Every finding on record at The Orchards at Northwest

This citation pertains to intake 3171936.Based on observation, interview, and record review, the facility failed to provide two staff members during care for one (R101) of three residents reviewed for safety resulting in R101 falling off the bed onto the floor and sustaining an abrasion to their right kneecap. Findings include: The State Agency (SA) received a complaint that R101 rolled off the bed onto the floor when only one staff member was providing care. On 8/28/26 at 10:40 AM, R101 was observed seated in a wheelchair in the therapy department. During interview R101 said, I was getting cleaned up. I'm unable to move my legs and need a total of two people to assist me with getting changed. I only had the one girl. I told her I needed two. She said she could do it. She was on the one side of the bed and turned me toward the other side of the bed. I told her to stop pushing me because I was losing my grip on the sheet. She kept pushing me over and I fell off the bed onto my knees. I have a wound there. This shouldn't have happened. R101 pulled their right pant leg up to reveal their right lower leg and knee. R101's right knee had a small, discolored area on the kneecap that was clean, dry, and intact. According to the Electronic Health Record (EHR), R101 admitted to the facility with multiple diagnoses that included chronic pulmonary embolism, schizoaffective disorder, and generalized osteoarthritis. The Minimum Data Set, dated [DATE] indicated R101 had full cognition with a Brief Interview for Mental Status (BIMS) score of 15/15. R101 was identified to have impairment to both lower extremities and was totally dependent on two staff members for bed mobility. A care plan for Activities of Daily Living last revised on 7/22/26 had interventions that included to review the Kardex for resident care. R101's Kardex (quick reference guide for patient care) indicated R101 required 2 persons assist with bed mobility. A 'witnessed fall' report dated 7/21/26 at 10:45 PM written by Licensed Practical Nurse (LPN) B documented that R101 said, She turned me and I rolled off the bed. On 8/28/26 at 12:50 PM during an interview with LPN B they said, I was called to the room after the resident fell on the floor. There was only one CNA (Certified Nurse Assistant) in the room at the time. There should have been two but that CNA was new and didn't know. I took her (CNA C) out of the room and educated her on the using the Kardex to know how to care for the residents. The other two CNAs on that night took care of the resident (R101) after the fall. On 8/28/26 at approximately 1:00 PM CNA C was contacted by phone but was unable to be interviewed. CNA C did not return the phone call during the time of the survey. On 8/28/26 at 1:02 PM during an interview with CNA A they said that when they came to R101's room the resident was already on the floor. CNA A stated, There was only the one aide there. Yes, that resident needs two. We had three CNAs on that night. I don't know of them asking for help with her (R101). On 8/28/26 at 1:15 PM the Director of Nursing (DON) said that R101 was rolled off the bed when only one CNA provided care and there should have been two. The DON stated, They should have asked for assistance and not rolled the resident away from them. According to the facility's undated Nursing Standard of Practice (SOP) for Bed Mobility in part reads; Assisting Resident to Roll 1. Instruct the resident to bring his or her arms over the stomach, bend the knees, and then roll them toward the staff member. According to the facility's undated Nursing SOP for Logrolling a Resident in part reads;Procedure 1. Get help from a co-worker. 6. Position yourselves at the opposite sides of the bed. 12. Turn the resident toward you .

Based on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 03/08/2026 at 10:28 AM observed the sink faucet releasing a trickle of water when turned on in the first-floor nutrition room. An interview at this time with District Manager I regarding the faucet found they were unsure how long the faucet had been operating in this condition.On 03/08/2026 at 11:08 AM observed nails screwed into the cabinet doors beneath the sink in the third-floor nutrition room. When the cabinet doors were opened, the nails were observed protruding through the wood and sticking out approximately one inch. Further observation of the cabinet beneath the sink found a container with a thick black substance along the bottom edges. The container was situated beneath the drain line, and no active leak was observed.On 03/08/2026 beginning at 1:21 PM a tour of the facility was conducted with the Environmental Services Manager (ESM) K. On 03/08/2026 at 1:25 PM observed evidence of water damage with black residue on one area of the ceiling in the linen bulk storage room. A section of repaired ceiling was noted adjacent to the affected spot. An interview at this time with ESM K found the affected area was caused by a previous water leak.On 03/08/2026 at 1:32 PM observed disposable briefs and padding in plastic bags on the floor next to the clean linin rack in the first-floor clean linen room. Further observation found a bed pan on the floor beneath the storage rack.On 03/08/2026 at 1:45 PM observed a mop sink with a chemical pre-dispensing system in place and the faucet left on in the first-floor janitor closet. This set up puts undue back pressure on the faucet's internal atmospheric vacuum breaker (AVB), which can compromise the integrity of the mechanism. An interview at this time with ESM K found the faucets are kept on between uses. Further observation of the room revealed broken drywall above the mop sink, exposing the internal piping behind the wall. A hole was visible in the exposed pipe, and duct tape was observed on the wall surface around the broken drywall and peeling off.On 03/08/2026 at 1:47 PM observed a mop sink with a chemical pre-dispensing system in place and the faucet left on in the second-floor janitor closet, creating undue pressure on the faucets internal AVB.On 03/08/2026 at 1:55 PM observed disposable briefs in a plastic bag and personal clothing on the floor of the second-floor clean linen room. Further observation found a plastic bottle beneath the clean linen rack.On 03/08/2026 at 1:58 PM observed a shortened shower curtain with approximately one foot of curtain hanging down in the third-floor east wing shower room.On 03/08/2026 at 2:05 PM observed personal clothing in a plastic bag on the floor in the third-floor clean linen room. On 03/08/2026 at 2:15 PM observed a red residue along the bottom surface of the shower curtain in the third-floor west wing shower room. Further observation found a green substance in a crease along the floor of the shower room. An interview with ESM K at this time found the floors of the shower room are cleaned daily and Certified Nursing Assistants (CNAs) are responsible for cleaning between residents.On 03/08/2026 at 2:28 PM observed a brown smear on the shower chair seat in the second-floor west wing shower room. Further observation found an accumulation of white debris on the underside of the shower bed mat. A wooden stick was also observed beneath the shower bed mat. ESM K confirmed the observation.On 03/09/2026 beginning at 8:43 AM a facility tour was conducted with Maintenance Director (MD) L and Regional Maintenance Director (RMD) M.On 03/09/2026 at 8:54 AM observed a sink fixture in the first-floor soiled linen room. The sink fixture was observed loose to mount and able to move around.On 03/09/2026 at 9:06 AM observed a tissue pressed to the shower room floor of the second-floor east wing shower room.On 03/09/2026 at 9:10 AM observed the baseboard separating from the wall, with an accumulation of dust and debris behind the it in the second floor central supply room. A comb was also observed on the floor behind the baseboard adjacent to the storage rack. An interview with RMD M at this time indicated that maintenance walkthroughs are conducted to identify repair needs, and the facility uses TELS system for reporting repairs jobs.On 03/09/2026 at 9:17 AM observed a sink fixture in the second-floor east wing soiled utility room. The sink fixture was observed loose to mount and able to move around.On 03/09/2026 at 9:23 AM observed a two-compartment sink with accumulated white and grey debris filling the drain in the second-floor west wing soiled utility room. An interview conducted with RMD M at this time found they were unsure of what had occurred to the sink. Further observation of the room revealed a hopper with black particulates in the bowl.On 03/09/2026 at 9:37 AM observed five tiles were missing on the shower room floor in the second-floor west wing shower room.On 03/09/2026 at 9:47 AM observed a red residue along the bottom surface of the shower curtain in the third-floor west wing shower room. Further observation found a green substance in a crease along the floor of the shower room.On 03/09/2026 at 9:50 AM observed a mop sink with black and brown residue coating the base of the sink basin in the third-floor janitor closet. A green stick was observed protruding from drain and a plastic bag was covering the sink. Further observation revealed a chemical pre-dispensing system in place and the faucet left on at the mop sink, creating undue pressure on the faucets internal AVB.On 03/09/2026 at 9:54 AM observed a sink fixture loose to mount and able to move around in the third-floor west wing soiled utility room. Further observation found a hopper with brown residue in the bowl. On 03/09/2026 at 10:04 AM observed a sink fixture loose to mount and able to move around in the third-floor east wing soiled utility room.On 03/09/2026 at 10:14 AM observed a shortened curtain with approximately one foot hanging down in the third-floor east wing shower room. Further observation revealed a small plastic tube beneath the mat of the shower bed and an accumulation of white debris.On 03/09/2026 at 10:35 AM observed an adjustable countertop cover positioned over a sink in the spa room. Upon removal of the cover, a rubber band and hair strands were observed in the sink basin.On 03/09/2026 at 10:41 AM observed evidence of water damage with black residue on one area of the ceiling in the linen bulk storage room. A section of repaired ceiling was noted adjacent to the affected spot. An interview conducted at this time with RMD M indicated it is an old leak and needs to be replaced.On 03/09/2026 at 1:20 PM observed a gap at the wall mounted handrail bracket in the third-floor west wing, leaving a small, exposed hole and rough edges at the attachment point.A record review of the facility provided document entitled Environmental Safety Program Preventative Maintenance states, Preventive maintenance schedules shall be developed and implemented to ensure that the building and equipment are maintained in a safe and operable manner. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to ensure that the buildings, ground, and equipment are maintained in a safe and operable manner.

Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 03/08/2026 at 1:12 PM observed an inoperable water fountain in the basement indicating possible stagnant water.On 03/08/2026 beginning at 1:21 PM a tour of the facility was conducted with Environmental Services Manager (ESM) K. On 03/08/2026 at 1:37 PM observed a hopper in the first-floor trash room. An interview at this time with ESM K found the housekeeping team flushes the hopper once a week when cleaned but do not turn on the water at the hopper faucet or use the spray hose during this process.On 03/08/2026 at 1:42 PM observed slightly discolored water coming from the sink faucet for a few seconds before running clear in the first-floor soiled linen room. An interview with ESM K revealed the sink is cleaned but is not flushed. Further observation found the hopper faucet inoperable and not allowing water lines to be flushed indicating possible stagnant water. An interview with ESM K at this time found the hopper is not used by staff or flushed by housekeeping.On 03/08/2026 at 1:48 PM observed an inoperable hopper and sink in the second-floor west wing soiled utility room. An interview at this time with ESM K found the sink had not worked since they had started working here.On 03/08/2026 at 1:52 PM observed discolored water in the bowl of the hopper in the second-floor east wing soiled utility room. A sign was observed above the hopper that indicated not to put anything in the bowl. Further observation found the sink faucet inoperable, indicating possible stagnant water.On 03/08/2026 at 2:04 PM observed a tub with a missing handle attachment in the third-floor tub room. An interview with ESM K at this time found they had not seen the tub work since working here.On 03/08/2026 at 2:07 PM observed a hopper with water and black particulate material in the bowl in the third-floor east wing soiled utility room. An interview with ESM K at this time found the hopper bowl is cleaned but the hopper is not flushed at the faucet. Further observation found a sink fixture with one foot pedal tied up with a zip tie. When the remaining foot pedal was pushed no water came out indicating possible stagnant water.On 03/08/2026 at 2:12 PM observed slightly discolored water coming from the sink faucet for a few seconds before running clear in the third-floor soiled utility room. An interview at this time with ESM K found the sink is not flushed. Further observation revealed a hopper with no water present in the bowl, indicating inactive use of the water fixture. A black and brown layered residue was observed along the interior of the bowl leading to the drain line.On 03/08/2026 at 2:17 PM observed a tub with a missing handle attachment in the third-floor tub room. An interview at this time with ESM K found the tub is not used.On 03/08/2026 at 2:20 PM observed a tub and toilet in the second-floor west wing tub room. An interview with ESM K at this time found the tub was not flushed and toilet was not used or flushed.On 03/08/2026 at 2:26 PM observed slightly discolored water coming from the tub faucet for a few seconds before running clear in the second-floor east wing tub room. An interview with ESM K at this time found the tub is not flushed. On 03/08/2026 at 2:33 PM observed a tub with a missing handle attachment in the first-floor tub room.On 03/09/2026 at 8:29 AM an interview with Maintenance Director (MD) L found they are new to the facility and had been here for three weeks. When asked about control measures to prevent the growth of legionella, MD L stated the hot water tank is flushed once a month and they were not certain of any other controls. When asked if there is a log, MD L indicated that it generates in TELS once a month and is completed.On 03/09/2026 at 8:34 AM an interview with the Regional Maintenance Director (RMD) M found they do not do chlorine testing, and they test for legionella once a year using a test kit. When asked about other control measures other than flushing the boiler, RMD M indicated that is the only control. When asked about the water management binder, RMD M indicated they have not gotten the chance to fill it out yet and are in the process.On 03/09/2026 beginning at 8:43 AM a facility tour was conducted with MD L and RMD M.On 03/09/2026 at 8:47 AM observed a functional sink fixture and hopper in the first-floor west wing soiled utility room. When the cold and hot water hopper faucets were turned on, no water came out indicating the faucet had been turned off at the valve and possible stagnant water. An interview with the MD L at this time found they did not know if the sink was used and that the hopper is not flushed. On 03/09/2026 at 8:54 AM observed a functional hopper and sink fixture in the first-floor soiled linin room. An interview with the MD L at this time found they do not flush the sink or hopper and were unaware if they were used.On 03/09/2026 at 8:59 AM observed a utility sink with the cold water handle missing and the hot water handle turned off in the first-floor storage room. An interview with RMD M at this time found they were unaware if the water was turned off at the mainline or the fixture valve leaving possible stagnant water. On 03/09/2026 at 9:11 AM observed yellow and brown water discharging from the utility sink faucet for several seconds in the second-floor central supply room. MD L acknowledged the discolored water.On 03/09/2026 at 9:17 AM observed discolored water in the bowl of the hopper in the second-floor east wing soiled utility room. A sign was observed above the hopper that indicated not to put anything in the bowl. An interview with RMD M at this time found they were unaware how long the hopper had been out of order.On 03/09/2026 at 9:23 AM observed a two-compartment sink with accumulated debris inside the sink of the second-floor west wing soiled utility room. Interview with RMD M at this time found they were unsure of what had happened. Further observation found a hopper with black particulates in the bowl of the hopper. When turned on the hopper faucet and flush apparatus were inoperable and not allowing water lines to be flushed indicating possible stagnant water.On 03/09/2026 at 9:27 AM observed a tub connected to the water line but turned off at the fixture in the second-floor tub room indicating possible stagnant water.On 03/09/2026 at 9:43 AM observed a tub with a missing handle in the third-floor tub room. MD L indicated the tub is not used.On 03/09/2026 at 9:50 AM observed a mop sink with black and brown residue coating the base of the sink basin in the third-floor janitor closet. A green stick was observed protruding from drain and a plastic bag was covering the sink. An interview with housekeeper N found the sink is not working, and it has been out for a month.On 03/09/2026 at 9:54 AM observed a hopper with brown residue in the bowl in the third-floor west wing soiled utility room. An interview at this time with MD L found it is not flushed. Further observation found the flush apparatus and spray hose nonfunctional. MD L indicated the flush valve was shut off at the fixture. On 03/09/2026 at 10:00 AM observed uncapped fixture with a shut off valve coming from the wall in the third-floor pantry room. An interview at this time with RMD M indicated they did not know about it.On 03/09/2026 at 10:04 AM observed murky discolored water in the bowl of the hopper in the third-floor east wing soiled utility room. The hopper faucet and flush apparatus were observed functional. An interview with MD L at this time indicated they did not know if the hopper was used.On 03/09/2026 at 10:09 AM observed a water fountain inoperable on the third floor. An interview with RMD M at this time found they were unaware if the fixture was turned off at the mainline or the valve indicating possible stagnant water. On 03/09/2026 at 10:12 AM observed a tub with a missing handle attachment in the third-floor tub room. An interview at this time with MD L indicated it is not flushed.On 03/09/2026 at 10:24 AM an interview with RMD M found there is no established water management team, and it mostly falls on maintenance.On 03/09/2026 at 10:35 AM observed an adjustable countertop cover positioned over a sink in the spa room. Upon removal of the cover, a rubber band and hair strands were observed in the sink basin. When water was turned on it ran clear however pooled at the drain and began to discolor. An interview with Activities Director E at this time found a beautician comes once a month and the covered sink has not been used in years.On 03/09/2026 at 11:36 AM interview with Administrator found maintenance discusses water management in QAPI once a month, and there has been no meeting regarding water management with the new maintenance director.On 03/09/2026 at 2:01 PM an interview with Director of Nursing found there is no water management team in regard to legionella. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Eliminate dead legs, which are sections of no- or low-water flow.A record review of the facility provided binder entitled Legionella contained the CDC toolkit Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings. The toolkit contained no evidence of any completed work or implemented activities.

Based on interview and record review, the facility failed to report staffing data to the payroll-Based Journal (PBJ) with the potential to affect all 117 residents residing in the building. This deficient practice resulted in the potential for staffing concerns leading to quality-of-care concerns. Findings include:Per a review of the PBJ report for Fiscal Year Quarter 4 2025 (July 1 - September 30), the facility failed to submit data for the quarter. The facility also triggered for a One Star Staffing Rating, Excessively Low Weekend Staffing, No Registered Nurse Hours, and Failed to have Licensed Nursing Coverage 24 Hours/Day (indicating a lack of reported staffing or inadequate staffing). On 3/10/2026 at 1:41 p.m., the Director of Human Resources (HRD) was interviewed about the PBJ report and submission. The HRD was aware the PBJ was not submitted and said the PBJ was analyzed, reviewed and submitted to the corporate office to be submitted but it would have been late so it was not submitted. On 3/10/26 at 1:55 p.m., the Nursing Home Administrator (NHA) was interviewed about the PBJ report and submission. The NHA said Human Resources (HR) submits to CMS (Center for Medicaid/ Medicare Services). The NHA was not aware the PBJ was not submitted and said that the PBJ was reviewed and should have been submitted.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 03/08/2026 at 8:40 AM a tour of the kitchen was conducted with cook F who was serving as the acting manager for the day.On 03/08/2026 at 8:57 AM observed a plastic tube running from the ice machine drain line into the floor drain in the kitchen. The plastic drain line extended below the flood level rim of the drain, creating an improper air gap.On 03/08/2026 at 9:33 AM observed a black corrugated tube connected to the juice gun drain line leading into the floor drain in the kitchen. The tube extended down to the base of the floor drain, creating an improper air gap.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. On 03/08/2026 at 8:59 AM observed brown residue accumulated on the interior wall of the ice machine. An interview conducted at this time with [NAME] F revealed the kitchen staff does not clean the ice machine, and a different department is responsible for cleaning it.On 03/08/2026 at 9:02 AM observed water droplets and food particulates on the inside surface of two quarter pans that were stacked on the dry storage rack. [NAME] F removed pans to be washed. On 03/08/2026 at 9:17 AM an interview with [NAME] F found that the stand mixer is used a couple times a month. When asked what the cover over the mixer meant to kitchen staff, [NAME] F stated it is used to keep debris out. Upon removing the plastic cover, observation of the mixer found a pen in the bowl of the mixer and white residue on the upper area near the attachment.On 03/08/2026 at 9:22 AM observed a meat slicer covered with a plastic bag. Upon removing the plastic cover, observation of the slicer found dried residue on the backside of the blade. [NAME] F indicated they would take care of it. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.According to the 2022 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining.On 03/08/2026 9:08 AM an interview with [NAME] F found they were unsure whether the dishwasher operated as a chlorine sanitizing unit or a high temperature sanitizing unit.On 03/08/2026 at 9:09 AM observed the dish washer temperature and PPM (parts per million) log filled out for breakfast and lunch service. An interview at this time with cook F found they were unaware why it was filled out for lunch.On 03/08/2026 at 9:10 AM observed a chlorine test strip being run through the dishwasher. An interview with cook F found they were unaware what they were supposed to look for when performing the test.On 03/08/2026 at 9:26 AM during an interview with [NAME] F regarding the location of the mop sink found that the mop sink was located in the dirty dish room within a one compartment sink. A clear container was observed sitting at the base of the sink. On 03/08/2026 at 9:37 AM an interview conducted with kitchen staff G regarding use of the mop sink, found the mop sink is used to soak dishes in sometimes.On 03/08/2026 at 9:46 AM an interview conducted with Dietary Aid G and Dietary Aid H found they were unsure what they are expected to look for when completing the dish machine log. Dietary Aid G and Dietary Aid H were unaware as to whether the dishwasher operated as a chlorine sanitizing unit or a high temperature sanitizing unit.On 03/08/2026 at 3:16 PM an interview with the Dietary Manager J regarding the mop sink location found the mop sink is located outside the kitchen in a separate utility room. When asked if staff use the one compartment sink in the kitchen as the mop sink, Dietary Manager J stated no they are not supposed to.According to the 2022 FDA Food Code section 2-103.11 Person in Charge. The person in charge shall ensure that. Employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing, and chemical concentration, pH, temperature, and exposure time for chemical sanitizing.According to the 2022 FDA Food Code section 5-203.13 Service Sink, At least 1 service sink or 1 curbed cleaning facility equipped with a floor drain shall be provided and conveniently located for the cleaning of mops or similar wet floor cleaning tools and for the disposal of mop water and similar liquid waste.On 03/08/2026 at 8:55 AM observed an opened bag of lettuce in the walk-in cooler with a facility marked receive date of 3/3/26 and expiration date of 3/7/26. [NAME] F indicated they would throw it away.On 03/08/2026 beginning at 10:18 AM a tour of the nutrition rooms was conducted with District Manager I.On 03/08/2026 at 10:20 AM observation of the first-floor nutrition room found the following items:A package of watermelon and a package of pineapple stored together in the refrigerator with a facility marked date of 3/3/26. A fortified nutritional shake in the refrigerator with an expiration date of 3/7/26. A bag of potato chips in the cabinet beneath the sink. District Manager I removed items to be thrown away.On 03/08/2026 at 10:32 AM observation of the second-floor nutrition room refrigerator found the following items:A juice pitcher half filled with no lid on, without a label or date. A paper bag without a label or date. A plastic bag containing candy and a carry out box without a label or date. Lemon flavor thickening agent with a best by date of 2/16/26. A container of salad without a label or date. Yogurt parfait without a label or date. A box containing fries without a label or date. A carton of milk with an expiration date of 3/7/26. A bag containing packages of cheese and crackers with no facility marked date. District Manager I removed items to be thrown away.On 03/08/2026 at 10:48 AM observed an accumulation of brown buildup on the upper surface of the microwave in the second-floor nutrition room. On 03/08/2026 at 10:50 AM observed brown residue on the interior surface of the ice machine in the second-floor nutrition room. District Manager I confirmed the observation.On 03/08/2026 at 10:52 AM observation of the third-floor nutrition room found the following items:A fortified nutritional shake in the freezer, with manufacturer's directions on the box that state do not freeze. A Styrofoam cup with no label or date in the refrigerator. A mighty shake without a facility marked thaw date in the refrigerator. A cup of grapes with no lid and without a date in the refrigerator.On 03/08/2026 at 11:03 AM observed a paper bag inside the microwave with no date or label in the third-floor nutrition room. Further observation of the microwave found accumulated food residue on the upper surface of the unit.On 03/08/2026 at 11:05 AM observed a sealed package of cinnamon rolls with an expiration date of 2/5/26 in the cabinet of the third-floor nutrition room. On 03/08/2026 at 11:07 AM an interview with District Manager I indicated kitchen staff do not clean the microwaves in the nutrition rooms. Kitchen staff are responsible for ensuring the refrigerators are clean during walk throughs but are not responsible for clearing them out.On 03/08/2026 at 3:13 PM an interview with the dietary manager J regarding how date marking works found date marking is seven days out and three days for certain items such as sandwiches. When asked about the nutrition rooms, Dietary Manager J stated kitchen staff do not sort nutrition rooms or refrigerators, the staff go up as needed to clean.A record review of the facility provided document entitled Safe Storage & Handling of Outside Food states, Any food which is not going to be consumed immediately must be covered and labeled with the resident's name, and date the food was brought into the facility and placed into the unit refrigerator. Labels and the location of the refrigerator are available at the nurses' station as well as in the pantry area. All food that is stored in the refrigerator & not consumed within 3 days will be discarded by facility staff daily. Signage regarding this process is displayed on all fridges. Any food without the correct labeling will also be discarded.According to the 2022 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.According to the 2022 FDA Food Code section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food:.(2) Where it is not exposed to splash, dust, or other contamination.

Based on observation, interview, and record review the facility failed to ensure the smoking policy was implemented and practiced for one (R93) of one resident reviewed for accidents and hazards, resulting in (1.) smoking in the facility, (2.) smoking materials not stored in a safe place, (3.) potentially affect safe fire safety practices, (4.) and the potential for bodily harm. This deficient practice has the potential to affect all residents that reside in the facility. Findings include:On 3/08/2026 at 12:01p.m R93 was observed in the bedroom coloring. R93 was pleasant, alert, and oriented to person, place, and situation. The odor of cigarette smoke smelled from outside the bedroom. R93 was selected for review for residents that smoke. On 3/09/2026 at 9:11 a.m. - R93 was observed in the designated smoking area smoking independently with other residents. Review of the clinical record revealed R93 was initially admitted into the facility on 9/27/25 and readmitted from the hospital on 2/4/26 with diagnoses that included HIV, personality disorder, lupus, schizophrenia, bipolar type disorder, substance use disorder, and chronic obstructive pulmonary disorder. According to the admission/ 5-day Minimum Data Set assessment dated [DATE], R93 was cognitively intact with a BIMS of 15 and was independent with all activities of daily living. Review of the Smoking assessment dated [DATE] Resident is safe to smoke with supervision. A smoking assessment was not completed after readmission [DATE]) or quarterly. Review of the Smoking care plan with the start date of 10/6/25, last reviewed 1/20/26 documented in part the following: I am a smoker. I attempt to smoke in my room at times. I am a smoker. Educate me to not smoke in room.Interventions: Educated me to give activity my smoking products.May go on a leave of absence to the patio. Resident is not allowed to leave the premises without supervision. Notify the charge nurse if I have violated the policy. Review of the nurse's progress note dated documented in part the following: -10/7/25 Nurse Practitioner gave order for the resident to have LOA to the patio to smoke (unsupervised).-1/21/2026 Spoke with physician. Resident is only to go out with smokers when supervised. Review of the progress notes revealed the following regarding R93 smoking or in possession of smoking materials in the facility:- 10/8/2025 Writer spoke with resident regarding the smell of cigarette smoke in her room. Educated resident as to protocol and safe smoking practices. Writer scanned room, and several cig butts were found.- 10/10/2025 IDT discussed resident in behavior management meeting. Resident is non-compliant with smoking.- 10/13/2025 While rounding, writer smelled a strong marijuana odor coming from resident's room. Upon entering, resident's eyes were red and low. Clothing and skin smelled of marijuana.- 11/21/2025 Writer was informed by Activity staff that resident was smoking marijuana with another resident.- 11/28/2025 IDT discussed (R93) being non-compliant with smoking in her room.- 11/29/2025 While walking down the hallway, this writer and another nurse could smell cigarette smoke coming from room.- 12/12/2025 Writer found weed pen under resident pillow.- 12/24/2025 Resident has blunt wrappers scattered on the floor with tobacco also scattered all over the room. Cigarettes on the bedside table .- 1/20/2026 Strong odor of smoke noted to be coming from resident's room. Ashes found on beside table and remnants of cigar/cigarettes on the floor. On 3/10/2026 at 11:33 a.m. Regional Social Service A and Social Service Designee B were interviewed and said R93 was given verbal educations on the smoking policy. They were uncertain how R93 obtained smoking materials and possibly the family provided them. The family was not educated on the facilities smoking policy. On 3/10/26 at 2:40 p.m. Activities Director E was interviewed and said the front desk keeps R93's smoking materials however the activities department is responsible for keeping smoking materials which is kept in a cart and locked the office when not in use. On 3/10/26 at 2:43 p.m. R93 was interviewed and said they had possession of cigarettes. R93 reached in coat pocket and exposed the top part of a cigarette pack which had approximately 3-4 cigarettes in it. R93 said they did not have a lighter because the staff took it away. On 3/10/26 at 2:52 p.m. Receptionist C was interviewed and said a receptionist is at the front desk twenty-four hours. Receptionist C was asked to show where R93's smoking materials were kept. Receptionist C revealed a clear plastic bag from the desk drawer that only had an inhaler in it. There were no cigarettes in the bag. Receptionist C said R93 may have the cigarettes on their person. If the front desk staff suspect R93 has cigarettes, they are to inform the nurse. The nurse is to them confiscate the smoking materials. The nurses are informed almost daily that R93 may have smoking materials. On 3/10/26 at 3:00 p.m. LPN D was interviewed and said as of lately reports of R93 having smoking material had been less than before. It had been about three months since notified R93 had smoking material in their possession. The front desk may have reported it to another nurse that would answer the phone. In the past, LPN D had confiscated smoking materials from R93 if asked. On 3/10/26 at 3:15 p.m. the Nursing Home Administrator was interviewed and said they were not aware R93 currently had smoking materials or continued to smoke in the facility. Review of the facility's policy tiled smoking policy (no date), documented in part the following: . it is the policy of this facility to provide a safe smoking environment for residents who can smoke independently and are deemed a safe smoker based on a comprehensive smoking safety assessment. The facility maintains its status of providing a non-smoking environment and smoking may be in designated outdoor areas. Fundamental information: residents deemed safe to smoke will be offered the ability to smoke within the parameters established for smoking in the facility. Residents who violate the smoking rules established by the facility will no longer be able to exercise this privilege. Residents who display unsafe smoking behavior or who put themselves or others at risk of harm, or who violate the rules of the facility will not be allowed to smoke at the facility. Procedure: Residents who smoke will be assessed upon admission, quarterly, new request to smoke and as needed to assure ongoing safety. any resident who has been deemed safe to smoke will only do so in the designated smoking areas. Residents are not permitted to maintain on their person any smoking tools (i.e. cigarettes, lighters, cigars) and are required to return the items to the designated staff person or nurse. Violation of will result in termination of smoking privileges. Repeat violation of the smoking policy could result in a discharge from the facility.

Based on observation, interview, and record review, the facility failed to display current daily staff ratio information in a prominent area that was readily accessible for all 117 residents as well as visitors/vendors in the facility and ensure the proper retention of previous staff ratio postings. Findings include: On 3/8/26 at 8:30 AM, upon entry into the facility, a document titled, Daily Staffing Report, dated 3/6/26 was observed posted in the foyer. During an interview on 3/10/26 at 10:08 AM, Staffing Coordinator (SC) U confirmed responsibility for the daily staffing report Monday through Friday, and weekend supervisors were accountable for its completion Saturday and Sunday. SC U indicated the daily staff postings were to be available so families could check to see if there was adequate staffing. A review of daily staffing reports for January 2026 was conducted with SC U. Daily staff postings were not available for the following dates: 1/1/26, 1/3/26, 1/4/26, 1/9/26, 1/10/26, 1/11/26, 1/15/26, 1/17/26, 1/18/26, 1/24/26, 1/25/26, and 1/31/26. During an interview on 3/10/26 at 12:52 PM, the Director of Nursing (DON) said the purpose of the daily staff report was to show that they have appropriate staffing to provide adequate care. The posted information was for staff, family, and the residents. The DON confirmed that the weekend supervisor was responsible for completing the posting on Saturday and Sunday. On 3/10/26 at 4:20 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to ensure consistent coordination of care between the facility and the contracted dialysis center for one resident (R12) out of one resident reviewed for dialysis services. Findings include:During an interview on 3/9/26 at 9:29 AM, Licensed Practical Nurse (LPN) Y said completed dialysis communication sheets were put into a purple book at the nurse's station and then given to the Registered Dietitian (RD) for review. The following completed dialysis communication sheets for R12 were available at the nurse's station: 3/2/26, 3/4/26, 3/6/26. On 3/9/26 at 9:31 AM, R12 was observed at the nurse's station prior to being transported to the dialysis center. R12 responded pleasantly when greeted. During an interview on 3/9/26 at 1:05 PM, RD V was queried about available dialysis communication sheets for R12 and provided documents dated 12/15/25, 1/2/26, 1/30/26, and 2/6/26. RD V said they feel the rest of the communication sheets were at the nurse's station. During an interview on 3/9/26 at 1:30 PM, Unit Manager/LPN T said they ensure the floor nurses complete their portion of the dialysis communication sheets before the documents were given to the RD for review. On 3/9/26 at 1:37 PM the Director of Nurses (DON) said following the RD review, the communication sheets were given to medical records. The DON called medical records and requested available dialysis communication sheets for R12. On 3/9/26 at 1:46 PM, Medical Records Staff W provided dialysis communication sheets scanned in the electronic health record (EHR) for R12 dated 7/11/25, 10/24/25, 10/27/25, 10/29/25, 10/31/25, 11/5/25, 11/10/25, 11/12, 11/14/25, 11/17/25, 11/19/25, 12/5/25, and 12/10/25. Medical Record Staff W said there were no other dialysis communication sheets available in the medical records department for R12. On 3/10/26 at 8:15 AM, RD V presented additional dialysis communication sheets for R12 dated 1/2/26, 1/5/26, 1/12/26, 1/14/26, 1/16/26, 1/21/26, 1/28/26, 1/30/26, 2/2/26, and 2/6/26. During an interview on 3/10/26 at 11:07 AM, RD V said they were aware that some dialysis communication sheets were missing. Ultimately it was determined the following dialysis communication sheets were not available for R12 during the review period of January 2026 and February 2026: 1/7/26, 1/9/26, 1/19/26, 1/23/26, 1/26/26, 2/4/26, 2/9/26, 2/11/26, 2/13/26, 2/16/26, 2/18/26, 2/20/26, 2/23/26, 2/25/26, and 2/27/26. A review of the clinical record for R12 documented an original admission date of 5/24/25 and readmission date of 10/21/25. R12's diagnoses included end stage renal disease (ESRD) and atherosclerotic heart disease. Physician's orders documented R12 was scheduled for hemodialysis services weekly on Monday, Wednesday, and Friday. Review of R12's care plans documented in part the following:Focus: I am at nutritional risk related to: I have a chronic disease: ESRD on dialysis. Revised 9/1/25.Intervention: Intervention: Coordinate my nutrition plan with dialysis. Review communication sheets and labs monthly. Dated: 5/27/25. During an interview on 3/10/26 at 12:30 PM, the Director of Nursing (DON) reported that R12 does not refuse dialysis services. The DON said the purpose of the dialysis communication sheets was to collaborate with the dialysis center staff and physician to help create a positive health outcome for the resident. The facility policy titled, Dialysis Transportation, dated February 2018, documented in part, The dialysis communication form should accompany the resident to and from dialysis to assure continuity of communication. On 3/10/26 at 4:20 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to properly assess the nutritional status and implement nutrition interventions for one resident (R12) out of one resident reviewed for dialysis. Findings include: On 3/9/26 at 9:31 AM, R12 was observed at the nurse's station prior to being transported to the dialysis center. R12 responded pleasantly when greeted. When queried about their appetite and meals, R12 responded that they had been eating okay. R12 appeared thin in appearance. A review of the clinical record for R12 documented an original admission date of 5/24/25 and readmission date of 10/21/25. R12's diagnoses included end stage renal disease (ESRD) and atherosclerotic heart disease. Physician's orders documented R12 was scheduled for hemodialysis services weekly on Monday, Wednesday, and Friday. R12 was prescribed a regular diet of pureed texture with thin liquid consistency. Additional review of R12's medical record documented the following:1. Dialysis communication sheet dated 11/19/25: Please send provider note for urology or update noted on plan for the patient's dx (diagnosis): RCC (Renal Cell Carcinoma). The document indicated a review by the Registered Dietitian (RD), as indicated by the initials (XX) RD written on the document. 2. Nursing note dated 2/16/26: Received a phone call from NP (nurse practitioner) of nephrology from dialysis concerned in regards to consistent drop in HGB (hemoglobin). Stated that since 2/11/26 hgb went from 8.2 to 7.4 today; wants (R12) to see the urologist so (they) can have clearance to administer Epogen (an injectable medication used to promote red blood cell production) during dialysis treatment. MD notified to call back with urology consult and further treatment protocol no new orders for Iron or blood cell replacement at this time. NP concerned due to possible DX. Renal cell carcinoma awaiting consultation. 3. An emergency care conference was held for the resident on 2/17/26: (R12) has renal carcinoma which was discussed with (R12's) son. The resident has an appointment to see a neurologist to get more information about the carcinoma. Hospice care was offered. The resident's son is not interested in signing (R12) up for hospice at this time. He wants to be notified about upcoming results from appointments. 4. Review of R12's care plans documented in part the following:Focus: I am at nutritional risk related to: I have a chronic disease: ESRD on dialysis. My renal RD has recommended I receive a supplement and that my diet be liberalized to regular. Revised 9/1/25.Intervention: I will receive a (specialized nutrition shake for people on dialysis) 1 carton/day as ordered. Date initiated 9/29/25. On 3/9/26 at 1:05 PM, an interview was conducted with RD V. RD V said they started working at this facility October 2025. Upon review of R12's medical record, RD V said they were unaware that R12 was diagnosed with renal cancer. RD V said renal cancer would change R12's nutritional requirements and affect nutrient absorption. An example provided by RD V was their protein requirement would change from 1.5 gm per kg (kilogram) of body weight to 2.0 gm protein per kg of body weight. RD V indicated R12 would need to receive extra calories otherwise their intake of protein would be use for calories (instead of repairing cells, muscle maintenance, and supporting growth). RD V indicated R12 was provided a specialized nutrition shake for people on dialysis, however, RD V was unaware that R12's specialized supplement order had been discontinued. RD V said R12 should be on this specialized supplement. Nutrition assessments for R12 completed by RD V on 1/7/26 and 2/28/26 did not address R12's diagnosis of renal carcinoma. During an interview on 3/9/26 at 1:30 PM, Unit Manager/Licensed Practical Nurse (LPN) T confirmed that R12 did not have a current order for the specialized supplement for people on dialysis. LPN T indicated this nutrition supplement was discontinued on 9/24/25. During an interview on 3/10/26 at 12:44 PM, the Director of Nursing (DON) said R12 should have received more nutrition because of the cancer diagnosis. A review of the facility policy titled, Nutritional Care, undated but provided during the survey, documented in part the following, Nutritional care is an individualized approach, which includes identifying and assessing each resident's nutritional status and risk factors, evaluating/analyzing the assessment information, developing and consistently implementing pertinent approaches, and monitoring the effectiveness of interventions and revising them as necessary. On 3/10/26 at 4:20 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to provide proper skin care for two residents (R61 and R117) out of two residents reviewed for skin conditions who were dependent upon staff for performance of activities of daily living (ADL). Findings include: R61. On 3/8/2026 at approximately 12:45 p.m. and on 3/9/2026 at approximately 12:17 p.m., R61 was observed seated in a wheelchair in the dining room. R61's face was observed to have dry skin with flakes. Large particles that appeared to be dry scalp flakes were visible in R61's hair. A significant amount of large flaky skin particles was observed on the front of R61's pants. During an interview, R61stated, I do not get anything for my dry flaky skin, but I want some moisturizer or something. On 3/10/2026 at approximately 10:00 a.m., R61's assigned Certified Nursing Assistant (CNA) S on 3/8/2026, 3/9/2026, and 3/10/2026 was interviewed regarding R61's dry skin. CNA S was asked if they noticed R61 to have flaky dry skin on the face and the scalp during care? CNA S stated, Yes, I think she has some kind of cream treatment for her dry skin. CNA S was then asked, were the cream applied to the resident's dry skin? CNA S stated, No, I did not. On 3/10/2026 at approximately 10:15 a.m. the 100 hallway Unit Manager (UM) P was interviewed regarding R61's dry skin. UM P was informed of R61's dry skin to the face, and scalp. UM P said the floor nurses should have applied the resident's medication for the dry skin. UM P was informed the Treat Administration Record (TAR) indicated the treatment was not completed. UM P said they should have applied the cream to R61's dry skin. On 03/10/2026 at 11:31 a.m., the 100 hallway Unit manager (UM) P entered the conference room and said this is the cream that R61 has orders for flaky dry skin. UM P presented the following tube ofcream and bottle of shampoo: 1. (hydrocortisone [NAME] USP 1% for relief of minor skin irritations' itching and rashes, apply to scalp (shampoo) topically every night shift every Wednesday's and Saturday's. 2) Ketoconazole shampoo 2% for topical application only apply the shampoo to the damp skin of the affected areas and a wide margin surrounding this area. lather, leave in place for 5 min. and then rinse off with water. Observation of the medications, it appeared the medications has not been used. UM P agreed and stated, Maybe its other tubes and bottles on the cart that they were using. UM P did not return with any other medication bottles or tubes prior to exiting the facility. According to the electronic medical record, R61 was admitted to the facility on [DATE] with diagnoses of heart failure, kidney calculus, major depressive disorder, and hypertension. R61 was alert and oriented and able to be interviewed. Review of the 1/19/2026 skin care plan documented, Problem: I have actual skin impairments related to dry skin to face and scalp. Interventions: For dry and flaky skin use high quality moisturizers to rehydrate my skin (hydrocortisone External Cream 2.5% Topical three times daily for 21 days. Ketoconazole Shampoo 2% every shower day x 21 days for dry skin. Observe my skin rashes for increased spread or signs of infection. Review of the March 2026 (TAR) documented, Hydrocortisone External Cream 2.5% Apply to face topically three times a day for dry skin for 21 days at the times of 0600, 1200 and 1800 hours. Review of the TAR revealed on 3/6/2026 at 1200 and 1800 and 3/7/2026 at 0600 and 1200 there were no signatures (blank) indicating the treatment was not completed. R117 - On 3/8/26 at 11:19 AM, during the initial tour of the facility, R117 was observed awake and in bed. When greeted, R117's response was generally incoherent. R117's feet were outside of the bed covers and appeared very dry with peeling skin. On 3/9/26 at 8:45 AM, during a return visit, R117 was observed awake in bed and their feet were outside of the bed covers. R117's feet continued to appear very dry with peeling skin. A review of the clinical record for R117 documented an admission date of 2/13/24. R117's diagnoses included schizoaffective disorder and cognitive communication deficit. Physician orders documented to apply Ammonium Lactate External Lotion 12% to resident's upper and lower extremities topically two times a day for itchy dry skin and torso. Dated 10/15/25. A review of R117's care plans documented in part the following: Focus: I need assistance with my ADL's related to impaired mobility, weakness and deconditioning. Intervention: I need partial/moderate assistance from staff with personal hygiene. Dated 2/14/24. Focus: I have actual impaired skin integrity related to scratching my left buttocks and in functional mobility and incontinences of bowel and bladder. Intervention: Ammonia lactate solution to bilateral upper and lower extremities twice daily. Dated 10/15/25. On 3/9/26 at 10:25 AM an observation and interview were conducted with Licensed Practical Nurse (LPN) X regarding R117's feet. LPN X described R117's feet as extremely dry and scaly. The areas in between R117's toes were extremely dry. Flakes of R117's dry skin were observed on the floor at the foot of R117's bed. LPN X said the ammonia lactate does not appear to be effective. LPN X said it was the nurse's responsibility to inform the doctor that the lotion was not working, and the resident needed something else. When informed that R117's feet appeared dry and scaly yesterday, LPN X said the certified nurse aides could have reported this concern to the nurse. On 3/10/26 at 12:30 PM, the Director of Nursing (DON) indicated that staff are expected to provide skin care for the residents. The DON said R117 was resistive to care. A review of R117's March 2026 medication administration record documented that out of the 17 scheduled applications of ammonia lactate lotion to date this month, there were only two refusals documented. The DON reviewed R117's clinical record and confirmed no other documented refusals of the ammonia lactate lotion during March 2026. The DON indicated R117's skin concerns and need for a change in intervention should have been addressed before today. On 3/10/26 at 4:20 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Based on observation, interview, and record review, the facility failed to provide assistive dining equipment for one resident (R49) out of two residents reviewed for limited range of motion (ROM).Findings include: On 03/08/2026 at 11:26 AM, R49 was observed in bed with contractures of both hands. On 3/09/2026 at 8:40 AM, R49 was observed eating breakfast in bed. R49's breakfast tray consisted of a divided plate and a regular glass. R49's meal ticket stated, highlighted, 2 handled cup; Divided plate. R49 was asked if staff brought her the 2 handled cup and replied, They didn't bring it to me. R49 demonstrated difficulty grasping and bringing the regular cup to her mouth.On 3/10/2026 at 8:44 AM, R49 was observed sitting in a Geri chair eating breakfast. R49 stated, They didn't give me the special cup, it's easier for me to drink with it. R49's breakfast tray consisted of a divided plate and a regular glass. R49's meal ticket stated, highlighted, 2 handled cup; Divided plate. On 3/10/2026 at 8:45 AM, Dietary Manager (DM) J was interviewed and stated, R49 should have a divided plate and a 2 handled cup for every meal. We must have missed it. We double check before the meal leaves. Sometimes we run out of the cups. We need to order more. DM J acknowledged R49's meal ticket stated, highlighted, 2 handled cup; Divided plate. On 3/10/2026 at 9:19 AM, Certified Nursing Assistant (CNA) R was interviewed and said she set up R49's breakfast tray this morning and there wasn't a 2 handled cup. CNA R further said she should have notified the nurse. On 3/10/2026 at 9:24 AM, Unit Manager (UM) T was interviewed and said R49 should have a 2 handled cup for every meal since R49 has hand contractures. UM T said the kitchen was responsible to provide dining adaptive equipment however the CNA should notify the nurse so that the nurse staff can obtain the adaptive equipment if it is missing.On 3/10/2026 at 10:15 AM, the Director of Nursing (DON) was interviewed and said the expectation is for R49 to have a 2 handled cup for every meal since R49 has hand contractures. Record review of R49's Electronic Health Record (EHR) revealed R49 was admitted to the facility on [DATE] with pertinent diagnoses of Peripheral Neuropathy, and Generalized Osteoarthritis.Review of the Minimum Data Set (MDS) dated [DATE] for R49 revealed a Brief interview for Mental Status BIMS of 6/15 severely impaired cognition and upper extremity impairment on both sides and required setup or clean up assistance for eating.Review of R49's care plan revealed in part, I am at nutritional risk r/t (related to) Dx. Osteoarthritis. I can feed myself with tray set-up and I have a good appetite. Review of the care plan did not reveal dining assistive equipment.Review of R49's physician orders did not reveal dining assistive devices.Review of the facility policy titled Quick resource Tool: Assistive Devices issued 9/1/2021 revealed in part.Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's ability to eat or drink independently. The assistive device/utensil requests will be entered into the individual resident profile in the menu management system for provision with each meal and snack.

Based on observation, interview and record review, the facility failed to ensure a medication cart was secured in accordance with professional standards for one medication cart of six medication carts reviewed for medication storage and safety.Findings include: On 03/08/2026 at 08:38 AM, during a tour of the third floor, a medication cart on hall Three- East was observed with a tubular lock key system extended outward (unlocked). The drawers to the cart were opened and closed to ensure findings. Three unidentified residents were observed sitting in wheelchairs close to the medication cart. One unidentified resident was observed walking up and down the Three-East hallway. No staff were observed in the Three-East hallway. The medication cart was stationed not accessible to view of the nursing desk.On 03/08/2026 at 08:40 AM, Nurse Q was observed walking back towards the Three-East Hall. Nurse Q was asked about the unlocked medication cart. Nurse Q stated that nurses are expected to lock their medication carts when not in view of their cart.On 03/10/2026 at 10:54 AM, the Director of Nursing (DON) was interviewed and informed that Nurse Q left her med cart unlocked and was not visible. The DON stated the medication carts should be locked.Review of the facility's policy Medication Storage in the Facility undated, revealed the following: Medication and biologicals are stored, securely, and properly following manufacturer's recommendations or those of the supplier.Medication rooms, carts, and medication supplies are locked or attended to by the persons with authorized access.

This citation pertains to intake number 2715345.Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistants were trained on repositioning techniques and implementing appropriate care when providing resident showers, resulting in one resident (R400) rolling off of the shower bed to the floor sustaining injuries. Findings include:On 01/22/2026 at 09:12 AM, R400 was observed in bed, on their back. R400's right knee was bent upwards and lying against the mattress. R400 had a right forehead/eyebrow scar from a laceration. R400 was queried about the laceration on their face. R400's speech was somewhat slurred, however, R400 was able to answer simple questions with incomplete, slow responses. R400 said (they) were on the bed (shower bed) and rolled over (R400 pointing to their right side) and fell on the shower floor. R400 was asked how many staff were helping with the shower and R400 said one. R400 was asked if they were still having pain. R400 pointed (with left hand) to their right knee and the knee fold. R400 exhibited a facial grimace and said, Hurt. Hurt.A review of R400's hospital documents dated 1/07/2026 revealed a diagnosis of Right eyebrow laceration requiring 13 sutures and Contusion of right elbow.A review of R400's electronic medical record (EMR)revealed an admission to the facility on 6/18/2019 with the diagnosis of Stroke Right-Side Hemiplegia (severe weakness of the right arm, leg, and sometimes face, resulting from damage to the left hemisphere of the brain), Diabetes mellitus, Diabetic retinopathy (a serious eye condition caused by high blood sugar damaging retinal blood vessels, potentially leading to blindness), Dysarthria (slurred, slow, or difficult-to-understand speech due to weakened or uncoordinated muscles), Aphasia (an acquired language disorder caused by damage to brain regions responsible for language), Vascular Dementia, and Seizure Disorder. Review of the Minimum Data Set (MDS) dated [DATE], revealed R400's Brief Interview for Mental Status (BIMS) was 99 which indicated the interview was unable to be completed.A review of R400's care plan dated 11/19/2025 revealed two people assist when showering.A review of R400's Minimum Data Set (MDS) section GG dated 10/13/2025 revealed the resident was totally dependent with shower/bath (MDS Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity, the assistance of 2 or more helpers is required for the resident to complete the activity.)A review of R400's Kardex (a quick-reference guide that summarizes key resident information, resident care) revealed the following: 2 persons assist when showering and using the shower bed.I am totally dependent on you for transferring.On 1/22/2026 at 09:40 AM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were asked to provide the name of the two CNAs involved in the care of R400 on 1/07/2026 when R400 rolled off the shower bed to the floor and sustained a laceration to the eyebrow. The NHA paused and stated, I need to check the schedule to see who was working. The DON and NHA were unable to provide evidence that the CNAs were provided training regarding the use of the shower bed and proper positioning after the accident.On 1/22/2026 at 11:04 AM, CNA B was interviewed via phone call and queried about the shower incident with R400. CNA B said they assisted CNA C with moving R400 with the Hoyer lift. CNA B asked CNA C if help was needed with showering R400. CNA B said CNA C denied needing assistance with the shower. CNA B reiterated that they only helped with the Hoyer lift.On 1/22/2026 at 11:27 AM, CNA C was interviewed about the shower incident involving R400. CNA C said, I got help from (CNA B) with transferring (R400) with a Hoyer lift. I took (R400) to the shower room and started showering. CNA C was asked if CNA B was in the shower room/stall assisting with the shower. CNA C stated, No. I was alone. I did not need help .I was washing (R400) and I asked (R400) to roll to their right side so that I could wash (R400's) bottom (CNA C demonstrated rolling the resident away) . R400 then rolled and kept rolling and I tried to push the shower bed toward the wall to stop the fall but (R400) ended up falling to the floor. CNA C was asked if R400's backside was facing CNA C. CNA C stated, Yes, (R400) was facing away from me. CNA C was asked how do nursing assistants receive information about resident care. CNA C said they don't receive a verbal report and read the Kardex at the beginning of the shift for resident care information. CNA C was asked if they received training on bed mobility and rolling the resident toward you, or away from you during care. CNA C stated, It depends on what I'm doing. If I'm washing their (residents bottom), I roll them away facing the other side.Why? Are you saying I should roll them toward me?On 1/23/2026 at 09:45 AM, Staff Development Coordinator (SDC) D was interviewed and queried about CNA training and if there was actual staff training for the use of shower beds. SDC D stated, Staff does not receive classroom training on how to use the shower beds. Staff Development Coordinator D was queried if CNAs received training on reading the Kardex. Staff Development Coordinator D said all staff are trained on giving morning report and reading the Kardex. SDC D was asked how staff were trained on bed mobility and positioning residents during shower/bed bath. SDC D stated, Staff should roll residents toward/facing them.they can roll out of bed if you roll residents away from you.I don't provide that type of training because it should be common sense.the CNAs should follow the Kardex.Review of the ORMI/Annual Tracking Log (Log for annual in-services/training for CNAs) which was undated, did not include training for bed mobility, Kardex training, nor shower bed training.On 1/23/2026 at 11:40 AM, the DON and the NHA were interviewed and queried about R400's fall from the shower bed. The DON was informed that CNA C reported showering R400 alone and rolled R400 away to wash their bottom, resulting in R400 rolling off the shower bed. The DON said she was unaware the resident rolled over to be washed and CNA C should have rolled the resident facing the CNA. The DON was queried about the number of staff required for R400 shower care according to the MDS, Care Plan, and the Kardex. The DON stated, There should have been two staff assisting with bathing. I see that we need to do some additional training.On 1/23/2026 at 10:53 AM, NHA said the facility does not have a specific policy for shower beds.A review of the facility's policy Bed Mobility (undated) revealed the following: Assisting Resident to Roll: 1. Instruct the resident to bring his or her arms over the stomach, bend the knees, and then roll toward the staff member.A review of the facility's policy Turning a Dependent Resident Toward you (undated) revealed the following: Reach over the resident, supporting the resident behind the shoulder with one hand and behind the hip with the other. Using good body mechanics roll the resident gently and smoothly toward you.

This citation pertains to intake number 2715345. Based on observation, interview, and record review, the facility failed to provide two staff during a shower and failed to reposition in a safe manner one dependent resident (R400) of three residents reviewed for accidents, resulting in a fall from the shower bed to the floor with subsequent pain and a facial laceration requiring sutures.Findings include: On 01/22/2026 at 09:12 AM, R400 was observed in bed on their back. R400's right knee was bent upwards and lying against the mattress. R400 was wearing glasses, a hospital style gown, and watching television. Observation of R400 revealed a right forehead/eyebrow scar. The sutures were removed. R400 was queried about the scar/laceration on their face. R400's speech was somewhat slurred, however, R400 was able to answer simple questions with incomplete, slow responses. R400 reported being on the bed (shower bed) and she rolled over and fell on to the shower floor. At that time, R400 pointed to their right side. R400 was asked how many staff were helping with the shower and R400 said one. R400 was asked if they were still having pain. R400, with the left hand) pointed to their right knee and the right knee fold. R400 exhibited a facial grimace and stated, Hurt. Hurt.A review of R400's electronic medical record (EMR) revealed an admission to the facility on 6/18/2019 with the diagnosis of Stroke Right-Side Hemiplegia (severe weakness of the right arm, leg, and sometimes face, resulting from damage to the left hemisphere of the brain), Diabetes mellitus, Diabetic retinopathy (a serious eye condition caused by high blood sugar damaging retinal blood vessels, potentially leading to blindness), Dysarthria (slurred, slow, or difficult-to-understand speech due to weakened or uncoordinated muscles), Aphasia (an acquired language disorder caused by damage to brain regions responsible for language), Vascular Dementia, and Seizure Disorder. A review of R400's Minimum Data Set (MDS) dated [DATE], noted a Brief Interview for Mental Status (BIMS) of 99 indicating the interview was unable to be completed.A review of R400's care plan dated 11/19/2025, revealed two people assist when showering.A review of R400's MDS section GG dated 10/13/2025, revealed R400 was totally dependent with shower/bath (MDS Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity, the assistance of 2 or more helpers is required for the resident to complete the activity.)-A. Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on bed revealed R400 was Dependent (MDS Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity, the assistance of 2 or more helpers is required for the resident to complete the activity.)-FF. Tub/shower transfer: The ability to get in and out of a tub/shower revealed R400 activity was not attempted due to medical condition or safety concerns.A review of R400's Kardex (a quick-reference guide that summarizes key resident information, resident care) revealed the following: 2 person assist when showering and using the shower bed.I am totally dependent on you for transferring.A review of R400's Order summary dated 1/08/2026 revealed the following: Lidocaine External Patch 4% Apply to right knee topically every 24 hours as needed for pain for 30 days.A review of R400's hospital documents dated 1/07/2026 revealed a diagnosis of Right eyebrow laceration requiring 13 sutures and Contusion of right elbow.On 1/22/2026 at 09:28 am, Licensed Practical Nurse (LPN) A was interviewed and queried about the incident that occurred with R400 in the shower room on 1/07/2026. LPN A said R400 did not want to use the wheelchair for their shower. R400 was placed on the shower bed by two Certified Nurse Assistants (CNA B and CNA C) with a Hoyer lift. LPN A said one of the CNAs was in the shower with R400. LPN A said the resident tried to reposition while being showered and fell off the shower bed. LPN A denied being in the shower room during care. LPN A said she was called to the shower room and R400 was screaming and bleeding from their head. LPN A reported she called 911.An observation of the shower room on 1/22/2026 at approximately 9:40 am, revealed a narrow opening to the actual shower stall. The shower bed could only fit partial way into the actual shower stall opening. In addition, there was a low bump (raised threshold) to enter the shower stall area floor. On 1/22/2026 at 11:04 AM, CNA B was interviewed via phone call and queried about the shower incident with R400. CNA B said they assisted CNA C with moving R400 with the Hoyer lift. CNA B asked CNA C if help was needed with showering R400. CNA B said CNA C denied needing assistance with the shower. CNA B reiterated that they only helped with the Hoyer lift.On 1/22/2026 at 11:27 AM, CNA C was interviewed (in person) about the shower incident involving R400. CNA C stated, I got help from (CNA B) with transferring (R400) with a Hoyer lift. I took (R400) to the shower room and started showering (R400). CNA C was asked if CNA B was in the shower room/stall assisting with the shower. CNA C said, No. I was alone. I did not need help .I was washing (R400) and I asked (R400) to roll to their right side so that I could wash (R400's) bottom (CNA C demonstrated rolling the resident away from her body) . R400 then rolled and kept rolling and I tried to push the shower bed toward the wall to stop the fall but (R400) ended up falling to the floor. CNA C was asked if R400's backside was facing (CNA C). CNA C stated, Yes, (R400) was facing away from me. CNA C was asked how CNAs receive information about resident care. CNA C said they don't receive a verbal report. CNA C said CNAs read the Kardex at the beginning of the shift for resident care information. CNA C was asked if they received training on bed mobility and rolling the resident toward you, or away from you during care. CNA C said, It depends on what I'm doing. If I'm washing their (resident's bottom) I roll them away facing the other side.Why? Are you saying I should roll them toward me?On 1/23/2026 at 09:45 AM, Staff Development Coordinator D was interviewed and queried about CNA training. Staff Development Coordinator D presented videos and staff annual tracking log (check off list). Staff Development Coordinator D was asked if there was actual training for the use of shower beds. Staff Development Coordinator D said, Staff does not receive classroom training on how to use the shower beds. Staff Development Coordinator D was queried if CNAs receive training on referencing the Kardex. Staff Development Coordinator D said all staff are trained on giving morning report and reading the Kardex. Staff Development Coordinator D was asked how staff were trained on bed mobility and positioning residents during shower/bed bath. Staff Development Coordinator D stated, Staff should roll resident toward/facing them.they can roll out of bed if you roll residents away from you.I don't provide that type of training because it should be common sense.the CNAs should follow the Kardex.On 1/23/2026 at 11:40 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were interviewed and queried about R400's fall from the shower bed. The DON said they were told that two CNAs used the Hoyer lift and transferred R400 to the shower bed. The DON stated, (CNA C) told me that she was bathing R400 and ( CNA B) was waiting by the door. The DON was asked if there were one or two CNAs providing a shower for R400. The DON stated, There were two CNAs. One CNA was washing (R400) and the other CNA was at the door. The DON was informed that CNA C specified showering R400 alone and rolled R400 away to wash their bottom, then the resident rolled off the shower bed. The DON stated, (CNA C) did not tell me that the resident rolled over to be washed. (CNA C) should have rolled the resident (facing the CNA). The DON was queried about the number of staff required for R400 shower according to the MDS, Care Plan, and the Kardex. The DON stated, There should have been two staff assisting with bathing. I see that we need to do some additional training.On 1/23/2026 at 10:53 AM, the NHA said the facility does not have a specific policy for shower beds.A review of the facility's policy Bed Mobility (undated) revealed the following: Assisting Resident to Roll: 1. Instruct the resident to bring his or her arms over the stomach, bend the knees, and then roll toward the staff member.A review of the facility's policy Turning a Dependent Resident Toward you (undated) revealed the following: Reach over the resident, supporting the resident behind the shoulder with one hand and behind the hip with the other. Using good body mechanics roll the resident gently and smoothly toward you. A review of the facility's policy Unit Rounds (undated) revealed the following:The purpose of unit rounds is to monitor residents throughout the day, connect with residents to assure their needs are met, and provide 1:1 education to team members if issues are identified. Rounds are conducted during shift change and include oncoming and off going shifts walking the unit together to assure residents are accounted for and residents needs are met.Shift huddles should occur after rounds are conducted.A request was made regarding a policy or procedure for the Kardex. None was provided by the end of survey.

Based on interview and record review the facility failed to ensure continuity of care for the role of an Infection Control Preventionist (ICP) and ensure the ICP completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards, outbreaks going undetected because of inadequate infection control surveillance, and a delay in infection control data collection and summary. Findings include: On 1/8/25 at 9:29 AM, a review of the facility's infection control program was with the Director of Nursing (DON) who has performed as the facility's designated infection control leader since August 2024. Review of the infection control books provided by the facility revealed no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed prior to her running the infection control program, it was overseen by the Infection Preventionist (IP) who resigned in early August of 2024. The DON was asked when they completed the Nursing Home Infection Preventionist Training Course training. The DON provided their certificate for IP that was dated November 18, 2024. The DON was then asked if there was anyone else in the facility that completed the required Nursing Home Infection Preventionist Training Course from August 2024 - November 17, 2024. The DON said, No. The course was over 19 hours. I did not have the time to complete the training until November (2024).

Based on interview, and record review the facility failed to maintain a continuous Antibiotic Stewardship Program that included monitoring antibiotic usage and following protocols for antibiotic use resulting in the potential for unnecessary medications and antibiotic resistance. Findings include: On 1/8/25 at 9:29 AM, a review of the facility's infection control program was conducted with the Director of Nursing (DON) who has performed as the facility's designated infection control leader since August 2024. Review of the infection control books provided by the facility revealed no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed prior to her running the infection control program, it was overseen by the Infection Preventionist (IP) who resigned in early August of 2024. The DON said, I hired another IP in September, but it did not work out. The DON was asked how they were able to identify residents on antibiotics during the months of August and September 2024. The DON said that they talked about residents on antibiotics during morning meetings, however, there was no documented evidence of resident use of antibiotices, indication of use, dosage, duration of antibiotic treatment, or the monitoring of symptoms In addition, the DON added, I just started working at this facility August 2024. A review of the Centers for Medicare and Medicaid Services (CMS) Form #20054 noted the following: Antibiotic Stewardship Program: o Written antibiotic use protocols on antibiotic prescribing, including the documentation of the indication, dosage, and duration of use of antibiotics; o Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections (e.g., SBAR tool for urinary tract infection (UTI) assessment, Loeb minimum criteria for initiation of antibiotics); o A process for a periodic review of antibiotic use by prescribing practitioners: for example, review of laboratory and medication orders, progress notes and medication administration records to determine whether or not an infection or communicable disease has been documented and whether an appropriate antibiotic has been prescribed for the recommended length of time. Determine whether the antibiotic use monitoring system is reviewed when the resident is new to the facility, when a prior resident returns or is transferred from a hospital or other facility, during each monthly drug regimen review when the resident has been prescribed or is taking an antibiotic, or any antibiotic drug regimen review as requested by the QAA committee; o Protocols to optimize the treatment of infections by ensuring that residents who require antibiotics are prescribed the appropriate antibiotic; and o A system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner. A review of the facility's policy, Infection Prevention and SOP, Antibiotic Stewardship revealed the following: The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events . The IP will critically evaluate each antibiotic ordered to determine the necessity of the antibiotic .Antibiotic use will be calculated on a monthly basis for QAQPI (Quality Assurance and Performance Improvement) purposes.

Based on interview and record review the facility failed to screen residents for eligibility to receive the COVID 19 vaccine and/or booster, provide education regarding the COVID 19 vaccine and/or booster, and offer the COVID 19 vaccine and/or booster, resulting in residents not receiving the Covid-19 immunization, and the potential for decreased protection from SARs-CoV-2 virus and serious illness and complications among residents that reside in the facility. Findings include: On 1/8/25 at 9:29 AM, a review of the facility's infection control program was conducted with the Director of Nursing (DON) who has performed as the facility's designated infection control leader since August 2024. Review of the infection control books provided by the facility revealed no documentation of an infection control program related to COVID 19 vaccines and/or boosters. The DON was asked about their COVID 19 vaccines. The DON stated, We do not have any COVID 19 vaccines. No one has received the vaccine. The DON also stated that they previously had an outside company that would come into the facility, provide the education, and administer COVID vaccines and/or boosters for staff and residents. However, the company was no longer available in Michigan. The DON was asked if residents would be offered COVID vaccines and/or booster. The DON said, We can call the pharmacy for COVID Vaccines. However, the DON was unable to explain why residents had not been offered and administered COVID 19 vaccines prior to the recertification survey. The facility policy for COVID 19 immunization for residents was requested but not provided.

Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program. Findings include: On 1/8/25 at 3:12 PM, the Nursing Home Administrator (NHA) was interviewed about the facility's QAPI program and process and identified customer service and adherence to the resident smoking policy as areas of concern and opportunities for improvement. The NHA said they were trying to get staff to speak with residents in a professional manner and that resident needs were being met. The NHA indicated that residents were keeping smoking paraphernalia on their persons and were going out to smoke when they got ready and there was no supervision. The NHA was unable to provide objective data gathered regarding these areas of concern. Therefore there was no analysis performed to identify trends and measure the effectiveness of the performance improvement plan. The NHA said the best practice would have been after the problem was identified to count the actual defective items and analyze the data monthly for improvement. The facility policy titled, Quality Assurance Performance Improvement, dated January 2019, was reviewed and the following was documented: - QAPI committee responsibilities include identifying and responding to quality deficiencies throughout the facility, and oversight of the facility's QAPI program. The committee must develop and implement corrective action and monitor those actions to ensure performance goals or benchmarks are achieve. It also determines what performance measures will be monitored, the schedule or frequency for monitoring this data, identifies opportunities for improvement and prioritizes issues by their size of impact. - Conducting the study: Measure the situation - utilizing objective criteria that outline the expected process to achieve desire outcome. The data tools can be customized to address the area being studies. Over a preplanned period of time, collect the data. On 1/8/25 at 5:30 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

Based on observation, interview and record review, the facility failed to continuously implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the potential for the spread of microorganisms, illness and other harmful pathogens among other residents that reside in the facility. Findings include: On 1/8/25 at 9:29 AM, a review of the facility's infection control program was conducted with the Director of Nursing (DON) who has performed as the facility's designated infection control leader since August 2024. Review of the infection control books provided by the facility revealed no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed prior to her running the infection control program, it was overseen by the Infection Preventionist (IP) who resigned in early August of 2024. The DON said, I hired another IP in September, but it did not work out. We did not have anyone to do the work . It just wasn't done. A review of the facility's policy, Infection Prevention and SOP, Infection Prevention and Control Program Overview Reveled the following: The infection prevention and control program is designed to identify and reduce the risk of acquiring and transmitting infection among residents, staff, volunteers students, and visitors Surveillance based on systematic data collection to identify to identify nosocomial infections .A system for the detection, investigation, analysis, and planning to prevent and control institutional outbreak of infectious diseases. 28214 Based on observation, interview, and record review the facility failed to properly store environmental services equipment. Findings include: On 1/7/25 at 11:30 AM, observation with Laundry Aid (LA) EE, revealed newly cleaned environmental services equipment (rags, mop heads, and towels) were stored in the soiled laundry area where items were placed into the washing machines. When asked, LA EE reported the items were clean and the facility did not any place to store them. On 1/8/25 at 2 pm with Head of Laundry (HL) FF the clean items were observed in the soiled laundry area. When queried HL FF acknowledged the environmental service equipment was not properly stored and explained that clean items should not be stored in an area where soiled articles are sorted and washed.

Based on observation, interview, and record review, the facility failed to: 1. Clean surfaces in the kitchen that were visibly soiled; 2. Maintain easily cleanable floors in various areas of the kitchen; 3. Ensure properly working garbage disposal and sink faucet; 4. Ensure chemical solution (quaternary) was an effective sanitizer; 5. Ensure pans were clean and air dried before stacking. This deficient practice would affect any resident that consumed food from the kitchen. Findings include: On 1/6/25 at 10:38 AM, during the initial tour of the kitchen with Dietary Manager (DM) N the following was observed: - caked up dust covered a white opaque circular disk above the handwashing sink - the trash can lid near the handwashing sink appeared dirty and uncleaned. - several floor tiles in the dish tank machine were chipped or missing rendering a floor surface not easily cleanable. - a splattering of grits was on the backsplash of the drain board on the clean side of the commercial dishmachine On 1/6/25 at 12:00 PM, during a return visit to the kitchen, the splattering of grits remained on the backsplash on the clean side of the dishmachine. DM N said it should be cleaned. On 1/8/25 at 2:15 PM, during a return visit to the kitchen with DM N the following was observed: - a pan on the floor underneath the garbage disposal contained a watery appearing fluid. The DM N said the garbage disposal was leaking. - a bucket of sanitizing solution was located under the counter in the cook's prep area. DM N said the solution contained a quaternary solution and should test near 200 parts per million (ppm). The solution tested less than 100 ppm. The DM N said the solution should have been disposed of. - in a clean pot/pan storage area, the surfaces of two full-size pans nestled together were soiled with food debris. Additionally, two 4-inch loaf pans were nestled together wet and soiled with food debris. The DM N said pan are supposed to be washed, sanitized, and put up dry. - the drip pan on the stove was very soiled with burnt food debris. The DM N said the drip pan should be cleaned after each meal. - the sink faucet in the cook's prep area did not shut off completely - several floor tiles were missing in the dry food storage room which exposed surfaces that were not easily cleanable. According to the 2013 FDA Food Code: -Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. - Section 4-602.11, Equipment Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be cleaned at any time during the operation when contamination may have occurred. - 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. - Section 4-703.11, Hot Water and Chemical. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized. - Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable On 1/8/25 at 5:30 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.

Based on interview and record review the facility failed to provide adequate supervision to a cognitively impaired resident (R501) who eloped from the facility unbeknownst to staff for two hours resulting in the likelihood for serious harm, injury, impairment, or death. Findings Include: According to the Facility Reported Incident dated 2/2/24, R501 was unable to be located in the facility during midnight rounds on 2/2/24 at approximately 12:30 AM. A facility campus wide search was conducted and R501 was not located. The Facility's Investigation summary dated 2/7/24 concluded that on 2/1/24 at approximately 10:45 PM R501 had walked out the facility's front door that was unattended and triggered the front door alarm. Licensed Practical Nurse (LPN) A went to the front door and looked in the foyer area and out the window. LPN A did not see anyone and reset the front door alarm without going outside the facility's front door. The reception-desk area at the front window/door area was unattended from approximately 10:30 PM - 11:00 PM during shift change. The afternoon shift 'reception-desk' staff had left prior to being relieved by the midnight shift 'reception-desk' staff. On 2/2/24 at approximately 10:30 AM the facility was notified that R501 had been located by police and brought to the hospital for evaluation. R501 was released to home in the care of family and not returned to the facility. A review of R501's Electronic Health Record (EHR) indicated the resident had resided at the facility since 2020 and was identified to have moderately impaired cognition with a Brief Interview for Mental Status (BIMS) of 10/15. R501 was ambulatory and required supervision and assistance from one person for activities of daily living that included getting dressed. On 2/21/24 at 9:30 AM during an interview with the Nursing Home Administrator (NHA) she said R501's midnight shift nurse, LPN E was conducting rounds at 12:30 AM and determined that R501 was not in his room. The facility and campus were searched, and the resident was not located. The police, local hospitals, and family of the resident were notified. On 2/2/24 at approximately 10:30 AM the hospital notified us that the resident was found, doing OK, and being released in the care of his family. The NHA said, The afternoon shift front desk person did not follow the facility's protocol. They left the front desk before the midnight shift staff arrived. The nurse (LPN A) didn't follow policy either. When the front door alarmed around 10:30 PM that night she only looked inside the facility and did not go outside. The Immediate Jeopardy (IJ) began on 2/1/24 when R501 eloped out the front door and through the parking lot gate. Nursing Home Administrator (NHA) was notified of the IJ on 2/21/24 at 2:04 PM. The surveyor confirmed by observation, interview, and record review that the IJ was removed and the deficient practice corrected on 2/2/24, prior to the start of the survey and therefore was past noncompliance. The IJ that began on 2/1/24 was removed on 2/2/24 when the facility: Review of assessment on new admission by the DON (Director of Nursing) or designee. - In-service elopement policy. - Conduct elopement drills - Update care plans as needed/ and orders as needed. Completed 02/02/24. The deficient practice was corrected on 2/2/24 after the facility took the following steps to systemically correct the noncompliance: (The Facility) identified 39 potential residents. An elopement risk assessment was conducted for residents residing in the facility at time of past noncompliance. Completed 2/2/24. Policy was reviewed and deemed appropriate at this time and ensured in-services were conducted on this to staff members. Reviewed the door alarm policy and deemed appropriate at this time. In-service was given to security to ensure there is no gap during shift change. The security will always ensure their relief is on seat before they can leave. Educate staff that the gate cannot be prop open and unattended. Nurse in-serviced on proper response to door alarm and elopement protocol. Completed 02/02/24. - Review of assessment on new admission by the DON (Director of Nursing) or designee. - In-service elopement policy. - Conduct elopement drills - Update care plans as needed/ and orders as needed. Completed 02/02/24. - Daily door alarms will be conducted by the Maintenance Director - on-going. - Social Service will conduct elopement assessment as needed. - on-going. - Administrator and/or designee will conduct elopement drill and conduct rounds as needed for any deficiencies noted during the drill - on-going. - Administrator and/or designee will report during QA monthly.

This citation pertains to MI 664. Based on interview and record review, the facility failed to ensure timely assessment and medical intervention for one resident (#801) reviewed for injury of unknown origin. Resulting in a delay in diagnosing a fracture and obtaining medical treatment and transfer to a hospital emergency room . Findings include: The facility self-reported that Resident #801 (R801) sustained an injury of unknown source. A review of the clinical record for R801 revealed an admitted [DATE] and discharged date of 3/11/2021. R801's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set, dated dated dated [DATE] documented severe cognitive impairment. On 3/23/2021 beginning at 2:05 PM, R801's clinical record and pertinent incident reports were reviewed and discussed with the Director of Nursing (DON). R801's clinical record documented in part the following progress notes: -3/10/2021 at 5:40 PM (created by Nurse A on 3/10/2021 at 10:50 PM): Observed resident on floor lying on side; upon assessment noted resident with bruising on face and hands. Resident is nonverbal and unable to explain what happened. (Physician H) phoned; ordered Tylenol 500 mg as needed (PRN) every six hours for pain. Neuro checks started and resident moved (to another room). Skull facial and right hand x-ray; waiting results. -3/10/2021 at 6:04 PM (created by Social Worker B): Social Worker (SW) was requested and escorted to the third floor by Evening Nurse Manager on 03/10/2021. Upon arrival, SW observed resident sitting calmly in wheelchair yet with physical injury to the face and hands. -3/11/2021 at 2:21 AM (created by Nurse C): Received patient in bed alert and watching the ceiling. Patient is nonverbal and no facial grimacing was noted during shift. Writer gave PRN Tylenol as prescribed. Writer kept bilateral hands elevated related to noted swelling. -3/11/2021 at 11:32 AM (created by Nurse D): STAT (testing requested to ensure prompt diagnostic results) x-rays for right hand swelling .on pain meds. -3/11/2021 at 12:42 PM (created by Nurse E): Writer received patient in bed asleep and easily arouse with confusion noted .Discoloration noted to patient face .Radiology technologist arrived and perform bilateral hand and forearm radiographs. Signs/symptoms of pain and distress noted. Scheduled pain med also given. A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -3/10/2021 at 5:45 PM (created by Nurse A): skull, orbital and facial x-ray STAT. -3/11/2021 at 10:23 AM (created by Nurse D): STAT x-ray to right hand for pain and swelling. When the DON was queried about her expectations for obtaining a STAT x-ray, she stated the x-ray should be completed within two to four hours. According to the DON, a facility document titled Unusual Occurrence Report, dated 3/10/2021 by Nurse A, was completed shortly after the fall occurred. The DON added that Nurse A noted bruising to (R801's) face and top of both hands on the report. The DON said the hand injuries suggested the resident was trying to break her fall when she fell . The DON acknowledged that according to the 3/10/2021 progress note created by Nurse A, R801 was supposed to receive skull facial and right hand x-rays. The DON stated that when the mobile radiology unit arrived on 3/10/2021 that R801 only received a facial x-ray. The DON added, There should have been an order on 3/10/2021 for the hand x-ray. A review of R801's radiology reports documented the hand x-rays were obtained on 3/11/2021 at 12:53 PM. Further review of R801's clinical record documented in part the following progress/clinical notes: -3/11/2021 at 4:20 PM (created by Nurse D): Received x-ray results with findings of proximal phalanx (a tubular long bone located in the bottom row of the finger bones) fracture of the second digit. Physician gave order to transfer to hospital. -3/11/2021 at 6:37 PM (created by Physician F): The Staff today asked me to see and treat the patient for pain due to a recent fall. Chief Complaint: Patient nonverbal with me, was guarding her face, eyes, and right hand/arm. Patient seen & examined today on Thursday 3/11/2021 with the Staff by my side. Patient was complaining of pain, location of pain is to the face/eyes/right hand/right arm; the duration of the pain has been for one day now supposedly, the pain is daily now, the pain is described as guarding her face and right hand/arm, the pain is worse with touch and certain movements. Radiology: Skull x-rays and right hand x-rays were done, both were reviewed by me today, and skull x-ray was negative for fracture but right hand showed a right index 2nd finger proximal phalanx fracture. The results were relayed to the Nurse DON today by me who said she updated the primary care physician. Assessment included: pain to the right hand; right index (2nd) finger proximal phalanx fracture. Plan included: continue with Tylenol for pain; transfer the patient to the hospital emergency room for the right hand 2nd finger (index) proximal phalanx fracture, for possible splint, and possible orthopedic surgery assessment. -3/11/2021 at 9:46 PM (created by Nurse G): (Ambulance) arrived to transfer resident to (hospital). On 3/23/2021 at 4:05 PM, when the Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, the DON said, I continue to educate. She's a new nurse. I did speak with her about ensuring x-rays are completed and to follow up on what was requested. We'll do an in-service on that. The Administrator stated there was nothing else they would like to add at this time. The facility document titled, Unusual Occurrences, undated, was reviewed and revealed the following: -The facility will take the measures necessary to provide residents, staff, and visitors with a safe and incident free environment. -An incident is an unusual occurrence that happens within the facility that results in, or could result in, resident/visitor injury or harm. -If an unusual occurrence occurs, immediately assess and treat the resident/visitor.

This citation pertains to intake #MI 61. Based on interview and record review, the facility failed to provide safe, appropriate and urgent interventions after dislodgement of a percutaneous endoscopic gastrostomy (PEG) tube, resulting in an Immediate Jeopardy for one (#501) of eight sampled residents reviewed for quality of care, resulting in harm when a urinary catheter was used as a substitute for a PEG tube, inserted into the PEG tube site, a physician order was not obtained for reinsertion of a tube or catheter by staff, an x-ray to verify proper placement of the catheter was delayed, liquid nutrition was administered through the catheter before the x-ray was performed and no physician order written [REDACTED]. The Director of Nursing was notified of the Immediate Jeopardy (IJ) on 9/19/19 at 6 PM. A plan to remove the immediacy was requested. The IJ was identified to begin on 8/25/19 at 9:50 PM when the PEG tube became dislodged and the urinary catheter was inserted as a substitution. The IJ was removed on 9/20/19, based on the facility's implementation of the plan of removal as verified by the surveyor. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with actual harm due to all staff not yet being inserviced and sustained compliance has not been verified by the State Agency. Findings include: The complainant reported to the State agency that resident #501's PEG tube became dislodged and the resident's bowel was ruptured when the tube was reinserted by facility staff, resulting in surgery for [REDACTED]. On 9/19/19 at 11 AM, the clinical record for resident #501 was reviewed and revealed: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted severe cognitive impairment and extensive assistance required for care including eating. The resident experienced significant weight loss and had a PEG tube (a feeding tube used for delivery of liquid nutrition directly into the stomach) inserted by mouth via endoscope directly into the stomach and coming out through the abdomen at the hospital on [DATE] due to poor oral food intake. Six cans of tube feeding formula daily, was prescribed through the PEG tube on 8/17/19 upon return to the facility. Per progress notes, the following events occurred: Notes by (assigned) nurse A on 8/25/2019 at 10:25 PM-Resident pulled peg tube out during flush at 9:50 PM foley (urinary catheter) placed Abdominal x-ray ordered for placement (location of the catheter). Will call hospital for reinsert for peg tube spoke to physician A portable abdominal x-ray was done at the facility on 8/26/19 at 10:11 AM to check for placement of the foley catheter, 12 hours after the PEG tube became dislodged and the foley was inserted. The x-ray order written by nurse A, did not note Stat (to be done immediately). The x-ray showed: A catheter [MEDICATION NAME] (goes crosswise) the right upper quadrant possibly representing a PEG tube. Correlation (an association) recommended. The organ that the catheter [MEDICATION NAME] was not identified on the x-ray. (See CAT scan result later in citation.) Midnight shift nurse H noted on the resident's medication records that 2 cans of tube feeding formula were given through the foley during the night of 8/25 to 8/26/19, before the x-ray was obtained. Notes by Nurse Practitioner on 8/26/2019 at 10:42 AM-Resident seen and examined in dining room Resident pulled out his PEG tube last night per staff. Foley in placed at this time. Resident will be sent back to the hospital for PEG replacement Adult failure to thrive-patient on Tube Feeding via PEG. Resident pulled out PEG last night. Resident schedule for PEG replacement at (hospital). Note by nurse on 8/26/2019 at 4:09 PM- noticed small bit of drainage to peg site 8/26/2019 at 9:13 PM Transfer to Hospital Summary note two cans of (formula) given as ordered noted drainage on peg tube bandage, dressing changed. After giving the formula, the following note read: Negative for residual. This is the first time staff was noted to have checked. (A PEG is checked for residual fluid to determine the amount of gastric contents in the stomach, to check for proper placement of the tube. The stomach usually has some residual fluid unless it is empty.) 8/26/2019 at 10:17 PM Transfer to Hospital Summary note-Resident was noted to have a moderate large amount of foul smelling drainage coming from peg tube site. (PCP) informed of residents condition transfer resident to hospital resident left facility 8/26/2019 at 10:33 PM Acute Transfer Form Note- Reason(s) for Transfer: Other -- foul smelling fluid oozing from peg tube site Unplanned pain at peg tube site. Negative bowel sounds in right lower quadrant. Recent peg tube placement. 8/26/18 addendum Transfer to Hospital Summary-Resident noted with foul smelling discharge coming from peg tube site that smelled like stool. The hospital records noted the following: emergency room treatment notes- recently place PEG tube on 8/16/2019 and that reportedly exchanged for a new one earlier today PEG tube malfunction, most notable for 'poop coming out the side of it' per the (family member) PEG tube in place, with what appears to be soft stool coming around the sides of the PEG tube a presentation concerning for PEG tube dislodgement in a recently placed peg tube now with frank stool coming out of the sides of it in a patient without evidence of bowel obstruction I am concerned for a PEG tube dislodgement and appropriate replacement, therefore get a CAT scan abdomen Patient's imaging (CAT scan) notable for PEG tube being in the colon (large intestines), start the patient on IV antibiotics CAT scan result- perforation of the [MEDICATION NAME] colon with a gastostomy tube inflated Final impression: PEG tube inappropriately in the [MEDICATION NAME] colon. (A PEG tube and foley catheter have a balloon at the end that is inflated after insertion to secure the devices in place to prevent dislodgement.) There appears to be a fecalent material coming out of the PEG insertion site, around the PEG tube itself The patient was admitted in critical condition Acute perforated bowel. status [REDACTED]. The resident was placed on IV antibiotics, [MEDICATION NAME] daily, Fluconazole daily and [MEDICATION NAME] every eight hours. From 1 PM to 3:30 PM, the following interviews took place: Nurse A was asked by phone what happened and said, I was new (date of hire 8/2/19) and a new nurse. This never happened to me before, a PEG tube coming out. I did not know what to do. I went to tell someone and (nurse B and C) came to help. When asked why a foley was used and not a PEG tube, she said, I assumed that's what they were supposed to do to maintain patency (keep the PEG tube site open). When asked if an x-ray was taken after the foley was inserted and if ordered Stat, nurse A said it was done, but not during her (afternoon) shift and said she did not know if it was ordered Stat or should have been. When asked by phone what she would do if a resident's PEG tube came out, nurse B said, I would get a foley. I was told to put in a foley if the PEG came out to maintain patency. It has to be done within two hours to prevent it (the insertion site) from closing up. When asked if the facility had PEG tubes available, nurse B said, I don't know if there are any. Staff Development Coordinator (Inservice nurse) D was queried and said, You can insert a foley if the PEG comes out. Was it a weekend? Maybe they didn't have a key to the supply room (to get a PEG tube). (The incident occurred on a Sunday. The central supply room is kept locked on weekends.) Staff D said unsolicited, They can even be fed through a foley. The central supply room was then observed with staff D and Central Supply manager E. There were two stacks of about 10 PEG tubes of various sizes near the door entrance. When asked if the tubes were just ordered and received, staff [NAME] said, No. We've always had them for a long time. An Incident report was reviewed with the Director of Nursing (DON). The report, written by nurse A noted: Pulled PEG tube out Writer observed nurse (not identified) insert foley abdominal x-ray ordered. The order for the portable x-ray, dated 8/25/19 at 10:53 PM, noted: Abdominal x-ray AP (anterior/posterior), (not Stat). When queried, the DON said, I know it was a foley and we did an inservice the next day because when I heard they put a foley in, I thought it should be done. An inservice training Attendance Form presented by staff D dated 8/27/19, was then reviewed with the DON titled PEG Reinsertion and Infection Control Safety. The duration of the inservice-15 minutes. The contents of the class, dated 5/27/11, titled Gastrostomy Tube Reinsertion (Chronic)-Action/Rationale, noted: Confirm physician's order for gastrostomy tube change; verify ordered tube size and type Obtain the correct size and type of replacement tube Insert the deflated balloon end of the gastrostomy tube into the ostomy site Inflate the balloon Aspirate stomach contents (check residual) to assess placement The first gastrostomy tube placed usually does not have a balloon and may be sutured in place. The first tube should not be changed for the first 14-21 days after placement and should be changed only by a physician. If this first tube should come out, the physician should be notified immediately Nurses A, B and C were not among the class attendees per the Attendance Form. The DON said, They should have got the inservice. Regarding PEG tubes being accessible to staff, the DON said, There is a key (to central supply room) on every key ring (carried by nurses). They should have gone there to get one. Regarding the timeliness of the x-ray, the DON said, It should have been ordered Stat. Regarding a physician order to reinsert a PEG or a foley, the DON said an order should have been written. When asked if there was a care plan regarding maintenance of the resident's PEG tube with interventions, such as keeping the head elevated, checking for placement/residual or what to do if dislodged, the DON looked in the resident's clinical record, did not find one and said a care plan should have been written. A request was made from staff D and the DON to see a policy on use of a foley catheter in place of a PEG for reinsertion, but none was provided by survey end on 9/19/19. On 9/19/19 at 5 PM, the resident's Primary Care Physician (PCP) was queried by phone about the use of the foley and said that he did not authorize using it. He said however, A foley should be put in to maintain patency because it's soft. They aren't allowed to put in PEGs because they are too hard and may perforate. If a foley is put in, they can send them (resident's) out the next day. This contradicted the inservice about interventions if a new PEG tube became dislodged. On 9/24/19 at 1:30 PM, when queried, the Medical Director said a PEG tube should be reinserted if available if a tube came out and an x-ray should be ordered Stat. He then said an x-ray would not tell exactly where the tube was located, but indicated that getting an x-ray was the standard of practice. He said the tube should only be inserted into the site 2 to 3 inches beneath the skin of the abdomen to maintain patency, then inflate the balloon. When told what the PCP said about staff not being allowed to reinsert PEG tubes, the Medical Director said that both PEG tubes and foley catheters were soft and flexible and said he would look into the situation further. On 9/20/19 at 8 AM, per review of the facility's undated Gastrostomy Tube Change and Reinsertion policy that was part of the inservice training on 8/27/19: Purpose-Gastrointestinal tubes will be changed/reinserted per physician's order, in resident's with established tracts in order to maintain patency for nutritional maintenance. A nurse performs this procedure Obtain physician's order assemble equipment Gently insert tip of tube into (PEG tube site) and guide it through tract into stomach. Check placement of tube after insertion. Aspirate gastric contents Inject air. Auscultate for air entry. Fill balloon per physician's order with water Verify with x-ray if necessary' or if there is a physician order. The policy did not address use of a foley catheter if a PEG tube was unavailable, obtaining a Stat x-ray, maintaining patency by insertion 2-3 inches below the skin as stated by the Medical Director or a procedure for dislodgement of a new PEG tube as instructed in the inservice. The facility submitted the following plan to remove the immediacy on 9/20/19: Element #1 Resident #501 no longer reside at the facility. Element #2 Residents that reside at the facility and have Enteral Feeding tube can be affected. An audit was conducted to residents that reside at the facility to ensure that residents with enteral feeding tube have orders to check for residual and placement prior to initiating feeding and medication. An assessment was completed to make sure the residents with eternal feeding have the right tude in place. Element #3 One to one in-service was provided to the three nurses mentioned in the citation with competency check completed and about the gastrointestinal tube change and reinsertion policy. Licensed Nursing staff will be in serviced about policies, gastrointestinal tube change and reinsertion, enteral nutrition guidelines and to include calling the MD to get order to replace Enteral feeding tube then gathering the right appropriate supplies gastrostomy feeding tube for peg tube placement from supply room, having eternal feeding tubes readily available on each unit in case of emergency and ordering a stat x-ray to verify placement after insertion of the peg tube. Policies gastrointestinal tube change and reinsertion, enteral Nutrition guidelines were reviewed and deemed appropriate. Element #4 The DON/designee will randomly audit resident with enteral feeding to ensure that residents with enteral feeding tube have orders to check for residual and placement prior to initiating feeding and medication and to make sure gastrostomy feeding tube availability in case of emergency. Weekly times four (4) weeks and then monthly times three (3) months. The Director of Nursing is responsible for compliance. Element #5 Date of compliance: 9/20/2019

This citation pertains to intake #MI 61. Based on interview and record review, the facility failed to provide safe, appropriate and urgent interventions after dislodgement of a percutaneous endoscopic gastrostomy (PEG) tube, resulting in an Immediate Jeopardy for one (#501) of six sampled residents reviewed with a PEG tube, resulting in harm when a urinary catheter was used as a substitute for a PEG tube, inserted into the PEG tube site and then liquid nutrition administered through the catheter, leading to emergency hospital treatment and abdominal surgery for [REDACTED]. Administrator was notified of the Immediate Jeopardy (IJ) on 9/19/19 at 6 PM. A plan to remove the immediacy was requested. The IJ was identified on 8/25/19 at 9:50 AM when the PEG tube became dislodged, the urinary catheter was inappropriately used and was improperly inserted into the bowel. The IJ was removed on 9/20/19, based on the facility's implementation of the plan of removal as verified by the surveyor. Although the IJ was removed, the facility's deficient practice was not corrected and remained isolated with actual harm due to all staff not yet being inserviced and sustained compliance has not been verified by the State Agency. Findings include: The complainant reported to the State agency that resident #501's PEG tube became dislodged and the resident's bowel was ruptured when the tube was reinserted by staff, resulting in surgery for [REDACTED]. On 9/19/19 at 11 AM, the clinical record for resident #501 was reviewed and revealed: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted severe cognitive impairment and extensive assistance required for care including eating. The resident experienced significant weight loss and had a PEG tube, used for delivery of liquid nutrition directly into the stomach, inserted by mouth via endoscope directly into the stomach and coming out through the abdomen at the hospital on [DATE], due to poor oral food intake. Six cans of tube feeding formula daily, was prescribed through the PEG tube on 8/27/19 upon return to the facility. Per progress notes, the following events occurred: Notes by (assigned) nurse A on 8/25/2019 at 10:25 PM-Resident pulled peg tub out during flush at 9:50 PM foley (urinary catheter) placed Abdominal x-ray ordered for placement (location of the foley catheter). Will call hospital for reinsert for peg tube spoke to physician A portable abdominal x-ray was done at the facility on 8/26/19 at 10:11 AM, 12 hours after the PEG tube became dislodged, which showed: A catheter [MEDICATION NAME] (goes crosswise) the right upper quadrant possibly representing a PEG tube. Correlation (an association) recommended. The organ that the catheter [MEDICATION NAME] was not identified on the x-ray. (See CAT scan result later in report.) Midnight shift nurse H noted on the resident's medication record that 2 cans of tube feeding formula were then given through the foley during the night of 8/25 to 8/26/19, before the x-ray was obtained. Notes by Nurse Practitioner on 8/26/2019 at 10:42 AM-Resident seen and examined in dining room Resident pulled out his PEG tube last night per staff. 'Foley' in placed at this time. Resident will be sent back to the hospital for PEG replacement Resident schedule for PEG replacement at (hospital). Note by nurse on 8/26/2019 at 4:09 PM- noticed small bit of drainage to peg site 8/26/2019 at 9:13 PM Transfer to Hospital Summary note two cans of (formula) given as ordered noted drainage on peg tube bandage, dressing changed. After giving the cans, the following note read: Negative for residual. This is the first time staff was noted to have checked. (A PEG is checked for residual fluid to determine the amount of gastric contents in the stomach, to check for proper placement of the tube. The stomach usually has some residual fluid unless it is empty.) 8/26/2019 at 10:17 PM Transfer to Hospital Summary note-Resident was noted to have a moderate large amount of foul smelling drainage coming from peg tube site order transfer resident to hospital resident left facility Reason(s) for Transfer: Other -- foul smelling fluid oozing from peg tube site Unplanned pain at peg tube site. Negative bowel sounds in right lower quadrant. Recent peg tube placement smelled like stool. The hospital records noted the following: recently place PEG tube on 8/16/2019 and that reportedly exchanged for a new one earlier today PEG tube malfunction PEG tube in place, with what appears to be soft stool coming around the sides of the PEG tube a presentation concerning for PEG tube dislodgement in a recently placed peg tube now with frank stool coming out of the sides of it in a patient without evidence of bowel obstruction I am concerned for a PEG tube dislodgement and appropriate replacement, therefore get a CAT scan abdomen Patient's imaging (CAT scan) notable for PEG tube being in the colon (large intestines), start the patient on IV antibiotics CAT scan result- perforation of the [MEDICATION NAME] colon with a gastostomy tube inflated Final impression: PEG tube inappropriately in the [MEDICATION NAME] colon. (A PEG tube and foley catheter have a balloon at the end that is inflated after insertion to secure the devices in place to prevent dislodgement.) There appears to be a fecalent material coming out of the PEG insertion site, around the PEG tube itself The patient was admitted in critical condition Acute perforated bowel. status [REDACTED]. The resident was placed on IV antibiotics, [MEDICATION NAME] daily, Fluconazole daily and [MEDICATION NAME] every eight hours. From 1 PM to 3:30 PM, the following interviews took place: Nurse A was asked by phone what happened and said, I was new (date of hire 8/2/19) and a new nurse. This never happened to me before, a PEG tube coming out. I did not know what to do. I went to tell someone and (nurse B and C) came to help. When asked why a foley was used and not a PEG tube, she said, I assumed that's what they were supposed to do to maintain patency (keep the PEG tube insertion site open). When asked if an x-ray was taken and if ordered Stat, nurse A said it was not done during her (afternoon) shift and she did not know if it was ordered Stat or should have been. When asked by phone what she would do if a resident's PEG tube came out, nurse B said, I would get a foley. I was told to put in a foley if the PEG came out to maintain patency. It has to be done within two hours to prevent it (the insertion site) from closing up. When asked if the facility had PEG tubes available, nurse B said, I don't know if there are any. (Nurse C could not be reached for comment.) Staff Development Coordinator (Inservice training nurse) D was queried and said, You can insert a foley if the PEG comes out and said unsolicited, They can even be fed through a foley. The central supply room was then observed with staff D and Central Supply manager [NAME] to have about 10 PEG tubes in various sizes near the door entrance that staff [NAME] said had been there for a long time. An Incident report was reviewed with the Director of Nursing (DON). The report, written by nurse A, that noted: Pulled PEG tube out insert foley abdominal x-ray ordered. The order for the portable x-ray dated 8/25/19 at 10:53 PM, noted: Abdominal x-ray AP (anterior/posterior) (not Stat). The DON said, It should have been ordered Stat. Regarding PEG tubes being accessible to staff, the DON said, There is a key (to central supply room) on every key ring (carried by nurses). They should have gone there to get one. Regarding an order for [REDACTED]. When asked if there was a care plan regarding maintenance of the resident's PEG tube with interventions, such as keeping the head elevated, checking for placement/residual or what to do if dislodged, the DON looked in the clinical record, did not find one and said a care plan should have been written. On 9/19/19 at 5 PM, the resident's Primary Care Physician (PCP) was queried by phone about the use of the foley and said that he did not authorize using it. He said however, A foley should be put in to maintain patency because it's soft. They aren't allowed to put in PEGs because they are too hard and may perforate. If a foley is put in, they can send them (resident's) out the next day. On 9/24/19 at 1:30 PM, when queried, the Medical Director said a PEG tube should be reinserted if available if a tube came out and an x-ray should be ordered Stat. He then said an x-ray would not tell exactly where the tube was located, but indicated that getting an x-ray was the standard of practice. He said the tube should only be inserted into the site 2 to 3 inches beneath the skin of the abdomen to maintain patency then inflate the balloon. On 9/20/19 at 8 AM, per review of the facility's undated Gastrostomy Tube Change and Reinsertion policy: Purpose-Gastrointestinal tubes will be changed/reinserted per physician's orders [REDACTED]. A nurse performs this procedure Obtain physician's orders [REDACTED]. Check placement of tube after insertion. Aspirate gastric contents Inject air. Auscultate for air entry. Fill balloon per physician's orders [REDACTED]. Per a Gastrostomy Tube Reinsertion (Chronic)-Action/Rationale policy dated 5/27/11: The first gastrostomy tube placed usually does not have a balloon and may be sutured in place. The first tube should not be changed for the first 14-21 days after placement and should be changed only by a physician. If this first tube should come out, the physician should be notified immediately The policies did not address use of a foley catheter if a PEG tube was unavailable, obtaining a Stat x-ray or maintaining patency by insertion 2-3 inches below the skin, as stated by the Medical Director. The facility submitted the following plan to remove the immediacy on 9/20/19: Element #1 Resident #501 no longer reside at the facility. Element #2 Residents that reside at the facility and have Enteral Feeding tube can be affected. An audit was conducted to residents that reside at the facility to ensure that residents with enteral feeding tube have orders to check for residual and placement prior to initiating feeding and medication. An assessment was completed to make sure the residents with eternal feeding have the right tude in place. Element #3 One to one in-service was provided to the three nurses mentioned in the citation with competency check completed and about the gastrointestinal tube change and reinsertion policy. Licensed Nursing staff will be in serviced about policies, gastrointestinal tube change and reinsertion, enteral nutrition guidelines and to include calling the MD to get order to replace Enteral feeding tube then gathering the right appropriate supplies gastrostomy feeding tube for peg tube placement from supply room, having eternal feeding tubes readily available on each unit in case of emergency and ordering a stat x-ray to verify placement after insertion of the peg tube. Policies gastrointestinal tube change and reinsertion, enteral Nutrition guidelines were reviewed and deemed appropriate. Element #4 The DON/designee will randomly audit resident with enteral feeding to ensure that residents with enteral feeding tube have orders to check for residual and placement prior to initiating feeding and medication and to make sure gastrostomy feeding tube availability in case of emergency. Weekly times four (4) weeks and then monthly times three (3) months. The Director of Nursing is responsible for compliance. Element #5 Date of compliance: 9/20/2019

This citation pertains to intake #MI 61. Based on interview and record review, the facility failed to ensure proper training and demonstrations of competency by nursing staff involving one (#501) of eight sampled residents reviewed for nursing services, resulting in staff inappropriately and improperly inserting a urinary catheter (foley) to replace a dislodged percutaneous endoscopic gastrostomy (PEG) tube, used for delivery of liquid nutrition directly into the stomach, leading to emergency hospital treatment and abdominal surgery, including bowel and gastric resections for a perforated bowel. Findings include: The complainant reported to the State agency that resident #501's PEG tube became dislodged and the resident's bowel was ruptured when the tube was reinserted by staff, resulting in surgery for [REDACTED]. On 9/19/19 at 11 AM, the clinical record for resident #501 was reviewed and revealed: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] noted severe cognitive impairment and extensive assistance required for care including eating. The resident experienced significant weight loss and had a PEG tube initially inserted at the hospital on [DATE] due to poor oral food intake. Six cans of tube feeding formula daily, was prescribed through the PEG tube. Per progress notes dated by nurse A on 8/25/2019 at 10:25 PM-Resident pulled peg tub out at 9:50 PM foley placed A portable abdominal x-ray was done at the facility to check for proper placement of the foley catheter on 8/26/19 at 10:11 AM, 12 hours after the PEG tube became dislodged and the foley was inserted. The x-ray order written by nurse A, did not note Stat (to be done immediately). Nurses noted on the resident's medication records that 2 cans of tube feeding formula were given through the foley catheter by midnight shift nurse H during the night of 8/25 to 8/26/19, before the x-ray was obtained. Notes by Nurse Practitioner on 8/26/2019 at 10:42 AM-Resident seen and examined in dining room Resident pulled out his PEG tube last night per staff. 'Foley' in place at this time. Resident will be send back to the hospital for PEG replacement 8/26/2019 at 9:13 PM Transfer to Hospital Summary note two cans of (tube feeding formula) given noted drainage on peg tube bandage, dressing changed. After giving the cans, the following note read: Negative for residual, the first time staff indicated about checking for residual. (A PEG tube is checked for residual fluid, the amount of gastric contents in the stomach, as a means of determining proper tube placement. The stomach usually has some residual fluid unless it is empty.) At 10:17 PM, Resident was noted to have a moderate large amount of foul smelling drainage coming from peg tube site transfer resident to hospital foul smelling fluid oozing from peg tube site that smelled like stool. The hospital records noted the following: peg tube now with frank stool coming out of the sides of it I am concerned for a PEG tube dislodgement and appropriate replacement, therefore get a CAT scan abdomen CAT scan result- Final impression: PEG tube inappropriately in the [MEDICATION NAME] colon The patient was admitted in critical condition Acute perforated bowel. status [REDACTED]. Nurse A (the resident's assigned nurse) was asked by phone what happened and said, I was new (date of hire 8/2/19) and a new nurse. This never happened to me before, a PEG tube coming out. I did not know what to do. I went to tell someone and (nurse B and C) came to help. When asked who inserted the foley, nurse A said it was nurse B. When asked why a foley was used and not a PEG tube, she said, I assumed that's what they were supposed to do to maintain patency (keep the insertion open). When asked if an x-ray was taken to confirm proper placement of the foley catheter and if ordered Stat, nurse A said it was not done during her (afternoon) shift and did not know if it was ordered Stat or should have been. When asked by phone what she would do if one of her resident's PEG tubes came out, nurse B said, I would get a foley. I was told to put in a foley if the PEG came out to maintain patency. It has to be done within two hours to prevent it (the insertion site) from closing up. When asked if the facility had PEG tubes available, nurse B said, I don't know if there are any and said that nurse A had inserted the foley. I was just there to provide assistance and to inflate the balloon (at the end of the catheter to hold it in place to prevent dislodgement). (Nurse C could not be reached for comment.) Staff Development Coordinator (Inservice nurse) D was queried and said, You can insert a foley if the PEG comes out. Was it a weekend? Maybe they didn't have a key to the supply room (to get a PEG tube). (The incident had occurred on a Sunday. The central supply room is kept locked on weekends.) Staff D said unsolicited, They can even be fed through a foley. The central supply room was then observed with staff D and Central Supply manager E. There were two stacks of about 10 PEG tubes in various sizes near the door entrance. When asked if the tubes were just ordered and received, staff [NAME] said, No. We've always had them for a long time. On 9/19/19 at 5 PM, the resident's Primary Care Physician (PCP) was queried by phone about the use of the foley and said that he did not authorize inserting it. There was no documented order to reinsert a PEG tube or to use a foley catheter. The Incident report was reviewed with the (DON). When queried, the DON said, I know it was a foley and we did an inservice the next day because when I heard they put a foley in, I thought it should be done. Staff D presented an inservice training Attendance Form dated 8/27/19 titled PEG Reinsertion and Infection Control Safety. The duration of the inservice-15 minutes. The contents of the class dated 5/27/11, titled Gastrostomy Tube Reinsertion (Chronic)-Action/Rationale, was reviewed with the DON and noted: Confirm physician's orders [REDACTED]. The first tube should not be changed for the first 14-21 days after placement and should be changed only by a physician. If this first tube should come out, the physician should be notified immediately Special consideration: The client and care person education will assist them in knowing how to react if tube comes out. The Attendance Form had signatures of 17 staff members, but only four attendees were nurses, including the DON. Per the facility staff roster, there were 52 nurses employed. Nurses A, B and C, who were involved in the incident, were not listed among the class attendees. There was no documented indication they received one to one inservice training. The DON said, They should have got the inservice. Regarding PEG tubes being accessible to staff, the Director of Nursing (DON) said, There is a key (to central supply room) on every key ring (carried by nurses). They should have gone there to get one. Regarding the timeliness of the x-ray, the DON said, It should have been ordered Stat. Regarding a physician's orders [REDACTED].>On 9/24/19 at 1:30 PM, when queried, the Medical Director said a PEG tube should be reinserted if available if a tube came out and an x-ray should be ordered Stat. He then said an x-ray would not tell exactly where the tube was located, but indicated that an x-ray was the standard of practice. He said if the reinserted tube was too small for the insertion site, the tube feeding may come back up and leak out, so if that happened, the resident should be sent to the hospital for placement. He said the tube should only be inserted into the site 2 to 3 inches beneath the skin to maintain patency then inflate the balloon. None of these instructions were mentioned in the inservice presentation. The inservice did not specify if reinsertion was for purposes of maintaining patency until transport to the hospital for placement or whether for permanent placement further down into the stomach, in which there were no detailed instructions provided either way. On 9/20/19 at 8 AM, per review of the facility's undated Gastrostomy Tube Change and Reinsertion policy that was part of the inservice training on 8/27/19: Purpose-Gastrointestinal tubes will be changed/reinserted per physician's orders [REDACTED]. A nurse performs this procedure Obtain physician's orders [REDACTED]. Check placement of tube after insertion. Aspirate gastric contents Inject air. Auscultate for air entry. Fill balloon per physician's orders [REDACTED]. The policy did not address use of a foley catheter if a PEG tube was unavailable, obtaining a Stat x-ray, maintaining patency by insertion 2-3 inches below the skin as indicated by the Medical Director or the procedure for dislodgement of a new PEG tube as instructed in the inservice.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY ASSESS AND MONITOR THE SKIN OF TWO RESIDENTS (#S 502 AND 515) OF SIX RESIDENTS REVIEWED WITH PRESSURE ULCERS OUT OF A TOTAL OF 24 SAMPLED RESIDENTS, RESULTING IN THE DEVELOPMENT OF AVOIDABLE PRESSURE ULCERS. FINDINGS INCLUDE: ON 4/16/13 AT 12:00 P.M., 1:00 P.M., 2:00 P.M. AND 3:00 P.M., RESIDENT #502 WAS OBSERVED SITTING UP IN A GERI CHAIR IN THE ROOM IN THE SAME UNCHANGED POSITION. THERE WAS AN INDWELLING CATHETER FED THROUGH RESIDENT #502'S LEFT PANT LEG. ON 4/16/13 AT 3:20 P.M. RESIDENT #502 WAS OBSERVED IN BED. THE STAFF IN THE ROOM STATED "I'M THE CNA (CERTIFIED NURSES ASSISTANT). WE JUST PUT THE RESIDENT TO BED." ON 4/17/13 AT 9:30 A.M., RESIDENT #502 WAS OBSERVED FOR WOUND CARE WHILE RESTING IN BED WITH A TUBE FEEDING INFUSING AT 90 CC/HOUR. RESIDENT #502 WAS NON-VERBAL, HAD AN INDWELLING FOLEY CATHETER, AN ALTERNATING PRESSURE MATTRESS ON THE BED AND A FALL MAT ON THE RIGHT SIDE OF THE BED. RESIDENT #502'S COCCYX WOUND WAS 5.5 BY 3.6 BY 0.8 CM (CENTIMETERS) AS MEASURED BY WOUND CARE NURSE "H" & "I". THE WOUND'S EDGES WERE IRREGULAR IN APPEARANCE. THE WOUND BED WAS PINK WITH HEAVY NON-ODOROUS SEROSANGUINOUS DRAINAGE. UPON COMPLETION OF THE WOUND CARE PROCEDURE, WOUND CARE NURSE "H" STATED RESIDENT #502 WAS NOT admitted WITH THE PRESSURE ULCER. REVIEW OF RESIDENT #502'S MEDICAL RECORD WITH WOUND CARE NURSES "H" AND "I" ON 4/17/13 AT 10:45 A.M. REVEALED THE FOLLOWING: PER THE ADMISSION RECORD FACE SHEET, RESIDENT #502 WAS ORIGINALLY admitted INto the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. PER THE NURSING ADMISSION assessment dated [DATE] RESIDENT #502 WAS readmitted WITH NO DOCUMENTED SKIN BREAKDOWN. PER THE FACILITY'S "ASSESSMENT OF RISK FACTORS FOR DEVELOPMENT OF PRESSURE ULCERS" COMPLETED BY WOUND CARE NURSE "H" ON 2/8/13, RESIDENT #502 WAS AT RISK FOR SKIN BREAKDOWN SECONDARY TO HAVING A [DIAGNOSES REDACTED]." PER THE BRADEN SCALE (A TOOL USED TO MEASURE PRESSURE SORE RISK WITH A SCORE OF 12 OR LESS REPRESENTING HIGH RISK), RESIDENT #502'S BRADEN SCORES WERE: 2/8/13 =15, 2/15/13=14, 2/22/13=14 AND 3/1/13=14. NO OTHER BRADEN SCORES WERE AVAILABLE FOR RESIDENT #502. THE RESIDENT WAS NEVER ASSESSED OR DETERMINED TO BE AT HIGH RISK FOR UNAVOIDABLE PRESSURE SORE DEVELOPMENT. THE WEEKLY HEAD TO TOE SKIN CHECKS WERE INCOMPLETE WITH OMISSIONS AND DOCUMENTED THE FOLLOWING: 2/8/13 "SKIN INTACT-YES, REDNESS NOTED TO PENIS GLAND" 2/16/13 "SKIN INTACT-YES, MILD REDNESS IN PERIANAL AREA" 2/23/13 NO DOCUMENTATION THIS WEEK 2/27/13 "SKIN INTACT-YES" 3/2/13 "SKIN INTACT-NO/TREATMENT IN PROGRESS" 3/6/13 SHEET BLANK 3/9/13 SHEET BLANK 3/13/13 SHEET BLANK 3/16/13 "SKIN INTACT-NO/CURRENT TREATMENT" 3/20/13 "SKIN INTACT-NO" 3/27/13 NO DOCUMENTATION THIS WEEK 4/3/13 "SKIN INTACT-NO" PER THE WOUND CARE LOGS RESIDENT #502's COCCYX WOUND DEVELOPED ON 2/20/13 WITH THE MEASUREMENTS OF 5.8 BY 4.0 BY 0.2 CM AND WAS A STAGE FOUR (FULL THICKNESS TISSUE LOSS WITH EXPOSED TENDON OR MUSCLE) PER THE MDS (MINIMUM DATA SET) DATED 2/14/13, RESIDENT #502 WAS TOTALLY DEPENDANT ON STAFF WITH BED MOBILITY, TRANSFERS, EATING, DRESSING AND PERSONAL HYGIENE. ALSO, THE MDS DOCUMENTED NO SKIN BREAKDOWN. REVIEW OF THE SKIN CARE PLAN DATED 2/8/13 DOCUMENTED APPROACHES "COMPLETE A FULL BODY CHECK WEEKLY, REPOSITION FREQUENTLY, OBSERVE SKIN DAILY AND REPORT CHANGES ." FACILITY STAFF FAILED TO SHOW EVIDENCE OF ANY MONITORING OR INTERVENTIONS OF THE PERIANAL AREA AFTER REDNESS WAS IDENTIFIED ON 2/16/13. WHEN QUERIED REGARDING THE ONSET OF RESIDENT #502'S PRESSURE ULCER,WOUND CARE NURSES "H" AND "I" WERE UNABLE TO EXPLAIN. WOUND CARE NURSE "H" STATED, "I DON'T KNOW WHAT HAPPENED HERE. WE SHOULD HAVE DONE BETTER." ON 4/19/13 AT 8:30 A.M., THE DON (DIRECTOR OF NURSING) WAS QUERIED REGARDING RESIDENT'S #502 PRESSURE ULCER DEVELOPMENT. THE DON STATED "THAT ONE I DIDN'T KNOW ABOUT. THAT IS I DIDN'T KNOW IT DEVELOPED HERE. I RECOGNIZED WE HAD AN ISSUE WITH THE COMPLETION OF THE THE SKIN ASSESSMENTS." PER THE FACILITY'S POLICY TITLED SKIN MANAGEMENT FACILITY GUIDELINES, DATED JANUARY 2013 DOCUMENTED: "THE FACILITY IS COMMITTED TO PROVIDING CARE AND SERVICES TO RESIDENTS TO PREVENT THE DEVELOPMENT OF SKIN BREAKDOWN...PLACE EACH RESIDENT ON A WEEKLY HEAD-TO-TOE SKIN ASSESSMENT...A QUALITY OF LIFE MEETING WILL BE CONDUCTED WEEKLY BY THE INTERDISCIPLINARY TEAM. RESIDENTS REVIEWED FOR SKIN ALTERATIONS ARE AS FOLLOWS: NEWLY DEVELOPED...PRESSURE ULCERS...THE DON/DESIGNEE WILL DOCUMENT IN THE MEDICAL RECORD THE RESULTS OF THE MEETING. ( ) ON 4/16/13 AT 9:20 A.M., RESIDENT #515 WAS OBSERVED IN BED. RESIDENT #515 WAS ALERT AND VERBAL. ON 4/18/13 AT 8:50 A.M., RESIDENT #515 WAS OBSERVED ON A LOW BED WITH A LOW AIR LOSS MATTRESS, A FOLEY CATHETER DRAINAGE BAG AND A LEFT SIDE FLOOR MAT. RESIDENT #515 WAS ALERT AND VERBAL. WHEN QUERIED IF HE HAD A "SORE", THE RESIDENT STATED, " IT IS ON MY LEFT SIDE AND GOT IT HERE". A NURSING ASSISTANT WAS OBSERVED ASSISTING THE RESIDENT FOR BREAKFAST. PER RECORD REVIEW ON 4/18/13 AT 9:05 A.M., RESIDENT #515 WAS ORIGINALLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE ADMISSION NURSING assessment dated [DATE] REVEALED LEFT SIDE WEAKNESS AND WARM, DRY AND SKIN WAS INTACT WITH NO ABNORMALITIES. REVIEW OF THE NURSES NOTES FROM 2/12/13 UNTIL 3/1/13 REVEALED NO DOCUMENTATION OF THE RESIDENT'S SKIN CONDITION. ADDITIONALLY, REVIEW OF THE "WEEKLY SKIN TO TOE SKIN CHECKS REVEALED THE FOLLOWING: ON 2/12/13 (admitted ) REVEALED THAT THE RESIDENT'S SKIN WAS INTACT, NO BRUISES AND NO RASHES. THERE WAS NO FURTHER SKIN TO TOE ASSESSMENT. REVIEW OF THE NURSES NOTES DATED 3/1/13 FOR 10:00 PM (22:00) REVEALED "EARLY WARNING WRITTEN ON 7-3 SHIFT FOR OPEN AREA ON BUTTOCKS". A COPY OF THE "EARLY WARNING REPORT WAS REVIEWED AND REVEALED A SKIN BREAKDOWN ON THE LEFT BUTTOCKS. THE REPORT HAD NO APPROXIMATE MEASUREMENT. (BLANK). A COPY OF THE EARLY WARNING REPORT WAS PROVIDED BY THE DIRECTOR OF NURSING DOCUMENTING A STAGE II (PARTIAL THICKNESS LOSS OF DERMIS) REDDEN NO DRAINAGE. THE ORIGINAL COPY WAS REQUESTED BUT WAS NOT PROVIDED. REVIEW OF THE CARE PLAN DATED 2/25/13 DID NOT ADDRESS TREATMENT INTERVENTIONS. THE CARE PLAN WAS REVIEWED ON 3/5/13 WHICH DOCUMENTED "SKIN SHEAR ON LEFT GLUTEAL AREA. THE CARE PLAN WAS REVIEWED ON 3/11/13 WHICH IDENTIFIED THE RESIDENT'S GLUTEAL AREA PRESSURE SORE AS "UNSTAGABLE" (FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE SORE IS COVERED BY SLOUGH AND OR ESCHAR IN THE WOUND BED). THE WOUND CARE GROUP WAS NOTIFIED AT THAT TIME. REVIEW OF THE NURSES NOTES FROM 3/2/13 UNTIL 3/5/13 DID NOT ADDRESS THE CONDITION OF THE SKIN OF THE LEFT GLUTEAL AREA. REVIEW OF THE NURSES NOTES DATED 3/5/13 AT 2:15 P.M., REVEALED "SKIN SHEARING. REVIEW OF THE WOUND/SKIN HEALING RECORD DATED 3/5/13 REVEALED A STAGE II PRESSURE ULCER WHICH MEASURED 1 CM. BY 1.5 CM. THERE WAS NO FURTHER DOCUMENTATION UNTIL 3/11/13. REVIEW OF THE NOTES BY THE WOUND CARE GROUP REVEALED AN UNSTAGABLE PRESSURE ULCER AT THE LEFT GLUTEAL AREA WHICH MEASURED 5.2 CM. (CENTIMETERS) X 5.4 CM. WITH SEROUS (FLUID) DRAINAGE. REVIEW OF THE PHYSICIAN'S PROGRESS NOTES DATED 2/20/13, 2/27/13, 3/6/13, 3/20/13, AND 3/27/13 DID NOT ADDRESS THE RESIDENT'S SKIN CONDITION OR THE IDENTIFICATION OF THE GLUTEAL PRESSURE SORE. DURING A PHONE INTERVIEW ON 4/18/13 AT 9:15 A.M. , THE ATTENDING PHYSICIAN OFFERED NO EXPLANATION OF THE RESIDENT'S CONDITION. ON 4/18/13 AT 10:30 A.M., A WOUND CARE OBSERVATION FOR RESIDENT #515 WAS DONE WITH TREATMENT NURSES "H" AND "I". IT WAS OBSERVED THAT THE LEFT GLUTEALE WOUND HAD A MODERATE SEROSANGUINOUS DRAINAGE (BLOODY MUCOID) AND MEASURED SEVEN (7) CM. IN LENGTH, BY SEVEN (7) CM. IN WIDTH AND 4.8 CM. IN DEPTH. DURING AN INTERVIEW ON 4/19/13 AT 9:15 A.M., THE DIRECTOR OF NURSING OFFERED NO FURTHER EXPLANATION. ( )

THIS CITATION PERTAINS TO INTAKE # MI 464 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ACCURATELY OR CONSISTENTLY ASSESS THE SKIN INTEGRITY AND IMPLEMENT PREVENTION INTERVENTIONS FOR ONE (#502) OF FOUR SAMPLED RESIDENTS REVIEWED WITH WOUNDS FROM A TOTAL SAMPLE OF FOUR RESIDENTS, RESULTING IN THE DEVELOPMENT OF FACILITY ACQUIRED PRESSURE ULCERS AND THE POTENTIAL FOR FURTHER SKIN BREAK DOWN. FINDINGS INCLUDE: ON 05/01/12 AT 8:00 A.M., DURING THE INITIAL TOUR OF THE FACILITY, UNIT MANAGER #1 EXPLAINED THAT RESIDENT #502 HAD A STAGE 2 PRESSURE ULCER ON HER LEFT HEEL AND STAGE THREE PRESSURE ULCERS ON HER RIGHT AND LEFT GLUTEAL (BUTTOCKS). RESIDENT #502 WAS OBESE, AND WAS OBSERVED TO BE LYING ON HER BACK WITH NO POSITIONING DEVICES NOTED. THE RESIDENT APPEARED TO BE ASLEEP. ACCORDING TO THE RESIDENT'S CLINICAL RECORD, RESIDENT #506 WAS A [AGE] year OLD FEMALE WHO WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED A BIMS SCORE OF 7 WHICH INDICATED SEVERE COGNITIVE IMPAIRMENT. THE MDS ALSO REVEALED THAT RESIDENT #502 REQUIRED ASSISTANCE WITH BED MOBILITY AND WAS AT RISK FOR DEVELOPING PRESSURE ULCERS BUT HAD NO UNHEALED PRESSURE ULCERS AT STAGE ONE OR HIGHER. ADDITIONALLY, THE MDS ASSESSMENT INDICATED THAT THERE WERE NO PRESSURE ULCERS PRESENT ON THE PRIOR ASSESSMENT. REVIEW OF THE NORTON PLUS PRESSURE ULCER SCALE DATED 02/09/2012 REVEALED A SCORE OF NINE, (SCORE OF 10 OR LESS = HIGH RISK FOR THE DEVELOPMENT OF PRESSURE SORES). ON 05/01/2012, REVIEW OF RESIDENT #502'S WOUND RECORDS INDICATED THAT ON 02/27/2012 A RIGHT HEEL WOUND 2.5 X 2.0 CENTIMETERS (CM) WAS IDENTIFIED ON RESIDENT #502. THE WOUND CONSULTATION REPORT DATED 02/27/2012, NOTED A WOUND ON HER RIGHT LATERAL HEEL, 2.5 X 2.0 CM, DRY DISCOLORED BASE, LEFT HEEL INTACT. REVIEW OF THE WEEKLY HEAD TO TOE SKIN CHECKS FOR THE MONTH OF FEBRUARY 2012 REVEALED DOCUMENTATION OF SKIN CHECKS ON 02/02/12, 02/09/12, AND 02/16/12 WITH NO NOTED SKIN ALTERATIONS. THERE WERE NO OTHER DOCUMENTED SKIN CHECKS NOTED FOR THE REST OF FEBRUARY 2012. FURTHER REVIEW OF THE WOUND RECORD DATED 03/12/2012 REVEALED THAT THE RESIDENT'S RIGHT HEEL AREA RESOLVED. HOWEVER, ON 03/18/2012 ANOTHER RIGHT LATERAL HEEL WOUND, 1.2 X 1.3 CM WAS IDENTIFIED ON RESIDENT #502. IN ADDITION, A LEFT SACRAL (BUTTOCK) WOUND, 5.5 X 2.3 CM, A RIGHT SACRAL (BUTTOCK) WOUND 3 X 3 CM , A LEFT GLUTEAL WOUND 3.5 X 1.5 CM AND A RIGHT GLUTEAL WOUND 3.3 X 1.2 CM WERE ALSO IDENTIFIED ON THE SAME DATE OF 03/18/2012. THE WOUND CONSULTATION REPORT DATED 03/19/2012 NOTED THAT THE RIGHT AND LEFT BUTTOCK WOUNDS WERE STAGE TWO PRESSURE ULCERS AND THE RIGHT & LEFT GLUTEAL WOUNDS AND THE RIGHT HEEL WOUNDS WERE STAGE THREE ULCERS. THE WOUND CONSULTATION REPORT FURTHER REVEALED THAT THE RIGHT LATERAL HEEL WOUND BASE WAS NECROTIC WITH MINIMAL SEROSANGUINOUS DRAINAGE. THE RIGHT GLUTEAL WOUND HAD A PINK BASE AND NECROTIC CORE WITH MINIMAL SEROSANGUINOUS DRAINAGE AND THE LEFT GLUTEAL WOUND HAD A PINK BASE WITH MINIMAL SLOUGH AND MINIMAL SEROSANGUINOUS DRAINAGE. REVIEW OF THE WEEKLY HEAD TO TOE SKIN CHECKS FOR THE MONTH OF MARCH 2012 REVEALED DOCUMENTATION OF SKIN CHECKS ON 03/01/12, 03/07/12, AND 03/14/2012 WITH NO SKIN ALTERATIONS NOTED. IT WAS UNCLEAR WHY THE RESIDENT'S HEEL WOUNDS WERE NOT DOCUMENTED ON THE SKIN CHECKS. THE INCOMPLETE WEEKLY HEAD TO TOE SKIN CHECK FORMS DATED 03/22/12 AND 03/29/12 DID HAVE DOCUMENTATION THAT REFLECTED "COCCYX AREA NOTED/RIGHT FOOT," HOWEVER, THE ENTRIES WERE NOT VALIDATED WITH A NURSE'S SIGNATURE. ON 04/02/2012 A NEWLY IDENTIFIED LEFT HEEL WOUND 0.8 X 2.0 CM WAS NOTED FOR RESIDENT #502. THE WOUND WAS DOCUMENTED AS A STAGE TWO PRESSURE ULCER. THERE WERE NO WEEKLY HEAD TO TOE SKIN CHECKS PROVIDED TO THE SURVEYOR FOR THE MONTH OF APRIL 2012 ON 05/02/2012 AT 1:30 P.M., TREATMENT NURSE #6 WAS ASKED ABOUT INTERVENTIONS USED TO PROMOTE HEALING AND PREVENT FURTHER DEVELOPMENT OF PRESSURE ULCERS ON RESIDENT #502. THE TREATMENT NURSE STATED, "SHE'S ON A PRESSURE REDUCTION MATTRESS, SHE WAS PROVIDED HEEL PROTECTORS AND WE USE A WEDGE TO POSITION HER AND TO FLOAT HER HEELS." IT WAS UNCLEAR HOW THE RESIDENT DEVELOPED A NEW WOUND TO HER LEFT HEEL ON 04/02/2012 IF PREVENTION INTERVENTIONS WERE IN PLACE. REVIEW OF THE IMPAIRED SKIN INTEGRITY CARE PLAN DATED 03/18/2012 DID NOT REFLECT THE INTERVENTIONS RECOUNTED BY TREATMENT NURSE #6. THE CARE PLAN DID INDICATE A SPECIALTY MATTRESS ON 03/18/2012. IT WAS UNCLEAR WHY THAT SPECIALTY MATTRESS WAS NOT PROVIDED WHEN THE HEEL WOUND WAS IDENTIFIED. THE TREATMENT NURSES WERE ASKED HOW THEY WERE INFORMED OF IMPAIRED SKIN INTEGRITY BY THE STAFF. THE NURSES EXPLAINED THAT STAFF COMPLETES AN "EARLY WARNING SHEET" TO ALERT THE WOUND TREATMENT NURSES OF ANY SKIN ALTERATIONS THAT ARE OBSERVED. WHEN THE TREATMENT NURSES WERE QUERIED ABOUT RESIDENT #502'S WOUNDS THAT WERE IDENTIFIED ON 03/18/2012, TREATMENT NURSE #7 REPORTED THAT SHE RECEIVED THE EARLY WARNING SHEET ON 03/18/2012 AND WHEN SHE MADE HER OBSERVATIONS OF THE RESIDENT'S SKIN ON THAT SAME DAY, SHE WAS SURPRISED TO SEE THE EXTENT OF THE RESIDENTS SKIN BREAKDOWN. TREATMENT NURSE #7 REPORTED THAT STAFF WAS DISCIPLINED FOR THEIR ACTIONS. ON 05/02/2012, RESIDENT #502 WAS OBSERVED LYING IN BED, ON HER BACK FROM 8:00 A.M. UNTIL APPROXIMATELY 10:30 A.M. THE RESIDENT HAD A PILLOW ON HER LEFT SIDE AND WAS WEARING BILATERAL HEEL PROTECTORS. THE RESIDENT'S HEELS WERE OBSERVED TO BE FLOATING. AT AROUND 12:00 P.M. UNTIL 1:30, THE RESIDENT WAS STILL OBSERVED TO BE LYING ON HER BACK. A BLUE POSITIONING WEDGE WAS NOTED ON HER LEFT SIDE; HOWEVER, IT WAS NOT EFFECTIVE IN POSITIONING HER TO HER SIDE. AT 1:45 P.M., ON 05/02/12 A WOUND OBSERVATION WAS MADE WITH THE TREATMENT NURSE'S. RESIDENT #502 WAS OBSERVED AND NOTED TO HAVE BILATERAL HEEL WOUNDS. THE LEFT HEEL WAS APPROXIMATELY 1 CM X 3 CM AND THE RIGHT HEEL WAS AROUND 3 X 3 CM. A MINIMAL AMOUNT OF SEROSANGUINOUS DRAINAGE WAS NOTED ON THE DRESSING FROM THE RIGHT HEEL. THE RESIDENT MOANED IN PAIN DURING THE WOUND OBSERVATION. EACH TIME THAT SHE WAS REPOSITIONED OR WHEN HER EXTREMITIES WERE MOVED, THE RESIDENT WOULD WINCE IN PAIN. OBSERVATION OF THE STAGE THREE COCCYX WOUND REVEALED THAT THIS WOUND WAS APPROXIMATELY 2.5 X 1 CM WITH MINIMAL DRAINAGE NOTED, AND THE RIGHT GLUTEAL WOUND WAS 0.3 X 0.2 CM. THE RESIDENT'S OTHER, PREVIOUSLY DOCUMENTED WOUNDS HAD RESOLVED. ON 05/02/2012 AT 4:00 P.M., REVIEW OF THE QUARTERLY NURSING assessment dated [DATE] REVEALED "SKIN-EXTREMITIES-MUSCULOSKELETAL: SKIN WARM, DRY, NO HISTORY OF [MEDICAL CONDITION], NO NEGATIVE HOMAN'S, NO TINGLING EXTREMITIES, NO WEAKNESS, NO DEFORMITY AND NO CONTRACTURES. PHYSICAL FINDINGS REVEALED NO ABNORMALITIES NOTED ON THE RESIDENTS SKIN." ON 05/02/2012 AT 3:15 P.M., THE DIRECTOR OF NURSES (DON) WAS QUERIED ABOUT RESIDENT #502'S ACQUIRED PRESSURE WOUNDS. THE DON EXPLAINED THAT TWO NURSES RECEIVED REPRIMANDS FOR THEIR LACK OF ASSESSING AND DOCUMENTING THE RESIDENT SKIN ALTERATIONS. THE DON STATED THAT NURSE #5 RECEIVED A FINAL WARNING AND NURSE #9, WHO WAS ALSO A UNIT MANAGER, RECEIVED A DISCIPLINARY ACTION. DURING AN INTERVIEW WITH THE FACILITY ADMINISTRATOR (FA) ON 05/02/2012, THE FA EXPLAINED THAT THE RESIDENT HAD EXPERIENCED A RECENT DECLINE IN HER HEALTH CONDITION. ON 05/02/2012 REVIEW OF THE FACILITY POLICY ENTITLED "PRESSURE ULCER AND SKIN CARE MANAGEMENT" DATED JULY 2011, REVEALED "A LICENSED NURSE CHECKS THE RESIDENT'S BODY FOR THE PRESENCE OF PRESSURE ULCERS, WOUNDS AND OTHER SKIN CONDITIONS ...A LICENSED NURSE COMPLETES A PRESSURE ULCER RISK ASSESSMENT USING THE NORTON SCALE ...EVERY 90 DAYS ...DOCUMENT APPROACHES AD INTERVENTIONS TO PREVENT AND/OR TREAT PRESSURE ULCERS IN THE CARE PLAN." ( )