his leg, R47 stated that he did not know who put it on or how long it had been on. The weekly skin assessment from 2/1/24 to 3/11/24 were requested for review for R47. The facility provided copies of the Nursing Skin Tool dated 2/5/24 which was signed by the nurse and 2/15/24, 2/19/24, and 2/26/24 that were not signed by the nurse. The Nursing Skin Tool was incomplete and did not reflect the signature of any nurse for over 3 weeks. There was no indication on the Nursing Skin Tool what was under the dressing to the right leg. The progress notes from 2/1/24 - 3/11/24 were reviewed and did not reflect any skin breakdown or indication for a dressing to the right lower leg. On 3/11/24 the Medication Administration Record for March 2024 was reviewed, and it did not reflect any treatment orders for the right lower leg. During an observation on 3/11/24 at 3:35 PM, Registered Nurse (RN) R stated she did not know what the skin condition was under the right lower leg dressing and noted there were no orders to treat the area. R47 was asked about the skin issue but could not recall when it happened, who put the dressing on nor when it was applied. RN R confirmed there was no date or initials on R47's dressing and was observed as she removed it. The dressing had a large amount of drainage that covered most of the dressing. The Surveyor and RN R observed 4 small open areas of light pink skin (approximately 0.5 cm each) that had active weeping of clear fluid coming from each area. After assessing the right lower leg, RN R stated she would notify the physician and obtain a treatment order. R23: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R23 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 1 out of 15 which represents R23 had severe cognitive impairment. The MDS reflected the R23 required 2 staff assistance with all activities of daily living. The weekly skin assessment from 2/1/24 to 3/11/24 were requested for review for R23. The facility provided copies of the Nursing Skin Tool dated 2/5/24 and 2/12/24 for review. The Nursing Skin Tool was incomplete and did not reflect the signature of any nurse for over 5 weeks. R63: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R63 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represents R63 had severe cognitive impairment. The MDS reflected the R63 required 2 staff assistance with all activities of daily living. The weekly skin assessment from 2/1/24 to 3/11/24 were requested for review for R63. The facility provided copies of the Nursing Skin Tool dated 2/19/24, 2/26/24, and 3/4/24 for review. The Nursing Skin Tool was incomplete and did not reflect the signature of any nurse for over 5 weeks. During an interview on 3/13/24 at approximately 11:00 AM, the Director of Nursing (DON) stated that she expected the nurses to assess and document skin assessments on the Nursing Skin Tool weekly. 37573 Deficient Practice Statement B This Citation pertains to Intake Number M100142728. Based on interview and record review, the facility failed to ensure that one resident (Resident #7) of 1 resident reviewed, received the medications necessary to prevent seizures. Findings include: Resident #7 (R7): Review of a Face Sheet revealed R7 originally admitted to the facility on [DATE] with pertinent diagnosis of epilepsy. In an interview on 3/11/24, Family Member (FM) P reported two weeks after R7 admitted to the facility he started to act differently and realized he was not getting his seizure medications which then led to him having a seizure and going to the hospital. Review of the Hospital discharge medications dated 1/20/24 for R7 included brivaracetam (Briviact, an anticonvulsant) 80 mg per G (gastro) tube 2 times daily and Oxcarbazepine (Trileptal, an anticonvulsant) 600 mg per G tube 2 times daily. Review of the Hospital Records dated 1/28/24 revealed R7 went to the hospital with diagnoses of acute seizure and chronic oromandibular dystonia (a neurological condition affecting the jaws, face, and mouth.) Living facility to call head and reported that she had not been getting his seizure medication for several days. The patient experienced repetitive eye blinking today, Review of the January Medication Administration Record (MAR) for R7 revealed he received Briviact 8 mL (milliliters) twice a day 1/21/24 to 1/23/24, and the morning dose on 1/24/24. Briviact is documented as unavailable from the 1/24/24 evening dose through 1/28/28. There is no record the resident received Trileptal in January. During an interview on 3/12/24 at 3:15 PM, Registered Nurse (RN) R reported that she was the nurse that completed R7's admission on 1/20/24. RN R reported that she had not completed an admission independently prior and had made errors. RN R reported that she had not entered all the medications into the EMR (electronic medical record) prior to the end of her shift and the oncoming nurse was to finish the medication reconciliation, which was not completed. Pharmacy: In an interview on 3/12/24 at 3:15 PM, Registered Nurse (RN) R reported that multiple attempts were made with the pharmacy to get R7's refill of Briviact, and the pharmacy would not release the medication without an updated prescription. In an interview on 3/13/24 at 1:00 PM, the Director of Nursing (DON) reported they had talked to the pharmacy extensively and there was some miscommunication on their end. This situation happened over the weekend. Review of an email correspondence thread between the facility and the pharmacy revealed that the pharmacy needed a new prescription for the Briviact before they could send it to the facility. Review of a Pharmacy Contract revealed Delivery: . agrees to deliver to [entity] six (6) days per week, Monday through Saturday, with an additional delivery if an emergency arises, except for circumstances and conditions beyond its control [entity] is available for assistance 24 hours per day, 365 days a year. Review of a pharmacy policy titled Orders/Delivery of Medications revealed: Medications will be ordered from [Pharmacy] in a manner that allows delivery to the facility on a timely basis. Timeliness will be assessed and will factor in the following: continuity of care, condition of the resident (severity/instability), category of medication, (antibiotic/analgesic) and the physician ordered start time. The facility will maintain accurate records of drug order and receipt.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1.) Hand sink was being used and properly maintained 2.) Food contact surfaces were being maintained in a clean and sanitary condition free from contamination, and 3.) Effectively maintain food and non-food contact areas, affecting 67 residents, resulting in the increased likelihood for cross-contamination and bacterial growth. Findings include: During the initial tour of the kitchen on 3/11/24 between 7:50 AM to 8:30 AM the following issues were observed: An observation of an unidentified man (he disappeared upon entry to the kitchen)was washing a soiled 3 to 4 round black rubber/plastic ring and a piece of drainpipe (from a torn apart 3- compartment sink) in the hand sink. Continuation of hand sink observation, unidentified man waved his hand and activated the automatic paper towel dispenser. A cart of resident mugs (blue) were being stored beneath the paper towel dispenser. The food contact portion of the mug was potentially contaminated when the automatic paper towel dispenser was activated by dripping wet and/or contaminated hands. Observation of hand sink revealed scale, dark black grime/sludge mixed with a few inches of ice in the bottom of sink. Observation of the Walk In Cooler (WIC) revealed dust, grime, and debris on the shelving and on the fan compressor grate. According to the 2017 FDA Food Code section 5-205.11 Using a Handwashing Sink, (A) A HANDWASHING SINK shall be maintained so that it accessible at all times for EMPLOYEE use. (B) A HANDWASHING SINK may not be used for purposes other than handwashing. According to the 2017 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 2017 FDA Food Code section 6-501.18 Cleaning of Plumbing Fixtures, PLUMBING FIXTURES such as HANDWASHING SINKS, toilets and urinals shall be cleaned as often as necessary to keep them clean. According to the 2017 FDA Food Code section 4-602.13, NONFOOD CONTACT SURFACES. NONFOOD CONTACT SURFACES OF EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During the 2nd Kitchen observation on 3/11/24 at 11:35 AM, next to hand sink is 5 tier cart storing clean lids, was partially over the sink exposing the lids to potential cross-contamination and splash during the hand washing process. According to the 2017 FDA Food Code section 4-902.12 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (Paragraph) (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE- SERVICE and SINGLE USE ARTICLES shall be stored: (1) In a clean; dry location: (2) Where they are not exposed to splash, dust, or other contamination; . (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (Paragraph) (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.

Based on observation, interview, and record review the facility failed to provide a dignified dining experience for 2 residents (Residents #23) R23 and (Resident #63) R63 observed for dining. Findings include: R63: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R63 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represents R63 had severe cognitive impairment. The MDS reflected the R63 required 2 staff assistance with all activities of daily living. During an observation of the East Hall on 3/11/24 at approximately 9:29 AM, State Trained Nursing Assistant (STNA) U was observed standing next and over R63 as she fed breakfast to R63. R63 was non communicative and was not able to be interviewed regarding the incident. The reasonable person would find it undignified to be assisted with dining while the staff member stood over them instead of seated at the same level. 37872 R23: R23 was admitted to the facility on [DATE], with diagnosis that included dementia, essential hypertension, Combined forms of age-related cataract, bilateral, chronic diastolic (congestive) heart failure, venous insufficiency, stage 2 Pressure ulcer of the left heel, muscle weakness and feeding difficulties. A review of R23's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/03/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 1 which revealed R23 is severely cognitively impaired. During a dining observation on 3/11/24 at 12:27 PM, staff are in the back of the dining room assisting two residents with their lunch. During R23's lunch, State Trained Nursing Assistant ([NAME]) S gets out of her chair, goes around resident's wheelchair, and stands on resident's right side. After looking around the main dining room [NAME] S picks up a bowl and beings assisting R23 with her lunch. [NAME] S stands over R23 during the remainder of residents' lunch. During an interview on 3/11/24 at approximately 12:37 PM, [NAME] S revealed standing over the resident, has become an issue in the last couple of months, (while assisting residents to eat) due to a large pillar blocking staffs view of the rest of the dining room.

Based on observation, interview and record review the facility failed to provide dependent residents with assistance to shower and with personal hygiene for 3 of 4 residents (Resident #23) R23, (Resident #47) R47 and (Resident #63) R63. Findings include: R47: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R47 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represents R47 was cognitively intact. The MDS reflected the R23 required 1-2 staff assistance with all activities of daily living. During an observation and interview on 3/11/24 at 3:35 PM, Registered Nurse (RN) R was observed removing both R47's socks to inspect his feet. Both socks were soiled, and the right sock had a hole in the heel that was the size of a silver dollar. RN R acknowledged the condition of the socks and stated they would be replaced. During an observation and interview on 3/13/24 at 11:10 AM, R47 was seated in his wheelchair next to his bed. R47's grip socks were visibly soiled, and the right sock had a hole in the heel approximately the size of silver dollar. When asked if the staff were able to provide a new pair of grip socks to R47, RN R stated, I will get him some. According to the shower sheets dated 2/1/24 - 3/11/24 provided for review, R47 had not had a shower in 14 days. R47's last shower was documented on 2/26/24. R23: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R23 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 1 out of 15 which represents R23 had severe cognitive impairment. The MDS reflected the R23 required 2 staff assistance with all activities of daily living. During an observation on 3/11/24 at approximately 8:40 AM and 3/12/24 at approximately 9:00 AM, R23 was observed seated in a wheelchair in the East Hall with her eyes closed resting. R23's hair was soiled with oil and several facial hairs were noted to the chin that were approximately 1 cm in length. According to the Activities of Daily Living care plan dated 11/21/19, the approach of 1-Provide nail care and shampoo hair with showers per weekly schedule. 2-Groom hair daily and encourage (name of R23) to participate as able. 3-Provide/assist with am & pm care, encourage (name of R23) to participate with hygiene as tolerated. 4-Assist with and/or shave facial hairs QD PRN (everyday as needed) or per (name of R23) preference. The weekly skin assessment/shower forms dated 2/1/24 to 3/11/24 were requested for review for R23. The facility provided copies of the Nursing Skin Tool dated 2/5/24 and 2/12/24 for review. The form reflected a bed bath was given on both dates and there was no evidence a shower was given as the care plan reflected. There was no bathing assistance provided since 2/12/24 (for over 4 weeks). R63: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R63 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represents R63 had severe cognitive impairment. The MDS reflected the R63 required 2 staff assistance with all activities of daily living. During an observation on 3/11/24 at approximately 9:08 AM and 3/13/24 at approximately 10:00 AM, R63 was seated in a reclining wheelchair in the East Hall. R63 had oily hair that was uncombed/tangled in the back and several long white chin hairs that were approximately 2 cm in length.

This citation has 3 DPS statements. This citation refers in part to MI00133328: DPS#1 Based on observation, interview and record review the facility failed to prevent accidents and hazards for 1 resident (R7) resulting in an Immediate Jeopardy (IJ) that began on 1/19/23, due to the facility's lack of policies and procedures to prevent hot liquid burns for R7. This deficient practice led to R7 experiencing multiple third degree burns and unnecessary pain and disfigurement and the potential for other residents in the facility to be at risk from burn, pain and injury. Findings include: A review of R7's Face Sheet, dated 2/15/23, revealed R7 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R7's Face Sheet revealed multiple diagnoses that included dementia, generalized muscle weakness, rheumatoid arthritis, and muscle spasms. A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 12/28/22, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 9 which revealed R7 was moderately cognitively impaired. In addition, R7's MDS revealed she needed supervision (oversight, encouragement, or cueing) for eating after staff setup her food and drinks. On 2/7/23 at 11:51 AM an interview was conducted with R7. R7 reported that a couple of weeks prior she was in the Activities room and spilled coffee on her right leg and that she was burned bad. R7 reported that staff put paste on it but that it still hurts. R7 reported that she was told to wear a dress and not slacks or pants to allow air to get to the wounds. R7 exposed her R thigh which revealed a large irregularly shaped area of scabbing with other smaller areas of scabbing covering most of the front right thigh. On 2/14/23 at 4:37 PM a follow up interview was conducted with R7 in her room. R7 indicated that the scabbing persisted on the right thigh and she exposed her left thigh to reveal scattered scabbing. R7 reported that this scabbing is also a result of the cup of coffee that spilled on her when she was in the Activities room. A review of R7's Other Events- Non Fall Resident Event report, dated 1/20/23, revealed on 1/19/23 at 2:45 PM, R7 spilled hot coffee on her lap while in the recreation room. R7 sustained burn injuries to her anterior (back side of thigh) right thigh (redness), anterior left thigh (redness), and left outer knee (superficial blister). However, there were not any measurements of the burn areas noted on the report. In addition, the report failed to reveal that follow-up assessments were conducted to monitor R7 for continued/worsening injuries related to the hot coffee burn (physical damage from a burn can take time to develop and burns should be monitored and assessed over time to determine the true extent of the damage). A review of the facility's Burn Investigation Report, undated, revealed on 1/19/23 at the request of the resident (R7) the Activity Assistant provided a cup of coffee to her in the Activity Room. The coffee was drawn directly form (from) the coffee machine in a Styrofoam cup that had a lid on it. The resident removed the lid to add creamer/sweetener to it and spilt the coffee on her lap. Actions: Activity Assistant notified nurse. Resident (Activity Assistant/nurse?) immediately returned resident to room for privacy. Resident returned to room. Clothing removed immediately. Noted general redness on left thigh, right thigh with superficial broken blister side of right knee. Cool immediately applied . A review of R7's Nursing note, dated 1/19/23, revealed, Called to see resident after spilling hot coffee on lap. Resident returned to room. Clothing removed immediately. Noted generalized redness on left thigh, right thigh with supeficial (superficial) broken blister side of right knee. Cool immediately applied . A further review of R7's progress notes, dated 1/19/23 to 1/25/23, failed to reveal any measurements of R7's burn injury areas prior to 1/26/23. A review of Activities Assistant (AA) H's typed and signed statement, undated, revealed R7 asked AA H for a cup of coffee. AA H put the coffee in a Styrofoam cup with a lid on it and handed it to R7. R7 asked for more cream and sugar and AA H went to get them. When AA H was getting the cream and sugar, he heard her shout out and saw she had spilled coffee on her thighs. AA H rushed her (R7) back over to her room, and told an aide what happened and she got the nurse. A review of R7's Wound Grids, dated 1/19/23 to 2/15/23, revealed the following: - Left Medial Thigh Superior Aspect (top inside area of the thigh) partial thickness burn (second degree burn)- original wound onset- 1/19/23 - 1/26/23= Measurement= 4.7 cm (centimeters) x 5.4 cm x 0.1 cm (length x width x depth). - 2/2/23= Measurement= 4.5 cm x 5.5 cm x 0.1 cm. - 2/9/23= Measurement= 2 cm x 3.9 cm x 0.1 cm. * There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area. - Left Medial Thigh (inside area of thigh) full thickness burn (third degree burn)- original wound onset- 1/19/23. - 1/26/23= Measurement= 6 cm x 6.5 cm x 0.1 cm. - 2/2/23= Measurement= 4.1 cm x 6.3 cm x 0.1 cm. - 2/9/23= Measurement= 4.3 cm x 3.6 cm x 0.1 cm. * There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area. - Left Posterior Thigh (area of the thigh on the back side of the thigh) partial thickness burn- original wound onset- 1/19/23 - 1/26/23= Measurement= 1.6 cm x 1.5 cm x 0.1 cm. - 2/2/23= Measurement= 1.1 cm x 1 cm x 0.1 cm. - 2/9/23= Measurement= wound healed. * There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area. - Right Anterior Thigh (area of thigh on the front side) full thickness burn- original wound onset- 1/19/23. - 1/26/23= Measurement= 3.3 cm x 4.2.cm x 0.2 cm. - 2/2/23= Measurement= 5.8 cm x 4.9 cm x 0.1 cm. - 2/9/23= Measurement= 2.3 cm x 5.6 cm x 0.1 cm. * There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area. - Right Lateral Thigh (area along the outside thigh) full thickness burn- original wound onset- 1/19/23. - 1/26/23= Measurement= 6.7 cm x 6.4 cm x 0.1 cm. - 2/2/23= Measurement= 14 cm x 9.5 cm x 0.1 cm. - 2/9/23= Measurement= 1 cm x 1 cm x 0.1 cm. * There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area. - Right Medial Thigh full thickness burn- original wound onset- 1/19/23. - 2/2/23= Measurement= 4 cm x 15.2 cm x 0.1 cm. - 2/9/23= Measurement= 14.5 cm x 8.4 cm x 0.1 cm. * There were not any measurements of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained two weeks after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area and/or within the first two weeks following the event. During an interview on 02/10/23 at 9:10 AM, the Director of Nursing (DON) stated, We don't measure bruises, red areas, and not always skin tears found on skin checks. As a result of the facility not measuring red areas, there was no way to know the measured extent of R7's original burn areas. A review of the University of Rochester Medical Center's Classification of Burns Encyclopedia reference, dated 2023, revealed, It may be impossible to classify a burn immediately when it occurs. It can progress over time so you may not know the full extent for a day or two (https://www.urmc.rochester.edu/encyclopedia). A review of the University of Rochester Medical Center's Classification of Burns Encyclopedia reference, dated 2023, revealed, First-degree (superficial) burns. First-degree burns affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and has no blisters. Mild sunburn is an example. Long-term tissue damage is rare and often consists of an increase or decrease in the skin color. Second-degree (partial thickness) burns. Second-degree burns involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful. Third-degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred (https://www.urmc.rochester.edu/encyclopedia). During an interview on 2/14/23 at 4:15 PM, Dietary Aide (DA) J revealed that for coffee, we get a red cup (plastic) and put ice in it because it comes out at 170-175 degrees. The red cups are stored on shelving approximately 15-20 feet away and the 16oz Styrofoam cups are to the right of the coffee machine in white plastic bins. DA J was asked to prepare a resident's coffee. DA J grabbed a red cup, filled it 3/4 full an adds approximately 8 ice cubes. The coffees temperature was 118 degrees within a minute using surveyor's thermometer. On 2/14/23 at 4:17 PM, Activity Aide (AA) M revealed, I get the residents coffee from the kitchen all the time. AAM stated, the coffee is now served in a red cup and ice is now added. Prior to the resident being burned it went in a Styrofoam cup. On 2/14/23 at 4:30 PM, a sign on the top of the on-demand coffee machine reflected the following information, Coffee Temp should not be 150F - 180F degrees Add ice if serving directly from machine. Please only use the cups above (picture of the facilities red plastic cup and the blue cups with lids) do NOT use Styrofoam cups for hot liquids. Dietary Manager (DM) K stated, she was not sure when the sign was put up (on the coffee machine), she stated the Nursing Home Administrator had put it up. A cup of coffee was currently unobtainable at this time. A message was flashing on the coffee machine and coffee was unable to be dispensed. DA J revealed this surveyor would have to wait due to it being overused. Approximately 12 large carafes were observed on carts waiting to be served with dinner. During the kitchen observation on 2/14/23 at 4:35 PM, DA J revealed what happened on the day the resident was burned. We were busy, we didn't really see them (activity staff) come in and they helped themselves to the coffee. We are always supposed to put ice in it, I don't think they did. After that happened (points to the coffee machine) that big sign went on. On 2/14/23 at 4:36 PM, the coffee machine quit flashing and the first coffee temped at 148F degrees. Approximately a minute later, a second cup tempted out at 167.7F. No thermometers were located near the vicinity of the coffee or ice machines. The closest thermometers were next to the microwave on the other side of the kitchen. On 2/15/23 at 8:40 AM an observation and interview were conducted at the coffee machine in the facility kitchen. Review of the coffee machine revealed a sign near the front top of the machine that read, Coffee temp should not be 150 to 180F (Fahrenheit) Add ice if serving directly from machine. Review of the area surrounding the coffee machine did not reveal any thermometers to determine the temperature of the coffee before or after ice had been added. Using a red handled coffee mug the vessel was filled with coffee directly from the coffee machine. This cup of coffee revealed a temperature of 179.2 degrees F. A second red handled coffee mug was filled with coffee directly from the facility coffee machine and revealed a temperature of 181.4 degrees F. Cook N reported that the temperature of the coffee is not checked or recorded. Cook N reported that if a resident requests coffee staff can call the kitchen or come directly into the kitchen and pour the cup. Cook N reported that any staff member can come into the kitchen if they are wearing a hair net. On 2/15/23 at 11:05 AM the NHA and DON were informed of an Immediate Jeopardy (IJ)identified on 2/15/23, that started on 1/19/23 when R7 was served coffee in the activity room, and she spilled coffee on her lap and sustained full thickness (third degree) burns. The coffee was not temped by staff. Coffee is still not temped by staff before serving and staff are instructed by a sign to add ice to coffee. On 2/15/23 at 8:40 AM, 2 cups of coffee were temped at 179.2 and 181.4 degrees Fahrenheit. Kitchen staff stated they add 2-3 cubes of ice to coffee, but do not temp the coffee. Any staff member is able to come to the kitchen and obtain a cup of coffee for a resident. R7 does not have a hot liquid assessment, and per her diagnosis she has dementia, has a BIMS of 9/15 (moderately impaired cognition), has muscle weakness and muscle spasms. Per interview with facility staff they do not have a policy or procedure for completing hot liquid assessments on residents. The identified risk of serious injury, serious harm, serious impairment or death was evidenced by: R7 having full thickness (third degree) burns, per the wound notes. The initial wound measurements were: wound 1, left posterior thigh 1.1cm x 1cm x 0.1cm; wound 2 left proximal medial thigh 4.5cm x 5.5cm x 0.1cm; wound 3 left distal medial thigh 4.1cm x 6.3cm x 0.1cm; wound 4 right lateral thigh 5.8cm x 4.9 cm x 0.1cm; wound 5 right proximal thigh 14cm x 9.5cm x 0.1cm; wound 6 right medial thigh 4cm x 15.2cm x 0.1cm. A third degree burn can be sustained by contact with hot liquid at 155 degrees for one second. The need for immediate action was: The facility must take temperatures of any hot food or liquids prior to serving to directly to residents. All residents must be assessed for safety with hot liquids. During the immediate jeopardy discussion on 2/15/23 at 11:05 AM, the DON again confirmed the facility does not do a hot liquid assessment and they do not even have a standard assessment for hot liquid safety. Occupational therapy does sometimes assess residents for the need for adaptive equipment. The NHA stated they had started a QA(Quality Assurance) Plan related to the burn and the NHA had been temping coffee weekly and determined 2-3 ice cubes will get coffee below 150 degrees Fahrenheit, which was the goal. The NHA confirmed this procedure was not written anywhere and the coffee was not being temped regularly. The NHA stated that 3-5 staff were also being quizzed weekly on new policy. The policy was their Pull/Pour policy which stated clothing would be removed from a resident immediately and cool liquid applied in the event of future hot liquid spills. The NHA and the DON were informed assessing their residents for safety with hot liquids as well as creating a policy and procedure for appropriate serving temperatures for hot liquids and taking temperature of those liquids prior to every service to residents would be key to removing the immediacy of the Immediate Jeopardy. On 2/15/23 at 4:00 PM, the NHA confirmed they did not yet have a removal plan. It was discussed the survey team could not verify the removal of immediacy until their plan was received. The NHA stated a plan would be completed and provided to the team lead and survey manager that evening or by the next morning. The Corporate Consultant L and DON were also present during this discussion. On 2/16/23 at approximately 8:10 AM, Telephone contact was made with the administrator and the need for a removal plan was discussed and questions answered regarding what was expected in a removal plan. The NHA stated they wanted to provide a past non compliance, but were informed this would not be acceptable and a removal plan needed to be completed. On 2/16/23 at 9:36 AM, the NHA sent an email which stated an Abatement Plan was attached. However, the NHA had attached an alleged past noncompliance related to the concern with R7 and not any steps to remove immediacy after they were informed of the IJ. The document was titled [Facility] Coffee Spill with Burn Timeline and revealed: On 01/19/2023, Nurse was notified of coffee spill and responded immediately. Clothing was removed immediately. Noted generalized redness on left thigh, right thigh with superficial broken blister side of right knee. Cool compress immediately applied. Pharmacy notified to send Silvadene stat. Son called and updated. PA, DON and Wound PA notified of coffee spill with bilateral thigh redness and superficial area of peeling to lateral right thigh. N.O. for Silvadene 1% cream to affected areas BID until resolved. The facility has one coffee machine that is located in dietary kitchen. Administrator reviewed last six months of monthly hot liquids temperature log. All data is within range of 150F to 180F degrees. During off times when coffee is not readily available at resident's requests, single cups of coffee will have 3 ice cubes added to cup. Resident had been assessed 12/17/2022, and working with OT. The functional skills assessment ADL for eating was documented as Independent. Resident was not assessed to require any adaptive devices or special cups or lids when eating or drinking. On 02/08/2023, resident was screened by OT which again revealed the resident did not require any adaptive devices or special cups or lids when eating or drinking. On 1/23/2023, Medical Director [name of medical director] examined the resident. Intact blisters noted over several locations. Consult for Avanti wound to follow the resident. Care Plans Updated: On 01/19/2023 a plan of care to address the wounds was implemented. On 02/03/2023, the resident's care plan was revised to include Resident prefers to receive black coffee from the kitchen and to put her own creamer/sweetener in it and to drink her coffee at times without a lid. Wound grids Completed: On 01/19/2023, wound grids started. Interventions to Address Similarly Situated Residents: On 01/20/2023, Sign was placed on the coffee machine to add 3 ice cubes to the cup of coffee when pouring it straight from the machine. On 02/03/2023, IDT team met to review incident, hot liquids pull/pour policy, and what would be the best method for resident to receive coffee safely while attending an activity. IDT team agreed with implementing a courtesy cart with a carafe of coffee, cups, lids, condiments, and a pitcher of cold water. Dietary manager educated dietary staff of the new protocol to provide the courtesy cart daily at 10AM and 2PM for the Activity department to utilize for residents in the Activity Room. This will enable facility to limit single cups of coffee during none meal times. Facility will continue to follow the current policy of having admissions screened by OT for adaptive equipment if applicable. All residents will be screened by OT at least quarterly and as identified with a change in condition for need for adaptive equipment. Hot liquids; (coffee, tea, soup, water, milk) will continue to be served in the proper dinnerware/serve ware with a lid or covering, depending on the type of hot liquid being provided unless OT has determined that a resident requires adaptive equipment on the completion of the resident's assessment. Education: On 02/03/2023 Staff education was completed on the Hot Liquids Pull/Pour policy and completed competency quiz. ED provided 1:1 education with the Activity Assistant on the Pull/Pour policy and on utilizing the red handled coffee cups and not Styrofoam cups for hot beverages. Coffee Temperature Audit: ED and Regional Nurse Consultant tested multiple cups of coffee, in various cups to ensure temperature of the coffee was within the facility policy for hot liquids range (150F to 180F degrees). Styrofoam Cup: Coffee Temperature straight from the Machine: 173F degrees Coffee Temperature after 3 ice cubes added to the cup: 139F degrees Red Coffee Cup: Coffee Temperature straight from the machine: 172F degrees Coffee Temperature after 3 ice cubes from the machine: 138F degrees QAPI/Audits: Administrator and/or designee will complete 4 random staff interviews on hot liquids policy weekly times 3 weeks, then monthly there after times 3 months to ensure hot liquids pull/pour policy is being followed. Administrator and/or designee will complete 1 coffee temp audit weekly times 3 weeks, then monthly there after times 3 months to ensure coffee temp is within range. On 2/16/23 at approximately 9:50 AM Telephone contact was made with the NHA confirming what was received was not a removal plan as discussed. The NHA was again informed about what was expected in a removal plan. On 2/16/23 at 1:22 PM an email was sent to the NHA informing them the survey would have to be exited without a removal plan since one had yet to be received. On 2/16/23 at 1:35 PM telephone contact was made with the NHA and they stated they would provide a removal plan immediately. On 2/16/23 at 1:37 PM, the facility plan to remove the Immediate Jeopardy was received. It was reviewed and accepted: 02/16/2023 Director of Nursing, and Corporate Clinical team created a hot liquid assessment, and implemented new hot liquid assessment protocol. All residents residing within the facility have been assessed per the hot liquid assessment. Director of Nursing and/or designee will educate all nurses on hot liquids assessment, and nurses will be required to complete assessment upon admission, readmission, quarterly, and significant change. On 02/16/2023, Administrator and/ or designee educated all dietary staff that coffee temperature will be obtained and logged on updated food temperature log with each meal. Dietary staff will temp and log individual requests of coffee from staff, or residents on coffee temp log that will be available in dietary department. On 02/16/2023, Administrator and/ or designee educated all staff that dietary department is responsible for providing and temping individual requests for coffee/ hot liquids. Non- Dietary staff are not permitted to enter kitchen to obtain hot liquids for resident safety. Director of Nursing and/ or designee will audit new admissions hot liquid assessment twice weekly for 4 weeks, then monthly thereafter times 3 months. To ensure staff are completing new protocol to minimize residents risk to hot liquids. Administrator and/ or designee will audit coffee temperature logs in kitchen twice weekly for 4 weeks, then monthly thereafter times 3 months. To ensure staff are temping all coffee for resident safety. On 2/17/23, the state agency began to validate the removal plan. Upon review of kitchen temperature logs for coffee and review of the kitchen with the NHA on 2/17/23 at 10:35 AM, it was revealed that although kitchen staff were taking a temperature of the coffee, they were not informed of nor had the facility identified what the target temperature of coffee should be. The NHA stated they were unsure but thought an acceptable range would not be from 150 to 180 degrees Fahrenheit and staff were no longer supposed to use ice to cool coffee. A sign was still placed on the coffee maker stating Coffee temp should not be 150F-180F degrees. Add ice if serving directly from machine. (photos of two different cups were pictured) Please use only cups above do NOT use Styrofoam cups for hot liquids. The coffee temperature log indicated 3 different temperatures logged and each indicated ice was added. The NHA was informed the sign in the kitchen conflicted with the direction staff had been given and NHA stated multiple times the sign would be taken down but did not take the sign down. Further discussion was completed with the NHA at 10:50 AM on 2/17/23 and she provided policy about acceptable food and drink temperature and confirmed coffee would be served at 150-180 degrees Fahrenheit. The NHA was informed the temperature range needed to be added to the temperature log and education started with dietary staff in order to remove immediacy. Proof of education being provided to dietary staff was provided at 11:05 AM, removing the immediacy. The NHA provided information regarding the dietary staff education: Effective 02/17/2023, coffee temperature will be obtained and logged on updated food temperature log with each meal. Dietary staff will temp and log individual requests of coffee from staff, or residents on coffee temp log that will be available in dietary department. Temperature range for hot liquids is 150F-180F. If temperature is within range, no ice is needed. Although the Immediate Jeopardy was removed on 2/17/23, the facility remained out of compliance with a scope of isolated and severity of actual harm that is not immediate jeopardy due to sustained compliance not being verified by the state agency and additional identified concerns related to accidents and hazards being identified through the survey. DPS #2 Based on observations, interview and record review the facility failed to implement and identify meaningful interventions to prevent falls for two residents (R12 and R51) reviewed for falls resulting in ongoing falls resulting in pain, facial bruising, head laceration, skin tears, and body bruising due to falls for R51, ongoing falls resulting in pain, a skin tear and hip fracture for R12, and the potential for further falls with serious injury for all residents at risk for falls. Findings include: R12 Review of R12's face sheet dated 2/14/23 revealed she was a [AGE] year old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis that included: dementia, unsteadiness on feet, restlessness and agitation, difficulty in walking, and fracture of the right femur. R12 was not their own responsible party for financial or medical decisions. A review of R12's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/24/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 4 which revealed R12 was significantly cognitively impaired. In addition, R12's MDS revealed she had two or more falls without injury her previous MDS assessment on 10/26/22. R12's 10/26/22 MDS assessment revealed she had a fall with major injury. R12's fall risk assessments completed on 5/10/22, 8/4/22 and 9/15/22 revealed she was at high risk for falls. On 2/8/23 at 9:53 AM, R12 was viewed in her room, an interview was attempted, but the resident presented with some confusion and could not recall any information about the care she receives in the facility. R12's falls for the last 9 months were requested and 6 fall incident reports were received. R12 fell on [DATE], 10/19/22, 10/31/22, 11/04/22, 12/26/22, and 2/1/23. All of these falls were unwitnessed. The fall incidents were compared to review of the resident's care plan printed 2/14/23. R12's care plan showed a problem area of Falls with a start date of 9/01/2016. [R12] is at risk for fall and or injuries due to a history of falls, cognitive deficits making her lack of safety awareness (not able to be educated, she does not remember things consistently), and the use of a diuretic medication. [R12] has a diagnosis of dementia, she has forgetfulness and reported while at home .she was also noted to be outside of the house during the nighttime hours confused. She uses a walker for ambulation .[R12] does not consistently remember to lock the brakes when required. Also scoots in seated wheeled walker and does not always use properly. The potential for fatigue and pain are present with the dx (diagnosis) of osteoarthritis and hypothyroidism. Review of R12's fall incident dated 8/27/22 revealed she had an unwitnessed fall without injury at 6:09 AM when the resident made unassisted attempt to get out of bed, slid to the floor. Additional interventions included encourage resident to utilize call light for transfer assistance, ensure proper positioning in (sic) while in bed. The only other intervention noted was to complete neurological checks on the resident. Review of R12's care plan revealed an intervention for falls on 8/27/22: Remind/encourage [R12] to use call light for assistance if needed despite the notation in problem area that she is not able to be educated. Review of R12's fall incident dated 10/19/22 revealed she had an unwitnessed fall at 1:20 AM resulting in pain the right lower extremity in her room. R12 was found sitting on her buttocks in front of her bed. Body audit shows extreme pain with movement to Right lower extremity .send to ED (emergency department) for eval. They were noted to be in Excruciating Pain- Worst possible at a 10 out of 10. No other intervention was noted other to send to the emergency department. Review of the resident's care plan revealed no intervention added. There is no intervention on R12's care plan that is on or around the date of this fall. Review of R12's progress notes revealed she sustained a fracture of her right hip as a result of this fall. A contact with R12's responsible party on 10/19/22 at 8:30 AM revealed it was decided to start R12 on hospice care as a result of her fall with hip fracture. Review of R12's fall incident dated 10/31/22 revealed she had an unwitnessed fall at 4:00 AM and was found laying on the floor between her bed and wheelchair, no injuries were noted. The added intervention was grippy socks. Review of the resident's care plan revealed the intervention use not skid socks to prevent slipping with transfers added to fall approaches on 10/31/22. The intervention encourage use of non skid footwear was also noted on 9/4/17. Review of R12's fall incident dated 11/04/22 revealed she had an unwitnessed fall with no injuries at 7:26 PM and was found sitting on her butt next to her wheel chair in her room next to bed. The noted intervention was again grippy socks. No other intervention was listed on the care plan matching on or around this date. Review of R12's fall incident dated 12/26/22 revealed the resident had an unwitnessed fall at 9:30 PM. They were found to be laying on the floor next to her bed with feet near head of bed and wheelchair next to her .resident yelled and would not move LLE (left lower extremity) . verbal order for L hip xray. R12 was noted to be in severe pain-horrible intense at a 7 out of 10. The added intervention was noted to be order for grippy strips to be placed on the floor in front of resident's bed. Review of R12's fall incident dated 2/1/23 revealed the resident had an unwitnessed fall at 11:00 PM when they were observed sitting on floor next to bed and wheelchair on opposite side. Residents black personal plastic bin tipped over next to resident. Resident unable to explain fall. Resident combative to staff. There were no noted injuries. An intervention of floor mat was indicated and later determined to be not appropriate and half assist rail was to be added to the open side of the bed to assist with self trans [TRUNCATED]

Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-center care plans for 3 residents (R12, R51 and R26) resulting ineffective and unimplemented care plans leading to ongoing falls, injury and pain for R12 and R51 and prolonged use of a feeding tube, anxiety and weight gain for R26 and the potential for all facility residents to not receive care and services to reach their highest potential. Findings include: R12 Review of R12's face sheet dated 2/14/23 revealed she was a [AGE] year old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis that included: dementia, unsteadiness on feet, restlessness and agitation, difficulty in walking, and fracture of the right femur. R12 was not their own responsible party for financial or medical decisions. A review of R12's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/24/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 4 which revealed R12 was significantly cognitively impaired. In addition, R12's MDS revealed she had two or more falls without injury her previous MDS assessment on 10/26/22. R12's 10/26/22 MDS assessment revealed she had a fall with major injury. R12's fall risk assessments completed on 5/10/22, 8/4/22 and 9/15/22 revealed she was at high risk for falls. On 2/8/23 at 9:53 AM, R12 was viewed in her room, an interview was attempted, but the resident presented with some confusion and could not recall any information about the care she receives in the facility. R12's falls for the last 9 months were requested and 6 fall incident reports were received. R12 fell on [DATE], 10/19/22, 10/31/22, 11/04/22, 12/26/22, and 2/1/23. All of these falls were unwitnessed. The fall incidents were compared to review of the resident's care plan printed 2/14/23. R12's care plan showed a problem area of Falls with a start date of 9/01/2016. [R12] is at risk for fall and or injuries due to a history of falls, cognitive deficits making her lack of safety awareness (not able to be educated, she does not remember things consistently), and the use of a diuretic medication. [R12] has a diagnosis of dementia, she has forgetfulness and reported while at home .she was also noted to be outside of the house during the nighttime hours confused. She uses a walker for ambulation .[R12] does not consistently remember to lock the brakes when required. Also scoots in seated wheeled walker and does not always use properly. The potential for fatigue and pain are present with the dx (diagnosis) of osteoarthritis and hypothyroidism. Review of R12's fall incident dated 8/27/22 revealed she had an unwitnessed fall without injury at 6:09 AM when the resident made unassisted attempt to get out of bed, slid to the floor. Additional interventions included encourage resident to utilize call light for transfer assistance, ensure proper positioning in (sic) while in bed. The only other intervention noted was to complete neurological checks on the resident. Review of R12's care plan revealed an intervention for falls on 8/27/22: Remind/encourage [R12] to use call light for assistance if needed despite the notation in problem area that she is not able to be educated. Review of R12's fall incident dated 10/19/22 revealed she had an unwitnessed fall at 1:20 AM resulting in pain the right lower extremity in her room. R12 was found sitting on her buttocks in front of her bed. Body audit shows extreme pain with movement to Right lower extremity .send to ED (emergency department) for eval. They were noted to be in Excruciating Pain- Worst possible at a 10 out of 10. No other intervention was noted other to send to the emergency department. Review of the resident's care plan revealed no intervention added. There is no intervention on R12's care plan that is on or around the date of this fall. Review of R12's progress notes revealed she sustained a fracture of her right hip as a result of this fall. A contact with R12's responsible party on 10/19/22 at 8:30 AM revealed it was decided to start R12 on hospice care as a result of her fall with hip fracture. Review of R12's fall incident dated 10/31/22 revealed she had an unwitnessed fall at 4:00 AM and was found laying on the floor between her bed and wheelchair, no injuries were noted. The added intervention was grippy socks. Review of the resident's care plan revealed the intervention use not skid socks to prevent slipping with transfers added to fall approaches on 10/31/22. The intervention encourage use of non skid footwear was also noted on 9/4/17. Review of R12's fall incident dated 11/04/22 revealed she had an unwitnessed fall with no injuries at 7:26 PM and was found sitting on her butt next to her wheel chair in her room next to bed. The noted intervention was again grippy socks. No other intervention was listed on the care plan matching on or around this date. Review of R12's fall incident dated 12/26/22 revealed the resident had an unwitnessed fall at 9:30 PM. They were found to be laying on the floor next to her bed with feet near head of bed and wheelchair next to her .resident yelled and would not move LLE (left lower extremity) . verbal order for L hip xray. R12 was noted to be in severe pain-horrible intense at a 7 out of 10. The added intervention was noted to be order for grippy strips to be placed on the floor in front of resident's bed. Review of R12's fall incident dated 2/1/23 revealed the resident had an unwitnessed fall at 11:00 PM when they were observed sitting on floor next to bed and wheelchair on opposite side. Residents black personal plastic bin tipped over next to resident. Resident unable to explain fall. Resident combative to staff. There were no noted injuries. An intervention of floor mat was indicated and later determined to be not appropriate and half assist rail was to be added to the open side of the bed to assist with self transfers. An intervention was added to R12's care plan on 2/9/23: 1/2 rail assist bar to open side of bed to assist with ADL (activities of daily life)/mobility. Review of R12's progress notes on 2/14/23 revealed she had an additional fall on 2/13/23. A request was made to the Nursing Home Administrator at 10:17 AM on 2/14/23 for the additional fall incident. Review of R12's fall incident dated 2/13/23 revealed the resident had an unwitnessed fall at 8:00 PM and was lying in the middle of bedroom on floor facing bathroom .abrasion noted to R elbow area . The listed intervention was request medication review to be implemented by Hospice and request orthostatic BP (Blood pressure) for 3 days. A similar intervention was also listed on R12's care plan on 3/16/22: medication review by Pharmacy consultant and orthostatic vs. On 02/14/23 at 10:30 AM, R12 was viewed laying in the middle of her bed and sleeping, her head toward the foot of her bed and feet on the floor. Grip strips viewed at the mid bed area to the head of bed. The resident's tray table and wheelchair were entirely covering the grip strips and R12's feet were past the end of the grip strips. At approximately 10:35 AM Corporate Consultant (CC) L was viewed on the hall and was directed towards R12's room asked if they say any concerns with current visible fall interventions. CC L agreed the grip strips were not under the resident's feet in her current position. R51 Review of R51's face sheet dated 2/14/23 revealed she was an [AGE] year old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis that included: cerebrovascular disease, dementia, difficulty walking, unsteadiness on feet, and muscle spasm. R51 was not their own responsible party for financial or medical decisions. A review of R51's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 12/28/22, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 5 which revealed R51 was significantly cognitively impaired. In addition, R51's MDS revealed she had two or more falls without injury and two or more falls with injury since her previous MDS assessment on 10/3/22. R51's fall risk assessments completed on 9/10/22, 10/10/22 and 1/10/23 revealed she was at high risk for falls. On initial tour of the facility, on 2/7/23 at 10:27 AM, R51 was viewed with a right eye upper cheek that was swollen with purple bruising. Certified Nursing Assistant (CNA) M stated that R51 had fallen that morning. On 2/7/23 at 12:25 PM, R51 was viewed in the dining room and staff were attempting to assist her to dine. R51 appeared lethargic and difficult to arouse and at times was grimacing in pain. On 2/7/23 at 1:20 PM an interview was completed in R51's room with her guardian and another visitor. R51 was viewed in her bed, grimacing and moaning softly in pain. R51's guardian stated that R51 had fallen early this morning when she tried to self-transfer. R51's guardian stated R51 was in so much pain, they are working on getting a hip x-ray due to the emergency room not completing an x-ray in that area and R51 having a concerning increase in pain in her hip area. R51's guardian stated R51 was in significant pain and they were just trying to keep her calm right now. R51's falls for the last 9 months were requested and 9 fall incident reports were received. R51 fell on [DATE], 11/4/22, 11/16/22, 11/27/22, 11/28/22, 12/9/22, 1/2/23, 1/7/23, and 2/7/23. 8 of these falls were unwitnessed. The fall incidents were compared to review of the resident's care plan printed 2/14/23. R12's care plan showed a problem area of Falls with a start date of 7/19/22: [R51] is at risk for falls/injury related to and the following concerns were checked: confusion/altered mental status, poor vision, history of falls, incontinent of bowel, and incontinent of urine. R51 was noted to be on medications that put her at risk including an anxiolytic (anxiety medication), antidepressant, antihypertensive (medication for blood pressure), laxative, and narcotic. Her gait stability was noted to be impaired. Review of R51's fall incident dated 9/15/22 revealed she had a witnessed fall in the hallway at 1:00 PM when she tripped over and IV pole. The listed intervention was to encourage resident to utilize her walker during ambulation. There was a corresponding care plan intervention with start date of 9/15/22 staff will administer IV medication while resident is in bed and will encourage resident to utilize her walker during ambulation. Review of R51's fall incident dated 11/4/22 revealed she had an unwitnessed fall in her room and was found at 5:00 AM laying on the floor next to bed .resident did hit her head & caused small amount of bleeding .small lump noted .Resident appears to have been sticking with her usual behavior, which is if she hears something going on outside of her room .or if staff does not answer her call or question what is going on, she goes to investigate .Resident was in PJs & sock, it appears she was getting up & slipped (she did not put her shoes/slippers on prior to ambulating/transferring) falling onto the floor & hit her head on the floor. The response was noted to be medication review. R51's care plan included the intervention grippy socks and medication review with start date 11/4/22. Review of R51's fall incident dated 11/16/22 revealed she had an unwitnessed fall at 3:35 PM and was found on the floor in her room and stated was going to bathroom. The noted intervention was to encourage to use restroom after meals. A corresponding care plan intervention was added 11/17/22: encourage to use restroom after meals. Review of R51's fall incident dated 11/27/22 revealed she had an unwitnessed fall and was found at 9:00 AM. R51 sustained injuries including a bruise on the left buttock and hematomas on the back of her head, left shin and left buttock as well as 2 skin tears on her right forearm. The resident was observed on the floor of her bathroom this morning at approx 8 am. She was laying on her back in front of the sink with her head in the doorway. A care plan intervention was added on 11/27/22: Close observation and frequent reminders to use walker. There was no parameters noted for how frequently to check on the resident. Review of R51's fall incident dated 11/28/22 revealed she had an unwitnessed fall in her bedroom and was found at 2:30 PM and was observed on the floor of her room, sitting with her back against the door. A care plan intervention was added on 11/28/22: Frequent reminder to use call light. R51 has dementia and is not cognitively intact. This intervention was also already on their care plan since 7/19/22 under fall interventions: encourage resident to use call light for transfer/ambulation assistance. Review of R51's fall incident dated 12/9/22 revealed she had an unwitnessed fall in her room and was found at 6:10 PM when she was ambulating to the restroom using a walker. Socks had no grip and resident was not wearing shoes as she was laying down in bed prior to fall and did not use call light for assistance. Interventions to add included reinforce need for call light use and socks with grips at all times. There were no added care plan interventions that were on or around the date of this fall. Review of R51's fall incident dated 1/2/23 revealed she had an unwitnessed fall in their bedroom and was found at 9:20 AM after trying to walk across the room with out her walker and fell . However, after further review, the full incident description under the section circumstances of the incident and evaluation referred entirely to another resident, R12, and appeared to have been copied and pasted from R12's fall report from 12/26/22, including her medical information and description of the fall sustained by R12 and the fall interventions completed for R12 for her 12/26/22 fall, which was to add grippy strips. The event report clearly was for R51 as her name was the heading on each page of the report and it was in her electronic medical record, however the narrative details were not about this incident. Review of R51's progress notes revealed she was going to go to the closet to get her clothes .Resident has had a recent change in narcotic and a medication review will be requested. R51's care plan had an added intervention on 1/2/23: grippy strips in front of bed there was no mention of a medication review in R51's care plan. Review of R51's fall incident dated 1/7/23 revealed she had an unwitnessed fall and was found at 11:00 PM in her room sitting on the floor next to wc (wheelchair). R51 had a skin tear to her left upper extremity due to the incident. The added intervention after the fall was noted to be toilet resident prior to going to bed. The care plan reflected offer toileting prior to bed was added on 1/7/23. Review of R51's fall incident dated 2/7/23 revealed she had an unwitnessed fall and was found at 1:30 AM in her room on the floor with a hematoma to the right eye and right knee and swelling in her right facial area. The resident was sent to the emergency room for evaluation following the fall and was unable to state a reason for getting out of bed. The interventions were noted to be x-rays, coordination of care with hospice completed and pain management assessment started. Medication review completed and resident pain medication was changed. An attached skin assessment for 2/8/23 also indicated multiple areas of discoloration and bruising on both legs, both arms, buttocks and back. A review of R51's care plan revealed no additional interventions were added subsequent to the 2/7/23 fall as of 2/14/23. On 02/14/23 at 09:48 AM an interview was completed with the Director of Nursing (DON) and CC L regarding falls. The DON stated in morning meeting, they go over falls together and discuss cause, what we can do in the future. CC L stated they do root cause analysis on falls in morning meetings. The DON was asked to look for proof of this analysis and provide these. It was discussed with the DON that the incident reports provided for R12 and R51 did not have this analysis documented and the interventions were weak as the falls progressed, since interventions that were standards of care such as grippy socks, grip strips on the floor and toileting residents before bed were examples of interventions after multiple falls. The DON agreed that things like grip socks and grip strips on the floor should be implemented early on when residents are identified as being at risk for falls. On 02/14/23 at 01:58 PM an interview was completed with the NHA (nursing home administrator) and she asked for the root cause analysis for falls that were requested from the DON. The NHA stated they have identified they had an issue with falls and it is on the agenda for Quality Assurance team to address. The NHA stated they have identified that the previous DON was not handling falls appropriately, and the new DON has only been in the role less for less than 2 weeks now. Corporate is helping them review falls and will be assisting them in addressing fall interventions. On 02/14/23 at 02:14 PM the interview with the NHA continued in her office. The NHA reiterated that it had been determined there was in issue with fall interventions. The NHA stated the last DON didn't realize what an intervention was and thought sending someone to the hospital was an intervention. The NHA stated they had tried to educate the DON regarding appropriate fall interventions and instructed her to bring falls to be reviewed by the IDT (inter-departmental team), but they were resistant to bringing incidents to the team to review. The NHA stated they identified the problem and the former DON and former ADON (assistant director of nursing) had been educated in November regarding expectations that included fall interventions. Corporate staff had been in the building and added a tool for morning meeting, but the former DON was resistant to using the discussion tool. The plan for all nursing staff to be educated regarding fall interventions by 2/22/23, and education was started on 1/30/23. The interventions implemented for R12 and R51 after falls were discussed and the NHA agreed things like grippy socks and grip strips to the floor should be a standard intervention if anyone was a fall risk or had one fall, not waiting for subsequent falls. The NHA also agreed interventions such as toileting a resident before bed should also be a standard of care and not a fall intervention. Review of facility policy Fall Investigation, undated, provided by the facility on 2/10/23 revealed: It is the Facility's Policy to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. A Fall Investigation must include: Immediate Safety Intervention and Root cause analysis with (sic) be conducted by a member of the IDT. R26 On 2/9/23 at 7:55 AM an interview was conducted with R26 in her room. At that time a tube feeding was in progress at 52 milliliters (ml) per hour (ml/h). R26 reported that about three years ago another resident threw away her dentures and she has been waiting for new dentures ever since. R26 reported the facility keeps promising to replace them but it has not happened yet. R26 reported she takes her medication whole orally and eats some food from the facility and brought in by family. R26 indicated she would rather consume food that requires teeth or dentures to eat. Review of the Electronic Medical Record (EMR) Care Plan for R26 reflected, Problem: Potential for Alteration in Dental Oral Status (related to) full dentures. The goal of this Care Plan concern reflected (R26) will .have proper fitting dentures in good repair .by target date. The Care Plan reflected this was initiated 8/17/2020. This Care Plan reflects that obtaining new dentures for R26 has been a known concern for approximately two and a half years. On 2/15/23 at 10:21 AM an interview was conducted with Medical Records Staff (MRS) Q. MRS Q reported and outlined a series of appointments, cancellations, change of dental providers and attempts to get dentures for R26 over the course of 2021, 2022, and 2023. MRS Q reported that R26 has a dental appointment scheduled during this annual survey. The Therapy Department document titled ST (Speech Therapy) Discharge Summary dated 9/16/21 was reviewed. The document reflected that (R26) prefers use of PEG tube feeding . And that (R26) is scheduled to get new dentures in several weeks and indicates she will eat more at that time. The document reflects that R26 was discharged from Speech Therapy Due to no progress toward consumption .with re-evaluation if changes occur. On 02/14/23 at 11:06 AM R26 reported she can take in enough calories oraly to sustain herself without the tube feeding and reported she likely could have had the feeding tube removed 6 or more months ago. Review of the EMR Progress Notes by Registered Dietician (RD) R dated 3/29/22 at 12:20 PM reflected R26 was receiving tube feeding at 52 cc per hour continuous for 24 hours a day for 1875 calories. The EMR Progress Note by RD R dated 8/9/22 revealed that R26 weight shows significant weight gain to 161 lbs. No changes in tube feeding orders were noted at that time. Review of the EMR vital sign weight history for R26 reflected on 2/7/23 R26 weighed 173 lbs. Review of the EMR vital sign weight history reflects an increase from 151 lbs. on 7/7/22 to 173 lbs. on 2/1/23 indicating a gain of 22 lbs. Review of the Doctors Orders for R26 reflected two active orders for tube feeding. One, dated 10/12/21, is for Isosource at 52ml/h continuous every 24 hours. A second order dated 2/7/23 for Isosource at 65 ml/h for 18 hours beginning at 5:00 PM and off at 11:00 AM. Also noted was an order for no straws dated 12/6/22. Review of the EMR Progress Note entered by RD R on 2/7/23 reflected documentation that the tube feeding rate was discussed with (R26) who agreed to change tube feeding time to being off (of the tube feeding) sometimes during the day. And that the tube feeding was to be adjusted to promote weight loss. Review of the EMR Progress Note by RD R reflected on 2/14/23 at 8:36 AM that R26 had reported to RD R that the new tube feeding schedule of a rate of 65 ml/h for 18 hours is going well. On 2/14/23 at 8:51 AM, 15 minutes following the documentation of RD R, the tube feeding for R26 was observed to be running at 52ml per hour from a bag that had been labeled to run at that rate for 24 hours and was started on 2/13/23. This conflicted with the documentation of RD R of the encounter 15 minutes prior to this observation. R26 did not indicate she was aware of a change in the tube feeding schedule. On 2/14/23 at 11:10 AM an interview was conducted with RD R. RD R reported R26 recently changed from a 24-hour continuous tube feeding to 18 hours on and 6 hours off. RD R was informed that the tube feeding was running at 52 ml/h and not at 65 ml/h as documented in her note of 2/14/23 at 8:36 AM today. RD R acknowledged that she did not look at the tube feeding rate in progress at the time of her encounter with R26. RD R reported that although two active orders are present the one that reflects a rate of 65 ml/h is the correct order. RD R was asked what she attributed the 22 lbs. weight gain over the course of seven months (7/7/22 to 2/7/23) without adjustment of the rate and volume of tube feeding. RD R reported that R26 will say she doesn't want to get off the tube feeding so I have to encourage her to eat more. RD R was informed that straws were present at bedside and RD R reported that the no straws order would have come from Speech Therapy. However, the order for no straws was dated 12/6/22 and Speech Therapy has not evaluated R26 since 9/16/21. RD R reported she doesn't currently have any measurable goals or timeframe's in the Care Plan for R26 because the Resident has declined to have the tube removed. RD R indicated that she is optimistic this might soon happen since R26 will be getting dentures. The first documentation identified that the facility was going to obtain replacement dentures for R26 is on the Care Plan dated 8/17/20. R26 has indicated that dentures would help in eliminating the need for nutrition by tube feeding but after more than twenty-nine months the Resident still does not have dentures. It is unclear if the appointment currently scheduled for replacement dentures will yield this result or if this will be a continuation of what R26 had endured since 8/17/20. Additionally, R26 has experienced a significant weight gain and gradual weight gains (14.5 % from 7/7/22 to 2/1/23) without adjustment to the tube feeding order. Review of the medical record did not result in discovery of referrals or evaluations by a physician to consider an adjustment to the tube feeding volume or other opinions of a medical professional. Conflicting Doctor's Orders were found to be incorrectly implemented as reported by RD R. The Doctor Order for no straws was not implemented or revised to accommodate the Resident prior to this survey. Per RD R, the Care Plan for R26 does not have any measurable goals or timeframe's to restore oral eating skills. Through interviews and documentation of the medical record it has been reported that R26 prefers to keep the feeding tube, but the documentation and statements simultaneously include that R26 is asking for replacement dentures. Lastly, during an interview R26 reported that she could have discontinued use of feeding tube feeding six or more months ago if she had dentures. No documentation was found that the facility provided R26 with appropriate treatment and services to enable the restoration oral eating skills or ensured quality care.

This citation has two Deficient Practice Statements (DPS) DPS #1 Based on observation, interview, and record review the facility failed to ensure enabling care and services were provided to one Resident (Resident #26 (R26)) receiving nutrition through a feeding tube to restore oral eating skills resulting in prolonged use of a feeding tube and anxiety and the potential for all facility residents with nutrition related needs to not receive enabling care and services to reach their highest practicalable potential. Findings: Review of the Minimum Data Set (MDS) dated [DATE] reflected that R26 was originally admitted to the facility 8/5/20 with pertinent diagnoses that included history of stroke with impairment to one side of the body. The MDS Brief Interview for Mental Status (BIMS) reflected R26 scored 15 out of 15 which indicated the Resident was cognitively intact. Section K (Swallowing and Nutrition) of the MDS revealed R26 has a feeding tube. On 2/9/23 at 7:55 AM an interview was conducted with R26 in her room. At that time a tube feeding was in progress at 52 milliliters (ml) per hour (ml/h). R26 reported that about three years ago another resident threw away her dentures and she has been waiting for new dentures ever since. R26 reported the facility keeps promising to replace them but it has not happened yet. R26 reported she takes her medication whole orally and eats some food from the facility and brought in by family. R26 indicated she would rather consume food that requires teeth or dentures to eat. Review of the Electronic Medical Record (EMR) Care Plan for R26 reflected, Problem: Potential for Alteration in Dental Oral Status (related to) full dentures. The goal of this Care Plan concern reflected (R26) will .have proper fitting dentures in good repair .by target date. The Care Plan reflected this was initiated 8/17/2020. This Care Plan reflects that obtaining new dentures for R26 has been a known concern for approximately two and a half years. On 2/15/23 at 10:21 AM an interview was conducted with Medical Records Staff (MRS) Q. MRS Q reported and outlined a series of appointments, cancellations, change of dental providers and attempts to get dentures for R26 over the course of 2021, 2022, and 2023. MRS Q reported that R26 has a dental appointment scheduled during this annual survey. The Therapy Department document titled ST (Speech Therapy) Discharge Summary dated 9/16/21 was reviewed. The document reflected that (R26) prefers use of PEG tube feeding . And that (R26) is scheduled to get new dentures in several weeks and indicates she will eat more at that time. The document reflects that R26 was discharged from Speech Therapy Due to no progress toward consumption .with re-evaluation if changes occur. On 02/14/23 at 11:06 AM R26 reported she can take in enough calories oraly to sustain herself without the tube feeding and reported she likely could have had the feeding tube removed 6 or more months ago. Review of the EMR Progress Notes by Registered Dietician (RD) R dated 3/29/22 at 12:20 PM reflected R26 was receiving tube feeding at 52 cc per hour continuous for 24 hours a day for 1875 calories. The EMR Progress Note by RD R dated 8/9/22 revealed that R26 weight shows significant weight gain to 161 lbs. No changes in tube feeding orders were noted at that time. Review of the EMR vital sign weight history for R26 reflected on 2/7/23 R26 weighed 173 lbs. Review of the EMR vital sign weight history reflects an increase from 151 lbs. on 7/7/22 to 173 lbs. on 2/1/23 indicating a gain of 22 lbs. Review of the Doctors Orders for R26 reflected two active orders for tube feeding. One, dated 10/12/21, is for Isosource at 52ml/h continuous every 24 hours. A second order dated 2/7/23 for Isosource at 65 ml/h for 18 hours beginning at 5:00 PM and off at 11:00 AM. Also noted was an order for no straws dated 12/6/22. Review of the EMR Progress Note entered by RD R on 2/7/23 reflected documentation that the tube feeding rate was discussed with (R26) who agreed to change tube feeding time to being off (of the tube feeding) sometimes during the day. And that the tube feeding was to be adjusted to promote weight loss. Review of the EMR Progress Note by RD R reflected on 2/14/23 at 8:36 AM that R26 had reported to RD R that the new tube feeding schedule of a rate of 65 ml/h for 18 hours is going well. On 2/14/23 at 8:51 AM, 15 minutes following the documentation of RD R, the tube feeding for R26 was observed to be running at 52ml per hour from a bag that had been labeled to run at that rate for 24 hours and was started on 2/13/23. This conflicted with the documentation of RD R of the encounter 15 minutes prior to this observation. R26 did not indicate she was aware of a change in the tube feeding schedule. On 2/14/23 at 11:10 AM an interview was conducted with RD R. RD R reported R26 recently changed from a 24-hour continuous tube feeding to 18 hours on and 6 hours off. RD R was informed that the tube feeding was running at 52 ml/h and not at 65 ml/h as documented in her note of 2/14/23 at 8:36 AM today. RD R acknowledged that she did not look at the tube feeding rate in progress at the time of her encounter with R26. RD R reported that although two active orders are present the one that reflects a rate of 65 ml/h is the correct order. RD R was asked what she attributed the 22 lbs. weight gain over the course of seven months (7/7/22 to 2/7/23) without adjustment of the rate and volume of tube feeding. RD R reported that R26 will say she doesn't want to get off the tube feeding so I have to encourage her to eat more. RD R was informed that straws were present at bedside and RD R reported that the no straws order would have come from Speech Therapy. However, the order for no straws was dated 12/6/22 and Speech Therapy has not evaluated R26 since 9/16/21. RD R reported she doesn't currently have any measurable goals or timeframes in the Care Plan for R26 because the Resident has declined to have the tube removed. RD R indicated that she is optimistic this might soon happen since R26 will be getting dentures. The first documentation identified that the facility was going to obtain replacement dentures for R26 is on the Care Plan dated 8/17/20. R26 has indicated that dentures would help in eliminating the need for nutrition by tube feeding but after more than twenty-nine months the Resident still does not have dentures. It is unclear if the appointment currently scheduled for replacement dentures will yield this result or if this will be a continuation of what R26 had endured since 8/17/20. Additionally, R26 has experienced a significant weight gain and gradual weight gains (14.5 % from 7/7/22 to 2/1/23) without adjustment to the tube feeding order. Review of the medical record did not result in discovery of referrals or evaluations by a physician to consider an adjustment to the tube feeding volume or other opinions of a medical professional. Conflicting Doctor's Orders were found to be incorrectly implemented as reported by RD R. The Doctor Order for no straws was not implemented or revised to accommodate the Resident prior to this survey. Per RD R, the Care Plan for R26 does not have any measurable goals or timeframes to restore oral eating skills. Through interviews and documentation of the medical record it has been reported that R26 prefers to keep the feeding tube, but the documentation and statements simultaneously include that R26 is asking for replacement dentures. Lastly, during an interview R26 reported that she could have discontinued use of feeding tube feeding six or more months ago if she had dentures. No documentation was found that the facility provided R26 with appropriate treatment and services to enable the restoration oral eating skills or ensured quality care. 31197 DPS #2 Based on observation, interview, and record review the facility failed to monitor skin, identify, prevent and treat wounds for one resident, Resident #32 (R32) reviewed for skin impairment. The deficient practice resulted in R32 developing a wound to his toe. Findings included: A request was made for a skin assessment policy. On 2/14/23 at 2:00 PM the Nursing Home Administrator (NHA) stated that she had double checked, and this is the only skin policy the facility had. The facility provided a copy of the Pressure Injuries: Assessment, Prevention and Treatment, undated and unsigned for review. The policy reflected, Assessment .2. Skin will be assessed routinely for the presence of developing pressure injuries and documented on the Nursing Skin Tool. R32 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R32 admitted to the facility on [DATE] with diagnosis that included but not limited to diabetes type 2, peripheral vascular disease and a right below the knee amputation. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represents R32 was cognitively intact. Record review of the Treatment Administration History (TAH) record from 1/1/23 - 2/14/23 was reviewed. The TAH reflected, Weekly skin assessment, document in progress notes. Notify MD (medical doctor) & wound nurse of changes. This order was signed as completed on 1/19/23, 1/26/23, and 2/2/23. On 2/9/23 it reflected, Resident unavailable, Comment: in chair, off unit. The TAH reflected the weekly skin checks were done for 3 of the 6-week period. Record review of the nursing progress notes from 1/1/2023 - 1/18/2023 was completed. The following progress notes related to skin were as follows: -1/1/23 at 2:11 PM No new skin issues, continue to (name of treatment) to sacral area. -1/8/23 at 3:10 PM Weekly skin assessment completed with no skin issues observed. -1/18/23 at 8:49 AM Resident came to nurse stating he noticed a dark scab on his toe this morning. States he notified the floor nurse who trimmed the toenail of his big toe which was pushing into the second toe causing trauma. Area is on second toe of left foot, inner aspect, 1.0 cm x 0.5 cm x uta (unable to assess). 100% nonviable tissue. Scant serosanguinous drainage. No surrounding erythema. Resident denies pain. Referral to Avanti wound specialists, MM-PA to be notified. Resident states he called his (guardian) last night around 2 am to notify her because he is nervous about the area. See grid (wound measurement) and tx (treatment) order. During an interview and record review on 2/14/23 at 3:00 PM, Nurse I reviewed the nursing notes regarding the new toe wound and stated that she thought she had charted it but must have forgotten. Nurse I stated that R32 had noticed a wound on his toe and brought it to my attention first thing that day (1/18/22). Nurse I stated that R32 had complained of pain to his toe (2nd toe on left foot). Nurse I stated that he had a sharp piece of nail (from the great toe) embedded in the side of his second toe. Nurse I stated that she used a tongue depressor to lift it slightly and snipped the sharp piece off and reported it to the wound nurse. During an interview on 2/9/23 at 3:46 PM, R32 stated he had a new wound to his second toe. R32 stated he's the toenail on the great toe caused it. R32 stated his roommate got his toenails trimmed by the podiatrist that comes to the facility and asked staff why he wasn't getting his done because they needed it. During a telephone interview on 2/10/23 at 9:29 AM, R32's Representative stated she was a bit upset about the new sore R32 had on his toe. R32's Representative stated that R32 was supposed to be seen by the podiatrist who came to the facility. R32's Resident Representative stated, I'd like to know what happened to that. I signed a form authorizing it. During an interview on 2/10/23 at 9:45 AM, the Director of Nursing (DON) stated staff do not trim R32's toenails, only podiatry can. A request for all podiatry notes for nail trimming from admission 10/4/22 - 2/10/23 was made. At 11:45 AM the DON provided the following documents for review: -A copy of the Request for Service dated 10/5/2022. R32's Representative signed authorizing services for audiology and podiatry, upon admission. -A Podiatry Visit Summary dated 10/13/22, 39 residents were treated and R32's name was not listed on the visit summary. -A Podiatry Visit Summary dated 12/29/22, 32 residents were treated and R32's name was not listed on the visit summary. When asked why R32's was not seen by podiatry since his admission, the DON stated the (name of the service) decides when residents will be seen. When asked if a staff member can recommend residents be placed on the podiatry list, the DON stated, Yes. Actually (name of R32) requested to see them. The DON stated she was unable to find any notes that R32's toenails were trimmed from admission until the wound was noted on 1/18/23 (15 weeks). According to the physician orders dated 1/20/23, Doxycycline was ordered for a diagnosis of paronychia (infection surrounding the nail) for the new ulcer on the left foot, second toe. According to the podiatry note dated 1/30/23 at 9:21 AM, R32 was evaluated by an offsite podiatrist. The note reflected, Pt (patient) seen with ulceration medial (side) left 2nd digit secondary to toenail digging into the skin. He noticed erythema (redness) and edema and was placed on doxycycline .Nails are elongated (long toenails) 1-5 L (all toes on left foot) there is thickening, subungual debris (accumulates under the nail) .Nails debrided L (nails trimmed to left foot) . The facility provided the following wound specialist notes with weekly wound measurements: -1/19/23 0.9 x 0.6 x 0.1 -1/26/23 0.7 x. 0.4 x 0.1 -2/2/23 0.4 x 0.4 x 0.1 During an interview on 2/20/23 at 2:34 PM, when asked about documenting the weekly head to toe skin assessments, the DON stated, We don't measure bruises, red areas or skin tears, only open areas. During an interview and record review on 2/14/23 at 2:00 PM, a request to review the skin assessments documented on the Nursing Skin Tool (according to the policy) from 10/4/22 - 2/14/23 was made and the facility provided the Nursing Assistant Bathing/Skin Tool instead. The NHA stated the facility was not able to locate the Nursing Skin Tools. The NHA stated that she did not expect the nurse aides to diagnosis and document skin assessments. The NHA stated, That's the licensed nurses responsibility.

Based on interview and record review, the facility failed to fully implement its established Quality Assurance Process Improvement (QAPI) plan and adequately and appropriately address known deficiencies resulting in 1.) The inability to sustain substantial compliance with federal regulations, 2.) unrecognized and incompletely evaluated systems leading to physical and psychosocial harm and diminished quality of life for residents living at the facility. Findings: The facility provided a copy of the policy titled, Quality Assurance Performance Improvement Plan Updated 12/2019. The policy reflected, Our QAPI Principals .Principle #2: Our organization utilizes data trends from many sources including CASPER, MY INTERVIEW and Nursing Home Compare to identify areas that may need interventions to improve outcomes .Principle #7: Our organization encourages all staff and stakeholders to identify breakdowns in service, opportunities for improvement and service gaps so that improvement can be made . Review of the facility survey history revealed the annual recertification survey event GYJG11 dated 2/01/22 found the facility non-compliant with federal regulations including but not limited to dignity, reporting injuries of unknown origin, falls, hot water hazards, sanitary food handling and kitchen, and pest control. On 1/19/23 at 2:45 PM, R7 sustained 6 full thickness burns to her bilateral thighs when she spilt hot coffee in her lap. The facility investigated and put interventions into place following the incident. On-going non-compliance at Accidents and Hazards for safe hot liquid handling was identified at a level of serious harm with injury. The facility was issued an Immediate Jeopardy notice by the survey team. The facility failed to identify the need to assess all residents for safe handling of hot liquids and take temperatures on hot liquids before serving. The facility developed a removal plan which was validated by the survey team on 2/17/23. Review of the survey history reflected the facility was cited for hot water hazards on 2/1/22 and did not sustain compliance. Review of the fall histories for R12 reflected 7 falls in 9 months and R51 sustained 9 falls in 9 months. The falls resulted in injuries such as pain, facial bruising, head laceration, skin tears, and hip fracture. The facility failed to thoroughly investigate and put meaningful interventions into place after both residents exhibited patterns and trends with falls. On 02/14/23 at 09:48 AM an interview was completed with the Director of Nursing (DON) and CC L regarding falls. The DON stated in morning meeting, they go over falls together and discuss cause, and what we can do in the future. CC L stated they do root cause analysis on falls in morning meetings. The DON was asked to look for proof of this analysis and provide these to the Surveyor. On 02/14/23 at 01:58 PM an interview was completed with the NHA (nursing home administrator) and she asked for the root cause analysis for falls that were requested from the DON. The NHA stated they have identified they had an issue with falls, and it is on the agenda for Quality Assurance team to address. The NHA stated they have identified that the previous DON was not handling falls appropriately, and the new DON has only been in the role less for less than 2 weeks now. Corporate is helping them review falls and will be assisting them in addressing fall interventions. On 02/14/23 at 02:14 PM the interview with the NHA continued in her office. The NHA reiterated that it had been determined there was in issue with fall interventions. The NHA stated the last DON didn't realize what an intervention was and thought sending someone to the hospital was an intervention. The NHA stated they had tried to educate the DON regarding appropriate fall interventions and instructed her to bring falls to be reviewed by the IDT (inter-departmental team), but they were resistant to bringing incidents to the team to review. The NHA stated they identified the problem and the former DON and former ADON (assistant director of nursing) had been educated in November regarding expectations that included fall interventions. Corporate staff had been in the building and added a tool for morning meeting, but the former DON was resistant to using the discussion tool. The plan for all nursing staff to be educated regarding fall interventions by 2/22/23, and education was started on 1/30/23. Review of the pest service inspection report dated 1/18/23 at 11:14 AM reflected the following areas of concern that required action: broken floor tiles in the Dementia shower stall floor identified ants were coming and going, remove and/or clean under kitchen equipment and tables to reduce pest allure (unsanitary conditions), and the appropriate placement of mouse traps. According to observations made by the survey team on 2/7/23 at approximately 10:00 AM, the items were not acted on by the facility and the pest issues continued. During an interview on 02/10/23 at 12:15 PM, Maintenance Director (MD) I revealed, I was unaware of any issues on the pest report. MD I further revealed that prior to this week he had not received any pest reports since he started because they were going to the previous maintenance person's email. MD I stated the pest reports pointed to ongoing issues that should have been corrected. This deficient practice resulted in continued non-compliance in the pest control and a sanitary kitchen which were both identified in the last annual survey. During an interview on 2/15/23 at 3:40 PM, the NHA identified issues that contributed to the QA programs effectiveness. The NHA identified staff turn over the past year for multiple positions which included by not limited to the NHA changed 3 times, the DON changed 3 times, the ADON changed 5 times, the ICP (infection control preventionist) changed 4 times. The NHA stated the staff could not stay organized to identify their deficient practices and put plans of correction into place.

This citation has two separate deficient practice statements, A. and B. A. Based on observation, interview and record review, the facility failed to: 1) have an accurate and timely infection tracking and monitoring system, 2) follow established COVID-19 testing guidelines per facility policy, 3) implement appropriate transmission-based precaution protocols (including Personal Protective Equipment [PPE] and resident room signage), and 4) practice appropriate hand hygiene. This deficient practice was identified as an Immediate Jeopardy (IJ) due to the failed facility COVID-19 tracking and testing systems had the likelihood to result in further infectious outbreaks for all residents and staff. The IJ began on [DATE], when the facility had 18 cases of COVID-19 positive residents, which by [DATE] increased to a total of forty COVID-19 positive residents, including nine deaths by [DATE]. As of [DATE] the facility had not corrected their infection tracking, surveillance, and COVID-19 testing systems to control the outbreak. The IJ notification was communicated verbally to the Nursing Home Administrator (NHA) on [DATE] at 12:15 PM and was followed with an email copy with request for an abatement plan. The IJ was removed on [DATE] at 4:30 PM when the accepted abatement plan had begun including: 1- Signage for COVID19 isolation rooms were updated to reflect the surgical mask requirement. 2- Infection control line listing was updated to reflect current status for all COVID-19 positive residents. 3- The surveillance facility map was updated to reflect current status for all infections within the facility. 4- The Health Department was notified of all COVID-19 Infections since [DATE]. They requested that the list be faxed to them. 5- Staff education on proper PPE use. The deficient practice continued at a pattern level of potential for more than minimal harm until onsite review and confirmation of the completion of the full plan of correction. Findings include: 1) On [DATE] at 10:10 AM, the Director of Nursing (DON) stated she was the designated Infection Preventionist (IP). A meeting to review the facility's infection control program was mutually agreed upon and set to begin at approximately 1:30 - 2:00 PM. The infection prevention program records including all surveillance line listing/tracking logs (for all resident and employee infections and for COVID-19), infection mapping (to show where infections were in the building), COVID-19 testing data (for both staff and residents) and antibiotic stewardship were requested for review prior to the meeting. The IP/DON agreed. As of [DATE] at 2:00 PM, no infection control program documents had been produced for review. Again, the information was requested, and more time was granted for the facility to deliver the requested records to show the facility's infection prevention and control program. Clarification was given to the IP/DON who stated she was still getting the information together. The monthly logs should be readily available as well as the other pieces of the infection control program such as any outbreak information, COVID-19 testing, contact tracing, action taken for employees (such as return to work data) and action taken for residents (such as room changes for quarantine). The IP/DON replied, We do not keep that information on a log. We keep a file on each person (residents and staff) in a green folder. All green folders were requested. On [DATE] at approximately 2:10 PM, a single sheet of paper was presented by the IP/DON with names of residents still residing in the facility who had tested positive for COVID-19 and the date their next COVID-19 test could be performed. A log of facility employees with dates of positive COVID-19 tests was obtained from human resources. The IP/DON stated any further details for each person was contained in the green folders. The green folder/COVID-19 data was compared with the information on the logs received. Six residents had different dates of COVID-19 positivity on the log verses the green folders. Five other residents on the COVID-19 positive test result log had no green folder or any other tracking data. On [DATE] at 2:20 PM, the IP/DON was queried regarding the five missing records / green folders for the residents who tested COVID-19 positive and were not documented. The IP/DON looked through a drawer of more green file folders, then through a pile of papers on her desk, and then she searched several piles on the floor behind her chair. The five green folders for the COVID-19 positive residents were not found. The IP/DON said she must not have made one for them and she still had sheets (of data) to file on her desk. Each of the residents without a green folder had tested positive for COVID-19 during the beginning of the month of [DATE], yet as of the end of the following month ([DATE]) no green folder or other record to track COVID-19 had been created. On [DATE] at 2:26 PM, the IP/DON was asked about mapping / tracking infections in the facility using a color-coded map of the building to follow the progression of infection. The IP/DON stated she did not do color sheets (mapping) for COVID-19 infections. The IP/DON presented the [DATE] and [DATE] mapping data for the tracking of other infections, and stated, We do not have the January color sheet done yet. The IP/DON said she did the infection tracking at the end of the month or the first week of the new month. She did not track information on current infections as they were discovered. On [DATE] at approximately 3:15 PM, the IP/DON brought the infection control records to meet and discuss the infection control program. The monthly infection line list was compared with a summary spreadsheet for the monthly data and the mapping (except for [DATE] which had not been started.) Each month had a spreadsheet indicating the number of infections without explanation or summary analysis and without review of the surveillance data or documentation of follow-up activity in response to the monthly infections. The [DATE] monthly summary had 12 infections documented, yet there were 13 infections line listed. The IP/DON stated possibly the resident with a prophylactic antibiotic may have been listed on the line listing and not the summary sheet. The [DATE] color mapping had 15 infections, while there were 13 infections on the monthly summary sheet and 18 infections on the line list. When an explanation of the discrepancies was requested, the IP/DON stated, I don't know why I am listing them on the line list. I would have to look and see what I did. The [DATE] color mapping had 16 infections, while there were 17 on the summary sheet and 16 on the line list. The IP/DON stated she was only off by one. Upon review of the resident COVID-19 test log, the IP/DON explained when the residents tested positive for COVID-19, a green file was started, and the Resident's responsible parties / families were then called. Six residents on the log were noted to have different test dates than were recorded on the test log provided. Three resident records had two different types of COVID-19 tests administered explaining the discrepancy, but three other residents (Resident #39, Resident #46, and Resident #40) had green folder test dates of [DATE], [DATE] and [DATE] respectively and yet the log reflected a COVID-19 positive test date of [DATE] for all three of these Residents. At approximately 4:30 PM on [DATE], the COVID-19 outbreak was discussed with the IP/DON who said there was no written summary of the outbreak (including information such as dates of COVID-19 positive occurrences, actions taken, residents' movement to quarantine, or resultant deaths). She only had the green files. The IP/DON stated the outbreak went until mid-[DATE] with 40 residents testing positive and seven resident deaths. There was a COVID-19 unit, but she was unsure how many rooms or beds were on the unit and would have to look in the electronic medical record to identify when residents were moved on to or out of the unit. The IP/DON stated she did not contact the Health Department but felt the previous NHA DD might have called. During a phone interview on [DATE] at 5:29 PM, NHA DD discussed the COVID-19 outbreak in [DATE] through [DATE]. NHA DD stated, No, I did not write a summary of the outbreak. She communicated with the health department by turning in the paperwork on positive tests, but the health department was not called to obtain advice during the outbreak. NHA DD discussed the process of the green folders used for employees as well as for residents who were COVID-19 positive. She said there was no line listing to track COVID-19. The facility policy titled Coronavirus (COVID 19) dated [DATE] read in part: The Health Department should be notified about residents with severe respiratory infection . The facility policy titled Coronavirus (COVID-19) Protocol dated [DATE] read in part: Residents positive/or presumed positive with COVID-19: 2. The local health department and the state health department will be notified. 3. The local health department will assist in providing direction of transporting the resident to an available bed at a hospital if indicated. On [DATE] at 9:45 AM, the Corporate Nursing Consultant Registered Nurse (RN) P stated the facility corporation writes facility policies and uses the CDC for policy guidelines. During an interview with the IP/DON and RN P on [DATE] at approximately 8:00 AM, the IP/DON was asked for the number of residents involved in the COVID-19 outbreak of November/[DATE] and the identity of those who had expired in the outbreak. At approximately 8:30 AM, the IP/DON stated there were 37 residents in the outbreak and she was getting a list of those residents who had expired during this outbreak. Shortly thereafter, the IP/DON stated she was mistaken and there had been 9 deaths in the COVID-19 outbreak rather than the 7 deaths originally reported on [DATE]. At approximately 10:00 AM, the COVID-19 outbreak count of November/[DATE] was revised by the IP/DON to be 40 residents who had tested positive for COVID-19 and not 37 residents. 2) During an interview with the IP/DON on [DATE] at 11:24 AM, staff testing was discussed. There were discrepancies from the master testing sheet and the green folder information. The green folder for Dietary Aide (Staff) T revealed he had symptoms of vomiting and a runny nose. The IP/DON stated the vomiting notation was an error, and he only had a runny nose. The information in the green folder also indicated Staff T was tested for COVID-19 on [DATE]. The IP/DON stated that also was incorrect and should have indicated the test was given on [DATE]. Staff T worked [DATE] in the kitchen and tested positive for COVID-19. The IP/DON explained the form was typed over another copy of the form and information had been carried over on the wrong form. The IP/DON stated Staff T tested positive for COVID-19 and was sent home. On [DATE] at approximately 11:30 AM the daily COVID-19 screening sheets were reviewed with Staff Z. No COVID-19 entry screening sheet could be found for Staff T on the date he tested positive on [DATE]. During an interview with Staff T and the NHA on [DATE] at approximately 11:45 AM, it was revealed that no screening sheet had been found for the day of [DATE] for Staff T and he was asked if it was possible he may not have screened in on that day. Staff T said yes it was possible he did not screen in upon coming to work. Staff T did remember the day was a mandatory testing day. (The facility tests employees on Mondays and Thursdays.) Staff T stated he heard the announcement for testing and left the kitchen to be tested . He stated it was about 10 or 10:30 AM and he reported for testing, returned to the kitchen and went about my work. Staff T said later after lunch he was called to the DON's office and was told he was COVID-19 positive. He said he was not happy as he had no symptoms and would not be able to work and he felt fine. Staff T reported the DON then sent him home. Staff T stated he left the DON's office, punched out immediately, and went home. A copy of the timecard with actual time worked indicated Staff T punched out at 1:30 PM. The NHA was asked how quickly the COVID-19 test results were available and he answered, 15 minutes. The NHA said if Staff T tested positive for COVID-19 at 10:00 AM he should have been sent home at 10:15 AM and not 1:30 PM. 3) During the review of the infection control program with the IP/DON on [DATE] beginning at approximately 3:15 PM, the Transmission Based Precautions for Resident #150 were discussed. A sign had been posted on Resident #150's door for airborne rather than droplet precautions. The IP/DON stated, That is the wrong one. I do not know who put that up there. 4) During the breakfast meal observation on [DATE] at 8:32 AM, Certified Nurse Aide (CNA) F and CNA BB were delivering meal trays from the meal cart which had arrived from the kitchen. After the first two trays were delivered, CNA F and CNA BB were asked if they had washed the resident's hands. Both the CNAs acknowledged they had not. CNA F stated, No, I didn't even think about it. On [DATE] at 10:10 AM, the DON/IP said the residents should always have their hands washed before a meal. A hand hygiene policy was requested. A policy titled Hand Washing/Hand Hygiene dated ,d+[DATE] was reviewed but provided only guidelines specifically for employees for proper and appropriate hand washing and hygiene techniques. The policy did specify handwashing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: . e. Before eating. A policy specific to resident hand hygiene was not presented prior to the conclusion of the survey. 1) On [DATE] at 3:16 PM, an interview was conducted with the DON/IP regarding the mapping and line listing for infections acquired by the facility residents during the months of [DATE] through [DATE]. Review of the infection control line listing and infection control summary in comparison revealed unmatched number counts of acquired various (ie. skin, urine, respiratory) resident infections. The DON/IP was asked why the numbers did not match and responded, I must have miss counted. Review of the Covid-19 resident census tracking during the months of [DATE] through [DATE] completed by the DON/IP, the green folders, and the polymerase chain reaction (PCR) test results revealed inaccurate and inconsistent dates. Review of the Covid-19 resident test tracking system revealed a list of forty-five residents and the current census is fifty-five. The DON/IP was asked why the other ten residents were not listed on the current list and responded, If they are not on that list then they get tested tomorrow on another list. Review of facility policy titled Infection Surveillance and Monitoring Program, dated ,d+[DATE] read in part; Purpose: The infection surveillance program refers to ongoing systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risk, to try to reduce morbidity duty and mortality and to improve resident health status .Procedure: 2. Review tracking and trending of infections. On [DATE] at approximately 3:30 PM, an interview was conducted with the DON/IP regarding reporting communicable disease. The DON/IP was asked if the facility was reporting to the health department and responded, most of them .usually the Covid ones yes. The DON/IP was then asked how long they are quarantining residents and responded, Well, that just changed, so seven to ten days .if they develop signs and symptoms at work, we test them right away and if they are positive, we send them home .First we screen them. On [DATE] at 8:38 AM, an interview was conducted with the DON/IP regarding the tracking of Covid-19 for the residents. The DON/IP was asked if the tracking system was accurate and responded, I agree that it is not an accurate tracking system, some residents are missing off the list, and have inaccurate dates of when they tested positive and started with signs and symptoms. Review of facility policy titled Infection Surveillance and Monitoring Program, dated ,d+[DATE] read in part; Purpose: The infection surveillance program refers to ongoing systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risk, to try to reduce morbidity duty and mortality and to improve resident health status .Procedure: 2. Review tracking and trending of infections. 2) Review of the Covid-19 testing for employees, the testing logs, tracking tool, and documentation revealed numerous errors in the record keeping, lack of information, an incomplete list of current employees being tested . The Covid-19 testing for employees also included employees who were former employees on the list used for tracking, discrepancies in the number of logged Covid-19 tests done. Comparing the logs to the sign-in sheet for employees there were inaccurate dates, missing test results, and inconsistent dates for when to resume testing after acquiring Covid-19 in employees. Review of the facility policy titled Covid-19 Testing dated [DATE], read in part; Policy: To decrease the risk of transmission and prevention of Covid-19, multiple means of testing may be utilized for individuals requiring testing for Covid-19 .Staff Member Scheduled Testing: Any employee whose last test date exceeds the required time frame will be required to be tested prior to returning to work .D.) Outbreak Resident and Staff: Any one staff member or resident that test positive is considered an outbreak for that facility. Test all residents and staff every ,d+[DATE] days until 14 days has elapsed from the most current positive test. Any employee whose last test date exceeds the required time frame will be required to be tested with results prior to returning to work .If POC test is positive; staff member: removed from the facility to self-isolate for 10 days and would need approval from the Employee Health nurse to return .Documentation .2.) Documentation of testing will be documented on an employee .tracking log testing dates. 3.) Documentation log will be specific to testing reason .b.) Outbreak: dates and results of initial testing and retesting for all residents and staff. 3) On [DATE] at 12:45 PM, an observation was made of the Southwest hallway and the signs of the transmission-based precaution (TBP) rooms. One room had a sign on the door indicating droplet precautions and another room had a sign on the door indicating airborne precautions with the door open. On [DATE] at 1:45 PM, an observation was made of Resident #150, from the room with the TBP sign airborne precautions was outside of their room in a wheelchair, without a mask on and sitting in front of the nurse's station on the Southwest hallway. Resident #150's Electronic Medical Record (EMR) revealed an admitted [DATE] and admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Covid-19 Screenings Transfer Tool dated [DATE] revealed Resident #150 had not received the COVID-19 vaccination. A physician order dated [DATE] contained the following order, in part, Droplet precautions per facility protocol. A copy of the facility's undated Coronavirus (COVID-19) Protocol contained the following information, in part, S2. staff prevention measures .4. Staff will wear N 95 masks in quarantine rooms covered by a disposable surgical mask. Surgical mask will be disposed of upon exiting the room .11. Eye protection will be cleaned when exiting a resident's room when in quarantine or individual isolation room. Recommended : a. supply care givers with 2 sets of eye protection and paper bags. b. Doff and clean eye protection when exiting the room and place in bag .8. If the resident needs to exit their room for any reason, a mask must be placed on the resident during transport . The facility's Covid 19 Pandemic Admission/Readmission which was updated on [DATE], contained the following information, Policy: it is the policy of this facility to admit/readmit patients in a manner that reduces the risk of exposure to existing residents .4. Not fully vaccinated, unvaccinated and admissions displaying COVID-19 symptoms will admit to yellow rooms(quarantine) . category yellow .Residents would be placed on droplet precautions including (N 95 mask with a surgical mask covering N 95 and eye protection) for a minimum of 14 days, with droplet precautions signage posted on door. Doors to resident rooms are to remain closed if tolerated . On [DATE] at 11:15 AM, an interview with CNA H and when asked if she knew why Resident #150 was on TBP she responded, I am not sure, but I think it is because she is not vaccinated. During this time Resident #150 was observed scooting outside of her room in her wheelchair with a mask worn below her nose. Approximately five minutes later CNA I entered the TBP room of Resident #150 without a gown, mask or gloves on. On [DATE] at 1:37 PM, an observation was made of Resident #150, again out of her room in her wheelchair and with her mask below her nose. On [DATE] at 10:44 AM, an observation was made of CNA BB entering a TBP room for droplet precautions without applying a surgical mask over her N-95 and then after leaving the TBP room did not wipe down her goggles. On [DATE] at 10:56 AM, an observation was made of CNA BB entering TBP room with stethoscope, blood pressure cuff and pulse oximetry (devices used to obtain an oxygen saturation). CNA BB came out of the TBP room a few minutes later and then proceeded to place the stethoscope, blood pressure cuff and pulse oximetry onto a cart in the Southwest hallway with other vital sign obtaining equipment used for other residents that were not on TBP precautions back on the cart. An interview was conducted on [DATE] at 11:08 AM, with CNA BB regarding the actions taken when she went into the TBP room with the medical equipment. CNA BB was asked if she used the equipment on the TBP resident she responded, No. CNA BB was asked why she took the medical equipment in the TBP room she responded, I don't know. Because the TBP rooms have designated equipment in their rooms in the top drawer. CNA BB was then asked how she would prevent the spread of infectious diseases with the dirty equipment she responded, I would wipe them down. CNA BB was asked if she cleaned the medical equipment that she took in the TBP room earlier, and responded, No. I should have. On [DATE] at 3:50 p.m., a phone interview was conducted with County Epidemiologist EE. When asked if she had told the facility to not call them about COVID-19 positive cases, Epidemiologist EE stated No. We were in touch with them. We even sent them variant test kits, but as far as I know we never received any results back. On [DATE] at 1:06 p.m., the IP/DON was asked about the variant test kits that the county health department had sent them. The DON reported that she did remember getting some test kits. On [DATE] at approximately 3:45 p.m., the IP/DON reported that they had received two results out of 4 kits sent. The IP/DON reported that 2 of the Residents that were positive during the November/[DATE] outbreak had been positive with the Delta variant of COVID-19. The IP/DON reported that she was aware that this meant that the Residents who tested positive in the Fall of 2021 were still susceptible to becoming infected with a subsequent variant. B. Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria in the facility water system, in accordance with QSO ,d+[DATE] Hospitals/CAHs/NH, Revised [DATE]. The facility failed to Develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential for the proliferation and transmission of Legionella in the circulating water of the building and the spread of Legionella infections in all 48 residents. Findings include: On [DATE] at 9:30 AM, an interview with Maintenance Director/ Staff A was conducted to review the facility's WMP for the control of Legionella in the water supply system. Staff A produced a notebook with pages of tables with dates. When asked about the information in the book, Staff A stated it was the facility's documentation of flushing various fixtures in the building. When asked if the facility had an actual Water Management Plan, which identified a water management team, control points, and critical limits of measurable parameters within the water system, Staff A stated No. When asked if he was familiar with the CMS QSO ,d+[DATE], the CDC document Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, or ASHRAE 188, Staff A stated I think I have seen them. The facility did not have any of these documents available for use or reference. The following components were absent from the facility WMP: A. Designation of a Water Management Team (WMT). B. An assessment of the facility's water system to identify risk locations. C. Identification of control points where effective mitigation measures can used. D. Identification of set critical limits related to the risk areas identified and which can be controlled. E. Identification of defined control measures and locations related to risk and the critical limits which are set. F. Implementation of regular scheduled mitigation program. G. An evaluation process to determine how the WMP is functioning. The following is the accepted Abatement plan to remove the Infection Control and Prevention immediacy: 1) [DATE] at 4:00 pm The following policies were reviewed and deemed appropriate. a. Infection Surveillance and Monitoring Policy b. Infection Reporting c. Infection Control Log d. Reportable Diseases in (state) by Condition e. DONN/DOFF Procedure 2) [DATE] 2:00 pm DON, ADON, and NHA were re-educated on the following policies a. Infection Surveillance and Monitoring Policy b. Infection Reporting c. Infection Control Log d. Reportable Disease in (state) by Condition e. DONN/DOFF Procedure 3) [DATE] @ 2:15 pm Signage for COVID19 isolation rooms were updated to reflect the surgical mask requirement by DON and signage updated on current precaution rooms by ADON 4) [DATE] by 4:30 pm the Infection control line listing has been updated to reflect current status for all COVID19 positive residents by DON 5) [DATE] by 4:30 pm the surveillance facility map has been updated to reflect current status for all infections within the facility by DON 6) [DATE] at 1:59 pm The Health Department was notified of all COVID19 Infections since [DATE] via list faxed to them. 7) All staff who potentially could enter a COVID19 isolation room will be re-educated to the proper PPE use by DON/Designee Any staff member that has not received education as of [DATE] will receive education prior to the start of their next shift.

This deficient practice has two parts, 1. and 2: 1. Based on observation, interview, and record review, the facility failed to ensure a thorough risk assessment, adequate interventions, and supervision were provided to prevent falls and resident to resident incidents for three Residents (#35, #24, and #40) out of 20 Residents reviewed for supervision. This deficient practice resulted in a fall with fracture and resident to resident sexual interactions, as well as the potential for further incidents. Findings include: Resident #35 On 1/25/22 at approximately 10:50 a.m., Resident #35 was observed up in her wheelchair trying to self propel down the hall. Resident #35 was observed with a square cushion between her legs velcroed to both of her thighs. A review of Resident #35's medical record revealed she admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and left femur fracture. A review of her 11/12/21 Minimum Data Set (MDS) assessment revealed she scored 0/0 on the Brief Interview for Mental Status (BIMS) assessment revealing severely impaired cognition. A review of progress notes dated 1/25/21 revealed, Resident was observed on the floor between her bed and the window at approx (approximately) 7:30 a.m. Resident's vitals were normal . observed to have a shortening of her left extremity as well as pain on assessment . and At approximately 1:45 pm this afternoon, RR (Resident Representative) called this facility to let us know this resident does have a fx (fractured) left hip and will be having surgery tomorrow . A review of a fall investigation dated 12/25/21 revealed the following: Fall with injury .7:30 a.m., . Was the Patient Injured? Abnormal alignment - of left lower extremity . Resident room . Was fall witnessed? No . Response: Resident's bed changed to a non electric bed . A review of a Fall Witness Statement Form written by CNA X dated 12/25/21 revealed, . The bed was raised .Brief half off and slightly damp. 630 (am) dry, bed comfort level. 7:15/7:30 likes to stay in room. A review of a Fall Witness Statement Form dated 12/25/21 from CNA Y revealed, At approximately 7:30 am (Resident #35) was observed on the floor on the right side of her bed. Her bed was raised to the highest position . Per this investigation Resident #35 was unable to state what happened and the bed had been found in the highest position. A review of Resident #35's care plan for falls revealed new interventions dated 1/26/22 (during the survey) which revealed, Additional intervention for 10-13-2021 (fall). Maintenance evaluation for anti-roll backs system for proper functioning. System functioning correctly. Replaced electric bed for manual bed on 12/25/21. Further review of this care plan revealed no interventions for which bed height would be safest for the resident, despite being found on the floor with her bed in the highest position. On 1/31/22 at 2:00 p.m., an interview was conducted with the Director of Nursing (DON) and Corporate Nurse Consultant/Registered Nurse (RN) P. When asked about Resident #35's fall on 12/25/21 the DON reported that it had not been reported as they pretty much knew what had happened. The DON reported that since the bed was found in the highest position, Resident #35 must have raised the bed up herself. When asked why a Resident with a BIMS of 0/0 would have an electric bed with access to the remote, the DON reported that many of the beds were electric and that it had never been an issue before. The DON reported that the remotes were usually attached to the bed enabler bars. On 2/1/22 at 10:48 a.m., Resident #35 was observed in bed wearing just a brief and T-shirt. The bed was at a normal height and Resident #35 was grabbing on to the arm rest of wheelchair that was positioned on the right side of her bed. Resident #35 was also attempting to swing her legs over the side of her bed. Staff were notified and reported that they would get her up out of bed. Resident #40 and Resident #24 On 1/26/22 at 12:04 p.m., Resident #40 and Resident #24 were observed sitting in the hallway with CNA R beside them. Resident #40 and #24 were observed to be sitting quite close together and holding hands. CNA R was called away by another resident requesting assistance. Resident #40 was then observed to look around and see if any staff were nearby then proceeded to grab Resident #24's head and start passionately kissing him. This Surveyor walked to face Residents #40 and #24 and Resident #40 then proceeded to grab Resident #24's genitals over his pajama pants. Resident #24 made eye contact with this surveyor and appeared to be pushing Resident #40's hands away from him. This Surveyor found the closest staff member, CNA R and reported the observation. CNA R then sighed and reported, It's supposed to just be kissing and hand holding. On 1/26/22 at approximately 3:45 p.m., CNA Y was in the hallway with Residents #40 and #24 and witnessed Resident #40 grabbing between the legs of Resident #24. CNA Y asked the Residents to please keep their hands above the waist. A review of Resident #24's medical record revealed he admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance. A review of his 12/9/21 MDS assessment revealed he scored 5/15 on the BIMS assessment indicating severely impaired cognition. A review of Resident #24's care plan for behaviors revealed the following .(Resident #24) has displayed an emotional/physical connection with another resident (Resident #40) which both resident families are in support of (1/5/22) Encourage and provide opportunities for resident and other resident (Resident #40) to spend time together in facility supported areas. (1/5/22) Encourage resident and other resident (Resident #40) to participate in leisure activities and facilitated/monitored to promote engagement together. (1/5/22) Monitor for increased need of affection/increased sexual desire . This care plan did not give boundaries as to what the families had agreed upon regarding physical touching. A review of Resident #40's medical record revealed she admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and [CONDITION(S)]. A review of her 1/6/22 MDS revealed she scored 3/15 on the BIMS assessment indicating severely impaired cognition. A review of Resident #40's care plan for behaviors revealed, . (Resident #40) has displayed an emotional/physical connection with another resident (Resident #24) which both resident families are in support of .(1/5/22) Encourage and provide opportunities for resident and other resident (Resident #24) to spend time together in facility supported areas. (1/5/22) Encourage resident and other resident (Resident #24) to participate in leisure activities and facilitated/monitored to promote engagement together. (1/5/22) Monitor for increased need of affection/increased sexual desire . On 1/31/22 at 1:00 p.m., an interview was conducted with the DON. When asked about what boundaries for Resident #40 and #24's relationship the families had agreed to, the DON reported there was a progress note that the families were on board with the relationship. The DON verified she was unable to determine what boundaries had been set from reviewing the medical records, and she was unaware if the families had been notified of the touching. When asked to provide a policy on resident relationships, the DON reported they did not have a policy for that. 2. Based on observation, interview, and record review, the facility failed to ensure hazardous agents were securely stored for one (Resident #5) of one resident reviewed for presence of hazardous agents in resident rooms. This deficient practice resulted in the potential for resident's access, exposure, and ingestion of hazardous material leading to serious illnesses and/or injuries. Findings include: A review of Resident #5's face sheet revealed an admitted [DATE] and medical diagnoses which included a stroke with left sided weakness, enteral feeding (receiving nutrition through a tube inserted into the digestive track), falls, diabetes, depression, and anxiety. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14/15, indicating Resident #5 was cognitively intact. On 01/26/22 at 10:38 a.m., Licensed Practical Nurse (LPN) E was completing care for Resident #5 when Resident #5 reported she kept muscle rub in her top drawer of her dresser. LPN E set resident care materials on top of the dresser and opened the Resident #5's dresser. An opened box of muscle rub and a tube of skin rash cream was observed along with resident incontinence care items. Resident #5 then reported she also had flea killer her family member had brought in to give to another resident as a joke. A canister of flea killer was visible on top of Resident #5's nightstand, next to where LPN E stored Resident #5's tube feeding equipment. LPN E confirmed she had not seen the flea killer when she placed the tube feeding equipment and confirmed this is where Resident #5's tube feeding equipment was stored. LPN E removed the canister of flea killer from Resident #5's room, but the muscle rub ointment and skin rash cream remained stored in the dresser drawer. LPN E stated there were residents who wandered and could potentially get into the flea killer which could cause serious illness. On 1/26/22 at approximately 10:41 a.m., LPN E notified the Director of Nursing (DON) of the flea killer that had been kept in Resident #5's room. The DON reported it was unacceptable for hazardous agents to be kept in resident's rooms because they could be very harmful if residents inadvertently accessed them, concerns were also voiced by the DON regarding the muscle rub and skin rash cream being kept in Resident #5's drawer. The DON was not sure how the flea killer had made it into Resident #5's room or why it had not been discovered by staff. A review of the [Brand Name] flea killer product label revealed following information, in part, Precautions statements Hazards to Humans and Domestic Animals Caution: Harmful if swallowed. Avoid breathing dust and contact with eyes, skin or clothing. Thoroughly wash with soap and water after use. Do not contaminate feed, water, or foodstuffs. Remove pets, birds, and cover fish aquariums before use. Keep children and pets off treated surfaces during application and until surfaces are vacuumed .Storage & Disposal Do not contaminate water, food or feed by storage or disposal. Pesticide storage: Store in cool, dry (preferably locked) storage area inaccessible to children and pets .

This citation pertaining to intake number MI 640. Based on observation, interview, and record review, the facility failed to assess and monitor 1 Resident (R 11) for weight loss and nutritional needs, resulting in R 11 developing severe weight loss, low serum [MEDICATION(S)] and pressure ulcers. Findings include: Review of R 11's face sheet, no date, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R 11 had a court appointed guardian. Review of R 11's Letters of Guardianship of Individual with Developmental Disability Probate Court report dated 10/21/21 revealed R 11's family member R was his medical guardian and S was his court appointment financial guardian. Prior to 10/21/21 S was R 11's medical and financial guardian. During a telephone interview on 11/2/21 at 11:39 AM, with Guardian R, R 11's family member reported she worked closely with guardian S, and she has been able to visit R 11 in a conference room intermittently since his admission in June. Guardian R said she has taken R 11 out of the facility several times and assist with his medical appointments. Guardian R said she has requested to see R 11's buttock with a nurse or doctor present because R 11 complains of pain in his buttock when he is up in his wheelchair for visits, but the facility will not allow that. Guardian R said she has not received any notification form the facility that he has any skin break down. R 11's Guardian R said she was very concerned about the R 11's eating as he looks like he is losing weight, complains of dental pain and needs to see an oral surgeon. R 11's Guardian R said the facility has not informed her that R 11 has lost any weight. Guardian R said she went to court to get medical guardianship because Guardian S has a lot of people to take care of and cannot come in as often as she can, and R 11 needs her help and encouragement. Guardian R said communication with the facility has been very difficult and she was very frustrated as she did not think they listen to her. During a telephone interview with R 11's Guardian S on 11/3/21 at 9:39 AM Guardian S confirmed she was R 11's guardian for medical and financial until 10/21/21. As of 10/21/21 Guardian R was medical guardian, and she remains financial guardian. Guardian S said she had been R 11's Guardian since he was [AGE] years old. Guardian S said the facility did not inform her that R 11 had significant weight loss or of any skin breakdown. Review of R 11 Psychology Assessment for decision making ability dated 8/19/21 revealed under the section, Summary of Findings: Impaired general cognition, Impaired verbal reasoning. Impaired verbal memory. The overall level of functional ability for day-to-day tasks was in the below range. The current cognitive difficulties are persistent symptoms or associated personality change, sufficient to interfere with the performance of duties or social adjustment. The summary concluded with, The resident was not able to understand or appreciate his current predicament. He could not reason through hypothetical situations related to his current situation and was not able to express choice in a meaningful manner. Based on the information gathered and with a reasonable degree of neuropsychological certainty, [R 11] lacks the capacity to make or participate in complex medical and/or financial decisions. Review of R 11's weights revealed he weighed 261 pounds on admission (6/10/21), on 6/16/21 he weighed 253 pounds, on 6/30/21 he weighed 246.1 pounds, on 7/1/21 he weighed 243.7 pounds, on 7/28/21 he weighed 243.8 pounds, on 8/5/21 he weighed 243.8 pounds, on 9/7/21 he weighed 242 pounds, on 10/7/21 his weight was not taken on 10/30/21 he weighed 214 pounds. R 11 was observed in bed on 11/2/21 at 11:10 AM, R 11 had dry scabbed lips, he was lying on his back with his head near the upper rail of the left side of his bed. R 11 had a dressing on his left buttock with no date or initials. The dressing had soaked through in center greater than 2 inches in diameter. R 11's pressure relieving boots were in his wheelchair. He had a standard facility mattress on his bed. R 11 had lip balm on his bedside table and several drink cups. R 11 reported problems swallowing food and having a sore buttock. During an interview with the Director of Nursing (DON) on 11/2/21 at 11:30 AM, the Surveyor asked the DON about R 11's nutritional status due to extremely dry lips and reporting he was having problems with swallowing. The Surveyor also reported she observed a dressing on R 11's buttock with no date and the dressing was saturated. The DON said R 11 was weighed on 10/30/21 and his weight was 214 but she needed a reweight. The DON said she was not aware of any weight loss or skin ulcers on R 11 buttock. During an interview on 11/2/21 at 2:05 PM, with Certified Nurse Aides (CNA's) P and Q they said they had noticed R 11 clothing had gotten very loose and he was no longer eating his favorite foods. They said they weighed him on 10/30/21 and were aware of his weight loss on 10/30/21. They said they weighed him in his wheelchair on 10/30/21 and it weighed 59 pounds. They verified his wheelchair weight today and it still weighed 59 pounds. He had the lift sling under him which weighed 2.2 pounds. They took him to the same scale and his weight was 273 pounds. They subtracted the weight to the sling and wheelchair. His weight today was 211.8 pounds. His weight on 10/30/21 was 214. Review of R 11's progress note dated 11/2/21 at 2:46 PM revealed, Went to residents room to assess for dehydration. Asked resident if this writer could look into his mouth. Asked if he had bit his tongue or lip and he stated, 'No don't think so.' Asked if he wanted his toothbrush and toothpaste out and he did brush his teeth, he didn't rinse very well. Asked him if he needed more water to rinse with because it looked like he had toothpaste on his tongue. He stated 'I never rinse it all out.' Asked if he was ok with that or if needed this writer today anything else. He stated 'No I'm fine.' Asked how much water he was drinking, and she stated, 'None and I don't want any' Educated him on keeping hydrated and that his mouth looked a bit dry. He said 'I drink my drink pop that's good enough.' Again educated him on drinking water and asked if he wanted some fresh water. He stated 'Ok.' Asked if he would like ice, he stated, 'Yes, a little' Showed him a line on his water cup and he stated that was good on the ice. Note was signed by the DON. Review of R 11's progress note dated 11/2/21 at 3:10 PM revealed, Asked resident when in his room to look at his bottom. He stated 'No, they just looked at it' Asked if this writer could look at it later and he didn't answer just looked at this writer. Will attempt to look at it later today. Note was signed by the DON. Review of R 11's progress note dated 11/2/21 at 3:58 PM revealed, Discussed with PA (physician assistant) residents weight loss in the last two months. PA gave order for ProSource 30 ml BID (twice a day). Note was signed by DON. Review of R 11's progress noted dated 11/2/21 at 9:32 PM revealed, Current meal acceptance averages 50 - 75% of meals. Intake stabilizing following previous decrease. House supplement once daily, initiated 6/18/21 with varied acceptance. Per discussion with ADON (assistant director of nursing) and IDT (interdisciplinary team), Gelatin once daily initiated 10/19 for skin healing to promote adequate intake. Per MAR (medication administration record) acceptance is variable with refusal noted. Substitutes, such as nutritional juice, offered for refusals of ordered supplements with varying acceptance. He is noted to refuse cares, meds and getting out of bed at times in addition to meals and supplements. He notes a decreased appetite, but unsure of cause. He continues to consume candy and soda per his preference. Weight obtained 10/28/21 suggest weight loss of 28 pounds. He experienced increased lethargy, cough, oral and tooth pain over the past 60 days with decreased intake. He refuses to participate in the dental exam and has not had further complaints of tooth pain. Per nursing he refused favorite foods at times as well. Note was signed by registered dietitian (RD) O. Review of R 11's progress note dated 10/19/21 at 12:42 PM revealed, Resident was reviewed with ADON (assistant director of nursing) for altered skin to buttocks areas. He continues on NAS (no added salt), regular texture, thin liquids diet. Per nursing he refuses some meals except what family brings in for him. Intake average: 50 - 75% of meals. CBW (current body weight) 242 lbs. Weight has been stable no significant changes. Recent weight was refused per nursing. Recommend to continue on house supplement, and also add on Gelatin supplement to promote skin healing. RD to continue to monitor. Note signed by RD O. Review of R 11's Clinical Notes from his dental appointment on 10/26/21 revealed, Pt (patient) presented for hygiene appointment but was upset that it was a morning appointment. Stated his gag reflex is worse in the mornings. We were unable to obtain any x-rays or even get mirror in the mouth for an exam, even with the use of Hurricane spray (medicated spray for pain). Pt reported having a numb feeling on the right side of his mouth (right mandible, tongue chin and lip) Attempted to take Panoramic film but patient cannot stand and could not sit up enough to reach mouthpiece on pan machine. Without x-rays or being able to do any exam, Dr feels it would be best to refer to the oral surgeon to see if they can identify the cause of the paresthesia (numbness). If U of M reject the referral, we may need to refer to his PCP (primary care physician). During a telephone interview on 10/3/21 at 2:05 PM with RD O, she said she was not aware of R 11's significant weight loss until 11/2/21 when she was informed by the DON. RD O said when she did her assessment on R 11 on 10/19/21 she went by the information the ADON provided. RD O denied asking certified nurse aides any questions. RD O said she was not aware R 11's clothing was very loose, and he was no longer eating his favorite foods. RD denied requesting another weight on the day of her assessment (10/19/21) or attempting to assess for weight loss other than previous weights. RD O said they do not record types of food like protein or meals family bring into the facility. RD O said she became aware of R 11's refusal for dental care by verbal report from nursing. RD O denied reading R 11's dental report. Review of progress noted dated 11/3/21 at 2:07 PM revealed, His mouth does look dry. Contacted PA (physician assistant), he gave order for CMP (blood work up) and will look to see if he is dry and will order fluids intravenous (IV) if needed. Changed his diet to Mechanical soft per PA, r/t (related to) mouth being sore and not eating well. Discussed with his [medical guardian] the interventions the PA and this writer she stated, 'Anything that will help.' She then proceeded to state he didn't like the hamburger he gagged on it. This writer asked her to clarify gag, was it too dry he couldn't swallow, was his mouth too sore? She stated 'It might have been a little of all of the that.' She stated he likes soups, chili, chicken noodle and she wants to bring some of that in. Note was signed by the DON. R 11 was observed in bed being evaluated by Speech Language Pathologist (SLP) T on 11/4/21 at 9:13 AM. R 11 was in bed. SLP T explained to him he would eat better if he was up in his chair. When R 11's was asked if he wanted to eat sitting up in his chair he agreed. When Certified Nurse Aides (CNA) U and P were asked to get him in his chair for breakfast they responded he did not request to get up a few minutes ago when we were in his room. CNA U and P went in R 11's room and confirmed he wanted to be up or breakfast and got him out of bed with a mechanical lift. The caregiver Kardex was reviewed with CNA U and P. There was no indication they were to encourage R 11 to be up in his chair for meals. Review of R 11's care plan revealed there was a care plan for altered nutrition that started on 11/3/21. One of the approaches was listed as, approach [R11] before meals to encourage him to get up for meals in w/c (wheelchair). Educate he will be able to swallow better and digestion will be easier. (CNA U and P were not able to locate this intervention on the electronic Kardex on 11/4/21 around 9:00 AM). During an interview with the DON on 11/4/21 at 2:05 PM, the DON reviewed R 11's medical record with the Surveyor. The DON was not able to locate any documentation that showed the facility reapproached R 11 to get a weight after he refused on 10/7/21 until 10/30/21. The DON could not find any documentation the R 11's guardian was notified of his refusal to have his weight taken on 10/7/21. The DON said the second weight done on 10/30/21 was not entered correctly in the system so she was not able to see the second weight when she was asked about it on 11/2/21. The DON said she could not see any documentation that R 11's guardian or physician were notified of the significant weight loss that was noted on 10/30/21. The DON could not find any documentation tracking food intake that the family brings. The DON said she should have notified the guardian of the weight loss when she became aware of it on 11/2/21 when she notified the physician. Review of R 11's laboratory results from 11/3/21 revealed his serum [MEDICATION(S)] was 2.5, normal serum [MEDICATION(S)] is 3.4 to 4.8. According to the Mayo Clinic, www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/8436. Serum [MEDICATION(S)] is useful for assessing nutritional status. Hypoalbuminemia (low [MEDICATION(S)]) can be caused by low protein intake. Review of a typed timeline provided by the Director of Nursing (DON) for R 11's wounds on his buttock revealed, R11 developed a wound on his right buttock on 9/5/21 that measured 4.7 cm L x 4.5 cm W x 0.1 cm D on 10/5/21 the wound was 1.0 cm x 2.0 cm W x 0.1 cm D. The timeline indicated the right buttock healed on 10/12/21. The timeline indicated R 11 left buttock had an open area on 10/8/21 that measured 1.0 cm L x 1.2 cm W x 0.1 D. On 11/2/21 the timeline revealed the wound on the right buttock was open again and measured 4.2 cm L x 2.5 cm W x 0.1 D and the left upper buttock remained open at 2.5 cm L x 4.2 cm W x 0.2 D. Review of R 11's progress note dated 11/4/21 at 8:53 AM, revealed R 11's physician was in and evaluated his wounds. The physician said the wound on the left buttock was a stage 2 ulcer.

This citation is in reference to MI 447, MI 929 and the COVID-19 focused infection control survey. Based on observation, interview, and record review, the facility failed to follow CDC (Center Disease Control) and CMS (Centers for Medicare and Medicaid Services) guidelines and recommendations to contain and prevent the spread of COVID-19, resulting in an Immediate Jeopardy (IJ) when the facility staff did not appropriately utilize or don PPE (personal protective equipment) and follow basic infection control practices to reduce the potential for the spread of COVID-19. After a facility staff tested positive, two residents (Residents #1 and #2), contracted COVID-19. The facility did not ensure appropriate monitoring of R1 and R2 after exposure to COVID- 19. This deficient practice resulted in the continued risk for infectious disease spread in the facility and placed all residents and staff at risk for serious harm, injury, and /or death from COVID-19 and other infections. Findings include: On [DATE] at 12:02 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were informed of an Immediate Jeopardy (IJ) that was identified on [DATE] and began on [DATE] when the facility became aware that Resident #1 tested positive for COVID-19 after a staff member tested positive for COVID-19 on [DATE] and the facility failed to follow CDC and CMS guidelines to reduce the potential for the spread of COVID-19 by allowing staff to be in contact with one another and enter the building without face coverings, isolating residents with uncleanable equipment, not utilizing PPE and infection control procedures appropriately during resident care, and not following proper sanitation and PPE procedures in the kitchen. Resident #1 and Resident #2 Review of face sheet for Resident #1 revealed they were a [AGE] year old male who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. They have a current [DIAGNOSES REDACTED]. Review of face sheet for Resident #2 revealed they were a [AGE] year old male who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2 had a subsequent [DIAGNOSES REDACTED]. Resident #2 was noted to be currently deceased . Interview with the NHA on [DATE] at approximately 8:30 AM revealed they had a staff member, N test positive for COVID-19 as well as two residents, Resident #1 and Resident #2. Staff N was a part time activity staff and most likely had contact with Resident #1, but was unlikely to have had contact with Resident #2 due to their activity preferences. Resident #1 and Resident #2 were roommates. Resident #1 tested positive for COVID-19 first and then Resident #2 tested positive later. Resident #2 is currently deceased . The NHA was asked if they were doing any in house contact tracing regarding the outbreak, she stated the health department was doing the contact tracing. The NHA stated that all staff and residents were being subsequently tested every ,[DATE] days. The NHA admitted due to Staff N's position as activity staff, it was likely they could have had contact with multiple residents. It was confirmed that neither Resident #1 or Resident #2 had left the building prior to their positive COVID-19 tests. Review of progress notes and facility provided COVID Outbreak Tracking revealed Staff N was tested on [DATE] during a work shift and the test results were received by the facility on [DATE]. Resident #1 was tested for COVID-19 on [DATE] and the facility was notified on [DATE] 11:55 AM that the test was positive. He was placed in airborne isolation per a progress note on [DATE] at 12:30 PM. Resident #2 tested negative for COVID-19 on their [DATE] test, but were placed on droplet precaution isolation on [DATE] due to his roommate's positive diagnosis. Resident #2 was retested for COVID-19 on [DATE] and the facility received positive results at some time on [DATE] prior to a progress note at 2:20 PM where the resident was informed of the positive COVID-19 results. Further review of Resident #1's progress notes revealed that on [DATE] at 5:05 AM, it was documented Resident has stated he has been coughing throughout the night and had been awake since 2 am. He stated he was unable to eat last night but did manage to drink his coffee . A progress note on [DATE] at 2:08 PM revealed: Resident had been coughing with increased frequency today. He had c/o (complained of) sore throat. When resident talks he (sic) voice is cracking and very raspy sounding . No additional progress notes were documented until [DATE]. On [DATE] a progress note on 2:22 PM noted no COVID-19 symptoms that day. Further review of Resident #2's progress notes revealed he consented to a referral to hospice services on [DATE]. On [DATE] at 5:45 PM a progress note documented Resident finished eating as much of his dinner as he wanted then vomited it . A progress note documented that Resident #2 was found at 11:25 PM on [DATE] to have no respirations or heart tones. Review of death certificate for Resident #2 signed on [DATE] by Doctor BB revealed a cause of death: Covid 19 and [MEDICAL CONDITION] (stroke). Screening and staff/vendor entry Upon entry into the facility on [DATE] at approximately 8:00 AM, pre-screening was completed by Receptionist M. Screening was completed in a small enclosed entryway to the facility. There was one door into the facility and past the screening area a second door into another larger entryway area where staff masks were viewed. The second larger entryway is open to a window to the reception desk. The reception desk and office door was open to one of the halls to the rest of the building. A sign was viewed on the window wall just past the initial entry door which read: 6 easy steps but very important steps to begin your day here at (facility) 1.) Upon entering use hand sanitizer 2.) Be assessed 3.) Open the door, use hand sanitizer as you enter 4.) Put on your mask 5.) Fill out your assessment form 6.) Open the door, use hand sanitizer as you enter. During an interview with staff member F who wished to remain anonymous on [DATE] at 3:35 PM, they shared concerns regarding staff screenings into the building. Staff F stated that staff are not required to wear any face coverings while they are being screen when they enter and exit the building. Staff F stated there was one day where a staff member that was assigned to care for the COVID-19 positive resident was also completing staff screenings during the same shift. During an observation on [DATE] starting at 4:00 PM, within less than five minutes three different staff were seen entering or exiting the building with no face covering. At approximately 4:15 PM two additional staff were viewed exiting the building one shortly after the other with no face covering. During an observation on [DATE] at approximately 9:38 AM a staff member was viewed entering the building with no face covering. During an observation on [DATE] at approximately 10:07 AM a staff member was viewed in the second entryway waiting to check out without a face covering. They passed another staff member who had just been screened who also was not wearing a face covering. As they exited the building they passed an additional staff member who was waiting to be screened who also did not have a face covering. They were all less than 6 feet apart. An interview was completed with staff O on [DATE] at approximately 11:10 AM. Staff O stated they were not required to enter the building with any face covering. They put on a mask after they complete their COVID-19 screening. Environment and supplies On [DATE] a request was made to the DON for a list of residents that were on isolation precautions. A list was provided with 8 residents listed. At 3:30 PM an interview was completed with the DON regarding 8 residents being on isolation precautions, but 11 rooms having a zip wall or precautions noted. The DON stated that if a resident's zip wall was rolled up, they were no longer in isolation, they just did not take the zip wall off. A couple residents that have had an appointment here or there, the plastic was just left up. Review of the facility map as well as facility tour and the list of isolation precaution residents revealed that residents on isolation precautions were not cohorted in the same area. Residents not on isolation precautions were next to and across the hall from residents on islolation precautions. Residents on isolation precautions were residing on three of four different halls in the facility. Per review of facility policy COVID 19 Pandemic Admission/Readmission with no listed implemented or last updated date revealed those on droplet precautions for various reasons including leaving the facility for medical appointments, [MEDICAL TREATMENT] or new admissions are coded as yellow. Yellow residents should ideally, the locations would be a cluster of rooms or a designated unit. If unable to accommodate, an individual room can be utilized, Doors to resident rooms are to remain closed if tolerated by resident(s) unless clinically contraindicated or to participate in an activity. Clear plastic may be applied to the door frame if the resident request, and If able, dedicated staff should be assigned to the Category Yellow area. On [DATE] at approximately 3:50 PM a tall white laundry basket with open top and holes in the sides was viewed full of soiled gowns outside a resident room who was on isolation precautions. Resident #16 (a resident not on isolation precautions) was viewed sitting outside of their room less than 6 feet from the laundry basket and had no face covering on. Staff use of PPE and hand hygiene During a facility tour which began at 8:45 AM on [DATE], CNA Q was viewed in a resident hall with their KN95 mask below their nose. They were viewed going from room to room taking meal requests, at times with the mask below her nose, at other times pulling the mask down to speak to residents. They were viewed entering beyond the doorway of six different rooms, three with droplet precaution rooms and three rooms with no specific precautions; without donning any further PPE and without hand hygiene. On [DATE] at 10:05 AM Registered Nurse (RN) S was viewed walking down the dementia care hall with their KN95 mask below their nose, they fixed their mask, then sat with Resident #15 in the hallway and then the mask fell below their nose again. On [DATE] at approximately 2:55 PM CNA D was observed leaving a resident room on the dementia care hall with no observed hand hygiene. No hand sanitizer dispensers were noted on the unit. CNA D was viewed to be wearing pants and a shirt with no visible pockets. CNA D was interviewed regarding hand hygiene. CNA D confirmed there were not dispensers of hand sanitizer on the unit, but there was hand sanitizer at the nurses station. The nurses station was noted to be not convenient to resident rooms and it was stated to CNA D it did not appear they could have hand sanitizer anywhere on their person, CNA D stated that today and most days they would wash in and out of resident rooms or run down to the nurses station if they were not in a resident room. During an interview with staff member F who wished to remain anonymous on [DATE] at 3:35 PM, they shared concerns regarding staff use of PPE. Staff member F stated that multiple staff think that it is acceptable to go from room to room with the same isolation gowns on. Staff F stated they questioned coworkers about this and some claimed they were told it was okay. Staff F stated they have seen other staff reuse isolation gowns at least 4 separate times since a resident tested positive for COVID-19. Staff F denied there were any PPE shortages. On [DATE] at approximately 11:30 AM RN S was viewed at the nurses station that was adjacent to two halls with residents on isolation precautions, their KN95 mask was below their nose. Two other staff members were also at the nurses station. On [DATE] at approximately 11:35 AM, Admissions Coordinator H was viewed walking down the hall near another staff member and having a conversation, staff H was viewed to lean in to speak to the other staff member and lower her KN95 mask below her mouth while speaking and then replaced the mask. On [DATE] at approximately 11:38 AM an interview was completed with Business Coordinator G in their office. Their KN95 mask was observed to be below the nose during the interview. On [DATE] at approximately 12:24 PM, Business Coordinator G was viewed in the hall with their KN95 mask below their nose. An interview was completed with CNA Z [DATE] at approximately 4:20 PM. They were questioned about recent infection control re-education that was completed. CNA Z stated they were not surprised about the re-education because they had definitely noticed the mask issue with my coworkers. Per review of facility posted signs on isolation precaution rooms for a resident on Droplet Precautions Everyone must: Clean hands when entering and before leaving a room. Wear mask and gloves when entering room. Healthcare Professionals Must: In addition to standard precautions, if contact with secretions likely, use gown, glove, mask, and eye cover. For a resident with Airborne Precautions Everyone Must: Clean hands when entering and before leaving room. Wear gown, mask, and gloves when entering room. Healthcare Professionals Must: In additional to standard precautions, if contact with secretions likely use gown, glove, mask and eye cover. Per review of facility provided CDC (Centers for Disease Control) guidelines entitled Sequence for putting on Personal Protective Equipment (PPE) Instructions for putting on a gown include: Fasten in back of neck and waist. Instructions for putting on a mask or respirator include: Fit flexible band to nose bridge and Fit snug to face and below chin. Kitchen and dietary service On [DATE] at 9:05 AM, dietary staff R was viewed in the kitchen with a KN95 mask below their nose. They were viewed to be washing carts. Dietary staff R advised they wash the carts with 2 pumps per sink full of water and gestured to the container under the sink which was viewed to be Emerald glo. R was asked about the process for cleaning the carts. R stated the carts come in and they are emptied of any dishes and then they are cleaned with the Emerald glo solution and then air dried. R was specifically asked if there are any other steps were taken to clean the carts and they stated no. Review of the container of Emerald glo revealed instructions to sanitize after use with an appropriate no rinse sanitizer. Dietary staff R was again asked if the carts were cleaned with any other sanitizing product other than the Emerald glo and they stated just two pumps of the cleaner. Review of product information obtained from https://www.industrialsoap.com/product/emerald-glo-co ncentrated-dish-,[DATE]/ on [DATE] revealed Emerald Glo is a concentrated hand dish detergent and not a disinfectant. During observations of the dining services for [DATE] which began at 11:45 AM, Dietary staff R advised residents on isolation precautions had their meals placed in styrofoam containers and they were delivered on the carts (carts Dietary staff R was previously cleaning). During meal delivery observed at approximately 12:10 PM, the carts were viewed in the hall to have styrofoam containers of food being delivered to rooms of residents on isolation precautions. During meal service, CNA Q was observed to go into three different droplet isolation precaution rooms with meals without gloves or performing hand hygiene. CNA Q was viewed to have the bottom set of ties on the isolation gown untied and the gown was moving open and closed while they were walking, exposing their pants. On [DATE] at approximately 3:10 PM dietary staff U was viewed with their KN95 mask below their nose. Dietary staff U and T confirmed kitchen staff are to wear masks at all times in the kitchen. Dietary staff T was asked about other sanitation procedures and they stated that the carts are for delivery of isolation meals and not for dirty dishes. The cleaning process includes first cleaning with the Emerald Glo detergent and then with a bleach cleaner before air drying. Review of facility provided procedure Dietary Precautions for Isolation with a last revised date of [DATE] revealed the goal to prevent the spread of infection. Procedures include Staff will wear appropriate PPE when entering room to serve the meal, and Meal carts that are used for the isolation units are to be washed down with soap and water to remove debris. After debris is removed; carts to be wiped down with bleach solution. Per facility policy titled Coronavirus with no implemented or last revised date listed revealed the facility must ensure employees are educated and trained on the appropriate use of PPE prior to caring for a patient in droplet precautions and employees must Perform proper hand hygiene with soap an water or alcohol-based hand rub (ABHR) before and after all patient/resident contact . On [DATE] at approximately 11:30 AM, the facility plan to remove the Immediate Jeopardy was accepted and the state agency began to validate the removal plan with which included: The residents who were in isolation (8) have the potential to be affected. No residents or Staff currently have COVID Currently all residents are covid free and are asymptomatic Two Residents previously had Covid. One was asymptomatic and the other was noted to have complained a sore throat and cough. The Resident who was asymptomatic had many comordities including [MEDICAL CONDITION], Diabetes and was currently receiving hospice services. All residents have the potential to be affected by this deficient practice. Altercare of Big Rapids has been conducting covid testing on residents and staff every ,[DATE] days since the first exposure was identified. No new cases in past 13 days. Staff testing will continue every ,[DATE] days. Currently policy is resident can stay in own room if they do not have a roommate - with proper precautions (droplet) in place. If they become symptomatic or covid positive they are moved to a designated covid room with airborne precautions. Immediate education to be provided staff members [DATE] *How to deliver meals to isolation rooms including the need to preform hand hygiene before and after tray delivery, the use of gloves when entering isolation rooms and that their gowns must be tied at the neck and the waist. [DATE]*Proper positioning of masks on face. Noses and mouth must be covered. [DATE]*All meal carts are to be washed down with dish detergent and water solution to remove food debris and then wiped down with Ready to Use Bleach (RTU) between meals. [DATE]*Residents who are on Isolation precautions and receive meals from the kitchen will continue to be listed on the isolation list in the kitchen. The resident identified as a concern does not receive meals from the kitchen. [DATE]*The plastic barrier used on the doorways were removed at 1301 and resident doors were shut. [DATE]*An OnShift message was sent out to all staff to communicate the need to wear a mask when entering the building to be screened and that you may not sit in cars with other people when on break. Message also addressed that mask must cover the nose at all times. All staff will be receiving education prior to the start of their Next shift. The above items are part of our policy. The above is not new to our policies and procedures Our policies and procedures are reviewed and revised with each new CMS or BHCS update. Staff are trained on policies and procedure. Altercare Big Rapids policies and procedures coincide with CDC/CMS guidance. AUDITS: The Director of Nursing Services or designee will perform random audits7 days a week for 14 days to ensure the staff are performing hand hygiene; Wearing gloves and donning and doffing gowns properly between isolation rooms and that masks are worn properly to ensure mouth and nose are covered. This audit will then be performed randomly 5 times a week for 8 weeks The Executive Director or designee will audit food cart sanitation 5 x a week randomly to ensure the carts are bleached when returned to the kitchen. This audit will be performed for 10 weeks. The Executive Director or designee will audit the kitchen's list of isolation residents that receive food trays to ensure it has all residents listed who receive food from the kitchen. This audit will be performed 5x a week for 10 weeks. The Executive Director will randomly audit the staff entering the building and going on breaks 5 times a week to ensure the staff are wearing Mask when entering the building to be screened and are not in close proximity to each other while on break. This audit will be performed 5x a week for 10 weeks. Staff are immediately (on the spot) educated and the resident are currently assessed for covid symptoms twice a day. DNS will be notified of the deficient practice. The Audits will be reported on a reviewed thru the QA process monthly x 3 months. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance with a scope of pattern and severity of No actual harm with the potential for more than minimal harm that is not immediate jeopardy due to continued instances of noncompliance observed and sustained compliance not being verified by the state agency.

Based on observation, interview and record review the facility failed to provide quality of care for 1 resident (#51) from 18 residents observed eating from a total of 23 residents, resulting in Resident #51 who had a recent history of a 40 pound weight loss, being served in bed for a lunch meal with low positioning of the bed, with the meal tray set at nose level and the lids not removed from the containers or opened when the meal tray was delivered. No eating assistance was provided. Findings include: Record review of facility Weight Policy dated 8/1/2015, revealed a resident's weight will be monitored to evaluate the resident's nutrition status, within the parameters of the resident's overall medical condition. Record review of facility 'Weighing and Measuring the Resident' policy page W4-7, undated, revealed it is the facility's policy to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident . The facility did not have a policy in place for the Hoyer scale weight procedure. Resident #51 was observed being weight with a Hoyer scale raised just off the bed. Record review of facility 'Meals-Serving in-Room' policy, page M-12/13, undated, it is the facility's policy to provide adequate nutrition for the resident. Procedure: (7.) The resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his or her meal in bed, use wedges and pillows to achieve a nearly upright position. Steps in the procedure- (1.) Provide hygiene for the resident and then place the tray on the over bed table or serving area. Be sure it is adjusted to a comfortable position and height for the resident. (3.) Place drink within easy reach. Open beverage cartons as necessary. Resident #51: Record review of Resident #51's 14 day Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year-old male with a Brief Interview of Mental Status (BIMS) score of 12 out of 15, cognitively impaired. Functional status section G of the MDS- eating- noted that Resident #51 was assessed to need (1) supervision- oversight, encouragement or cueing with (2) one person physical assist. Functional limitation in range of motion section G 0400 noted (2) impairment on both sides of upper and lower extremities. Record review of Resident #51's 30 day Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with a Brief Interview of Mental status (BIMs) score of 12 out of 15, cognitively impaired. Functional status section G of the MDS eating noted that Resident #51 was assessed to need (2) Limited Supervision- resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance, with (2) one person physical assist. Functional limitation in range of motion section G 0400 noted (2) impairment on both sides of upper and lower extremities. Dining Observation: General observation on 12/05/17 12:57 PM, Resident #51 up in w/c chair with ground meats, did not eat ant of the food items on the plate. Did drink glass of orange juice. Resident was assisted from the dining room by staff back to his room. Staff member did not offer assistance or offering another choice of foods. Record review of Resident #51's food acceptance electronic log dated 12/5/17 noted lunch as 1-25% food accepted. Observation on 12/6/17 at 8:05 AM of Resident #51 was seated up in wheelchair in room. 12/06/17 08:25 AM Main dining room seated at table next to window. 12/06/17 08:31 AM Oatmeal given, and orange juice he did drink the juice. 12/06/17 09:04 AM Resident in main dining room appears asleep in w/c, oatmeal untouched, waffle and eggs untouched, ground meat untouched. 12/06/17 09:06 AM Certified Nurse Assistant (CNA) J removed resident from dining room without asking if he needed assistance or offering another choice of foods. Certified Nurse Assistant (CNA) J wheeled Resident #51 back to his room [ROOM NUMBER] and left resident with call light in reach seated up in wheelchair at bedside. Record review of Resident #51's food acceptance electronic log dated 12/6/17 noted breakfast as 1-25% accepted Record review of Resident #51's admission assessment form dated 10/12/17 revealed an admission weight of 279.8 pounds. Assessment noted hearing impairment, severely impaired with no vision or sees only light, colors or shapes. Eyes do not appear to follow objects with [MEDICAL CONDITION] in right eye. Oral assessment noted broken or loosely fitting teeth. Skin assessment noted that Resident #51 had a surgical scrotum wound, but no pressure ulcer areas upon admission. Record review of Resident #51's weight log dated 10/12/17 through 12/6/17, revealed admission weight of 279.8. The next weight was 10/18/17 (6 days later) 245.8, loss of 34 pounds. On 10/19/17 weight of 241.6 (1 day) loss of 4.2 pounds. On 10/23/17 weight of 235.6, loss of 6 pounds. On 10/29/17 weight of 225.6, loss of 10 pounds. On 11/7/17 weight 213.6, loss of 12 pounds. On 11/14/17 weight of 207.4, loss of 6.2 pounds. On 11/26/17 weight 202.4, loss of 5 pounds. On 12/4/17 weight of 193.8, loss of 8.6 pounds. Record review of Resident #51's weight log revealed that on 12/6/17 at 9:04 AM CNA W noted a weight of 196.4 pounds, the surveyor at that time noted the resident seated in the dining room. Observation on 12/06/17 10:42 AM of Hoyer transfers with assist of two staff from wheelchair to bed. Resident #51 was noted to be seated up in wheelchair for over two hours without position change. Record review of Resident #51's 'Nutritional observation' form dated 10/18/17 revealed a mechanical soft diet with food and fluid intake between 51-75% with no adaptive equipment used, usual body weight of 240 pounds was noted. Record review of Resident #51's 'Skin-Wound Document Grid' dated 10/20/17 revealed bilateral medial buttocks, wound developed in house, 12 cm X 10 cm X 0 denuded skin, red and blanchable. Record review of nutritional Progress note dated 10/23/17 noted: Diet Mechanical soft with thin liquids due to poor dentition. Intake fair per Food Acceptance Record, Nutrition support-none at this time. Skin: no concerns with pressure areas .235.6#, reweigh was taken after admission weight or later weight was thought to be questionable, most recent weight indicates 10# loss, he is trending toward a significant loss in 30 days. Record review of Resident #51's 'Skin-Wound Document Grid' dated 10/29/17 revealed wound location of upper inner buttocks, wound developed in house, a pressure injury stage II, measurements of 1 cm X 5 cm X 0.1 cm with scant exudates. Record review of Resident #51's 'Health Care Services Consent Form' signed and dated my family representative requested hearing services, Dentistry services and optometry services. Dentistry services were scheduled to come to see residents at the facility on 10/26/17 per the ADON C, but that Resident #51 was not added to the list and the dentistry services only come once every 3 months. Record review of Resident #51's 'Initial Care Conference' dated 10/17/17 revealed that skin assessment was at high risk, with bladder and bowel incontinence. Family reported few natural teeth both upper and lower, diet changed to mechanical soft due to poor dentition. Record review of Resident #51's 'Speech Therapy Evaluation' dated 10/26/17 revealed that the resident demonstrated an increase in chewing time with mechanical soft solids, but the initiated swallow with no difficulty. Resident was mechanical soft solids due to poor dentition. Behavioral-Emotional: In an interview on 12/07/17 10:33 AM with Social worker Z revealed that Resident #51 will down play concerns. There alot of family dynamics, she prefers to speak with family members together. Resident # 51 appears depressed, but has no anti-depressant meds, refuses assessments. Mental health Behavioral care solutions health services, we make referrals for residents to be seen. Resident #51 refused to be seen by psych. [MEDICATION NAME] was added recently by physician. Record review of Resident #51's physician orders [REDACTED]. There was no [DIAGNOSES REDACTED]. Record review of Resident #51's physician progress notes [REDACTED]. The progress note documented the physician writting 'Doing well, eating well . no new complaints. Observation on 12/07/17 01:24 PM Resident # 51 was noted to be lying in bed slumped over to the left side and low in bed with the head of the bed elevated, attempting to eat lunch. Position of over bed table was set at the resident's nose level. Observation of the lunch tray revealed that the Lids were not removed from beverage glasses, the milk carton not opened. The surveyor went to get the Nursing Home Administrator (NHA) A and the Director of Nursing (DON) B and brought them into the room to view Resident #51's positioning with meal. The NHA and DON noted the Resident #51 still laying on the right hip with the tray at nose level and set about getting assistance for the resident. In an interview on 12/07/17 at 01:38 PM with the DON B revealed that, she went with surveyor to Resident #51's the room and the resident was scooched down in the bed eye level with the meal tray. DON B stated I went got CNA J, we brought him up in bed and positioned for being able to eat his meal. I did educate the CNA. Although the DON stated it was the nurse on duty who placed the tray in the room and left. Record review of Resident #51's Nutritional Status care plan dated 10/23/17 and updated 10/27/17 did not have any interventions/approaches for supervision or assist with meals in place.

Based on observation, interview and record review the facility failed to prevent a pressure ulcer development for (1) resident (#51) of 5 residents reviewed for pressure ulcers from a total of 23 residents, resulting in Resident #51, who was admitted with no pressure ulcers, to develope an open pressure ulcer to the left buttocks needing treatments. Findings include: Record review of facility's 'Pressure Injuries: Assessment, Prevention & Treatment' policy undated, revealed it is the facility's policy to identify residents at risk for developing pressure injuries, implementing interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. Interventions and preventive measures as indicated based on resident risk factors. (7.) Encourage resident to shift weight every 15 minutes while seated in a chair as able. (25.) Refer resident to a dentist. Unstageable Pressure Injury Protocol definition: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Resident #51: Record review of Resident #51's admission assessment form dated 10/12/17 revealed an admission weight of 279.8 pounds. Assessment noted hearing impairment, severely impaired with no vision or sees only light, colors or shapes. Eyes do not appear to follow objects with [MEDICAL CONDITION] in right eye. Oral assessment noted broken or loosely fitting teeth. Skin assessment noted that Resident #51 had a surgical scrotum wound, but no pressure ulcer areas upon admission. Record review of Resident #51's 14 day Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with a Brief Interview of Mental status (BIMs) score of 12 out of 15, cognitively impaired. Functional status section G of the MDS eating noted that Resident #51 was assessed to need (1) supervision- oversight, encouragement or cueing with (2) one person physical assist. Section M- Skin conditions revealed that the resident #51 was assessed at risk, but was admitted with no pressure ulcer areas noted. Record review of Resident #51's 30 day Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with a Brief Interview of Mental status (BIMs) score of 12 out of 15, cognitively impaired. Functional status section G of the MDS eating noted that Resident #51 was assessed to need (2) Limited Supervision- resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance, with (2) one person physical assist. Section M- Skin conditions revealed that the resident #51 developed an unstageable 0.4 cm X 0.4 cm X 0.0 cm pressure ulcer. Observation and interview on 12/8/17 at 9:35 AM with Assistant Director of Nursing (ADON) C and Licensed Practical Nurse (LPN) I of Resident #51's Pressure ulcer treatment revealed a measured open ulcer of 0.7 cm X 0.5 cm with slough noted at base to the left buttocks area. Assistant Director of Nursing (ADON) C, who is also the wound care nurse stated that the wound was bigger this week. Record review of Resident #51's 'Physical Therapy Progress & Discharge Summary' dated 11/9/17 noted therapy advised nursing on bed mobility and positioning to reduce risk of decubs (Pressure ulcers) and decrease effort/assistance. Record review of Resident #51's 'Occupational Therapy Progress & Discharge Summary' dated 11/8/17 noted the resident is dependent on caregivers for toileting, dressing, bathing and positioning. Dining Observation: General observation on 12/05/17 12:57 PM, Resident Larry up in w/c chair with ground meats, did not eat ant of the food items on the plate. Did drink glass of orange juice. Resident was assisted from the dining room by staff back to his room. Staff member did not offer assistance or offering another choice of foods. Record review of Resident #51's food acceptance electronic log dated 12/5/17 noted lunch as 1-25% food accepted. Observation on 12/6/17 at 8:05 AM of Resident #51 was seated up in wheelchair in room. 12/06/17 08:25 AM Main dining room seated at table next to window. 12/06/17 08:31 AM Oatmeal given, and orange juice he did drink the juice. 12/06/17 09:04 AM Resident in main dining room appears asleep in w/c, oatmeal untouched, waffle and eggs untouched, ground meat untouched. 12/06/17 09:06 AM Certified Nurse Assistant (CNA) J removed resident from dining room without asking if he needed assistance or offering another choice of foods. Certified Nurse Assistant (CNA) J wheeled Resident #51 back to his room [ROOM NUMBER] and left resident with call light in reach seated up in wheelchair at bedside. Record review of Resident #51's food acceptance electronic log dated 12/6/17 noted breakfast as 1-25% accepted Record review of Resident #51's admission assessment form dated 10/12/17 revealed an admission weight of 279.8 pounds. Assessment noted hearing impairment, severely impaired with no vision or sees only light, colors or shapes. Eyes do not appear to follow objects with [MEDICAL CONDITION] in right eye. Oral assessment noted broken or loosely fitting teeth. Skin assessment noted that Resident #51 had a surgical scrotum wound, but no pressure ulcer areas upon admission. Record review of Resident #51's weight log dated 10/12/17 through 12/6/17, revealed admission weight of 279.8. The next weight was 10/18/17 (6 days later) 245.8, loss of 34 pounds. On 10/19/17 weight of 241.6 (1 day) loss of 4.2 pounds. On 10/23/17 weight of 235.6, loss of 6 pounds. On 10/29/17 weight of 225.6, loss of 10 pounds. On 11/7/17 weight 213.6, loss of 12 pounds. On 11/14/17 weight of 207.4, loss of 6.2 pounds. On 11/26/17 weight 202.4, loss of 5 pounds. On 12/4/17 weight of 193.8, loss of 8.6 pounds. Record review of Resident #51's weight log revealed that on 12/6/17 at 9:04 AM CNA W noted a weight of 196.4 pounds, the surveyor at that time noted the resident seated in the dining room. Observation on 12/06/17 10:42 AM Hoyer transfers with assist of two staff from wheelchair to bed. Resident #51 was noted to be seated up in wheelchair for over two hours without position change.

Based on observation, interview and record review the facility failed to maintain nutrition/hydration for 4 sampled residents (#16, #24, #51, and #60) from 7 residents reviewed for hydration and nutrition from a total of 23 residents resulting in the potential for malnutrition and dehydration related to upper respiratory infections and weight loss. Record review of facility Weight Policy dated 8/1/2015, revealed a residents weight will be monitored to evaluate the resident's nutrition status, within the parameters of the residents overall medical condition. Record review of facility 'Weighing and Measuring the Resident' policy page W 4-7, undated, revealed it is the facility's policy to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident . The facility did not have a policy in place for the Hoyer scale weight procedure. Resident #51 was observed being weight with a Hoyer scale raised just off the bed. Record review of facility 'Meals-Serving in-Room' policy, page M-12/13, undated, it is the facility's policy to provide adequate nutrition for the resident. Procedure: (7.) The resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his or her meal in bed, use wedges and pillows to achieve a nearly upright position. Steps in the procedure- (1.) Provide hygiene for the resident and then place the tray on the over bed table or serving area. Be sure it is adjusted to a comfortable position and height for the resident. (3.) Place drink within easy reach. Open beverage cartons as necessary. Resident #51: Record review of Resident #51's 14 day Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with a Brief Interview of Mental status (BIMs) score of 12 out of 15, cognitively impaired. Functional status section G of the MDS eating noted that Resident #51 was assessed to need (1) supervision- oversight, encouragement or cueing with (2) one person physical assist. Record review of Resident #51's 30 day Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with a Brief Interview of Mental status (BIMs) score of 12 out of 15, cognitively impaired. Functional status section G of the MDS eating noted that Resident #51 was assessed to need (2) Limited Supervision- resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance, with (2) one person physical assist. Dining Observation General observation on 12/05/17 12:57 PM, Resident Larry up in w/c chair with ground meats, did not eat ant of the food items on the plate. Did drink glass of orange juice. Resident was assisted from the dining room by staff back to his room. Staff member did not offer assistance or offering another choice of foods. Record review of Resident #51's food acceptance electronic log dated 12/5/17 noted lunch as 1-25% food accepted. Observation on 12/6/17 at 8:05 AM of Resident #51 was seated up in wheelchair in room. 12/06/17 08:25 AM Main dining room seated at table next to window. 12/06/17 08:31 AM Oatmeal given, and orange juice he did drink the juice. 12/06/17 09:04 AM Resident in main dining room appears asleep in w/c, oatmeal untouched, waffle and eggs untouched, ground meat untouched. 12/06/17 09:06 AM Certified Nurse Assistant (CNA) J removed resident from dining room without asking if he needed assistance or offering another choice of foods. Certified Nurse Assistant (CNA) J wheeled Resident #51 back to his room [ROOM NUMBER] and left resident with call light in reach seated up in wheelchair at bedside. Record review of Resident #51's food acceptance electronic log dated 12/6/17 noted breakfast as 1-25% accepted Record review of Resident #51's admission assessment form dated 10/12/17 revealed an admission weight of 279.8 pounds. Assessment noted hearing impairment, severely impaired with no vision or sees only light, colors or shapes. Eyes do not appear to follow objects with [MEDICAL CONDITION] in right eye. Oral assessment noted broken or loosely fitting teeth. Skin assessment noted that Resident #51 had a surgical scrotum wound, but no pressure ulcer areas upon admission. Record review of Resident #51's weight log dated 10/12/17 through 12/6/17, revealed admission weight of 279.8. The next weight was 10/18/17 (6 days later) 245.8, loss of 34 pounds. On 10/19/17 weight of 241.6 (1 day) loss of 4.2 pounds. On 10/23/17 weight of 235.6, loss of 6 pounds. On 10/29/17 weight of 225.6, loss of 10 pounds. On 11/7/17 weight 213.6, loss of 12 pounds. On 11/14/17 weight of 207.4, loss of 6.2 pounds. On 11/26/17 weight 202.4, loss of 5 pounds. On 12/4/17 weight of 193.8, loss of 8.6 pounds. Record review of Resident #51's weight log revealed that on 12/6/17 at 9:04 AM CNA W noted a weight of 196.4 pounds, the surveyor at that time noted the resident seated in the dining room. Observation on 12/06/17 10:42 AM Hoyer transfers with assist of two staff from wheelchair to bed. Resident #51 was noted to be seated up in wheelchair for over two hours without position change. Record review of Resident #51's 'Nutritional observation' assessment form dated 10/18/17 revealed a mechanical soft diet with food and fluid intake between 51-75% with no adaptive equipment used, usual body weight of 240 pounds was noted. Record review of Resident #51's 'Skin-Wound Document Grid' dated 10/20/17 revealed bilateral medial buttocks, wound developed in house, 12 cm X 10 cm X 0 denuded skin, red and blanchable. Record review of nutritional Progress note dated 10/23/17 noted: Diet Mechanical soft with thin liquids due to poor dentition. Intake fair per Food Acceptance Record, Nutrition support-none at this time. Skin: no concerns with pressure areas .235.6#, reweigh was taken after admission weight or later weight was thought to be questionable, most recent weight indicates 10# loss, he is trending toward a significant loss in 30 days. Record review of Resident #51's 'Skin-Wound Document Grid' dated 10/29/17 revealed wound location of upper inner buttocks, wound developed in house, a pressure injury stage II, measurements of 1 cm X 5 cm X 0.1 cm with scant exudates. Record review of Resident #51's 'Health Care Services Consent Form' signed and dated my family representative requested hearing services, Dentistry services and optometry services. Dentistry services were scheduled to come to see residents at the facility on 10/26/17 per the ADON C, but that Resident #51 was not added to the list and the dentistry services only come once every 3 months. Record review of Resident #51's 'Initial Care Conference' dated 10/17/17 revealed that skin assessment was at high risk, with bladder and bowel incontinence. Family reported few natural teeth both upper and lower, diet changed to mechanical soft due to poor dentition. Record review of Resident #51's 'Speech Therapy Evaluation' dated 10/26/17 revealed that the resident demonstrated an increase in chewing time with mechanical soft solids, but the initiated swallow with no difficulty. Resident was mechanical soft solids due to poor dentition. Behavioral-Emotional: In an interview on 12/07/17 10:33 AM with Social worker AA revealed that Resident #51 will down play concerns. There alot of family dynamics, she prefers to speak with family members together. Resident # 51 appears depressed, but has no anti-depressant meds, refuses assessments. Mental health Behavioral care solutions health services, we make referrals for residents to be seen. Resident #51 refused to be seen by psych. [MEDICATION NAME] was added recently by physician. Observation on 12/07/17 01:24 PM Resident # 51 was noted to be lying in bed slumped over to the left side and low in bed with the head of the bed elevated, attempting to eat lunch. Position of over bed table was set at the resident's nose level. Observation of the lunch tray revealed that the Lids were not removed from beverage glasses, the milk carton not opened. The surveyor went to get the Nursing Home Administrator (NHA) A and the Director of Nursing (DON) B and brought them into the room to view Resident #51's positioning with meal. The NHA and DON noted the Resident #51 still laying on the right hip with the tray at nose level and set about getting assistance for the resident. In an interview on 12/07/17 at 01:38 PM with the DON B revealed that, she went with surveyor to Resident #51's the room and the resident was scooched down in the bed eye level with the meal tray. DON B stated I went got CNA J, we brought him up in bed and positioned for being able to eat his meal. I did educate the CNA. Although the DON stated it was the nurse on duty who placed the tray in the room and left. Observation on 12/08/17 08:39 AM Resident #51 up in W/C in dining room for breakfast meal, seated in back of ding room in the assisted dining area. Updated nutrition notes once survey began 12/5/17: Start Date: 10/24/2017 (LTG) Last Reviewed/Revised: 10/24/2017 02:48 PM Category: Dental Care PROBLEM: Larry has the potential for dental complications due to admitting with few of his natural teeth , broken and brown in color. Family reports Larry has partials at home, he has hidden them. Start Date: 10/23/2017 (LTG) Last Reviewed/Revised: 12/05/2017 11:55 AM Category: Nutritional Status PROBLEM: Larry is at risk for altered nutrition r/t inadequate intake to meet needs, impaired labs, sig wt loss since adm, adm dx of impaired nutritional status, GI ulcer, DM, Esophagitis and cognitive deficits; Impaired Skin. Wt loss-'R' with variable meal intakes including meal refusals, c/o's poor appetite, poor acceptance of nutritional supplements, refusal of snacks & added food items. Resident #16: According to Resident #16's physician orders [REDACTED]. On 12/5/17 at 4:20 PM, resident was observed in bed appeared flushed, squirming around in bed, grunting, no fluids in reach, water container was up on dresser out of arms reach of resident. On 12/05/17 at 4:30 PM, Certified Nurse Aide CC reported Resident #16 did not eat much today temperature was 99.6. On 12/06/17 11:14 AM, RN G was asked what Resident #16 temperature was for the day and responded, Resident's temp was 100.1 axillary this morning at 7:30 AM RN G was asked if Resident 16 had received any Tylenol and responded, I forgot. It is usually 100.6 before we give Tylenol. RN G was asked if an assessment had been completed on Resident and stated, I have not checked lung sounds yet, has occasional cough, not bringing anything up. 12/06/17 03:18 PM RN G was asked who she had assessed for respiratory symptoms and reported she had assessed Resident #16's lung sounds with Rhonchi and an axillary temperature of 100.1 at lunch time. (there was no record of this information in the nurse progress notes). According to Resident #16's nurse progress notes the only documentation that was completed on Resident #16 was on 12/5/17 at 8:05 PM, in bed all day with elevated temp- came down after Tylenol 650 mg given this am; did not arouse for breakfast or lunch. On 12/7/17 at 5:40 PM, during med pass observation Resident # 16's dinner tray was brought to the room by RN F and left for CNA to come to feed at a later time. Two CNA's were observed in the dining room serving trays to residents and there was no CNA on the unit. According to Resident #16's vital sign record a temperature was done on 12/05/2017 11:01 AM, Resident # 16 vital sign record revealed temp 99.4. On 12/05/2017 04:02 PM, Resident # 16 vital sign record revealed temp 99.6. On 12/06/2017 07:29 AM, Resident # 16 vital sign record revealed temp 100.1. On 12/07/2017 04:11 PM, Resident # 16 vital sign record revealed temp 100.4. On 12/08/2017 01:59 AM Resident # 16 vital sign record revealed Temp 100.3. The temperatures did not accurately record where the temperatures were taken (orally, axillary) and there was no documentation there were any retakes after 4 hours for monitoring of the temperatures. Review of Resident #16's Respiratory Care plan has displayed signs of upper respiratory infection was initiated on 12/6/17 (2 days after initial infection started) with intervention of consult with hospice, encourage fluids, frequent hand washing, and monitor vital signs. Resident #24: According to Resident #24's Physician Progress orders Resident was an [AGE] year old female admitted tot he facility on 11/29/13 with [DIAGNOSES REDACTED]. 12/07/17 05:56 PM, Resident # 24 observed in her room with dinner sitting on tray table untouched. Resident observed sleeping, bent over sitting in w/c with arms out almost touching floor. RN F asked Resident #24 if she wanted a grilled cheese and offered an orange drink. Resident #24, stated oh yes please! and was observed to have drank the entire container of orange drink. Resident #24 complained of being cold and was covered with shall. Review of Resident #24's Nurse progress notes reviewed on 12/8/17 No documentation noted from 12/2/17 until 12/7/17 at 3:52 PM, 7-3 PM respirations even and non-labored, lungs clear per scope, continues with croupy non-productive cough, up in w/c in room for meals ate poorly for both, ;laid down between breakfast and lunch. Emergency contact (name) called and was upset that she was not made aware of Resident's change in condition and concerned she did not eat well today. Nurse apologized and given update on her condition and explained that today was the day she ate poorly and we will continue to monitor, but she is drinking fluids well and that is more important at this time; acknowledge understanding and would like to be kept informed of any changes. Resident #60: 12/6/17 at 8:20 AM. Resident 60 was noted in the assisted dining room feeding herself breakfast and was observed with a productive coughing with 2 other residents at the same table. 12/06/17 02:28 PM Resident #60 observed wheeling self in the hall was was observed coughing with other residents in the hall. 12/06/17 02:48 PM review of Resident #60's Nurse progress notes revealed there was no documentation of a respiratory assessment completed on Resident #60 every shift to monitor for respiratory assessment from 12/1/17 through the survey on 12/8/17 with Resident #60 having active symptoms of an Upper Respiratory Infection (URI). 12/6/17 at 3:15 PM, CNA walked up to to Nurses on the dementia unit at shift change and ask RN G and RN Q for a tissue as Resident #60 had coughed up phlegm all over her uniform pants. RN G handed her a box of Kleenex to wipe the phlegm off her uniform. Neither RN G or Q were observed to encourage the CNA to change out of her uniform pants or to wash her hands following the incident. 12/06/17 03:18 PM, G was asked who she had assessed and reported Resident #60 was not on her list to get a temperature or listen to her lung sounds. Review of Resident #60's Vital signs revealed on 12/8/17 temp 99.5 at 2:12 AM, there were no other temperatures documented Review of Resident #60's care plans revealed no Respiratory care plan which included encourage fluids during a respiratory infection and ongoing temperature.

Based on interview and record review the facility failed to identify risk factors and implement interventions to prevent an unstageable pressure ulcer for 1 resident (Resident #1) out of 3 residents reviewed for new or worsened pressure ulcers from a total sample of 9 residents resulting in Resident #1 being hospitalized for [REDACTED]. Findings include: Review of a facility policy Pressure Ulcers: Assessment, Prevention and Treatment (undated) reflected It is the facility's policy to identify residents at risk for developing pressure ulcers, implement interventions to prevent the development of pressure ulcers and provide care for existing pressure ulcers. The procedure required 1. A pressure ulcer risk assessment will be completed upon admission, quarterly, annually and with significant change. 2. Skin will be assessed routinely for the presence of developing pressure ulcers and documented on the Nursing Skin Tool. Review of a facility policy Pressure Ulcer Risk Assessment reflected It is the facility's policy to provide guidelines for the assessment and identification of residents at risk for developing pressure ulcers. General guidelines indicated 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure of a decrease of circulation (blood flow) to that area, which destroys the tissues. 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, ankles and toes. 3. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. 4. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. 5. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. 6. Once a pressure ulcer develops, it can be extremely difficult to heal. 7. Encourage the resident to participate in active and passive range of motion exercises to improve circulation. 8. Ensure that the resident drinks plenty of fluids and eats a well balanced diet. 9. Pressure ulcers are a serious skin condition for the resident. 10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #1 was a [AGE] year-old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) assessment indicated Resident #1 was cognitively intact as evidenced by a score of 13/15 and needed extensive assistance from two people for bed mobility and toilet use and was totally dependent on two people for transfers. Review of a hospital Physician Transfer Summary, dated 4/19/17 reflected No active wound care orders found. An Intact Skin Assessment reflected that the bilateral coccyx was assessed as having a Flat, red, [DIAGNOSES REDACTED] (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.). Review of a Nursing Admission-Clinical Admission Documentation dated 4/19/17 reflected that Resident #1 was admitted to the facility from a hospital after a stroke with left sided weakness. The section of the assessment pertaining to the Skin Observation reflected the nurse who documented the assessment did not complete a Braden Skin Risk Assessment which included the evaluation of Resident #1's sensory perception (the ability to respond meaningfully to pressure related discomfort), moisture exposure, the degree of Resident #1's activity level, Resident #1's ability to change and control body position, Resident #1's nutritional status or problems with friction/shear. The nurse who documented the Nursing Admission Assessment did NOT identify Resident #1 as being a HIGH risk for skin breakdown despite his [DIAGNOSES REDACTED]. The admission assessment reflected Resident #1 was admitted without wounds of any kind. The Baseline Care Plan (an initial care plan implemented immediately after admission to address care needs) did NOT include interventions that addressed Resident #1's risk for pressure ulcer development. Review of Illustration of Documentation and Measurements of Skin Areas, dated 4/19/17, reflected Resident #1 had two small bruises (no measurements) on his right inner elbow and had slight redness in a crease near his groin as evidenced by two small circles drawn on a body diagram on the right inner elbow and a line drawn toward the figure's right groin area. No other skin alterations were identified on the day Resident #1 admitted to the facility. Review of an admission Progress Note documented by Physician Assistant (PA) Q on 4/19/17 did not reflect any skin alterations or wounds had been reported or were identified. The assessment and plan (A/P) did not reflect interventions or approaches the address Resident #1's risk of pressure ulcer development despite clearly documented neurological and musculoskeletal deficits. Review of a Nursing Assistant Bathing/Skin Tool reflected that on 4/20/17 Resident #1 refused a shower and was given a bed bath. No documentation of any skin alteration was noted. On 4/24/17 Resident #1 was again given a bed bath, this time the Nursing Assistant documented a Red sore on right ankle, buttock sores, redness on back. Review of Resident Progress Notes from 4/19/17-5/2/17 did not reflect any communication related to the findings documented on the Nursing Assistant Bathing/Skin Tool identified on 4/24/17. Review of a Wound Progress Note dated 4/25/17, (a day after the Nursing Assistant documented the wounds on the 'Nursing Assistant Skin/Bathing Tool') documented by Assistant Director of Nursing (ADON) O reflected Resident #1 had impaired mobility, diabetes, Continuous Urinary Incontinence or Chronic Voiding Dysfunction, serum [MEDICATION NAME] below 3.4 g/dl and a hemoglobin less than 12 mg/dl and was non-compliant. In the Comments section of the Wound Progress Note, no description of the pressure ulcer or skin was noted, instead reflected Cleanse with NS (normal saline), pat dry, apply Santyl (a prescription ointment that cleans wounds to clear the way for healthy tissue) to wound bed, cover with Allevyn gentle (a soft gel adhesive for use on fragile skin). Change every 3 days and PRN (as needed). Review of an Observation Report: Skin-Wound Grid documentation dated 4/26/17 (two days after the nursing assistant documented Resident #1's wound), documented by ADON O, reflected Resident #1 had what was being documented as a DTI (deep tissue injury) from left buttock to right buttock The Original wound onset date was noted as 4/25/17, located left buttock across coccyx to right buttock and indicated the wound that developed was an in-house acquired pressure injury classified as a deep tissue injury that measured 12.5 cm x 7 cm with a depth that was Unable to be Observed (UTO). The documentation reflected there was no tunneling or undermining. The Wound Surface Description reflected Wound noted to be closed DTI, area non-blanchable, no drainage noted. The documentation indicated Resident #1 did not complain of pain and the physician was notified. A second Observation Report Skin-Wound Grid Documentation dated 4/26/17 described a Coccyx open DTI. The Observation report defined Deep Tissue Pressure Injury as Persistent non-blanchable deep red, maroon, purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The original wound onset date was 4/25/17, located on the medial coccyx (middle of the coccyx) and was an in-house acquired deep tissue pressure injury that measured 1.5 cm x 1.6 cm x 0.1 cm without tunneling or undermining with a purple wound base. The Wound Surface Description reflected Wound base noted to be purple, non-blanchable, no drainage noted, wound base appears to be moist. Surrounding tissue noted to be dark purple and non blanchable. The documentation reflected Resident #1 did not complain of pain and the physician was notified. Review of a physician progress notes [REDACTED].#1 was being seen for F/U (follow-up). Complains of 10 out of 10 pain all over. Per chart records, appetite has been poor to fair. Admission labs significant for [MEDICAL CONDITION], elevated LFT's (liver function tests) and mild leukocytosis. PA Q noted Resident #1 was weak, having difficulty voiding and walking, had wounds and left sided [MEDICAL CONDITION]. PA Q noted an irregular stage 2 wound on left lateral malleolus (ankle), skin avulsions on medial buttocks: one approximately nickel sized adjoined to one approximately dime-sized with approximately 2 inch curvilinear tear on opposing buttock. Avulsions are overlying extensive skin bruising/pinkness which blanches. The assessment and plan for Resident #1's skin breakdown on his bilateral buttocks and left ankle was discussed wound care plans with nurse & D/W (daughter/wife), PT (physical therapy) to evaluate positioning. Review of a Progress Note dated 4/28/17, documented by PA Q reflected Resident #1 was complaining of pain to his back and buttocks and progression of Resident #1's wounds, Left lateral malleolus with yellowed wound bed and increased border redness and large brown eschar (thick, dry, black necrotic tissue) over sacrum and medial buttocks with increased surrounding skin hyperemia (redness). The Assessment and Plan for the treatment of [REDACTED]. Coccyx wounds-cleanse with sterile water, pat dry, apply Santyl to wound beds (and lateral malleolus wound), cover with Allevyn dressing and change every three days. 4. Back/buttock pains, [MEDICATION NAME] (an opioid pain reliever) 5 mg 30 minutes before PT/OT (Physical Therapy and Occupational Therapy) sessions and every 6 hours as needed; and [MEDICATION NAME] (an anti-anxiety medication) 0.25 mg every 12 hours as needed for restlessness or anxiety. Review of Resident #1's Care Plan History dated 4/18/2017-7/11/2017 reflected that a care plan for Resident #1's wounds was not developed until 4/28/17, 4 days after a Nursing Assistant identified the skin alterations on a Skin/Bath sheet. A Care plan for Resident #1's RISK for developing skin breakdown was not started until 4/28/17, 9 days after Resident #1 admitted to the facility and after Resident #1 had already developed pressure ulcers. Review of physician's orders [REDACTED].#1's stay at the facility) reflected nursing staff were to apply No sting barrier film to left ankle twice daily until resolved and was not initiated until 4/26/17. an order for [REDACTED]. an order for [REDACTED].#1 transferred from the facility to the hospital for treatment of [REDACTED]. Review of the hospital Physician Report ED (Emergency Department) dated 5/2/17 reflected Resident #1 was transferred to the local hospital emergency department on 5/2/17 and was assessed as having a large sacral ulcer with surrounding [DIAGNOSES REDACTED]. There is a smaller superficial ulcer on the left buttock. There is a pressure ulcer on the lateral malleolus of the left ankle. Further review of the hospital records indicated the Impression and Plan for Resident #1 This patient presents with worsening sacral ulcer. There does appear to be cellulitic component to this. His laboratory workup shows leukocytosis and elevated [MEDICATION NAME]. His presentation is concerning [MEDICAL CONDITION]. He also has positive urinary tract infection today as well. A 30 ml/kilogram IV fluid bolus was initiated. Blood cultures and urine cultures are pending. He was treated with [MEDICATION NAME] and [MEDICATION NAME] (antibiotics). Repeat [MEDICATION NAME] was ordered and is slightly elevated compared to the 1st. This patient does not have [MEDICAL CONDITION], and is in fact hypertensive. I did talk to our hospitalist here who came and evaluated the patient at the bedside. He is concerned about the size of the sacral ulcer and the need for advanced wound management including possible wound VAC. He recommended transfer to Grand Rapids campus for ongoing care given the significant wound needs. I spoke with the hospitalist at (another hospital) the patient will be transferred by ambulance to the hospitalist for ongoing care. The patient remained hemodynamically stable before transfer. The discharge [DIAGNOSES REDACTED]. Urinary Tract Infection, 3. [MEDICAL CONDITION]. During an interview on 7/12/17 beginning at 11:20 a.m. in the presence of the facility Medical Director R, Physician Assistant (PA) Q, Director of Nursing (DON) B, and the Assistant Director of Nursing (ADON) O, DON B said the expectation is that nurses assess every resident for risk factors that would contribute to the development of a pressure ulcer and complete a physical assessment within a few hours of admission to the facility and that interventions to prevent the development and/or worsening of a pressure ulcer be implemented immediately. DON B said Resident #1 was not admitted to the facility with a pressure sore. DON B said Resident #1 was not admitted to the facility with a Deep Tissue Injury and reported We own that (the pressure sores) 100%.

This citation has three Deficient Practice Statements DPS A, DPS B and DPS C. DPS A: Based on observation, interview and record review the facility failed to prevent falls for 4 of 8 residents (Resident #2, #4, #5, and #8) reviewed for falls in a total sample of 15 residents resulting in, Resident #4, #5 and #8 to sustain avoidable falls and Resident #2 sustained an avoidable fall with serious injury (hip fracture) that resulted in a significant change in condition. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed that Resident #2 was a [AGE] year-old female, who was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's MDS, dated [DATE], for the Brief Interview for Mental Status (BIMS), reflected a score of 0 out of 15 representing severe cognitive impairment. Resident #2 required the assistance of 2 staff members to bathe/shower, dressing, transferring, bed mobility and for toileting. During observations on 12/5/16 at approximately 1:00 PM, on 12/6/16 at approximately 8:00 AM and 12/7/16 at approximately 7:30 AM, Resident #2 was observed in her bed. Resident #2 was unable to answer any questions due to her severe cognitive impairment. During an interview on 12/6/16 at approximately 4:20 PM, the MDS Registered Nurse (RN) E stated that Resident #2 had an increasing behavior of uncontrollable verbal squealing/screeching and was sent out to be evaluated from 9/8/16 through 9/24/16. RN E stated that when Resident #2 was readmitted to the facility the behavior was not eliminated but much better. RN E stated that Resident #2 sustained a fall (while at the facility) and fractured her hip and was sent to the hospital again on 10/20/16 until her return on 10/24/16. RN E stated that Resident #2 suffered a decline due to the hip fracture and the facility completed a significant change in condition MDS with a date of 10/31/16. On 12/7/16 at approximately 12:35 PM and interview and record review was conducted with the Nursing Home Administrator (NHA) A. Record review of the incident report dated 1/31/16 at 9:15 AM reflected that Resident #2 sustained an unwitnessed fall and was observed on the floor, in the hallway lying on her back. The evaluation reflected that Resident #2 had not slept the night before and the intervention to prevent reoccurrence was to provide 1:1 supervision until she sits or lays down and stays to rest. This intervention was added to the falls care plan and dated for 1/31/16. Record review of the incident report dated 4/16/16 at 10:30 PM reflected that Resident #2 sustained an unwitnessed fall and was observed on the in the hallway lying on the floor. The evaluation reflected that the Resident was ambulating just prior to the fall and has poor posture and the intervention to prevent reoccurrence was to provide staff assistance with ambulation when she is up at night and walk with her until she goes back to bed or sits down. This intervention of If resident is awake at night, staff to propel with her until she is resting in bed or sitting in a supervised area was added to the falls care plan and dated for 4/16/16. According to the policy neuro checks will be conducted post-fall but no documentation was located for review. Record review of the incident report dated 4/19/16 at 1:04 AM reflected that Resident #2 sustained an unwitnessed fall and was found on the floor, in her room between the bed and the window. The evaluation reflected that her nonskid socks were worn and were replaced and may have tripped on the over the bed tray table. The intervention of over the bed table to be placed over the foot of resident ' s bed or away from bed when resident is lying in bed was added to the falls care plan and dated for 4/19/16. According to the policy neuro checks will be conducted post-fall but no documentation was located for review. Record review of the incident report dated 8/8/16 at 12:31 AM reflected that Resident #2 sustained an unwitnessed fall and was observed on the floor in the hallway near the nurses desk. When staff saw her on the floor they notified the nurse. The evaluation reflected that Resident #2 was not able to sleep and she was up ambulating in the hall unassisted (the care planned intervention dated 1/31/16 reflected that she would have 1:1 supervision to walk at night) and may have been bumped by another resident in a wheelchair (this was not witnessed). Resident #2 sustained bruising to her forehead, nose and around the eyes. The intervention of If another resident is noted to get near her using a .wheelchair, staff to intervene to ensure safety was added to the care plan on 8/23/16 (15 days later). It was noted that the intervention was similar to the invention added on 1/31/16 and 4/16/16 (see above). When asked about the lack of 1:1 staff supervision while Resident #2 was awake and out in the hallway during the night, the NHA A stated, They may have been busy with another resident. Record review of the incident report dated 9/6/16 at 5:20 AM reflected that Resident #2 sustained an unwitnessed fall and was observed on the floor of her room. The evaluation reflected that Resident #2 was more restless and had increased behaviors of squealing and was not easily diverted. The intervention of If resident is awake staff to keep her in common area so they offer immediate assistance if she tries to stand up was added to the care plan on 9/7/16. According to the policy neuro checks will be conducted post-fall but no documentation was located for review. Resident #2 was sent out and evaluated and treated from 9/8/16 - 9/24/16 for uncontrollable squealing, which according to RN E interview was improved upon her readmission to the facility. Record review of the MDS dated [DATE] reflected that Resident #2 required one to two person (staff) assistance with walking, transferring, bed mobility, dressing, eating, toilet use and personal hygiene. The MDS reflected that Resident #2 was not safely capable to perform ADL ' s without staff assistance. According to the ADL care plan dated 12/20/15, last revised on 11/17/16 under Problem reflected, She ambulates independently on unit . and under the Approaches it does not list the assistance needed for ambulation, transfers, dressing, or bathing. The ADL care plan did not specify the level of care that Resident #2 required to safely ambulate. When asked what assistance was needed to ambulate at this point in time, NHA A stated, She bent way over when she walked and didn't 't pick her head up to see where she was going. She was severe cognitive impairment and the staff needed to guide her. She needed assistance at times but she could still walk at that time. When asked how the staff knew when to provide the assistance, NHA A stated, Well, when she looked like she needed it. Record review of the incident report and witness statements dated 10/19/16 at 1:15 PM reflected that Resident #2 sustained an unwitnessed fall in the entryway of room #113 (another residents room) laying on her left side/back with her head towards the doorway. She was last seen by staff at approximately 1:00 PM seated in the hallway after lunch. Resident #2 was transferred to the hospital for evaluation where it was determined that she had sustained a hip fracture and underwent surgical repair and on 10/24/16 was readmitted to the facility for post hip fracture care. When asked what Resident #2 ' s abilities have been since she was readmitted to the facility, the NHA A stated, Well she can walk (only) with therapy, she can move around in bed, but might not be able to get out of bed, and she might not be able to get up from a chair. When asked what interventions were put into place to prevent reoccurrence, the NHA A stated, We had to wait for her to come back (from the hospital) .we are doing the same things and she has therapy. Record review of the MDS dated [DATE] for Significant Change in Condition reflected that Resident #2 (after the hip fracture and surgical repair) required extensive assistance of 2 staff members for all ADL and was unable to walk. The Fall care plan was last revised on 11/17/16 which reflected no changes in approaches and the last approach (intervention was added on 9/7/16 which was before the fall with hip fracture). The ADL care plan was last revised on 11/17/16 and still reflected that Resident #2 walked independently on the unit. When asked if the ADL and Falls care plan accurately reflected the care that should be provided to Resident #2, the NHA A agreed that the care plans did not. Resident #2 demonstrated a pattern of falls due do to the lack of staff assistance and staff supervision required to ensure her safety and subsequently sustained a hip fracture and a significant change in her condition. There have been no changes in her care plans to prevent further falls since 9/7/16. (# ) On 12/5/16 at 10:00 AM, during initial tour, on the Speret Unit, Resident # 4 was observed on the toilet in her room. Nurse CC said Resident 4 was not aware that she should put on her call light and ask for assistance. While Nurse CC was still talking, resident 4 transferred herself off of the toilet and propelled herself out of the bathroom and headed toward her roommate's bed, then Nurse CC intervened. Resident 4's profile printed 12/6/2016 reflected Resident 4 was was at high risk for elopement, high risk for falls and moderate risk for skin impairment. The activities of daily living portion of the profile dated 9/1/15 reflected she needed a 1 person assist for transfers. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident 4 had severe cognitive impairment, she rejected care every 1 to 3 days, she needed limited assistance of one person with transfers, she needed supervision with ambulation in her room, and she had 2 or more falls within this quarter. physician progress notes [REDACTED]. That Resident 4 had 2 falls in the past 2 weeks and sustained a contusion to the right side of her head, she fell out of bed for one of the 2 falls and slid out of her chair for the other fall. This said progress notes stated Resident 4 was finding it more difficult to ambulate and was able to transfer herself. The physician's progress notes dated 9/25/16 reflected she was wheelchair bound, could transfer herself to the commode, her Dementia was unchanged and she did have visual change that she was legally blind. This same physician progress notes [REDACTED]. The physician's progress notes dated 10/28/16 reflected Resident 4 had a fall two days ago. No trauma. Ambulating like normal. Unsteady on her feet at times but using her walker. given list of meds (medications) that may cause falls. Removed Norco fro her med list (was taking PRN (as needed). The Event report dated 1/25/16 at 4:50 PM, described Resident 4 had a fall on the way out of the dining room and bumped her head on the door after landing on her buttocks. Evaluation reflected Resident 4's shoe was caught on the rubber transition strip on the floor causing her to loose her balance and fall. She was noted to have a small raised area on the back of her head. Transition strip removed, will be cleaned and re glued to the floor. Event report dated 3/5/16 reflected Resident 4 had a fall 3/4/16. The evaluation notes described Resident 4 was observed with a 6 cm X 5.7 cm dark purple bruise on her upper right arm, when she sits down she will lean forward with her arms over the top of walker which is in direct line of the bruise. The bruise was observed and evaluated after Resident 4 said my arm hurts. The intervention was for staff to provide assistance to Resident 4 if noted to be searching to ensure resident will not bump self. However, the evaluation reflected her bruise came from leaning on walker not from bumping herself. The next event report was dated 3/21/16 and fall occurred that day at 8:15 PM, fell next to another residents room. Ambulance called for transfer to ER. The witness interview form reflected staff looked for Resident 4 and the resident in room 113 door was shut and that staff did not think Resident 4 was in room 113. The staff person looked into room 113 anyway and observed (Resident 4) on the floor and her leg was tangled with the chair in his room. It appeared that she had tried to transfer herself into the chair and fell . The intervention was to ensure Resident 4 would be one of the first residents to be offered evening care and rest. The Fall care plan that had been updated 12/19/15 reflected Staff to be aware of when she (Resident 4) is in the hallway and if she goes to the wrong room, redirect and escort her out. Do not let her close the door to that room which could cause her to loose her balance. Assist her back in to the hallway. The event report did not address if the interventions to address behavior were implemented this time, and if it was why didn't work. The Event report dated 7/9/16 reflected Resident 4 had a unwitnessed fall in her room and complained of right wrist pain. At 2:00 PM she complained of pain at the site of hematoma. She had a 0.5 by 0.7 cm abrasion to the left side of head and a 6.5 by 5.5 cm 0.6 cm height hematoma at right side forehead. The evaluation notes reflected she rolled out of bed while positioning herself. The intervention was staff placed DPM (Defined Perimeter Mattress) on the bed so Resident 4 could identify the perimeter of the mattress. The immediate safety measures was to add anit-roll back to wheelchair. However, the facility determined she fell out of her bed and not her wheelchair. The intervention was also to ensure Resident 4 would be one of the first residents to be offered evening care and rest. The Event report dated 7/14/16 reflected Resident 4 was observed in her room in front of the wheelchair. No injuries noted. She is restless at times and has severe visual and hearing deficits. At times she will reach out when in her chair looking to reach onto furniture, doors, staff etc. In this case she was reaching out when she slide out of her chair. Will place Dycem on her wheelchair to prevents sliding. The Resident Safety Record dated 11/7/16 reflected Resident 4 was observed on floor in bathroom. She had been transferring herself onto the toilet and slid to the floor. Bathroom door open - light not turned on. The Intervention was to leave the bathroom light on after dark or use a night light so she can be able to see better with her poor eyesight. The Activities of Daily Living care plan dated 9/1/15 reflected Resident 4 needed extensive assistance of one person for transfers. The Resident Profile reflected the fall care plan was updated 10/11/16 reflected was to look in room each time they passed her room to see if she was in bathroom or going to the bathroom. They are to offer assistance to her as she will allow in transferring on and off toilet. The Resident Safety Record dated 12/2/16 reflected Resident 4 reached for blanket that went onto the floor and slid out of her wheelchair. No injuries. The plan was to replace Dycem as the piece on the chair was too small. The resident should have had the right size Dycem in place since the intervention for Dycem was added on 7/14/16. Also was resident in her anti-roll back wheelchair, if so how would she have slid out? On 12/7/16 at 10:35 AM, during an interview with Administrator A she was asked about the fall concerns for Resident 4 and the follow up for each concern, such as were the prior interventions in place at the time of the fall, she was also asked for the neurological checks for each fall with a head injury. Administrator A did not return with the requested information. The event reports did not indicate if any of the prior interventions were in place before the resident fell . Other interventions did not make sense to add for that particular falls root cause. For example, if a resident fell out the intervention was an anti roll back wheelchair, and a bruise determined to be from leaning had an intervention of Resident 4 is searching, protect her from bumping herself. ( ) Resident 5's Annual Minimum Data Set ((MDS) dated [DATE] and Quarterly MDS dated [DATE] respectively reflected Resident 5 was an [AGE] year old female that could not be interviewed and had severe cognitive impairment required extensive assistance for transfers, ambulation and with her toilet needs. Both assessments also reflect she had 2 or more falls during those quarters. Resident 5's fall care plan reflect Resident 5 was at risk for falls and injury related to confusion, history of falls, incontinent of bowel and bladder and had an impaired gait. The facility's Resident Profile printed 12/6/16 for Resident 5 reflected Resident 5 is at high risk of falls. Resident 5 had 7 falls between 2/21/16 and 8/23/16. The Event Report dated 2/21/16 reflected Resident 5 was still in bed but awake. Staff heard noise, observed on floor next to bed. The intervention was to implement 1:1 when resident was showing signs of restlessness. The Event Report dated 4/15/16 reflected Resident 5 had an unwitnessed fall and was observed on the floor, prior she had been in bed. This incident Resident 5's daughter was asked if there was a mat on the floor and the facility documented it was not. Facility's intervention was to rely on Resident 5's husband to let them know when he finished visiting so, they can watch Resident 5 and her husband forgot to tell staff when his visit was finished. The Event Report dated 4/24/16 reflected Resident 5 fell out of bed. The facility spoke to family member and the family member wondered could they move the bed up against the wall like it was before. Resident fell on the floor because she was attempting to get out of bed without help. Intervention to keep bed against the wall and mat on the floor (mat was already on the floor and the bed should have already been against the wall). The Event Report for Resident 5's fall on 5/30/16, reflected she fell out of bed. The immediate safety intervention was to toilet her before laying her down. The Event Report for a fall in the dining room (5:00 PM) on 7/4/16 reflected under evaluation that Resident 5 was sitting in her wheelchair in the dining room at the table in front of the doorwall at mealtime. Resident 5 started to stand up and staff observed this and went over and assisted her back in to chair, as nurse aide was passing beverages she had to turn her back to Resident 5, when she turned around Resident 5 was standing and was observed falling to floor. The facility's evaluation concluded When in the dining room staff will serve residents maintaining full view of residents throughout the meal. The immediate safety measures were to do 1:1 observation when the resident was agitated. The Event Report dated 7/5/16, reflected Resident 5 had an unwitnessed fall, Resident 5 was observed on floor next to her bed. Resident (5) is noted to stay content watching baseball games, especially the Tigers so after assisting her in bed after lunch staff will turn her TV on to a baseball game for there to watch. After assisting her to bed staff will turn to Tiger game. Also Resident (5) is to be placed with staff 1:1. The Event Report dated 8/23/16 reflected Resident 5 had an unwitnessed fall, the immediate safety measures were to toilet Resident 5 before putting her to bed. On 12/7/16 at 10:35 AM, during an interview, Administrator A stated the fall Resident 5 had in the dining room was because staff were transporting other residents to the dining room. Thus, the intervention of having staff watch Resident 5 full view while in the dining room was not an achievable goal. Administrator A stated the intervention of having the husband alert the staff when he was done visiting with Resident 5 was could be deleted because Resident 5's husband cognitive status had greatly declined to the point where he should be a resident at this facility. Resident 5's spouse was still listed on the care plan to notify the staff when he leaves dated 4/15/16. When Administrator A was asked about the Tigers baseball game, she said she realized that was seasonal and the Tiger game was not always going to be on, Administrator A was asked what else can the staff do if the Tiger game was not on and she said we should re-evaluate. An intervention in her fall care plan for Resident 5 to have her bed up against the wall on 4/19/16. The facility implemented a plan to be with Resident 5 for 1:1 after a fall on 7/4/16. Resident 5 fell again on 7/5/16 and implemented the same plan, without stating if the 1:1's were still in place, where the 1:1's being implemented and why would it be successful on 7/5/16 if it was not successful on 7/4/16. ( ) Record review of facility 'Falls and Falls Risk, Managing' (undated) it is the facility's policy based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. (1.) Staff will identify appropriate interventions to reduce the risk of falls. (4.) If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach is still relevant. (5.) If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. (6.) Staff will identify and implement relevant interventions (e.g. hip padding or treatment of [REDACTED]. 'Monitoring of Subsequent Falls and Fall Risk' the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. Record review of Resident #8's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with cognitive impairment. Resident #8 was noted to have bilateral upper extremities amputations upon the MDS assessment form. [DIAGNOSES REDACTED]. Observation on 12/5/16 at 10:50 AM of Resident #8 while on lying on the bed revealed that the resident had bilateral amputation of the right arm and left arm from the elbow. There were bilateral prostheses noted in the wheelchair at bedside. Record review of Resident #8's facility 'Event Reports' dated 8/19/16 observed on floor in his room. 'Event Reports' dated 9/20/16 observed on floor in his room and upon assessment was noted to have abrasion on his left outer canthus area that measured 0.5cm X 0.2 cm, also noted to have a bruise to his left chest area under the nipple that measured 3cm X 2 cm and was sent to the emergency room . 'Event Reports' dated 10/14/16 observed resident sitting on floor in his room. 'Event Reports' dated 10/17/16 observed on floor in his room. 'Event Reports' dated 10/26/16 resident was heard yelling for help. Upon entering the room he was observed sitting on floor in his room. 'Event Reports' dated 10/28/16 resident observed lying on floor, noted resident stood up and got tangled in his catheter tubing and lost his balance and fell , with two lacerations to the forehead. Sent to emergency room . Record review of Resident #8's care plan Falls dated 5/26/2016 revealed that Resident #8 was a risk for falls due to a history of falls, [DIAGNOSES REDACTED]. Interventions included to educate resident as able about limitations and safety concerns (cognitive impairment diagnosis) the care plan had intervention for staff to look in room when passing. There was no interventions for a known resident with cognitive impairment and known not to use the call light system for assistance to have increased supervision or frequent checks by staff or motion detectors to trigger when the resident is moving after multiple documented falls while in the resident room. # DPS B: Based on observation, interview and record review the facility failed to maintain safe water temperatures for 1 of 14 bathroom sink temperatures taken resulting in a water temperature above 120 degrees that could potential cause a burn. Findings include: According to the State Operations Manual 483.25(h) Accidents reflected, Physical Plant Hazards .Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, and tubs. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. Some States have regulation regarding allowable maximum water temperature. Table 1 illustrates damage to skin in relation to the temperature of the water and the length of time exposed . Table 1 reflected that a 3rd degree burn (full thickness burn) could occur with 15 seconds of exposure at a temperature of 133 degrees. On 12/7/16 at approximately 8:00 AM an environmental tour and general observations were made together with the Maintenance Director (MD) J. When asked if the facility monitors the water temperatures in the building, the MD J stated, Yes, I do. I like to keep them between 112-115 degrees. MD J turned the bathroom sink on in the bathroom sink of room #115 and measured the water temperature as 136 degrees. This surveyor confirmed the reading and felt the stream of hot water that was too hot to hold your hand in. MD J turned off the faucet and advised this surveyor that he was going to immediately turn the hot water heater down to a safe level. ( ). DPS C: Based on observation, interview and record review the facility failed to ensure proper fitting mattress and bedframes for 1 of 15 residents (Resident #6) reviewed for safe bed mattresses in a total sample of 15 residents resulting in the potential for Resident #6 ' s mattress to slide during a transfer and cause a fall. Findings include: On December 6, 2016 at 6:50 a.m., resident #6 was observed lying on her bed inside her room. At the foot of her bed, the mattress was observed to be be too short for the mattress, and there was a gap between the edge of resident #6's mattress and the foot of her bed. At that point, facility Nurse (Y) was taken to resident #6's room and shown the gap at the foot of the bed. Staff nurse (Y) agreed that there should be a wedge inside the gap, as many of the beds have blue plastic wedges to eliminate the gaps. Nurse (Y) stated that she would contact the maintenance department to place a wedge in resident #6's bed. At 12:30 p.m. on December 6, 2016, Maintenance Director (J) was asked to measure the gap on resident #6's bed. Upon entering resident #6's room, a blue wedge was observed between the end of her mattress and the foot of the bed. Upon removal of this wedge, a gap was measured by Maintenance Director (J) of two inches. The wedge was placed back on resident #6's bed. On December 6,2016 at 2:30 p.m. resident #6 was interviewed inside her room. She stated that she knows she is not to get out of her bed by herself, but stated that she does get up out of bed by herself. Resident #7, who is resident #6's roommate stated that she had observed resident #6 get out of the bed by herself even though she is not supposed to. On December 6, 2016 at 2:40 p.m., staff Nurse (Y) who was working on resident #6's hallway was interviewed outside resident #6's room. Staff Nurse (Y) stated that she was aware of resident #6 getting out of her bed by herself on occasion, and that the gap at the end of resident #6's mattress needed to be eliminated with the blue wedge to prevent an accident if the mattress moved while resident #6 was self-transferring out of her bed. The most recent fall risk assessment completed by facility staff on resident #6 in October 2016 documented her at high risk for falls and having had 1 to 2 falls in the past 3 months. ( )

This Citation pertains to intake number MI 401 Based on observation, interview and record review, the facility failed to provide adequate supervision and prevent the elopement in 1 of 6 residents (Resident #101), from a total sample of 6 residents, resulting in an Immediate Jeopardy (IJ) when Resident #101, who was identified at a risk of elopement and who had a history of [REDACTED]. This deficient practice places 5 additional residents identified as risk for elopement, at risk for serious harm, injury and or death. Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #101 had severe cognitive impairment with a Brief Mental Score (BIMS) of 5. The MDS indicated Resident #101 had wandering behaviors 4-6 days per week of the assessment period, and was ambulatory with a cane with supervision in the hallway. Review of the Elopement Risk assessment dated [DATE] revealed Resident #101 was a moderate risk of elopement. Review of the Fall Risk assessment dated [DATE] revealed Resident #101 was a high risk for falls. Review of the Nurses Notes revealed on 5-24-13 at 5:15 am, Resident #101 was observed "going out the front door sounding the alarm." Review of the Nurses Notes revealed on 5-24-13 at 6:30 pm, Resident #101 was "Heading toward the front door", staff put 15 minutes checks in place. Review of the Nurses Notes revealed on 6-2-13 at 2:55 pm, Resident #101 was "exit seeking, setting off door alarm, very agitated", staff put 15 minute checks in place. Review of the Nurses Notes revealed on 6-11-13 at 8:15 pm, Resident #101 was observed by staff at the front entrance in which Resident #101 stated, "I'm going to the doctor." Review of the Nurses Notes revealed on 6-19-13 at 8 pm, Resident #101 was exit seeking and set off the alarm to the front door of the facility. Review of Resident #101's Care Plan did not reflect any additional changes in the plan of care from May 2013 through June 2013. Review of the Nurses Notes dated 6-30-13 at 3:18 pm revealed Resident #101 was found by the neighbors outside of the facility near their fence, and the neighbors alerted the facility that one of their residents was outside of the facility unsupervised. The notes indicated Resident #101 was last seen in the facility at approximately 1:30 pm sitting in a chair at the west nurse's station. Review of the Facilities surveillance video dated 6-30-13 at 1:32 pm revealed Resident #101 walked out of the front entrance door after 2 visitors had exited the facility. The video revealed that the front entrance door had a slow closing hinge and was not completely closed when Resident #101 caught the door and exited out behind them approximately 13 seconds later. The surveillance video then showed a visitor entering the facility approximately 20 minutes later at 1:52 pm and a staff nurse and Certified Nurse Aide (CNA) (identified by the Nursing Home Administrator #1) exiting the facility a few moments later to retrieve Resident #101 from the neighbor's yard. In an interview on 7-9-13 at 9:20 am, Nursing Home Administrator #1 and Director of Nursing (DON) #2 reported that the front entrance door has a keypad lock with a code that needs to be punched in, and that the front entrance door had a 15 second delay before the alarm would sound. Nursing Home Administrator #1 and DON #2 reported that the alarm would not have sounded, as the visitors used the keypad to unlock the front door, and Resident #101 exited out the front door, while it was still open before the 15 seconds were up to set off the alarm. In observation on 7-9-13 at 9:00 am, the front entrance door upon exiting the facility was noted to have a keypad lock with the code posted on the keypad, to the left of the front entrance door. Upon entering the facility to the right of the front door is a button to push to enter in which unlocks the front door. Upon opening the front entrance door, a soft beep is heard, then after a few seconds an alarm rings if the door is still open. There were no signs posted as to alert visitors not to allow Residents outdoors unsupervised. In an interview on 7-9-13 at 11:30 am Certified Nurses Aide (CNA) #6 reported she was the full time day shift aide who normally was assigned to Resident #101. CNA #6 reported that over the last few months, Resident #101 had been wandering a lot in the facility, going to all doors and wiggled the handles to open them, usually looking for a bathroom. CNA #6 reported that Resident #101 was very confused, had poor vision and ambulated independently with his cane around the facility. CNA #6 reported that Resident #101 was identified as an elopement risk and was in the "green elopement book at the desk". CNA #6 reported that she had performed 15 minute checks on Resident #101 in the past at times when his wandering had increased, but that she had not been instructed to perform 15 minute checks for Resident #101 on 6-30-13. CNA #6 reported that on 6-30-13 after lunch Resident #101 had been wandering, but the last time she had seen him, he was with the nurse. In an interview on 7-9-13 at 12:00 pm, Registered Nurse (RN) # 3 reported that on 6-30-13 after lunch approximately 1:15 pm, Resident #101 came out of the dining room and stated, "I need to go home." RN #3 reported that Resident #101 was becoming agitated, as a CNA took him for a short walk, but was unable to handle him, so she walked him back to RN #3 when at that time RN #3 was attempting to redirect him and distract him. RN #3 reported she then sat Resident #101 down in a chair at the west nurse's station, got him a coke and a cookie, then went to assist another resident down the hall. RN #3 reported that on 6-30-13 at 1:30 pm was the last time she had seen Resident #101 prior to the elopement. RN #3 reported that Resident #101 was identified as an elopement risk and that his profile and picture were in the elopement book as at risk. RN #3 reported that she did not feel 15 minute checks were needed on this date and that she did not initiate them for Resident #101. In an interview on 7-9-13 at 11:55 pm, CNA #5 reported that on 6-30-13 after lunch, she was notified that Resident #101 had eloped the facility, CNA #5 reported that she went outside to assist in bringing him back to the facility. CNA #5 reported that when she got outside, other staff members were assisting Resident #101 and they were coming back from the field area near the neighbors fence. CNA #5 reported that Resident #101 was a known wanderer and at risk for elopement. Observations were made by the Surveyor on 7-9-13 at 1:30 pm of Resident #101 residing now on Speret Hall, (a closed and keypad locked dementia care unit). Resident #101 was observed dozing off in a chair in the hallway. On 7-9-13 at 1:45 Resident #101 was observed ambulating with his cane on the unit. Resident #101's gait was quick and steady, and a CNA directed him to his room. Resident #101 was observed to be alert, disoriented to place, talkative but unable to carry on a whole conversation with staff and Surveyor, without losing his train of thought and forgetting what he was talking about. On 7-9-13 at 3:45 pm, the Surveyor was provided by Licensed Practical Nurse (LPN) # 4, a list of Residents who were moderate to high risk for elopement. The list revealed 5 Residents who were ambulatory and at risk of elopement, in addition to Resident #101. On 7-10-13 at 4:00 pm, the Nursing Home Administrator #1 was notified of the Immediate Jeopardy that began on 6-30-13, when the facility failed to provide adequate supervision and prevent the elopement of Resident #101, which was unbeknownst to staff. Resident #101 was found by the neighbors approximately 20 minutes after exiting the facility, two houses down from the facility in the back yard/field area of the neighbors house. On 7-11-12, the Surveyor confirmed that the facility staff had implemented the following to remove the Immediate Jeopardy: 1. On 6-30-13 at 1:53 pm, Resident #101 was returned to the facility and provided direct supervision until he was transferred to the facility's Speret Hall (a closed, keypad locked unit) at 3:15 pm. RN # 3 performed a head to toe assessment on Resident #101 and found no injuries. 2. The facility conducted a head count when Resident #101 was brought back to the facility on [DATE] at 1:53 pm, all Residents were present and accounted for. 3. On 6-30-13 the Facility reassessed 85 out of 85 Residents for elopement risk. Results indicated 5 residents who were at risk of elopement . The facility reviewed all high and moderate risk residents careplans and updated the careplans. The facility reviewed all Elopement books on all units and ensured that the Elopement books were up to date and current with photographs of Residents, and current description of Residents. 4. On 6-30-13 and 7-1-13, the Facility inserviced 119 out of 124 employees on the Facility Elopement policy and procedure. The remaining 5 staff were either on vacation, were as needed employees or on a leave of absence. The remaining 5 staff will be required to be in-serviced before returning to work. 5. The alarm activation time on the delayed egress doors located at the front entrance, employee entrance and the storage area entrance, was decreased from 15 to 8 seconds. 6. The posting of the code that was on the keypads exiting the doors, was removed on 7-10-13, visitors were observed getting the code from the receptionist at the front desk in order to exit the facility. 7. On 7-10-13 signs were posted on the exit doors for visitors and families to check and make sure the doors close securely when leaving the facility, and not to assist a resident to exit the facility and notify staff if they see someone attempting to exit the facility. On 7-11-13 Inservicing of staff was completed for 96 of 123 staff members on the posting of the door signs. 8. The maintenance supervisor and or designee is responsible for daily alarm checks on the doors 7 days a week. In case of a loss of power or activation of the fire alarm, a staff person is assigned to monitor the delayed egress doors until the power has been restored or an all clear for the fire alarm is called. The Nursing Home Administrator is responsible for sustained compliance. Although the Immediate Jeopardy was removed on 7-11-13, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with a potential for harm that is not Immediate Jeopardy due to the fact all employees were not yet in-serviced and sustained compliance had not yet been verified by the State Agency. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT AN AVOIDABLE FALL FOR 1 OF 8 RESIDENTS REVIEWED FOR FALLS (#10), FROM A TOTAL SAMPLE OF 17 RESIDENTS, AND FAILED TO MAINTAIN SAFE WATER TEMPERATURES IN ACCORDANCE WITH FACILITY POLICY IN 2 OF 12 RESIDENT BATHROOMS REVIEWED FOR THE ENVIRONMENT (ROOMS 127 AND 130), RESULTING IN A FALL WITH A PAINFUL INJURY (FACIAL LACERATION REQUIRING SUTURES) FOR RESIDENT #10, AND THE POTENTIAL FOR BURNS RELATED TO EXCESSIVELY HOT WATER TEMPERATURES IN ROOMS 127 AND 130. FINDINGS INCLUDE: ACCORDING TO THE RESIDENT ADMISSION RECORD (NO DATE) RESIDENT #10 WAS ORIGINALLY admitted to the facility on [DATE] WITH THE FOLLOWING MEDICAL Diagnoses: [REDACTED]. RECORD REVIEW OF RESIDENT #10'S MINIMUM DATA SET (MDS) ADMISSION assessment dated [DATE] DOCUMENTED THAT RESIDENT #10 HAD SCORED 14 OUT OF 15 POSSIBLE POINTS ON HIS BRIEF INTERVIEW FOR MENTAL STATUS (BIMS), MEANING THAT RESIDENT #10 WAS COGNITIVELY INTACT. THE SAME MDS DOCUMENTED THAT RESIDENT #10 WAS AT HIGH RISK FOR FALLS AND DOCUMENTED THE INITIATION OF A FALL CARE PLAN. RECORD REVIEW OF THE FACILITY "EVENT REPORT" DATED 01/20/2013 DOCUMENTED THE FOLLOWING: RESIDENT #10 HAD AN UNWITNESSED FALL WITH INJURY ON 01/20/2013 AT 01:30 P.M. AND WAS TRANSPORTED TO THE LOCAL emergency room . THE "EVENT INTERVIEW FORM" DATED 01/20/2013 DOCUMENTED: "RESIDENT OBSERVED ON FLOOR NEXT TO BED...NURSE OBSERVED A LACERATION ABOVE RIGHT EYE & ABRASION ACROSS BRIDGE OF NOSE...RESIDENT DENIES ANY OTHER INJURIES, ONLY PAIN ABOVE RIGHT EYE. WHEN ASKED ABOUT INCIDENT, RES(IDENT) STATED, 'I WAS SITTING ON THE EDGE OF MY BED AND SAW THE WASTE PAPER BASKET TIPPED OVER, SO I WENT TO PICK IT UP & fell .' PARAMEDICS CALLED TO TRANSPORT TO (NAME OF TREATING MEDICAL CENTER)." RECORD REVIEW OF THE LOCAL emergency room REPORT DATED 01/20/2013 DOCUMENTED THAT RESIDENT #10 RECEIVED 11 SUTURES FOR A LACERATION. RECORD REVIEW OF RESIDENT #10'S FALL PLAN OF CARE (PROBLEM START DATE OF 8/27/2012) REFLECTED THAT ON 11/05/2012 THE FACILITY DOCUMENTED THEY WOULD INITIATE "GRIP SOCKS ON WHEN IN BED" AS A INTERVENTION FOR FALL PREVENTION. THE FACILITY "EVENT REPORT" DATED 01/20/2013 DID NOT DOCUMENT WHETHER RESIDENT #10 HAD GRIP SOCKS ON HIS FEET AT THE TIME OF HIS FALL. ADDITIONALLY, RECORD REVIEW OF THE NURSING PROGRESS NOTES FROM 01/20/2013 FAILED TO DOCUMENT IF RESIDENT #10 WAS USING GRIP SOCKS AT THE TIME OF HIS FALL. OBSERVATIONS AND INTERVIEW WITH RESIDENT #10 WERE CONDUCTED ON 08/06/2013 AT 9:00 A.M., IN RESIDENT #10'S ROOM AT THE BEDSIDE. DURING THE INTERVIEW RESIDENT #10 WAS OBSERVED TO CHANGE HIS POSITION IN BED FROM A LYING POSITION TO A SITTING POSITION ON THE EDGE OF THE BED, WITH HIS FEET RESTING ON THE FLOOR. RESIDENT #10 THEN STATED, "I DON'T KNOW WHY THEY MAKE THIS FLOOR SO SLIPPERY, I NEED SPECIAL SOCKS." RESIDENT #10 THEN DEMONSTRATED, WHILE SITTING ON THE EDGE OF THE BED, HOW SLIPPERY THE FLOOR WAS BY USING A SLIDING SHUFFLING MOTION WITH HIS FEET. RESIDENT #10 FURTHER STATED THAT HE HAD A RECENT FALL WHICH CAUSED HIM INJURY, "I WAS SITTING ON THE EDGE OF THE BED AND I STARTED TO SLIDE OFF THE BED." RESIDENT #10 AGAIN MADE THE SHUFFLING MOTION WITH HIS FEET AND STATED, "I COULDN'T STOP MYSELF." IN A FRUSTRATED TONE OF VOICE, RESIDENT #10 THEN STATED, "I NEED GRIPPY (GRIP) SOCKS." (GRIPPY SOCKS ARE UTILIZED BY NURSING FACILITIES TO REDUCE SLIPPING AND FALLS.) AT THE TIME OF THE INTERVIEW, IT WAS OBSERVED THAT RESIDENT #10 WAS WEARING STANDARD SOCKS AND DID NOT HAVE GRIPPY SOCKS ON HIS FEET. RESIDENT #10 WAS UNABLE TO REMEMBER IF HE HAD GRIPPY SOCKS ON AT THE TIME OF HIS FALL. FURTHER REVIEW OF RESIDENT #10'S MEDICAL RECORD (I.E., "EVENT REPORT" RECORDS DATED 09/24/2012, 10/10/2012, 11/05/2012, 11/19/2012, 01/09/2013 AND 01/13/2013) REFLECTED THAT RESIDENT #10 HAD PRIOR FALLS ON THOSE DATES THAT WERE UNWITNESSED AND WITHOUT INJURIES. RECORD REVIEW OF THE FACILITY'S "EVENT REPORTS" DATED 11/19/2012, 01/09/2013 AND 01/13/2013 (AFTER THE FALL CARE PLAN INTERVENTION DATED 11/05/2012 FOR GRIP SOCKS) FAILED TO DOCUMENT IF THE GRIP SOCK INTERVENTION HAD BEEN IMPLEMENTED, OR WHETHER RESIDENT #10 HAD GRIP SOCKS ON AT THE TIMES OF THE FALLS. NO DOCUMENTATION COULD BE LOCATED IN THE NURSING PROGRESS NOTES FOR THE CORRESPONDING FALL DATES TO INDICATE WHETHER RESIDENT #10 HAD BEEN WEARING GRIP SOCKS AT THE TIMES OF THE FALLS. ON 03/07/2013 AT APPROXIMATELY 10:00 A.M., NURSE AIDE STAFF "F" WAS INTERVIEWED OUTSIDE OF RESIDENT #10'S ROOM. DURING THE INTERVIEW, STAFF "F" IDENTIFIED HERSELF AS THE NURSE AIDE WHO FREQUENTLY HELPED RESIDENT #10 GET DRESSED IN THE MORNING. STAFF "F" STATED SHE DID NOT PUT GRIPPY SOCKS ON RESIDENT #10 ON THE MORNING OF 03/07/2013. STAFF "F" FURTHER STATED, "I DON'T KNOW IF I CAN EVER RECALL HIM (RESIDENT #10) EVER HAVING THEM." DURING INTERVIEW AND OBSERVATIONS CONDUCTED ON 03/07/2013 AT APPROXIMATELY 10:15 A.M., RESIDENT #10 WAS ASKED PERMISSION FOR THIS SURVEYOR TO LOOK THROUGH HIS CLOTHING. NO GRIP SOCKS WERE LOCATED AMONG RESIDENT #10'S POSSESSIONS. ON 03/07/2013 AT APPROXIMATELY 1:30 P.M. THE ADMINISTRATOR AND DIRECTOR OF NURSING WERE INTERVIEWED IN THE ADMINISTRATOR'S OFFICE. THIS SURVEYOR'S OBSERVATIONS OF RESIDENT #10 IN HIS ROOM WITHOUT GRIPPY SOCKS ON HIS FEET (OR AVAILABLE IN HIS ROOM) WERE DISCUSSED. NEITHER THE ADMINISTRATOR NOR THE DIRECTOR OF NURSING COULD RECALL IF RESIDENT #10 HAD GRIPPY SOCKS ON HIS FEET AT THE TIME OF HIS FALLS. ON 03/08/2013 AT APPROXIMATELY 8:30 A.M., RESIDENT #10 WAS OBSERVED WITH GRIPPY SOCKS ON HIS FEET AS HE LAID IN BED. ( ) ON 3/7/13 THE ENVIRONMENTAL TOUR WAS CONDUCTED WITH THE MAINTENANCE DIRECTOR (STAFF K) FROM APPROXIMATELY 10:00 A.M. TO 12:20 P.M. THE FOLLOWING OBSERVATIONS WERE MADE: THE HOT WATER TEMPERATURE IN THE RESIDENT LAVATORY IN ROOM 127 WAS MEASURED AT 126.1 DEGREES FAHRENHEIT USING A DIGITALLY CALIBRATED THERMOMETER. THE HOT WATER TEMPERATURE IN THE RESIDENT LAVATORY IN ROOM 130 WAS MEASURED AT 126.1 DEGREES FAHRENHEIT USING A DIGITALLY CALIBRATED THERMOMETER. THE MAINTENANCE DIRECTOR (STAFF "K") WAS INTERVIEWED AT THE TIME THE WATER TEMPERATURES WERE DISCOVERED AND VERIFIED THE READINGS. STAFF "K" STATED," I CHECK THE HOT WATER TEMPERATURES IN THE ROOMS EVERY WEEK. I'VE NEVER HAD A TEMP THIS HIGH ON THIS SIDE OF THE BUILDING." STAFF "K" WAS ASKED WHAT TEMPERATURE THE BOILER WAS SET AT FOR THE RESIDENT ROOMS. STAFF "K" INDICATED THAT HE KEPT THE BOILER TEMPERATURE SET AT 125 DEGREES (FAHRENHEIT). ACCORDING TO THE FACILITY'S POLICY "WATER TEMPERATURE MONITORING IN RESIDENT CARE AREAS", UNDATED, WATER TEMPERATURES WERE TO BE MAINTAINED BETWEEN 105 DEGREES AND 120 DEGREES IN RESIDENT CARE AREAS. ACCORDING TO THE "TIME AND TEMPERATURE RELATIONSHIP TO SERIOUS BURNS" TABLE (TABLE 1) IN THE STATE OPERATIONS MANUAL (UNDER THE REGULATORY REQUIRMENT AT F323), A 3RD DEGREE BURN CAN OCCUR AFTER 3 MINUTES EXPOSURE TO WATER TEMPERATURES OF 124 DEGREES FAHRENHEIT AND AFTER JUST 1 MINUTE OF EXPOSURE TO WATER TEMPERATURES OF 127 DEGREES. ON 3/7/13 AT APPROXIMATELY 12:20 P.M., THE HOT WATER TEMPERATURES WERE CHECKED AGAIN WITH STAFF "K" PRESENT. THE HOT WATER TEMPERATURE IN THE RESIDENT LAVATORY IN ROOM 127 WAS 133.4 DEGREES FAHRENHEIT AND THE HOT WATER TEMPERATURE IN THE RESIDENT LAVATORY IN ROOM 130 WAS 133.2 DEGREES FAHRENHEIT. STAFF "K" VERIFIED THESE TEMPERATURE READINGS. ACCORDING TO THE "TIME AND TEMPERATURE RELATIONSHIP TO SERIOUS BURNS" TABLE (TABLE 1) IN THE STATE OPERATIONS MANUAL (UNDER THE REGULATORY REQUIRMENT AT F323), A 3RD DEGREE BURN CAN OCCUR AFTER JUST 15 SECONDS EXPOSURE TO WATER TEMPERATURES OF 133 DEGREES. ACCORDING TO STAFF "K"'S MONITORING LOG, DATED 2/7/13 (THE LOG SHOULD HAVE BEEN DATED 3/7/13), STAFF "K" NOTED AT 1:00 P.M., "I ADJUSTED THE WATER HEATER TEMPS. (SIC) DOWN BY 5 '(DEGREES) SO THAT THE HIGHEST SETTING IS @ (AT) 120 (DEGREES)." ( ).

This citation pertains to intake: MI 647 Based on observation, interview, and record review the facility failed to prevent the elopement and ensure the safety of 1 resident (Resident #101), from a total sample of 7 out of 36 residents, who are ambulatory and who are cognitively impaired and/or identified as an elopement risk, when Resident #101 exited the facility on 3-10-2012 at approximately 8:35 AM, unbeknownst to facility staff, through an unlocked maintenance door that had a deactivated alarm and was discovered by a staff member in the middle of a driveway behind the building, resulting in the potential for serious harm, injury, and/or death Findings include: Per a facility "Face Sheet", Resident #101 was a [AGE] year old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per a "Minimum Data Set" (MDS), dated [DATE], a "Brief Interview for Mental Status" (BIMS) test was conducted and Resident #101 scored a 2 out of 15 indicating severe cognitive impairment. Resident #101 required extensive assistance from two staff members for bed mobility, transfers and toileting. Resident #101 normally used a wheelchair or walker for mobility and was able to self-propel while in the wheelchair. During a telephone interview on 3-13-2012 at 1:00 PM, Dietary Aide #4 stated she was arriving for work on 3-10-2012 at 8:40 AM and observed Resident #101 halfway across the parking lot at the back of the building, where employees park. Dietary Aide #4 put her car in park, got out, covered the resident with her jacket, engaged the brakes on Resident #101's wheelchair, moved her car out of the way and shut it off. Dietary Aide #4 went back to Resident #101 and wheeled him into the building via the maintenance door, which was ajar. Dietary Aide #4 stated no alarm was sounding and she proceeded to take Resident #101 to his nurse. Per a statement, dated 3/10/2012 and signed by Registered Nurse (RN) #5, Resident #101 was brought to her by Dietary Aide #4 who told her Resident #101 had been outside the maintenance door. RN #5 completed an assessment on Resident #101 and no injuries were noted. During a telephone interview on 3-12-2012 at 1:05 PM, RN #5 affirmed the statement reviewed by this surveyor was true and accurate. An interview on 3-13-2012 at 1:15 PM, RN #6 (West Hall Nurse), revealed RN #5 got a key from her to turn the alarm back on and to ensure the door was firmly shut. RN #6 stated that she assisted RN #5 and could verify that the alarm had not been on prior to her turning it back on 3-10-2012, after Resident #101 was returned to the facility. An observation on 3-13-2012, beginning at 10:10 AM, revealed all exits from the facility are equipped with magnetically engaged locks that require a code for exit. Each door is also equipped with an alarm, which sounds upon opening and can only be silenced with a key. The alarm cannot be shut off upon closure of the door and, once activated, it must be turned off with a key and then turned back on to reactivate. During an interview on 3-13-2012 at 1:30 PM, Maintenance Director #3 stated he had been called in on 3-10-2012 to check all the locks in the building after the elopement of Resident #101. Maintenance Director #3 stated he replaced the closure device present at the top of the door that Resident #101 eloped from, because the door had not been closing completely and he now checks all the door alarms daily. Maintenance Director #3 reported that a delivery of supplies was made on Friday 3-09-2012 and the alarm had been turned off at that time and was never turned back on until after Resident #101 was discovered outside by Dietary Aide #4 on 3/10/12. Record review of "Weekly Exit Door Inspection" record for the year of 2012 specified "Check the condition of door and delay egress locking system and function weekly. If problem exsists, address immediately." There was no indication that the alarm functionality was reviewed. The fact that the hydraulic door closing device was not working properly was not noted on the "Weekly Exit Door Inspection", including the day that Maintenance Director #3 documented doors were inspected, which was on 3-10-2012, the day Resident #101 eloped from the facility. On 3-15-2012 at 9:30 AM, the Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy that began on 3-09-2012 and was identified by this surveyor on 3-13-2012, when, on 3/9/12, the facility failed to secure and alarm a door after a delivery, which led to Resident #101 eloping from the facility on 3-10-2012. This deficient practice placed 36 residents, who were cognitively impaired and/or identified as an elopement risk, at high risk for serious harm, injury, and/or death. On 3-16-2012, the surveyor confirmed that the facility staff implemented the following to remove the Immediate Jeopardy: On 3-10-2012: 1. Maintenance Director #3 replaced the closer on the identified exit door and checked the alarm for proper functioning. 2. Maintenance Director #3 inspected all 11 exit doors for condition of the door, locking system, and alarm system. 3. In servicing completed for all 39 employees which included all departments who were scheduled for this date, on description of the event, facility response to the event, elopement notebooks, response staff is to take with potential or actual elopement events, interventions implemented for the resident involved in the event, and identification of who is high risk in the facility. 4. Maintenance Director initiated daily audits of the exit doors to ensure doors are latched and alarm is functioning. Daily audits were continued by Maintenance Director #3 or designee. 5. Elopement assessments for any resident that was not already assessed in the month of March (74 of 91 residents) had their elopement assessment updated by a registered nurse. 6. Elopement Notebooks were updated with the Resident #101's information. 7. Nurse stayed with Resident #101 1:1 through 10:00 PM in the evening. 8. Resident #101 was placed on 15 minute checks starting on 3-10-12 at 10:00. On 3-13-12 9. Reviewed and revised elopement and missing resident policy and procedure. Revisions include the addition of a facility head count. 10. Reviewed and revised exit door and security and alarm inspection policy and procedure. Revision is daily inspection of all alarmed doors. On 3-14-12: 11. 1 elopement drill completed. 12. 123 out of 124 staff were inserviced on the revised elopement policy and procedure, and what to do if a resident is found outside, what if an alarm is activated on an exit door, and what to do if a resident is missing. Remaining staff not permitted to return to work until a face to face in-service is completed. 13. Exit door audit completed. Although Immediate Jeopardy was removed on 3-14-2012, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because all staff had not been inserviced and sustained compliance has not been verified by the State Agency. 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