Every finding on record at Thornapple Manor

Based on interview and record review the facility failed to obtain informed consent for psychotropic medications (prescription drugs that alter chemical levels in the brain to affect a person's mood, thoughts, behavior or perception) for 2 residents (Resident #80, Resident #88) out of 5 residents reviewed for psychotropic medications resulting in lack of documentation of communication/education to the resident/resident representatives for initiation and/or dose changes of psychotropic medications. Findings include: Resident #80 (R80)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R80 admitted to the facility on [DATE] with pertinent diagnoses including Alzheimer's disease {disorder that primarily affects memory, thinking, and behavior and is the most common cause of dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities)}, dementia with anxiety, dementia with psychotic disturbance (cognitive decline accompanied by hallucinations, delusions, or paranoia, significantly affecting patients and caregivers) and depression. Brief Interview for Mental Status (BIMS) was not able to be completed due to R80's cognitive impairment. Review of R80's physician orders revealed she was on the following psychotropic medications Xanax Oral Tablet 0.25 MG (milligrams). Give 0.25 mg by mouth as needed for anxiousness for 14 Days PRN (as needed) BID (twice a day). Start date 4/22/2026. Olanzapine Oral Tablet. Give 10 mg by mouth at bedtime related to dementia with other behavioral disturbance. Start date 12/9/2025. Escitalopram Oxalate Oral Tablet. Give 10 mg by mouth at bedtime related to depression. Start date 12/9/2025. Review of R80's chart revealed there were no consents for the psychotropic medications (Xanax, Olanzapine and Escitalopram) and there were no progress notes or other documentation stating this was completed. Resident #88 (R88)Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R88 admitted to the facility on [DATE] with pertinent diagnoses including Alzheimer's disease {disorder that primarily affects memory, thinking, and behavior and is the most common cause of dementia (decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities)}, anxiety, dementia without psychotic disturbance and depression.Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15 which indicated R88's cognition was moderately impaired.Review of R88's physician orders revealed the following psychotropic medications Buspirone HCl (hydrochloride) Oral Tablet. Give 5 mg by mouth in the morning related to depression and generalized anxiety. Start date 4/5/2025. Trazodone HCl Oral Tablet. Give 100 mg by mouth at bedtime related to depression. Start date 8/21/2024. Cymbalta Oral Capsule Delayed Release Particles. Give 20 mg by mouth in the morning related to depression. Start date 11/27/2024. Review of R88's chart revealed there were no consents for the psychotropic medications (Buspirone, Trazodone, Cymbalta) and there were no progress notes or other documentation stating this was completed. During an interview on 4/22/2026 at 2:45 PM, Director of Nursing (DON) B stated that the facility dropped the ball on the regulation updates from April 2025 and they don't have consents for R80's and R88's psychotropic medications. DON B stated that they just developed a new psychotropic consent form in February and they will be using that moving forward. During an interview on 4/23/2026 at 8:42 AM, Director of Social Services (DSS) AA stated that they use psychotropic medication forms for any residents that are new admits and are on psychotropic medications, with an increase in those medications, or if they added a new psychotropic medication. DSS AA reported that she thought R80's consent form was signed but she couldn't find it and stated that the resident/responsible party should still be contacted and this should be documented in the resident's chart. DSS AA stated that R88 doesn't have consents for the psychotropic medications since the facility was originally doing consents for antipsychotic medications only and not for antidepressant or antianxiety medications. DSS AA stated the facility didn't want to go back and fill out forms for R88 since she was on her psychotropic medications for a while and they didn't want to back date it. DSS AA said the facility would be using the new psychotropic consent forms they developed in February moving forward. During another interview on 4/23/2026 at 9:55 AM, DON B stated that she thought R80's psychotropic medications form was signed but they couldn't find it. Review of the Use of Psychotropic Medications Policy with an effective date of 1/19/2026 revealed . Procedure: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 7. The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options. This includes any indicated documentation of rationale for prescribing multiple psychotropic medications or switching from one type of psychotropic medication, specifically an antipsychotic medication, to another category of psychotropic medication.9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.) .

Based on observation, interview, and record review the facility failed to implement enhanced barrier precautions (EBP) related to the presence of a pressure wound for 1 (Resident #5) of 3 residents reviewed for pressure wounds resulting in the potential for the spread of infection, cross contamination, and disease transmission.Findings include:Resident #5Review of an admission Record revealed Resident #5 was a female who originally admitted to the facility on [DATE] and had pertinent diagnoses which included: personal history of other infectious and parasitic diseases, dementia, and dermatitis (a condition of the skin, when it becomes red, swollen, and sore).Review of Order Summary for Resident #5 on 4/21/26 revealed .Apply a thin layer of honey (effective natural wound healing substance it is antibacterial, anti-inflammatory, and tissue-regenerative properties) to open area on right hip and cover with 2x2 border gauze (a 2 inch by 2 inch padded with gauzed and adhesive dressing) to promote analytic debridement (a gentle, selective wound-cleaning method that uses the body's own enzymes and immune cells to removed dead tissue in a moist environment) with a start date of 4/9/26. Cleanse left hip with normal saline, cut xeroform (a sterile non adherent gauze wound dressing impregnated with petroleum) to size and cover with 2x2 border gauze to promote autolytic debridement every day shift with a start date of 4/21/26.Review of Wound Care note for resident #5 dated 4/14/26 and 4/21/26 revealed .wound site: Left hip, stage 3 pressure wound.Review of Pressure Injury and Peripheral Ulcer QA Log dated 4/14/26 revealed .(Name Redacted) Resident #5 facility acquired on 4/8/26 on left hip pressure stage III (3).In an interview on 4/22/26 at 2:03 PM, Registered Nurse/Infection Preventionist (RN/IP) T reported enhanced barrier precautions were used for chronic wounds and the signage was posted in the resident's room on the personal protective equipment dispenser. RN/IP T reported there was no physician order, EBP was only in a resident's care plan and care guide for staff to reference. RN/IP stated, we star it and make it bold, so staff does not miss it.Review of Resident #5's care plan revealed no noted care plan for the implementation of EBP.During multiple observations in Resident #5's room, on 4/21/26, 4/22/26, and 4/23/26, there was no noted signage indicating Resident #5 was in enhanced barrier precautions.In an interview on 4/23/26 at 9:36 AM, Certified Nurse Assistant (CNA) X reported Resident #5 was not in enhanced barrier precautions and CNA X confirmed Resident #5 did have a wound on one of her hips.In a subsequent interview on 4/23/26 at 11:24 AM, CNA X reported EBP was used for residents who had chronic wounds, catheters, or PICC line (Peripherally inserted central line, a type of intravenous line for administration of medications or fluids).In an interview on 4/23/26 at 11:34 AM, RN/IP T reported Resident #5 did not have a wound and she was not in EBP. RN/IP T reported Resident #5 had a recurring wound that healed and reopened on her hips, and she was in and out of EBP. RN/IP T reported if Resident #5 had a current wound, she would not implement EBP during the first 4 weeks of treatment because a wound was not a chronic wound until it had been present and open for 4 weeks. RN/IP T reported she would wait 4 weeks to see if the wound resolved before she would implement EBP. RN/IP T reported she received weekly wound log from RN E and the last one she received on 4/10/26 was dated 4/7/26 and Resident #5 was not listed as having a wound. IP had not received another wound log since then. RN/IP T reported if Resident #5 had a wound, then yes, she should have been in EBP. RN/IP T stated I will go put her in right now.In an interview on 4/23/26 at 12:59 PM, RN E reported Resident #5 most certainly did have a wound on her hip. RN E reported it was an ongoing situation with Resident #5; the wound would heal and then reopen. RN E reported Resident #5 was not in EBP and that the wound had not present for longer than 4 weeks. RN E reported she was notified of Resident #5's wound on 4/8/26 and she added her to the wound log on 4/14/26. RN E reported RN/IP T was who would implement EBP after a wound was present for 4 weeks and considered chronic.In an interview on 4/23/25 at 12:59 PM, Director of Nursing (DON) B reported EBP was used for chronic wounds, and she defined chronic wounds as wounds lasting longer than 4 weeks. DON reported EBP should be implemented if a wound was a stage 3.Review of facility policy Enhanced Barrier Precaution with a revision date of 4/2025 revealed .it is the policy of (Name Redacted) to follow the CDC's guidance on Implementation of Personal Protective Equipment .EBP will be initiated for any of the following.chronic wounds. Examples may include but are not limited to. pressure injuries/pressure ulcers.Review of the Center for Disease Control (CDC) Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent the Spread of Multidrug-resistant Organisms (MDROs) (April 2, 2025) revealed, Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds .are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds . regardless of MDRO colonization.

This citation pertains to intake #2737521.Based on interviews and record review, the facility failed to effectively implement abuse policies and procedures that ensure staff report all alleged violations of abuse immediately to the Nursing Home Administrator (NHA) or designee for 1 resident (Resident #101) of 1 resident reviewed for an allegation of staff to resident abuse, resulting in delayed investigation of an allegation of potential abuse/mistreatment with the potential to impact safety. Findings include: Review of the facility policy Abuse, Neglect and Exploitation last revised date of September 2025 revealed, . Procedure: .It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc. to promptly report an incident or suspected incident of neglect or resident abuse to facility management. The abuse coordinator in the facility is the Administrator, Director of Nursing or facility appointed designee. Report allegations or suspected abuse, neglect or exploitation immediately to: 1. Administrator, 2. Director of Nursing, 3. Other officials in accordance with state law. 4. State survey and certification agency through established procedures .Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, early onset alzheimer's disease, anxiety and depression. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 11/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #101 was cognitively intact. Review of Resident #101's Care Plan revealed, Focus: I have dx (diagnosis) of depression and anxiety .I have reported a significant trauma history and have trauma and stressor-related disorder. I had a father who was verbally and physically abusive, a mother that had mental health issues .My first husband was physically abusive, and my second husband was controlling and manipulative .Date initiated: 8/26/25 .In an interview on 2/18/26 at 10:23 AM, Resident #101 reported that when people are mean to her, she tends to shut down, but that it had only happened one time since she had been in the facility. Resident #101 explained that Certified Nursing Assistant (CNA) K was having a bad day, had a temper tantrum and threw something that ended up knocking Resident #101's coffee over onto her lap. Resident #101 reported that she had forgiven CNA K and did not want to dwell on it. In an interview on 2/18/26 at 10:45 AM, CNA K reported that a few weeks ago while she was cleaning the cover to her tablet, CNA M and Resident #101 were teasing her about the way she was cleaning it. CNA K reported that she took it personally and got frustrated after a few minutes; CNA K reported that she tossed the tablet cover towards CNA M, but it knocked Resident #101's coffee mug over, and it spilled onto Resident #101's lap. CNA K reported that she apologized and made sure Resident #101 was not hurt. In an interview on 2/18/26 at 10:48 AM, CNA M explained details of the incident that occurred between herself, Resident #101 and CNA K on 1/31/26 at about 10:30 AM. CNA M stated that she and Resident #101 were teasing CNA K about how she was cleaning her tablet cover and CNA K got upset and tossed the cover. CNA M reported that the cover went in Resident #101's direction, knocked her coffee over and it spilled onto her lap. CNA M reported that she didn't think it was appropriate for CNA K to behave that way in front of the resident, but CNA M did not notify anyone else about the incident until later that day when she asked Life Enrichment Staff (LES) I about it. CNA M reported that concerns related to abuse were to be reported to the nurse. In an interview on 2/18/26 at 3:07 PM, LES I reported that on 1/31/26 CNA M came to her late in the day on 1/31/26 and asked for her advice on how to go about handling the incident that occurred that morning. LES I reported that CNA M reported to her that CNA K had gotten upset and threw her tablet cover and it knocked Resident #101's coffee over and onto her lap. LES I reported that she thought the behavior could be abusive, so she called another coworker Resident Care Coordinator (RCC) L. LES I reported that RCC L suggested that CNA M write a statement and put it in Registered Nurse (RN) P's mailbox. LES I reported that concerns related to abuse would normally be reported to the nurse, but that day there was a new nurse (Licensed Practical Nurse (LPN) G) working and they didn't think she would know what to do.In an interview on 2/18/26 at 1:49 PM, LPN G reported that on 1/31/26 at approximately 5:30 PM CNA M reported to her that Resident #101 and CNA M were making jokes about the way CNA K was cleaning a tablet cover and it ticked off CNA K so CNA K threw the tablet cover at them. LPN G stated that she reported the concern to the next nurse, RN H when she arrived at approximately 6:00 PM because she did not know what else to do.In an interview on 2/18/26 at 1:59 PM, RN H reported that when she arrived to work on 1/31/26, LPN G reported that there had been an incident that occurred earlier that day where CNA K had thrown her tablet and it had hit Resident #101's coffee. RN H reported that she got busy with medication administration and then remembered about the incident around 1:00 AM (2/1/26). RN H reported that she notified the House Supervisor LPN E and asked that the cameras be reviewed to verify what happened. RN H reported that LPN E asked her to interview Resident #101 before the end of the shift. RN H reported that she did not have the DON's phone number and normally contacted her team lead RN P when there were concerns related to mistreatment of a resident. In an interview on 2/19/26 at 10:46 AM, House Supervisor LPN E reported that she had received a text around midnight on 1/31/26-2/1/26 from RN H to call her. During the call RN H apologized for not contacted LPN E sooner but would like the cameras to be reviewed related to a reported incident that a CNA had thrown a tablet at a resident. In the video surveillance, LPN E saw that Resident #101 and CNA M were sitting at a table in the dining room and CNA K sat down with and was cleaning the tablet cover, all three of them were talking back and forth, then CNA M said something to CNA K, then Resident #101 said something to CNA K, and that was when CNA K looked at Resident #101 and threw the tablet cover. The tablet cover hit Resident #101's cup and spilled coffee on her lap; the cover would have hit the resident had it not hit her cup first. LPN E reported that she knew it was a big deal and notified Director of Nursing (DON B) right away. In an interview on 2/18/26 at 11:52 AM, DON B reported that she had received a call from LPN E at 3:48 AM on 2/1/26 reporting that CNA K had an outburst. At that time DON B was not given any other details and interpreted the incident to be a conflict between CNA M and CNA K and Resident #101 had witnessed it and therefore did not have an immediate concern for abuse and had instructed LPN E to interview all staff and the resident and that DON B would review the video surveillance when she was able to get access. DON B reported that since the incident, the involved staff have been re-educated on the importance of notifying herself DON B immediately when there is a potential concern with mistreatment of a resident. Noted that approximately 17 hours had passed between when the incident occurred, and when DON B was notified of the potential abuse allegation.In an interview on 2/19/26 at 12:00 PM, NHA A reported that she was notified on 2/1/26 that Resident #101 had witnessed an altercation between CNA K and CNA M. NHA A reported she was not told that CNA K threw her tablet cover and it knocked the resident's coffee over and spilled on her lap. NHA A reported that they have educated staff time and time again about reporting immediately if there is any abuse concern. Review of an email correspondence addressed to DON B from LPN E on 2/1/26 at 6:41 AM revealed, I talked with (CNA K) and (CNA M) and also (LPN G). (CNA K) wrote a statement for me and said she had tossed the tablet cover at (CNA M) out of anger and frustration, because she felt (Resident #101) was picking at her and (CNA M) was encouraging it. She said she knew she should not have reacted in anger and should have removed herself from the situation. I talked to (CNA M) on the phone and she also had written up a statement yesterday that got placed in (RN P's) box. I asked her to fax it to the nursing office today so I could get it to you. (CNA M) told me that she and (Resident #101) were playfully picking on (CNA K) for using a bleach cloth to clean the tablet cover and that (CNA K) had blown up and said something along the lines of everybody needs to stay out of my business and threw the tablet cover at them. You will see on camera that after a few minutes (CNA K) walks towards the nursing office but stops and turns around throwing her hands up in the air and saying something. (CNA M) said that she made another angry comment and swore. I assume more of the details will be in (CNA M's) statement. When I talked to (LPN G) she said that (CNA M) didn't report anything to her until about 5:30 and she thought (Resident #101's) coffee had been spilled but not on her. It looked like (Resident #101's) drink was water on camera, but it was coffee. The aides told me that (Resident #101) would remember the events of yesterday, so I asked (RN H) to talk to her before she leaves and to also assess her for any possible injury from the coffee spill. I educated (LPN G) and (RN H) about nursing response and handling the situation, and also (CNA M) and (CNA K) for handling the situation and also for resident safety. I will have all statements that I receive in your mailbox for you to eval .Review of Employee Interview performed by DON B dated 2/2/26 revealed, Brief description of incident being investigated: reports were made that (CNA K) on 1/31/26 became frustrated and flung an Ipad cover which knocked over a resident's drink at the dining room table with a resident present. Camera's show (CNA K) flings the cover, it did quickly fly and tip over the drink which spilled in her lap. This was an inappropriate outburst in a resident area. Then continued being aggressive that next day with coworker. clapping and making a big deal when a mistake was made. Commenting rudely and making an uncomfortable work environment that the trainee was reassigned to another CNA . Review of an Employee Disciplinary Form dated 2/4/26 revealed, (CNA K) was discourteous when became upset with another staff and a resident. Flung an Ipad screen cover when frustrated. Then inappropriate the next day with co-worker/trainee related to incident .

This citation pertains to Intake # 2605454.Based on interview, and record review, the facility failed to implement care plan interventions to ensure safety and thoroughly document/investigate a fall in 1 of 4 residents (Resident #102) reviewed for safety and fall prevention, resulting in a fall with a right fibula fracture for Resident #102, and the potential for additional falls/injuries.Findings include:Resident #102Review of an admission Record revealed Resident #102 was a female, with pertinent diagnoses which included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), Alzheimer's disease, dementia, depression, osteoporosis (a condition in which the bones become weak and brittle), and arthritis.Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 7/11/25, revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated moderate cognitive impairment.Review of a Care Guide for Resident #102, dated 8/11/25, revealed TOILETING .2 ASSIST WITH GAIT BELT TO STAND AT GRAB BAR IN BATHROOM WHILE COMMODE IS PLACED BEHIND HER .In an interview on 9/3/25 at 12:48 PM, Certified Nursing Assistant (CNA) F reported she responded to Resident #102's room on 8/17/25 at approximately 9:30 PM after CNA U called over the walkie for assistance. CNA F reported when she arrived at the room, she observed both Resident #102 and CNA U on the floor in the bathroom, with the CNA's right arm and right leg underneath the resident. CNA F reported she was told by CNA U that Resident #102 was lowered to the floor and did not hit her head. CNA F reported Resident #102 did not complain of pain at that time, and after Licensed Practical Nurse (LPN) K assessed Resident #102, she (CNA F) and LPN K used a gait belt to transfer Resident #102 up into her wheelchair, then into bed. CNA F reported a few hours later, Resident #102 put her call light on and complained of a cramp in her leg. CNA F stated, I rubbed it a little bit but that didn't help. CNA F reported she then notified the nurse of the new pain complaint. CNA F reported staff should always check the Care Guide before providing care to a resident. CNA F reported when an incident like this occurs, the nurse will typically complete an incident report. CNA F reported after the incident involving Resident #102 on 8/17/25, LPN K did not complete an incident report.In an interview on 9/3/25 at 1:15 PM, CNA U reported on 8/17/25 at approximately 9:30 PM she was assisting Resident #102 to the bathroom and stated .I did not realize she was a two-person (assist) . CNA U reported Resident #102 stood at the grab bar and she (CNA U) cleaned Resident #102 up and removed the commode from behind her. CNA U reported Resident #102 then stated, Oh no! and started to tilt sideways, losing her balance. CNA U reported she held up Resident #102's pants and lowered her to the floor, and stated, I was kind of underneath her. I slowly lowered her to the floor because I couldn't get to my walkie. I called once she was on the floor . CNA U reported after she called for assistance, CNA F and LPN K responded. CNA U reported LPN K assessed the resident and checked her vital signs. CNA U reported initially Resident #102 did not complain of pain, but once Resident #102 was transferred to bed she started complaining of a leg cramp. CNA U reported they did have a Fall Huddle in the room but reported she was unsure if an incident report was completed. CNA U reported she learned after the incident that Resident #102 was a two-staff assist in the bathroom, and that this change to her Care Guide had occurred a few days prior to the incident. CNA U reported the Care Guide should be checked before providing care to a resident and acknowledged that she did not check the Care Guide prior to assisting Resident #102 to the bathroom on 8/17/25.In an interview on 9/3/25 at 2:00 PM, CNA G reported on 8/18/25 she was assisting Resident #102 with morning care, and the resident complained of pain in her right leg. CNA G reported when Resident #102 was rolled onto her left side, her right leg hurt more. CNA G reported staff ended up using a dependent lift on 8/18/25 to transfer Resident #102 to her wheelchair due to the pain, which was unusual for Resident #102. CNA G stated, I could tell in her face that it hurt. CNA G reported Resident #102 was able to stand at the grab bar later in the afternoon on 8/18/25 and reported her right leg was still sore, but she was able to put pressure on it. CNA G reported Care Guides provide guidance on how to care for the residents and are posted in the closets. CNA G reported the Care Guide should always be checked before providing care to a resident.In an interview on 9/4/25 at 8:17 AM, CNA H reported on 8/19/25 Resident #102 complained of right leg pain when being assisted with bed mobility. CNA H reported she did not observe any visible injuries, and when asked Resident #102 could not recall a cause or reason for the pain in her right leg.In an interview on 9/4/25 at 11:18 AM, LPN K reported on 8/17/25 at approximately 9:30 PM, CNA U called via a walkie for assistance in Resident #102's room. LPN K reported when she arrived at Resident #102's room, she observed Resident #102 on the floor in the bathroom on her right side, with CNA U sitting beside the resident. LPN K reported she asked what had happened and CNA U told her the resident was lowered to the ground. LPN K stated, I should have done an incident report. LPN K reported Resident #102 did not complain of any pain and did not appear to have any visible injuries upon assessment. LPN K reported CNA U had completed a one-person assist with toileting when the resident required two-staff assist with toileting per her Care Guide.In an interview on 9/4/25 at 1:07 PM, Registered Nurse (RN) Team Lead P reported on 8/22/25, Resident #102 was complaining of pain in her right leg. RN Team Lead P reported staff had identified/documented Resident #102's complaints of leg pain earlier in the week and had notified the doctor to assess the resident. On 8/22/25, Resident #102 did not want to get up for BINGO, which was unusual for her, so she (RN Team Lead P) went to the room to assess Resident #102. RN Team Lead P stated, When I flexed her (right) knee she was immediately painful . RN Team Lead P reported there were no recent incidents or falls noted in the medical record. RN Team Lead P reported the physician was notified and orders were obtained for an X-ray.Review of a Health Status note for Resident #102, dated 8/22/25 at 12:17 PM, revealed .Resident is reporting pain R (right) buttocks which continues down through to the right foot. Resident is unable to show exact area, but during assessment knee is bothered when moving. R leg does have increase in swelling. While resident using leg to propel wheelchair it is causing pain .any bending at the knee is also causing pain. Physician on call contacted and (X-ray) ordered .Review of a Radiology Report for Resident #102, dated 8/22/25, revealed .REASON FOR EXAM: PAIN .Results: Right knee .Conclusion: Fracture of the proximal fibula .Results: Right tibia and fibula .Conclusion: Fracture of the proximal fibula .Review of a Health Status note for Resident #102, dated 8/23/25 at 12:33 PM, revealed (Family Member) called back and discussed new orders with this nurse. (Family Member) brought up that she was here on (8/18/25) and she talked with this writer at that time about resident having pain in RLE (right lower extremity), which she had stated she thought was arthritis. She thanked staff for getting (the X-ray) and also asked if we knew when the injury occurred. This writer informed her that we are unaware of an incident that caused this .Review of a facility investigation revealed On 8/22/25 .(Director of Nursing (DON) B) was notified that a resident (Resident #102) had a fractured right fibula. Per staff and records review there was no known fall or other cause of the injury .It was noted that Monday, 8/18/25 was when (Resident #102) first started c/o (complaining of) pain and having decreased mobility. The statements reveal that Monday morning she required the use of the mechanical lift .Cameras were reviewed and it was noted that on the evening of 8/17/25, staff .were seen reporting to the resident's room quickly with the fall-huddle clip board and the vital cart machine at approximately (9:32 PM). Upon interviewing the staff, there was an incident of the resident being lowered to the floor in her bathroom on 8/17/25 .Results of the investigation and interviews (revealed that Resident #102) was lowered to the floor by (CNA U) on 8/17/25. (CNA U) was using a gait-belt and commode as is per the resident's plan of care. She did however transfer (Resident #102) by herself .(Resident #102's) plan of care was changed on 8/11/25, prior to the incident to .2 assist with gait belt to stand at grab bar in bathroom while commode is placed behind her .Review of an Incident/Accident Report for Resident #102, dated 8/17/25 at 9:34 PM, revealed .I (LPN K) was called into resident's room to see resident lying on her right side in the bathroom. Resident was on the commode before this. (CNA U) was with her and stated that resident did not fall and that she lowered her down to the floor. CNA was sitting on the floor with resident. The resident had a pillow under her head .Resident was assessed and no pain was noted. I asked resident if she hit her head and she stated no. I asked resident if she got hurt and she said no she didn't get hurt. CNA and I helped her back into her wheelchair with her gait belt and another staff member put her wheelchair underneath her. I had help with a CNA and assisted resident into bed using her pivot disc . Note this Incident/Accident report was not created/completed until after Resident #102's fracture was identified.Review of the policy/procedure Maintaining and Establishing Care Guides, dated 9/2025, revealed .A care guide/kardex is a quick reference tool based off the resident's individualized plan of care that was developed by the resident and members of the interdisciplinary team. This information should be easily located and used by staff to assist the resident with their direct care needs .Review of the policy/procedure Incident Reports, dated 8/2025, revealed It is the policy of (Facility Name) to complete an investigation i.e. incident report (IR) when a resident falls or sustains an injury. The purpose of the IR is to complete a thorough assessment of the incident, identify the root cause, and a corrective action in hopes of preventing the incident from re-occurring. An Accident/Incident Report must be completed on the shift in which the accident/incident occurred .An incident report will be completed by the nurse whom the incident is reported to or identified by .The incident report will include the (resident's) recollection (when available) and .A description of what happened, including staff/witness statements .In the event of a fall, a Fall Huddle will be completed .The (nurse's) assessment and description of the medical treatment administered .A description of the corrective actions and/or preventive measures implemented to prevent such accident/incident from recurring .A comprehensive investigation will be completed by the Risk Management nurse as soon as possible .During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education to all staff on checking the care guide before providing care or assistance, re-education to the nursing staff on the policy/procedure Maintaining and Establishing Care Guides as well as the importance of checking the care guide before providing any care, and a process change to how changes in the care guides are communicated to nursing staff via the huddle board. The policy/procedure Incident Reports was updated to better define a fall, and nurses were educated on this policy/procedure and when an incident report must be completed. The facility was able to demonstrate monitoring of the corrective action and maintained compliance. Compliance date of 9-3-25.

This citation pertains to Intake # 2606671.Based on interview, and record review, the facility failed to protect the resident's right to be free from misappropriation of property in 1 of 4 residents (Resident #103) reviewed for misappropriation of property, resulting in the resident's money being taken by a staff member without the resident's consent.Findings include:Resident #103Review of an admission Record revealed Resident #103 was a female with pertinent diagnoses which included anxiety.Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 6/20/25, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated she was cognitively intact.Review of a facility investigation revealed (Resident #103) reported to Life Enrichment staff .she was missing a small zippered purse/pouch with about $10 worth (of) quarters in it and that a second change pouch was empty that had previously had about $10 worth of quarters in it as well. She reported to the staff that she had them both on Friday when she put away her bingo money, and that she noticed them missing Monday morning. She reports that they were in her night stand drawer side by side and the missing zippered purse was a black/blue colored pouch with a small flap and a logo on it .An investigation was immediately started with the review of camera footage .Camera footage was reviewed for the weekend, starting Friday afternoon after (Bingo). Saturday 8/9/25 at 3:18:55pm an agency staff is seen entering the resident's room and comes out at 3:20:47pm. It is noted that when she comes out it appears that she has something heavy and full in her right pocket of her scrub top. Camera footage follows her up the hall where she pulls out a dark colored pouch from her right pocket, unzips it, and appears to insert something small into it. She then goes back into the employee area and takes money out of a pouch and purchases a bag of chips at approximately 3:25 (PM) then starts to leave but comes back to the vending machine and purchases a Gatorade using the same pouch. When she turns around the pouch is clearer on the camera and is a dark blue/purple in color. The footage of the pouch/purse was shown to the resident and she confirms that it is her missing change purse .In an interview on 9/3/25 at 2:43 PM with Administrator A and Director of Nursing (DON) B, camera footage was reviewed to confirm the evidence summarized within the facility investigation. Administrator A and DON B reported while reviewing the camera footage during the investigation, they observed Agency Certified Nursing Assistant (CNA) T enter Resident #103's room on 8/9/25 at approximately 3:18 PM, then exit a few minutes later. Administrator A and DON B confirmed Resident #103 was not in her room at that time, and when Agency CNA T exited the room at approximately 3:20 PM, the front pocket of her scrub top appeared weighed down (as if something heavy was in the pocket). Administrator A and DON B reported Agency CNA T then proceeded to the service hallway and purchased some items from the vending machines. Administrator A and DON B were able to capture a still from the camera footage showing Agency CNA T holding a small, dark-colored bag in her hand. Administrator A and DON B reported Resident #103 was shown the still from the camera footage and identified the small, dark-colored bag as her missing change purse.In an interview on 9/4/25 at 11:57 AM, Resident #103 reported she had two small bags with quarters in her nightstand in her room. Resident #103 reported one was a blue stuffed bird with approximately ten dollars of quarters inside, and the other was a small, dark-colored purse with an additional ten dollars of quarters. Resident #103 reported she recalled adding some money to one of the small bags (the blue stuffed one) and stated On Saturday morning (8/9/25) it was so full .I remember thinking I'm going to have to remove some quarters . Resident #103 reported on Monday, 8/11/25, she realized the small, dark-colored purse was missing and the blue stuffed bird bag was empty. Resident #103 reported she notified staff, and they searched her room with no bag or quarters found. Resident #103 reported the facility completed an investigation into her missing bag/money and showed her a photo of Agency CNA T holding a small bag near the vending machines. Resident #103 identified the small purse in the photo as her missing coin purse, and stated, They showed me her hand, and she was holding the bag . Resident #103 stated, I felt really bad. I was hurt because this is my home .I want to feel safe here. I didn't want to accuse anyone . Resident #103 recalled her interactions with Agency CNA T and described her as standoffish. Resident #103 reported she did not recall Agency CNA T ever assisting her (Resident #103) with care and stated she (Resident #103) makes her own bed and there was no reason for Agency CNA T to be in her (Resident #103's) room on 8/9/25.In an interview on 9/4/25 at 1:19 PM, Director of Social Services C reported on 8/11/25 there was a staff meeting and a life enrichment staff member reported Resident #103 had some missing money. Director of Social Services C reported Administrator A and DON B were notified and an investigation was initiated. Director of Social Services C reported Resident #103 reported a small change purse was missing which had contained approximately ten dollars of quarters, and a second fuzzy bag which contained another ten dollars of quarters was empty. Director of Social Services C reported they reviewed the camera footage and observed Agency CNA T enter Resident #103's room on 8/9/25 at approximately 3:18 PM. Director of Social Services C reported Agency CNA T was in the room for approximately 2-3 minutes. Director of Social Services C reported when Agency CNA T exited the room, one of her pockets looked puffier and different than in previous camera views. Director of Social Services C reported they pulled pictures from the camera footage and showed them to Resident #103, who was able to identify the bag in Agency CNA T's hand as her missing change purse.Review of the policy/procedure Abuse, Neglect and Exploitation, dated 11/2024, revealed .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .

Based on observation, interview, and record review, the facility failed to implement care plan interventions to prevent falls in 1 of 28 residents (Resident #114) reviewed for comprehensive care plans, resulting in the potential for falls and injury. Findings include: Review of an Admission Record revealed Resident #114 was a male, with pertinent diagnoses which included dementia, heart failure, diabetes, and high blood pressure. Review of a Fall Risk Assessment for Resident #114, dated 1/21/25, revealed he was at High Risk for falls. Review of a current Care Plan for Resident #114 revealed the focus .I AM AT RISK FOR FALLS R/T (related to) A HIGH FALL RISK ASSESSMENT SCORE AND fell ATTEMPTING TO TRANSFER OUT OF THE RECLINER WITH THE FOOTREST ELEVATED . with interventions which included .NON-SKID STRIPS IN FRONT OF RECLINER . both revised 1/24/25. In an observation on 3/17/25 at 11:59 AM, Resident #114 was in his recliner in his room. Noted non-skid strips on the floor under the recliner, sticking out along the left side (not in front of the recliner). In an observation on 3/17/25 at 4:25 PM, Resident #114 was in his recliner in his room with the footrest elevated. Noted non-skid strips on the floor under the recliner, sticking out along the left side (not in front of the recliner). In an observation on 3/18/25 at 4:03 PM, Resident #114 was in his recliner in his room with the footrest elevated, apparently asleep with his eyes closed. Noted non-skid strips on the floor under the recliner, sticking out along the left side (not in front of the recliner). In an observation on 3/19/25 at 8:50 AM, Resident #114 was not present in his room. Observed Resident #114's recliner and noted non-skid strips on the floor under the recliner, sticking out along the left side (not in front of the recliner). In an interview on 3/19/25 at 1:13 PM, Registered Nurse (RN) JJ reported Resident #114 was independent with transfers and ambulation, but did have a history of falls. RN JJ reported the non-skid strips to the floor in front of Resident #114's recliner were added as an intervention after a fall to provide additional traction when transferring out of the recliner. RN JJ reported the non-skid strips should be positioned in front of the recliner. In an observation on 3/19/25 at 1:21 PM, Resident #114 was in his recliner in his room with the footrest elevated, visiting with family. Noted non-skid strips on the floor under the recliner, sticking out along the left side (not in front of the recliner). Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.19.1, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, dated October 2024, revealed .the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care . According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing, Tenth Edition - E-Book (Kindle Location 15861 of 76897). Elsevier Health Sciences.A nursing care plan includes nursing diagnoses, goals and/or expected outcomes, individualized nursing interventions, and a section for evaluation findings .The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures .The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care .

Based on observation, interview, and record review, the facility failed to provide appropriate and adequate oxygen management and tubing care for 3 of 3 residents (R19, R53, and R117) reviewed for respiratory and oxygen care, resulting in the potential of a vulnerable population being at risk for infection and harm. Findings include: R19 According to R19's Minimum Data Set (MDS) dated [DATE], the resident had a diagnosis of debilitating cardiorespiratory conditions and received oxygen therapy. Review of R19's Diagnoses dated 4/1/24, revealed, Dependence on supplemental oxygen. Review of R19's Order Summary dated 3/28/225 revealed, Continuance oxygen at 2L/Min (liters per minute) via Nasal cannula (NC). Review of R19's Medication/Treatment Administration dated 3/1/25-3/31/25 indicated the resident received 2L/MIN via nasal cannula on day and night shifts from 3/1/25 throughout the survey, 3/19/25. Review of R19's eMAR (electronic chart) Kardex (CNA (certified nursing assistant) guide to resident-specific cares) dated, as of 2/13/25 revealed, O2 (oxygen) w/ (with) Liter Flow-Oxygen continuous oxygen at 2L/MIN via nasal cannula. During an observation and interview on 3/17/25 at 10:49 AM, R19 was being transferred from toilet to wheelchair by Certified Nursing Assistant (CNA) U who asked resident if she wanted to be put on her room oxygen concentrator. A portable tank was on the back of resident's wheelchair with tubing not labeled. R19's room oxygen concentrator was set at 2 lpm (liters per minute) with tubing dated 3/3/25. R19 stated, I wear oxygen 24/7 and I feel dry, and my nose runs. During an interview on 3/18/25 at 8:15 AM, Licensed Practical Nurse (LPN) EE stated, Usually day-shift nurses and CNAs check oxygen tubing to make sure it has been dated within the week for infection control purposes. During an observation on 3/18/25 at 10:51 AM, R19's room oxygen concentrator tubing dated 3/3/25. During an observation and interview on 3/18/25 at 10:56 AM, R19 was in the common area wearing her portable oxygen via a nasal cannula. The portable tank indicated the tank was empty with the arrow pointing in the red. The tubing was not labeled. The tank had a label card indicating it belonged to R19, with a start date of 3/17/25, at a liter flow of 2 lpm (liters per minute). R19 stated, I wear oxygen all the time. If I don't wear it I get out of breath. The resident was audibly wheezing slightly. During an observation and interview on 3/18/25 at 11:02 AM, CNA DD stated, Agency CNA staff got (R19) up into her wheelchair this morning. All nursing staff are responsible for checking on oxygen levels in the portable tanks. It takes a badge to go out the doors and into the oxygen storage areas. Agency does not have a badge to get into the oxygen storage areas. CNA DD replaced R19's portable tank with a full one and continued using the unlabeled tubing. CNA reported night shift replaces the oxygen tubing. During an interview on 3/18/25 at 2:15 PM, CNA W stated, I am here through a staffing agency. I have a badge, but I am not sure if it gets me into the oxygen storage. If a resident needs a new oxygen tank, I have to inform another CNA or nurse and they would tell me to go get a tank or they would go get one. I got (R19) ready this morning by looking at her Kardex in her closet. It said to put on her portable oxygen at 2 liters so that is what I did. Review of CNA W Agency Certified Nursing Orientation Checklist dated 12/6/24 indicated was oriented to Oxygen Room/Humidifier Bottles. During an interview on 3/18/25 at 2:25 PM, CNA V stated, I am here through a staffing agency. I have a badge, but I've never tried in 5 months I've been here to use it to get into the oxygen storage area. Usually, a facility CNA will go get portable oxygen tanks if they are needed. Review of CNA V Agency Certified Nursing Orientation Checklist dated 2/7/25 indicated was oriented to Oxygen Room/Humidifier Bottles. Observed on 3/18/25 at 2:30 PM R19's Kardex in her closet indicated the resident was to wear oxygen at 2 lpm. The resident was napping in a recliner wearing oxygen running from the concentrator via a nasal cannula that was dated 3/3/25 2L. R46 According to R46's Minimum Data Set (MDS) dated [DATE], the resident scored 13/15 (cognitively intact) on her BIMS (Brief Interview Mental Status) with diagnoses that included debilitating cardiorespiratory conditions that required oxygen therapy. Review of R46's Diagnoses included chronic obstructive pulmonary disease, unspecified (COPD), dependence on supplemental oxygen, chronic respiratory failure with hypoxia (low level of oxygen in body tissues) Review of R46's Order Summary dated 5/14/2021, revealed, O2 2 to 4 liters NC continuous with Humidifier for SOB (shortness of breath) Review of R46's Medication/Treatment Administration Record (MAR/TAR) March 2025 revealed no orders for oxygen use. Review of R46's Care Plan dated 1/13/2025, LTC (long term care) due to a previous left hip fracture with repair and CHF (congestive heart failure) with goals of showing no declines with ADLs (activities of daily living) AEB (as evidenced by) no significant changes, and using interventions that included O2 liter flow-2 to 4 liters O2 via nasal cannula/humidifier continuously. Review of R46's Kardex as of 3/18/25 revealed, O2 liter flow - 2 TO 4 liters O2 via nasal cannula/humidifier continuously. During an observation on 3/17/25 at 9:20 AM, R46 was wearing oxygen via a portable oxygen tank with tubing that was not labeled. The oxygen concentrator that was next to the resident's bed had tubing that was not labeled with a humidifier bottle that was dated 2/25/25. During an observation and interview on 3/18/25 11:13 AM, R46 was in her room sitting in her wheelchair wearing oxygen connected to a portable oxygen tank via tubing. The portable oxygen tank was empty as indicated by the pressure gauze with the arrow in the red. CNA Z stated, I put (R46) in the wheelchair this morning and looked at her oxygen tank (portable). Now, I see It is empty. I changed the tank at 7:30-8:00 am this morning. She should be put on the concentrator when she is in her room. I don't know who last looked in on her. CNA Z left the room to get another portable oxygen tank and a pulse oximeter (measures oxygen in body) R46 stated, I feel like heck. I am tired out. The resident then self-ambulated out of her room and headed to the dining room. She was breathing with audible gasps. During an observation and interview on 3/18/25 at 11:21 AM, CNA 'Z brought a portable tank to R46 in the hall outside of the resident's room and checked her pulse ox. During this time, Registered Nurse (RN) LL came to R46's side and stated, The oxygen tubing is dated 3/11/25) and R46 is on between 2 to 4 liters per minute depending on what the resident wants and needs. CNA Z then assisted R46 into her room where she placed a new portable oxygen tank to R46's wheelchair and read the pulse ox to be 95%. After reading the pulse ox, CNA Z connected R46 to the portable oxygen via a nasal cannula and set the flow rate to 3 lpm per R46 request. R46 stated to CNA Z and surveyor, I'm sleepy then self-ambulated to the dining room where breakfast was being served. Observed in R46's closet a resident-specific Kardex that indicated O2 liter flow 2 to 4 liters O2 via nasal cannula/humidifier continuously. During an interview on 3/19/25 at 11:28 AM, Infection Control Preventionist (IPC) MM and Director of Nursing (DON) B stated, Oxygen tubing should be changed out every Tuesday night by night shift. Humidifiers should also be changed out with tubing weekly. Our policy reflects this. 36221 Resident #117 Review of an Admission Record revealed Resident #117 was a male, with pertinent diagnoses which included heart disease, high blood pressure, and cancer. Review of a Minimum Data Set (MDS) assessment for Resident #117, with a reference date of 1/17/25, revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated he was cognitively intact. Review of an Order Summary Report for Resident #117 revealed the active physician order .Oxygen 2 Liters NC (nasal cannula) prn (as needed) for SOB (shortness of breath) as needed . with a start date of 7/15/24. In an observation on 3/17/25 at 2:44 PM, Resident #117 was in bed in his room. Observed an oxygen concentrator along the wall beside his bed, not in use. Observed the oxygen tubing (nasal cannula) laying directly on the floor, not stored in a plastic bag. No date noted on the oxygen tubing to indicate when it was last changed. In an observation and interview on 3/18/25 at 3:56 PM, Resident #117 was in bed in his room. Observed an oxygen concentrator along the wall beside his bed, not in use. Observed the oxygen tubing (nasal cannula) laying directly on the floor, not stored in a plastic bag. No date noted on the oxygen tubing to indicate when it was last changed. Resident #117 reported he has not required supplemental oxygen for several weeks, and stated .they kept it (the oxygen concentrator and tubing) there in case I needed it . In an interview on 3/19/25 at 1:19 PM, Registered Nurse (RN) JJ reported oxygen tubing should be changed weekly. Review of the policy/procedure Oxygen Use & Storage, revision date 12/2024, revealed .Policy: To provide oxygen therapy in a safe and clean method per each resident's individual need .Gather, label, date, and change, equipment i.e. concentrator, oxygen tank, nasal cannula, or mask, and if needed extension tubing for the resident .Nursing Assistants are expected to check the oxygen flow liter and poundage gauge whenever they are providing care to the resident .Change cannula, mask, plastic bags, and if present the humidifier bottle weekly on midnight shift according to schedule. Nursing Assistant's will label tubing with a sticker, which indicates liter flow rate ordered, date opened, and their initials .Oxygen tubing cannulas and/or masks are to be stored in the plastic bags when residents are not using the equipment .

Based on observation, interview, and record review, the facility failed to ensure 1.) implementation of Enhanced Barrier Precautions (EBP) per standards of practices for 1 of 6 residents (R53) all reviewed for infection control, and 2.) adequate handling of soiled linen, resulting in the potential for cross-contamination, harborage of bacteria, and increased infections in a vulnerable population. Findings include: According to R53's Minimum Data Set (MDS) dated [DATE], the resident had diagnoses that included non-traumatic brain dysfunction requiring her to be dependent for all cares including toileting and unhealed stage 3 and stage 4 pressure ulcers. During an observation and interview on 3/17/25 at 10:23 AM, R53 was in bed being prepared for a brief change by two Certified Nursing Assistants (CNA) BB and TT Inside the resident's room on the wall next to the door was CDC (Centers for Disease Control) signage indicating the resident was on Enhanced Barrier Precautions with gown and gloves to be worn with direct cares. CNA BB stated, (R53) has one wound on her coccyx that is deep. She also has a small wound on her ankle. CNA TT stated, I am an agency CNA. Both CNAs donned gloves but did not don gowns before starting the brief change for R53. R53's soiled brief was removed after which a bandage dated 3/16 was seen on the resident's coccyx. After removing the soiled brief neither CNA changed their gloves throughout the process and applying a clean brief and pants. Part way through the brief change, CNA BB stated, We (both CNAs) were supposed to wear a gown because of (R53's) open wound. CNA TT stated, I'm used to the PPE sign and supplies being on the door before you enter a room. I've been here since October 2024. During an interview on 3/17/25 at 10:49 AM, CNA U stated, I am on my 3rd shift in the facility. I am used to Enhanced Barrier Precautions being noted on the resident's door by a sign and PPE on the door in a cart as your first walk in. During an interview and record review on 3/19/25 at 8:20 AM, Licensed Practical Nurse (LPN) EE reviewed R53's Kardex in the resident's closet. The Kardex did not specifically say resident was on Enhanced Barrier Precautions but indicated gown and gloves were to be worn during high-contact cares. During an interview on 3/19/25 at 11:28 AM, Infection Control Preventionist (IPC) MM and Director of Nursing (DON) B stated During brief change, gloves should be changed out when going from dirty to clean. Every morning all nursing staff have a meeting and residents on EBP is discussed. There is a huddle board at each nursing station that has a list of residents on EBP. The DON stated, I don't want the EBP signs on the outside of resident's door to make them feel like they are in isolation because this is their home. There is a Kardex for each resident in their closet where staff can view their needs. On the Kardex is does not say specifically Enhanced Barrier Precautions. But does say within a paragraph among other things to wear gown and gloves. The Charge Nurses do weekly audits to make sure the whole care guide is followed by nursing staff. Review of facility policy Enhanced Barrier Precautions effective date 10/2023, revealed, It is the policy of (name of facility) to follow the CDC's guidance on Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent the Spread of Multidrug Resistant Organisms (MDROs). Enhanced Barrier Precautions (EBP) refer to the use of gown and gloves during high-contact resident care activities for residents known to be colonized or infected with a targeted MDRO who do not meet the criteria for Contact Precautions, as well as those at increased risk of targeted MDRO acquisition (e.g., residents with wounds or indwelling medical devices) .PROCEDURE: Staff will receive training on EBP upon hire and annually and are expected to comply with designated precautions .The new Enhance Barrier Precautions sign hanging above the gown and glove holder inside the resident's room .Indwelling medical devices (e.g. central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomies) even if the resident is not known to be infected or colonized with a MDRO. Chronic Wounds. Examples may include but are not limited to: Pressure Injuries/Pressure Ulcers . During an observation on 3/17/25 at 10:49 AM, observed CNA U carrying soiled and dirty linen in a clear plastic bag to the hamper room holding the bag in ungloved hands and against her clothes in the 200 Hall. Review of facility policy, Laundry Transportation revised date 12/2023, revealed, Policy .This policy is to ensure the appropriate transporting of clean, dirty and infectious linen to minimize the risk of infection throughout the facility . Contaminated linen and laundry bags are not held close to the body or squeezed when transporting to hamper/utility room . Review of the facility policy, Nursing Standards of Care revised date 2/2025, revealed, .The employee will wear appropriate PPE (see policy: Standard precautions) when handling, cleaning or transporting soiled material .Following the residents individualized care guide/Kardex (resident specific care guide) is extremely important to providing safe quality care while meeting our resident's needs. In the care guide there is a section labeled Safety Interventions all staff should ensure these interventions are in place prior to leaving the resident .

This citation pertains to intake MI00147758. Based on interview and record review, the facility failed to recognize and report an injury of unknown origin for 1 (Resident #101) of 3 residents, reviewed for reporting, resulting in the lack of reporting and the potential for a delay in the investigation. Findings include: Resident #101 Review of an Admission Record revealed Resident # 101 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia. Review of Resident #101's Progress Note dated 10/28/24 at 4:10 PM revealed, Nurse was called to (Resident #101) room by staff member, noted a 9.5 cm x 9 cm bruise to right bicep. (Resident #101) is unable to describe what happened, but states It hurts, it hurts!. Order placed to monitor for s/sx (signs and symptoms) of infection x 5 days. Review of Resident #101's Progress Note date 10/28/25 AT 11:15 PM revealed, (Resident #101) is being monitored r/t (related to) bruise noted on bicep. S/s of pain noted as (Resident #101) was observed cradling and protecting area as well as when asked if she was hurting (Resident #101) violently nodded head and said yes. Swelling at the site is noted but (Resident #101) was not well compliant with allowing staff to fully inspect area. No signs of worsening condition of the bruise. Some noted swelling to the arm itself during visual assessment. (Resident #101) would not allow staff members to do a physical assessment. Scheduled pain medication administered, and (Resident #101) informed she could have prn (as needed) administration if needed . Review of Resident #101's Progress Note dated 10/29/24 at 1:06 PM revealed, Bruise has spread from right arm to chest. (Resident #101) continues to guard arm and been given PRN Morphine (pain medication) in between scheduled doses. Review of Resident #101's Progress Note dated 10/29/24 at 7:00 PM revealed, CNA'S (Certified Nursing Assistant) called the nurse to room . A 5 cm (centimeters) x open area on rt (right) of neck, 0.3 cm open area on left side of neck. Open area on left side of neck 1 cm. A bruise on left jaw 1 cm x 1 cm. Redness to left side of neck. Bruise to right top of hand 4.5 x 4 cm, with swollen fingers. Left lower extremity below knee is swollen. Bruises to third and fourth toe and to right third toe. Bruise to right elbow measuring 4 cm x 4 cm. (Resident #101) is unable to give a description as to what happened. (Resident #101) assessed for pain and other injuries. No other injuries noted at this time. The ADON (Assistant Director of Nursing) and DON (Director of Nursing) as well as Social Work. (Resident #101 Family Member) notified. Statements gathered from all staff present at that time that provided care, and changed to a 2 person assist at all times per DON. Review of Resident #101's Progress Note dated 10/30/24 at 3:29 PM revealed, Bruise on toes has spread to left foot. Swelling on left lower extremity under knee is bruising. (Resident #101) continues to be painful with arm guarding and facial grimacing . Review of Resident #101's Progress Note dated 10/30/24 at 4:41 PM revealed, Bruise noted to bottom of left foot. 4.5 cm x 4 cm. Review of Resident #101's Progress Note dated 10/30/24 at 5:57 PM revealed, Resident #101 passed away at 1702 (5:02 PM). Review of Resident #101's Progress Note dated 10/31/24 at 8:56 AM revealed, Following my arrival for shift I was joined by (Hospice Nurse E) to be made aware that (Resident #101's Power of Attorney) requested an examination of (Resident #101) and that a Medical Examiner would be coming to complete an assessment . During an interview on 11/14/24 at 10:37 AM, Licensed Practical Nurse (LPN) H revealed that she had been notified by a CNA after lunch on 10/28/24 that Resident #101 had a bruise. LPN H reported that she noted that the bruise was on Resident #101's inner arm and was about 9 x 9.5 cm. LPN H reported that she reported that Resident #101 was complaining of pain and that Resident #101 continued to yell out that her arm was broken. LPN H reported that she immediately reported the bruise to the DON B , ADON C, and social worker. LPN H reported that she had no idea how Resident #101 had obtained the bruise on her right arm. During an interview 11/14/24 at 2:10 PM, CNA O reported that she had observed bruising on Resident #101's toes and scratches on her neck when she and CNA J went to assist Resident #101 in the afternoon. CNA O reported that she immediately reported Resident #101's scratches and bruises to LPN Q who then came to assess Resident #101. CNA O confirmed that she witnessed DON A and ADON B come down to assess Resident #101. CNA O reported that she had not observed Resident #101 with bruising to her feet or scratches to her neck prior to the observation made on 10/29/24 in the afternoon. CNA O reported that she did not know how Resident #101 obtained the bruises or scratches. During an interview on 11/14/24 at 2:34 PM, CNA J reported that she and CNA O had cared for Resident #101 in the afternoon. CNA J reported that when she and CNA O were laying Resident #101 down, she noted that Resident #101 appeared to be in a lot of pain. CNA J reported that Resident #101 had scratches on her neck that looked fresh. CNA J reported that she also noticed that Resident #101's knee was very swollen, and that her knee had not looked swollen earlier in the day. CNA J reported that she also noted bruising on Resident #101's toes on both of her feet. CNA J reported that she did not know how Resident #101 had obtained the bruises or scratches, but she thought it happened in between lunch and dinner, as she did not note any bruises or scratches on Resident #101 earlier in the day. CNA J confirmed that she reported the bruising and scratches she found on Resident #101 immediately to LPN Q. During an interview on 11/14/24 at 12:01 PM, LPN Q reported that she had been notified by CNA's on 10/29/24 that Resident #101 had bruising and scratching that she did not have earlier that day. LPN Q reported that she first noticed bruises on Resident #101 toes, so she completed a full skin assessment and noted scratches on each side of Resident #101's neck, a bruise on the right side of Resident #101's jaw that was dark purple in color and an another area that was starting to bruise on the left side of Resident #101's jaw. LPN Q reported that she also noticed a bruise on the top of Resident #101's hand, and bruising on both of Resident #101's toes that were dark blue to purple in color. LPN Q reported that Resident #101's fingers were also swollen in between her index finger and her thumb on her right hand and that her left lower leg below her knee was also swollen. LPN Q reported that she immediately reported her assessment to the DON B and had all staff working that day with Resident #101 write statements. LPN Q did not know how Resident #101 had obtained the scratches or bruises on her body. During an interview on 11/14/24 at 3:17 PM, LPN P reported that she had been informed by LPN Q that Resident #101 had a bruise on her arm and that the facility did not know how Resident #101 had obtained the bruise. LPN P reported that she had observed the bruise on Resident #101's arm and that the bruise had spread to Resident #101's chest. LPN P reported that Resident #101 was in a lot of pain, and would not allow LPN P to touch her arm. LPN P reported that when she returned to work on 10/29/24 she had learned from LPN Q that new bruises and scratches were discovered on Resident #101. LPN P reported that when she went to assess Resident #101, and that Resident #101 was experiencing a significant amount of pain, so she contacted Resident #101's hospice nurse and requested that he come assess Resident #101. LPN P reported that Hospice Nurse (HN) E came to the facility on [DATE] to assess Resident #101's bruising and swelling, and made the decision to increase her pain medication to keep her more comfortable. LPN P reported that she had observed swelling on Resident #101's right hand and left leg, bruising on both feet and toes which was fresh purple in color and swelling in the left knee. LPN P reported that DON A had observed Resident #101 that evening, and informed LPN P that she thought Resident #101 was experiencing mottling (A skin condition that occurs when blood flow to tiny vessels under skin is disrupted). LPN P reported that she also worked on 10/30/24 after Resident #101 had passed away. LPN P reported that HN E had returned to the facility and spoke with Resident #101's family member. LPN P reported that HN E had informed LPN P that Resident #101's family member had requested a medical examiner assessment of Resident #101. LPN P reported that HN E remained at the facility with a police officer until the Medical Examiner arrived and the facility released Resident #101's body to the Medical Examiner. LPN P was not able to report how Resident #101 had obtained bruises and scratches. During an interview on 11/15/24 at 8:36 AM, HN E reported that he had been contacted by LPN P on 10/29/24 and asked to come to the facility and assess Resident #101 for the new bruises, scratches and uncontrolled pain that Resident #101 had. HN E reported that he noted that Resident #101 was in a lot of pain and appeared very uncomfortable. HN E reported that he noted lacerations on both sides of Resident #101's neck. HN E reported that the laceration on the right side of Resident #101 neck was 3 centimeter long and 1 centimeter long on the right side. HN E' reported that Resident #101 had bruising noted on her right upper arm and across her chest, bruising and swelling on her right hand, swelling and bruising on her left knee and bruising on the third toe on both of her feet. HN E reported that he was very concerned with the bruising and lacerations that he observed on Resident #101. HN E reported that he did not feel that any of the bruising appeared to be mottling or end of life progression. HN E' reported that he was concerned that the facility had not reported any kind of fall or reason that Resident #101 had the multiple bruises and lacerations. HN E reported that when he saw Resident #101 the following night, he also noted additional bruising on the top of her left foot, left knee, left hip and left check, and neck. HN E reported that the hospice aide had cared for Resident #101 on 10/28/24 and did not report any concerns or skin conditions. HN E reported that Resident #101's family had opted to have Resident #101 examined by a medical examiner due to the extent of her injuries that the facility could not provide a reason for how they were obtained. During an interview on 11/15/24 at 8:12 AM, DON B reported that she had been made aware of Resident #101's bruise on 10/28/24 and the new and additional bruising and lacerations on 10/29/24. DON B reported that she felt that Resident #101's injuries were related to her end stages of life. DON B confirmed that the facility did not contact the facility provider to assess Resident #101. DON B reported that she had completed an investigation on Resident #101's injuries, but she did not report the injuries of unknown origin to the State Agency because she did not feel that the injuries were related to abuse. During an interview on 11/15/24 at 10:48 AM, Nursing Home Administrator (NHA) A reported that she had been made aware of Resident #101's bruise on 10/28/24 and the new and additional bruising and lacerations on 10/29/24. NHA A reported that she did not report Resident #101's injuries of an unknown origin because she did not feel that the injuries were related to abuse. Review of the facility policy Abuse, Neglect, and Exploitation revealed the abuse policy did not define nor indicate what the facility should do regarding an injury of unknown orgin per the Code of Federal Regulations, State Operations Manual.

Based on observation, interview, and record review the facility failed to: 1. Clean food and non-food contact surfaces to sight and touch; 2. Ensure general repair of kitchen areas; 3. Ensure proper working order of dish machines; and 4. Use sanitizer in a manner that minimizes the risk of contamination. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 142 residents who consume food from the kitchen. Findings Include: 1. During a tour of the facility, at 10:15 AM on 1/31/24, an interview with Director of Dining Services (DDS) R found that the slicer gets used a couple times a week for slicing up meats. Observation of the slicer found some dried accumulation of meat shavings on the top and bottom backside of the blade. During a tour of the clean utensil bins, at 10:18 AM on 1/31/24, it was observed that the clean utensil bin containing spatulas was found with a white crusted stain in the bottom of the bin. An interview with DDS R found that the bins should get cleaned weekly. During a tour of the Mill Pond drink station, at 10:56 AM on 1/31/24, orange and brown accumulation was found on non-food contact portions of the juice machine's underside corners. Observation of the ice machine found black accumulation on the perimeter of the inside spout. When asked who takes care of the ice machines, DDS R stated that a vendor services the machines and maintenance would have records. During a tour of Cloverdale drink station, at 11:10 AM on 1/31/24, it was observed that the front underside portion of the juice machine was found with an accumulation of dried juice. Observation of the ice machine spout found that inside chute had some crusted white accumulation, and the outside perimeter of the chute was found to have an accumulation of black debris. During a tour of the Coldwater drink station, at 11:20 AM on 1/31 24, it was observed that the ice machine spout had black and white accumulation on the outside perimeter of the chute. During a tour of Sugarbush drink station, at 11:25 AM on 1/31/24, it was observed that the ice machine spout had black and white accumulation on the outside perimeter of the chute. During a tour of the Lighthouse Cove drink area, at 1:40 PM on 1/31/24, it was observed that the underside of the coffee spout was found with an accumulation of stuck on debris. During an interview with Facilities Services Manager M, at 2:40 PM on 1/31/24, found that the vendor that cleans the ice machines usually does two a month which gets every machine done every 6 months or more. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 2. During a tour of the kitchen, at 10:23 AM on 1/31/24, it was observed that the steam kettle fill was leaking water onto the ground on the cook line. When asked how long the fill had been leaking, DDS R stated it was new to her. During a tour of the main dish machine area, at 10:28 AM on 1/31/24, it was observed that heavy accumulation of debris was evident on the ventilation shaft for the dish machine. During a tour of the Whispering Way kitchen pod, at 10:34 AM on 1/31/24, it was observed that the microwave in this area was found with a half dollar size rusted pit on the inside ceiling. When shown to DDS R, she stated it would get replaced. Further review of the pod found chipping and flaking of the cabinet surfaces on doors and drawers. The cabinet doors to the right of the dish machine were found in poor condition with the left door was loose due to a weak top hinge. The tops of these cabinet doors were found with open and exposed wood from the chipping and flaking of the Formica surface. During a tour of the Mill Pond kitchen pod, at 10:50 AM on 1/31/24, observation of the clean utensil drawers found some degradation of the inside back wall of the drawers. This degradation was starting to leave small bits of particle board to flake off as staff open and close the drawers. According to the 2017 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. 3. During a tour of the Whispering Way kitchen pod, at 10:40 AM on 1/31/24, a review of logged dish machine temperatures for the week, found that both the breakfast and noon meal temperatures, dated 1/31/24, were found to be 175F, below the required minimum of 180F. During a tour of the Mill Pond kitchen pod, at 10:55 AM on 1/31/24, it was observed that the sanitizing rinse temperature logged for breakfast was only 179F. A review of the Daily Data Sheet, dated 1/31/24, for the Lighthouse kitchen, at 1:20 PM on 1/31/24, found that the recorded dish machine rinse temperature for the noon submission was 177F. A review of the Daily Data Sheet, dated 1/31/24, for the Harbor Bay kitchen, at 1:40 PM on 1/31/24, found the recorded dish machine rinse temperature for the noon submission was 178F. According to the 2017 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than: .(2) For all other machines, 82C (180F). 4. During a tour of the Harbor Bay kitchen, starting at 1:18 PM on 1/31/24, an interview with DDS R found that staff look for sanitizer to be in a concentration of 200 parts per million (ppm). At this time, the surveyor tested the quaternary ammonium sanitizer with the facilities QT-40 Hydrion test strips, and found it to be well over the 500 ppm max concentration on the test strip. Upon testing, it was also observed that the bucket was roughly half full. When asked how much water should be in the bucket, DDS R stated it should be near the top of the bucket, because the wiping cloths we use contain sanitizer, so if there is not enough water, the concentration will be too high. According to the 2017 FDA Food Code 7-204.11Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A)Meet the requirements specified in 40 CFR 180.940Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions), or(B)Meet the requirements as specified in 40 CFR180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations.

Based on observation and interview the facility failed to properly secure medications in a treatment cart (1 of 5 medication carts) resulting in the potential for compromise of medications and/or misappropriation of medications, and accidental ingestion. Findings include: During on observation on 2/2/24 between 9:27am-9:32am, a treatment cart sat unlocked and unattended near the 400-hall nurse's station. No staff were in the area. Several residents were in the dining room approximately 25' away and were noted to be mobile without assistance. The cart consisted of 4 drawers, all were unlocked and contained an assortment of prescription ointments and chemicals. A nurse was asked to come to the location. In an interview on 2/2/24 at 9:33am, Licensed Practical Nurse (LPN) L reported she was the nurse for the 400 hall and had not accessed the treatment cart since the beginning of her shift, a few hours earlier. LPN L reported the cart should have been locked to avoid any potential for compromise of the medications, and/or misappropriation, and accidental ingestion. LPN L reported she could not say how long the treatment cart had been left unlocked. LPN L confirmed that prescription medications used for the treatment of skin conditions, as well as: acetic acid (a corrosive liquid), menthol gel, diclofenac gel were present in the cart and could pose a hazard if ingested. In an interview on 2/2/24 at 11:37am Registered Nurse (RN) DD reported the treatment cart should always be locked when not attended by a nurse. RN DD confirmed that leaving the cart unlocked and unattended created a potential for compromise of the medications, misappropriation, and accidental ingestion.

Based on observation, interview, and record review the facility failed to provide food at a palatable temperature for 4 of 28 sampled residents (Resident #21, #84, #13, and #51) reviewed for food palatability, resulting in dissatisfaction with meals and the potential for decreased food consumption and nutritional decline. Findings include: Resident #21 Review of an Admission Record revealed Resident #21 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus (a condition where the body is not able to properly use sugar from the blood) and depression. In an interview on 1/31/24 at 11:12 AM, Resident #21 reported she ate her meals in her room and in the dining room, depending on her preference for that meal. Resident #21 reported no matter where she ate, the food was not warm enough. In a follow-up interview on 2/2/24 at 9:22 AM, Resident #21 reported lunch and dinner the day before and breakfast today was not hot enough. Resident #21 stated, It's never hot enough. Resident #84 Review of an Admission Record revealed Resident #84 was a female, with pertinent diagnoses which included: type 2 diabetes mellitus with hyperglycemia (a condition where the body is not able to properly use sugar from the blood with high blood sugar levels) and major depressive disorder. In an interview on 2/1/24 at 9:03 AM, Resident #84 reported food was not hot enough when she received her meals. In a follow-up interview on 2/2/24 at 8:55 AM, Resident #84 reported she thought the reason her meals tended to be cold by the time she received them in her room was because her room was one of the last hall trays to be served so things have time to get cool. In an interview on 2/1/24 at 12:56 PM, Registered Dietitian (RD) F reported residents have brought up the issue of food temperatures. In an interview on 2/2/24 at 8:46 AM, Certified Nurse Aide (CENA) K reported residents have complained to them about their food not being hot enough sometimes. 46999 Resident #13 Review of an Admissions Record dated 8/1/23 revealed Resident #13 was admitted to the facility with the following pertinent diagnoses: type 2 diabetes and major depressive disorder. Review of a Care Plan dated 1/29/24 for Resident #13 revealed a focus/goal/interventions as follows: Focus: My weight may fluctuate .I am receiving hospice services .these are my daily food preferences to assist with my daily meal planning. Goals: My intake will remain adequate. I will be offered meaningful choices in meals that are .satisfying to me. Interventions: I often enjoy having the following foods: sandwiches, meat loaf, potatoes, meat. In an interview on 2/1/24 at 8:53am, Resident #13 reported he usually ate in the dining room, but was one of the last residents served, and his food was often cold when it was brought to him. Resident #13 reported he frequently had to ask for the meal to be heated up which was frustrating because he had already waited to eat. Resident #13 reported sometimes when his meal arrived cold, he left the dining room in frustration, and did not eat. In an observation on 2/2/24 at 12:44pm, Dietary Aide (DA) RR plated a hot meal near the end of the meal service in the 300-hall dining room. Upon request, DA RR placed a food thermometer in the entree. The thermometer registered 126-130 degrees. In an interview on 2/2/24 at 12:46pm, DA RR reported she noticed that near the end of meal services, the food was sometimes under 135 degrees. DA RR reported she felt the warming pan did not keep the food heated adequately. 47659 Resident #51 Review of an Admission Record revealed Resident #51, was originally admitted to the facility on [DATE] with pertinent diagnoses which included quadriplegia (paralysis of all four limbs). During an interview on 2/01/24 at 12:55 PM, Resident #51 reported that she had concerns with the food that the facility served. Resident #51 reported that the food she received was often cold which affected the taste and quality of the food. Resident #51 reported that she had reported her concerns of being served cold food to management and the NHA, but that she was still receiving cold food frequently, and she did not feel that her concern had been addressed. 38905 During lunch service observations in the Sugarbush kitchen, at 11:55 PM on 1/31/24, an interview with Director of Dining Sservices (DDS) R found that hot food on the steam table should be 150F or above. When asked if the facility performs test trays or tray audits, DDS R stated that staff take the temperature of the food before it is served, and then take the temperature of all the product on the last regular meal sent out. When asked if there was a temperature that she would expect hot food to be when it gets to a resident, DDS R stated 135F. At this time, the surveyor asked that a test tray be provided after all residents have been served. At 12:00 PM on 1/31/24, an interview with DDS R found that the left steam well is down and they are currently waiting on it to get repaired. In the meantime, there are two cambro wick heating elements under that well keeping it warm. At 12:17 PM on 1/31/24, Dietary Aid (DA) E took a temperature of the last regular resident meal sent out and found that the mashed potatoes were only 111F. When she realized this, she heated up a cup of mashed potatoes in the microwave before serving the plate. After this was done, DA E made a regular test tray for the surveyor, and placed it in the microwave. When asked why she was putting the test tray in the microwave, DA E stated that she didn't want it to be cold. A review of the cooks sheet found that the temperature of the mashed potatoes was recorded over 160F at the start of service. During a review of the cook's log in the Coldwater kitchen, at 11:30 AM on 2/1/24, it was found that the breakfast meat served on 1/29/24 was logged at 109F at the beginning of service and at 105F at the end of service.

Based on observation, interview, and record review the facility failed to: 1.) promptly implement isolation precautions for a symptomatic resident, 2. ) implement wearing of Personal Protective Equipement (PPE) in a room where a resident had a contagious disease in 2 of 26 sampled residents (Resident #34 and #98), and 3.) properly sanitize shared equipment, reviewed for infection control, resulting in a potential for the transmission/transfer of pathogenic organisms and cross contamination between residents and staff. Findings include: Resident #34 Review of an Admission Recorddated 2/15/23 revealed Resident #34 was admitted to the facility with the following pertinent diagnoses: resistance to vancomycin (condition in which the individual's body has the presence of drug resistant bacteria, making bacterial infections more difficult to effectively treat). Review of a laboratory services test result report revealed a swabbed specimen was collected from Resident #34's nose at 2:53pm on 1/31/24, subsequent testing revealed the resident tested positive for Influenza A on 2/1/24 at 1:32am. Review of a care plan for Resident #34 revealed a focus/goal/interventions dated 2/1/24: Focus: I have influenza: Positive influenza. Goal: I will exhibit resolution of influenza .Interventions: All trash must be bagged at end of every shift .initiate droplet transmission precautions .a resident will be placed in private room if possible . on Kardex (care guide) under special alert section add droplet transmission precautions .attach sign visitors and staff before entering contact nurse for instructions on resident's door .limit the use of noncritical care equipment to resident .put soiled linen in green plastic bags and remove at end of every shift .resident to remain in room until afebrile (fever free) for 24 hours without the use of extra analgesics .wear a mask upon entering room . During on observation on 1/31/24 at 12:35pm, Resident #34 sat in her room, no isolation precautions were posted on her door and staff entered and exited the room without wearing personal protective equipment. In an interview on 1/31/24 at 12:37pm, Resident #34 reported she did not feel well, had complained of a sore throat for several days, and was frustrated because steps had not been taken to address her needs. Resident #34 reported she told at least 2 nurses about her symptoms, both looked at her throat and said she did not have lesions on the back of her throat, but nothing else was done. Resident #34 said They (the nurses) just said it's not strep and left it at that. It ticks me off because my throat is on fire, I'm coughing, and I don't feel good. Resident #34 confirmed she was not in isolation precautions, and that she needed physical assistance which required staff to be very close to her for several minutes at a time. In an interview on 1/31/24 at 3:45pm, Registered Nurse Supervisor (RN) CCC reported 5 residents on Resident #34's hall had been placed in isolation due to flu-like symptoms. In an interview on 2/1/24 at 2:29pm, Licensed Practical Nurse (LPN) S reported she became aware of Resident #34's complaint of a sore throat on 1/31/24. LPN S reported that residents who develop 1 or more symptoms of a potentially infectious illness, including but not limited to a sore throat, should be immediately be placed in isolation, and tested for influenza and covid. In an interview on 2/2/24 at 8:54am, LPN Z reported she became aware of Resident #34's complaint of a sore throat on 1/30/24. LPN Z reported she examined the resident's throat but did not initiate any further evaluation such as taking the resident's vital signs, completing a covid/flu screening. LPN Z reported Resident #34's throat did not have lesions on it, like strep. LPN Z reported isolation precautions were not implemented at that time despite the resident demonstrating at least one symptom of a potential contagious infection. LPN Z reported 8 residents were now in isolation on Resident #34's hall due to potential exposure or diagnosis of an Influenza A. In an interview on 2/2/24 at 1:52pm, Registered Nurse (RN) DD reported a resident with a sore throat, or any other symptom of an infection should immediately be placed in isolation precautions, and additional evaluations should be initiated, including assessing body temperature and other vital signs. In an interview on 2/2/24 at 2:11pm, Infection Preventionist (IP) U reported any resident who has at least one symptom of infectious illness, including a sore throat, should be immediately placed in isolation and the protocol should be initiated. When further queried about Resident #34 experiencing a sore throat on 1/30/24 and no isolation being implemented, IP U reported the nurse should have implemented a screening for illness, assessed the resident's vital signs (including body temperature and pulse) and isolation precautions should have been implemented. Review of physician's orders for Resident #34 revealed an order for droplet precautions related to influenza with a start date of 2/1/24 at 6am. Review of a Temperature Summary report for Resident #34 revealed no data was documented from 1/9/24-2/1/24 regarding the resident's body temperature. Review of a Pulse Summary report for Resident #34 revealed the resident's pulse was not documented on 1/30/24 or 1/31/24. Review of Prevention Strategies for Seasonal Influenza in Healthcare Settings, published by the Centers for Disease Control and Prevention, published 5/13/21, section 5 revealed droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after onset of illness. Review of Clinical Signs and Symptoms of Influenza published by the Centers for Disease Control and Prevention, published 10/3/22, revealed uncomplicated influenza is typically characterized by the abrupt onset of constitutional and upper respiratory tract signs and symptoms (fever .cough .malaise .sore throat .). 47659 Resident #98 Review of an Admission Record revealed Resident #98, was originally admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease. Review of Resident #98's Orders revealed, Order: Droplet precautions related to influenza. Start date 2/1/24. Review of Resident #98's Care Plan revealed, I (Resident #98) have Influenza aeb; Positive Influenza Date Initiated: 02/01/2024. Interventions: . Initiate transmission based precautions. A. Resident (#98) will be placed in private room if possible .E. Attach sign visitors and staff before entering contact nurse for instruction on residents door. Date initiated 2/1/24 . Wear a mask upon entering room and throw in waste basket on your way out. Date initiated: 2/1/24 . During an observation on 2/01/24 08:45 AM, Physical Therapy Assistant (PTA) BB entered Resident #98's room wearing a face mask and eye shield. It was noted that PTA BB did not wash his hands prior to entering Resident #98's room and did not don gloves or an isolation gown. PTA BB delivered a breakfast tray and assisted the resident in setting up the tray. PTA BB then exited Resident #98's room without doffing his face mask or washing his hands. During an interview on 2/01/24 at 8:48 AM, PTA BB reported that he did not know that he was required to wear a gown and gloves when entering Resident #98's room because she was on isolation precautions. PTA BB reported that he missed the sign on Resident #98's door with instructions on what PPE (personal protective equipment) was required for entering and exiting Resident #98's room. Review of the facility's Isolation Guidelines policy last revised 4/2021 revealed, POLICY: To provide a consistent approach to prevent the spread of infection and reduce the risk of transmittable infectious diseases to residents, employees, visitors, &/or volunteers. PROCEDURE: Isolation Guidelines are implemented when a resident has an infectious or communicable disease necessitating the use of Transmission Based Precautions (TBP), in addition to Standard Precautions, to interrupt the route of transmission of the illness. TBP are always used in addition to Standard Precautions .b.DROPLET OR MULTI-ROUTE TRANSMISSION PRECAUTIONS: A. Multi-route Transmission-Based Precautions would include any combination CDC definitions of airborne, droplet, or contact transmission based precautions. B. Are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions as well as infectious agents spread by direct or indirect contact with the resident's environment. C. Single resident room is preferred; in semi-private room, maintain spatial separation of 6 feet. D. Wear an isolation gown, gloves, eye protection, and mask upon room entry for all interactions . 45410 In an observation and interview on 1/31/2024 at 1:41 PM i room [ROOM NUMBER] and room [ROOM NUMBER], Certified Nursing Assistant (CNA) FF exited room [ROOM NUMBER] after using a mechanical lift, went directly into room [ROOM NUMBER] and used the lift to transfer another resident without sanitizing the lift in between use. CNA FF left the mechanical lift in room [ROOM NUMBER] and did not sanitize the lift after using it on the second resident. CNA FF reported she forgot to sanitize the lift after using it in room [ROOM NUMBER] and room [ROOM NUMBER]. CNA FF reported mechanical lifts should be sanitized after every use. CNA FF stated, I forgot, I should have. In an interview on 2/2/2024 at 12:16 PM, Registered Nurse AAA reported mechanical lifts are required to be cleaned in between every resident use. Review of facility procedure Examples of Shared Medical Equipment and High Touch Surfaces, provided 2/1/2024 at 8:46 AM, revealed .Shared Medical Equipment: Bleach containing wipe/cleaner . Nursing to clean between uses . Mechanical lift .

Based on observation, interview, and record review the facility failed to provide adequate supervision for 1 resident (Resident #38) of 7 residents reviewed for accidents/hazards resulting in the potential for residents to sustain a fall injury which have the potential to negatively affect the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #38 was a female with pertinent diagnoses which included stroke, paralysis on left side, osteoporosis (condition in which bones become weak and brittle), long term use of anticoagulant, dementia, disorders of bone density and structure, sciatica (pain runs down one or both legs from the lower back), pain in right leg, difficulty in walking, neuralgia (nerve pain usually caused by inflammation, injury, or infection), and abnormalities of gait and mobility. Review of current Care Plan for Resident #38, revised on 10/3/23, revealed the focus, .I am here r/t (related to) dementia and require assistance with my ADL's. Please update my care guide as my needs change . with the intervention .AMBULATION: Supervision with walker . Review of Fall Risk assessment dated [DATE], revealed, .3. History of Falls within last six months .2. 1-2 times .Medication use: Antihypertensives, Psychotropics .Gait Analysis: Uses an assistive device e.g. cane, walker, etc Moderate Risk . Review of Incident report dated 11/26/23 at 2:45 PM, revealed, .Nurse was called over to room [ROOM NUMBER] ASAP and bring a vital cart, when nurse arrived, resident was noted to be laying halfway in her bedroom doorway on her left side. Nurse asked if resident was in any pain, and she replied with just my pride, Resident denied hitting her head. Was wearing tennis shoes, glasses on, call light was not on, no incontinence, and walker was still in the bathroom .Resident Description: Resident said that she was trying to go to the bathroom but could not bear any weight on her left leg as it felt too weak, causing her to slide down onto the floor in the bathroom just in front of the sink area. She also said that she had crawled from the bathroom to her bedroom doorway to try and call for help.Immediate Action Taken: VS (vital signs) were taken and were all within normal limits and did not show any orthostatic hypotension. Resident was assessed for any injuries, and none were noted at the time of assessment. Staff was educated on not leaving the floor unless another staff member is there to relieve you so there is always eyes and ears present . Review of Fall Huddle Report dated 11/26/23 at 2:45 PM, revealed, .2 O'clock checks were done late. Hospitality aide ended up leaving at the end of her shift without someone relieving her (was watching the floor at the time while someone was on break) Interventions: Staff education . Review of Health Status dated 11/28/2023 at 04:27 AM, revealed, .Resident has no c/o beyond her baseline prior to fall. She has been ambulating with walker assist throughout the night. plan of care ongoing, no acute concerns at this time . In an interview on 02/01/24 at 02:46 PM, Certified Nursing Assistant (CNA) EEE reported she was completing room checks and saw her hand at the doorway to her room. CNA EEE reported the resident had lost her balance and could not reach her call light and crawled to her doorway. CNA EEE reported she went into the room and got her walker, call the nurse and completed vitals on the resident. CNA EEE reported the resident had reported she got a knot in her muscle. CNA EEE reported someone was always supposed to be there to supervise and monitor the residents. CNA EEE stated, I was on the other side of the building, and it was just me on the floor at the time other than the nurse. In an interview on 02/02/24 at 11:48 AM, CNA SS reported staff should always be on the floor to supervise the residents. During an observation on 02/02/24 at 11:45 AM, observed Resident #38 seated at the dining room table with her walker next to her on the right. Other residents were observed seated at the table as well. There were no staff present in the kitchen, dining, living, or office on the 600 unit. During an observation on 02/02/24 at 11:47 AM, Resident Care Coordinator DDD returned to the unit from break via the employee entrance with her drink in her hand and proceeded to the office. In an interview on 02/02/24 at 01:15 PM, CNA II reported it's important for all staff members to be on the floor because if there is a fall, two person assist, or if someone has to go to the hospital, one person cannot do it alone. If there is a fall, someone has to stay with the resident before they are assisted up. Falls could be prevented if the staff was using the safety measures such as gait belts, fall mats, and beds in low position and making sure they are answering call light quickly. We were taught to walk the hall to determine the location of the residents. In an interview on 02/02/24 at 01:36 PM, Licensed Practical Nurse (LPN) N reported we would want to have someone present at all times in case there was an emergency or if anything happens. You need a staff member present in case something happens. In an interview on 02/02/24 at 02:00 PM, Assistant Director of Nursing (ADON) DD reported there should be staff on the floor at all to times to supervise residents to ensure their safety.

Based on observation, interview, and record review the facility failed to position a urinary catheter collection bag to facilite drainage for 1 resident (Resident #22) of 4 residents reviewed for urinary catheter care, resulting in the increased risk of urinary tract infections and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #22 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and urinary retention. Review of a Minimum Data Set (MDS) assessment for Resident #22, with a reference date of 10/27/2023 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated Resident #22 was severely cognitively impaired. Review of a current hospice services Care Plan intervention for Resident #22, with a revision date of 11/14/2023, directed staff that Resident #22 required the extensive assistance of 1 or 2 staff with bed mobility. Review of a current foley catheter Care Plan intervention for Resident #22, with a revision date of 8/12/2020, directed staff that Resident #22 required the use of a urinary leg bag at all times. In an observation and interview on 1/31/2024 at 2:22 PM in Resident #22's room, Resident #22 was resting in his bed with his urinary leg bag attached to his upper leg with his legs elevated and the urinary drainage bag above the level of his bladder. Licensed Practical Nurse (LPN) YY reported Resident #22 used a leg bag 24 hours a day and while in bed. LPN YY reported the leg bag has an anti-reflux valve to prevent backflow. In an observation and interview on 2/1/2024 at 2:27 PM in Resident #22's room, Resident #22 was in his bed with his leg bag attached to his upper leg with his legs elevated. Resident #22's urinary leg drainage bag was positioned approximately 3 inches above the level of his bladder. LPN YY reported she was taught in nursing school that urinary catheter drainage bags should be placed below the level of the bladder to facilitate drainage. LPN YY reported the facility had residents who used urinary leg bags 24 hours a day. In an interview on 2/1/2024 at 2:35 PM, Registered Nurse Team Leader BBB reported she was not sure how completely Resident #22's urinary catheter leg drainage bag was emptying while he was in bed with the bag strapped to his leg. Review of email correspondence from Director of Nursing (DON) B, received 2/1/2024 at 6:06 PM, revealed Resident #22 was treated for a urinary tract infection in July of 2023 and in October of 2023. In a telephone interview on 2/2/2024 at 1:35 PM, Registered Nurse Urology Clinic Practice Manager Y reported if urinary leg bags were full or if the legs or drainage bag were elevated above the level of the bladder the urine would not drain appropriately as drainage was facilitated by gravity. Registered Nurse Urology Clinic Practic Manager Y reported urine not draining completely would increase the risk of urinary tract infections. Review of facility policy/procedure Nursing Standards of Care, Revised June of 2023, revealed .Catheter Care . Tubing and drainage bag will be positioned to allow for proper drainage .

Based on interview and record review the facility failed to ensure that a written agreement/policy between the facility and the dialysis provider (Name Omitted) was established and maintained for 1 resident (Resident #108) of 1 reviewed for dialysis services resulting in the potential for disruption in the continuity of care and /or the interruption of dialysis treatments. Findings include: Review of an Admission Record revealed Resident #108 had pertinent diagnoses which included: end stage renal disease (disease when the kidneys no longer work as they should), dependence on renal dialysis (blood purifying treatment when the kidneys no long work at optimum function), and type 2 diabetes mellitus (disease that causes high blood sugar levels). During an interview on 1/31/24 at 10:01 AM., Nursing Home Administration (NHA) A was asked for a copy of the facilities' contract or agreement with their chosen dialysis provider(s) and NHA A reported that the facility had no dialysis contract or agreement with any dialysis provider. NHA A reported that the facility used a local dialysis facility for their residents. During an interview on 1/31/24 at 10:01 AM., Director of Nursing (DON) B reported that the facility had never had a contract or agreement for dialysis services with any company. Review of Physician Orders for Resident #108 with an order date of 1/31/24 revealed, . (Name Omitted) to perform dialysis at 6:00 am every Monday, Wednesday, and Friday . Review of Care Plan for Resident #108 with a revision date of 3/21/2023 revealed, Focus: I need hemodialysis related to renal failure. I have a fistula in my left forearm that is being used . Goal: I will have no signs or symptoms of complications from dialysis . Interventions: contact (Name Omitted) dialysis center with any concerns . Dialysis on Monday, Wednesday, Friday . Encourage resident to go to the scheduled dialysis appointments . During an interview on 1/31/24 at 2:28 PM., Resident #108 reported that he received dialysis at (Name Omitted) Dialysis provider on Monday, Wednesday, and Friday every week. During an interview on 2/2/23 at 1:15 PM., NHA A reported that there was not any kind of contract or agreement between the facility and the (Name Omitted) Dialysis provider. NHA A reported she had another place to look to locate a contract or agreement. During an interview on 2/2/24 at 2:05 PM., NHA A' reported that she could not locate any contract or agreement between the facility and the (Name Omitted) Dialysis provider. No contract or agreement between the facility and the (Name Omitted) Dialysis provider was provided prior to exit.

Based on observation, interview, and record review the facility failed to identify post-traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 2 (Resident #33 and #90) of 3 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma. Findings include: Resident #33: Review of an Admission Record revealed Resident #33 was a female with pertinent diagnoses which included schizoaffective disorder, Alzheimer's disease, anxiety, tremor, auditory hallucinations, psychosis, and post-traumatic stress disorder (PTSD). Review of current Care Plan for Resident #33 revealed no focus or interventions which addressed the post-traumatic stress disorder diagnosis. Review of Resident #33's medical record revealed no Brief Trauma Questionnaire completed by staff for the diagnosis of post-traumatic stress disorder. During review of Resident #33's medical record, revealed a diagnosis provided by the county community mental health agency for post-traumatic stress disorder with no mention of the resident's trauma or triggers. In an interview on 02/02/24 at 12:44 PM, Social Services (SS) D reported there was not an assessment in Resident #33's record for PTSD. Review of the resident's care plan with SS D revealed she did not have interventions for PTSD. SS D reported the brief trauma questionnaire was completed at admission and when the resident's annual MDS assessment was completed a new brief trauma questionnaire would be completed as well, every year, and she was missed. Resident #90: Review of an Admission Record revealed Resident #90 was a male with pertinent diagnoses which included sleep terrors (night terrors), post-traumatic stress disorder (PTSD), dementia, and anxiety. Review of current Care Plan for Resident #90, revealed no focus or interventions for Resident #90's diagnoses of night terrors or PTSD. Review of Resident #90's medical record revealed no Brief Trauma Questionnaire completed by staff for the diagnosis of post-traumatic stress disorder. Review of Order Summary dated 8/22/23, revealed, .Xanax Oral Tablet 0.25 MG (Alprazolam) *Controlled Drug* .Give 0.25 mg by mouth at bedtime for INSOMIIA related to SLEEP TERRORS [NIGHT TERRORS] (F51.4) .indefinite end date: Time range: 1800-2100 . Review of Health Status dated 12/14/2023 at 3:28 PM, revealed, .Note was put into provider from pharmacy to consider dose reduction on Xanax. Provider disagrees with changing the therapy. Faxed to pharmacy and social work . In an interview on 02/01/24 at 02:15 PM, Director of Social Services (SSD) Y reported the brief trauma questionnaire was completed on admission and done on an annual basis when the MDS was reviewed. SSD Y reported Resident #90 does not like to discuss his history. SSD Y reported he was on a PRN (as needed) order for the Xanax but the provide did a scheduled order for him as he had been doing well. SSD Y reported family indicated they would prefer to not bring up the reasons for his night terrors or PTSD, and he has not had those (night terrors) since he had been at the facility. In an interview on 02/01/24 at 02:21 PM, Social Services (SS) D reported Resident #90 entered the facility for rehabilitation prior to being moved to long term care. SS D reported Resident #90's son reported his father reported he had night terrors, but the son had never observed him have them. SS D reported Resident #90 lived with his wife and she had passed away prior to him coming to the facility. According to, National Alliance on Mental Illness (NAMI) Post-traumatic stress disorder (PTSD) is an anxiety disorder that can occur after someone experiences a traumatic event that caused intense fear, helplessness, or horror. PTSD can result from personally experienced traumas (e.g., rape, war, natural disasters, abuse, serious accidents, and captivity) or from the witnessing or learning of a violent or tragic event .While it is common to experience a brief state of anxiety or depression after such occurrences, people with PTSD continually re-experience the traumatic event; avoid individuals, thoughts, or situations associated with the event; and have symptoms of excessive emotions. People with this disorder have these symptoms for longer than one month and cannot function as well as they did before the traumatic event. PTSD symptoms usually appear within three months of the traumatic experience; however, they sometimes occur months or even years later . https://namimi.org/mental-illness/ptsd

This citation pertains to MI00141167. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with major injury, and ensure that assistive devices (a gait belt) were used according to the care plan during a transfer for 1 (Resident #103) of 3 residents reviewed for falls, resulting in major injury when Resident #103 sustained a fall with a head laceration, multiple rib fractures, right scapular fracture, and an ADL (activities of daily living) decline. Findings include: .A gait belt provides a secure way to steady or guide patients who need assistance with ambulation when transferring or walking . [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 25912-25913). Elsevier Health Sciences. Kindle Edition. Review of an Admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: alzhiemer's disease and muscle weakness. Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 9/15/23 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #103 was cognitively impaired. Review of the Functional Status revealed that Resident #103 required limited assistance of 1 person for transfers and walking in her room. Review of the Health Conditions section revealed that Resident #103 had 1 fall since admission. Review of Resident #103's ADL Care Plan revealed, .I am here for LTC (long-term care) d/t (due to) Alzheimer's disease and do need assistance with my ADLS . Date Initiated: 3/22/23 .Interventions: .Transfers 1 assist with gait belt (ask resident most comfortable placement due to multiple right side rib fractures) NWB (non-weight bearing) right UE (upper extremity). Revision on: 12/4/23 . Prior to Resident #103's fall, Transfers-1 assist with gait belt. May use walker. Resident needs extra time and cueing to push up to stand and keep weight forward. 2 assist as needed during night time. Review of Resident #103's Fall Care Plan revealed, I had a fall with fracture. Date initiated 12/1/23. Interventions: Assist with transfers per Kardex (care guide). Keep w/c (wheelchair) (brakes locked) within reach when not in it. Therapy orders. Date initiated: 12/1/23. During an observation and interview on 12/6/23 at 11:05 AM Resident #103 was in her room, sitting in her recliner. Resident #103 was grimacing and restless. Resident #103 reported that she was in pain and could not get comfortable. Resident #103 had just finished with therapy. In an interview on 12/6/23 at 11:14 AM, Certified Occupational Therapy Assistant (COTA) E reported that day was the first time that she had worked with Resident #103, and that the goal was standing tolerance, balance and transfers in her room and stated, .she is non-weight bearing with her right arm due to a fracture . In an interview on 12/6/23 at 11:16 AM, Physical Therapy Assistant (PTA) C reported that Resident #103 required more assistance with transfers than she did prior to her fall on 11/22/23. Review of Resident #103's Fall Report dated 11/22/23 at 6:18 AM revealed, .nurse was called to room by CNA upon entering observed resident on floor sitting up with her back towards toilet. CNA was holding a wash cloth against her head which was bleeding. 0.6 x <0.1 laceration noted. Resident Description: Resident states I don't know .Laceration to left forehead cleansed and 3 steri strips applied No injuries observed post incident .Notes: 11/22/23: On 11/22 at 6:24 AM (Resident #103) had a fall in her bathroom. Per staff interview: The CNA was in her room at the time, she had just assisted (Resident #103) with her post toileting hygiene and pulled her pants up. The CNA stated (Resident #103) was standing with her walker in the bathroom when she (the CNA) stepped out of the bathroom to grab (Resident #103's) w/c (wheelchair) that was by the desk in her room. The CNA then reported as she turned around, (Resident #103) began to lose her balance and fall backwards. Following the fall (Resident #103) began to c/o (complain of) increased pain to her (R) (right) hip area, nursing contacted her PCP (primary care provider) and obtained x-ray orders. The (R) hip xray was later discontinued as she reported she was no longer painful with ROM (range of motion) in her (R) leg and was able to bear weight without difficulty during transfers. Mobile xray .No fracture or pneumothorax (abnormal amount of air in chest cavity) seen. 12/1/23: .On 11/24 the nurse observed a yellowing bruised area between her (R) rib and hip area with a moderate section of crepitus (a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone) just under the skin .The nurse called (Nurse Practitioner) to notify her of the above information along with she wasn't eating/drinking well;verbal orders were received for her to be sent to ER (emergency room ) for evaluation. Hospital radiology report on 11/24 showed: Acute minimally displaced right scapular (shoulder blade) fracture, acute comminuted (multiple bone splinters) and mildly displaced right posterior lateral rib fractures involving 5-10, acute superior endplate compression fracture of the T10 (thoracic (mid back) vertebra (spine) #10) and a small right hydropneumothorax (abnormal presence of air and fluid surrounding the lungs). (Resident #103) requires assist with transfers/ambulation and the CNA that was assisting her did not use a gait belt and stepped away from her to grab the w/c. The CNA was educated at the time of the fall on following her plan of care and has since been disciplined accordingly. (Resident #103) returned on 11/30 with therapy orders and her plan of care has been updated to meet her current needs . Review of Resident #103's Hospital Trauma assessment dated [DATE] revealed, .Assessment and Plan: .Injuries: RT (right) 5-10 posterolateral (back-side) rib fx (fracture), RT hemopneumothorax (abnormal amounts of both air and blood in the chest cavity), Extensive RT subcutaneous emphysema, T10 superior endplate fx, RT TP (transverse process: side of vertebra) fractures of T6 and T10, RT scapular fx .Plan: .pleural drain (chest tube to drain fluid) .Multimodal (several different) pain regimen and prn (as needed) antimetics (helps nausea), aggressive pulmonary toilet (attempts to remove fluid from lungs) .Daily CXR (chest xray) . In an interview on 12/6/23 at 1:31 PM, Certified Nursing Assistant (CNA) F reported that Resident #103 lost her balance and fell on [DATE], after CNA F had assisted her to stand up from the toilet and walked away to retrieve Resident #103's wheelchair. CNA F reported that she had not used a gait belt during the transfer and then left Resident #103 unattended standing up in the bathroom. CNA F reported that Resident #103's care guide indicated to use a gait belt with transfers. CNA F reported that she had written a statement immediately following the incident and handed presented it to Registered Nurse (RN) H, Risk Management-RN B went over the details of the fall with her at about 1:00 PM on 11/22/23, and that CNA F worked a full shift that day. CNA F reported that Assistant Director of Nursing (ADON) A called her at home on 11/24/23 and informed her that she was suspended from working, pending an investigation due to them discovering that Resident #103 had sustained multiple fractures from the fall. Then on 11/26/23 Director of Nursing (DON) called her and terminated employment due to having previous write-ups related to resident falls due to CNA F's failure to follow the care plan. Review of CNA F's Statement dated 11/22/23 revealed, I was transferring the resident (Resident #103) from the toilet to her w/c using her walker. When I went to go grab her w/c she started walking, lost balance and fell backwards towards the toilet, hitting her head on the toilet paper holder and back on the toilet. In an interview on 12/6/23 at 2:31 PM, ADON A reported that the facility determined the root cause of Resident #103's fall on 11/22/23 was due to CNA F leaving the resident unattended and without a gait belt on, and the CNA was educated on the spot, and then suspended from working after further review of Resident #103's injuries. ADON A reported that CNA F had multiple past incidents related to not following resident care plans in the past. In an interview on 12/7/23 at 11:27 AM, RN H reported that she assessed Resident #103 following the fall on 11/22/23, and she was complaining of pain in her hip and her head was bleeding. RN H reported that CNA F reported at that time, that Resident #103 fell while CNA F had stepped away from her for a moment to grab the wheelchair. RN H reported that she had discussed the details of the fall with Risk Management-RN B at about 8:00 AM on the morning of the fall. In an interview on 12/7/23 at 12:04 PM, Risk Management-RN B reported that she spoke with CNA F on 11/22/23 and that the CNA reported that she didn't use a gait belt and had left the Resident #103 unattended in the bathroom. RN B reported that CNA F was re-educated at that time. RN B reported that the facility held a nursing in-service on 11/30/23 to discuss the importance of following care guides and using a gait belt. RN B reported that she had provided the fall information to ADON later that same day, along with CNA F being written up. In an interview on 12/7/23 at 12:36 PM, Director of Rehab (DR) D reported that the therapy department had picked up Resident #103 for PT (physical therapy) and OT (occupational therapy) after returning from the hospital, due to a fall. DR D reported that Resident #103 had declined since pre-fall status, and that prior to the fall she required minimal to moderate assistance with bed mobility, transfers and dressing, but since the fall she was requiring moderate to maximum assistance. Review of Resident #103's Physical Therapy Evaluation and Plan of Treatment dated 12/1/23-12/30/23 revealed, .Reason for referral/current illness: .following fall .pt (patient) now has deficits in bed mobility, transfers, and ambulation .Fall Risk Assessment: History of Falls: Has patient fallen in past year? yes .Exact number unknown .Steadiness: Does patient feel unsteady when standing? yes. Does patient feel unsteady when walking? yes. Fear of falling: Does patient worry about falling? yes . In an interview on 12/7/23 at 12:50 PM, CNA P was working first shift that day, and reported that she had not received any re-education after Resident #103's fall, because the nursing in-service was held during the workday and only half of the CNA's could attend. In an interview on 12/7/23 at 12:55 PM, DON reported that the facility provided an in-person educational in-service for all nursing staff on 11/30/23 related to several issues which included following care plans and gait belt use. DON reported that the nursing staff that were not in attendance, had until 12/11/23 to complete the online version of the education. Review of a sign-in sheet for education November 2023 Nursing Staff in-Service indicated that 21 of 108 staff that were listed had attended the education on 11/30/23. Review of a course completion log for Resident hosted bed-making and Careguide reminders November 2023 indicated that 34 nursing staff and 1 housekeeping staff had completed the education. In an interview on 12/7/23 at 1:33 PM, ADON A reported that when it was discovered that CNA F had not provided the needed assistance, which resulted in Resident #103 falling, the facility did not formally assess all residents in the facility and/or educate all nursing staff and stated, .we terminated the CNA, so there would be no more residents effected . ADON A reported that on 11/27/23 she had asked the therapy director (DR D) to review all resident care guides to ensure that they were clear and that everything matched, so that the resident needs were clearly written for the CNA's to follow. ADON A reported that the nurses on the floor are required to perform one audit of CNA care weekly, and that was an ongoing facility procedure, not something that was implemented as a result of Resident #103's fall.

This citation pertains to intake #MI0014167 and MI00140487. Based on interview and record review, the facility failed to immediately report incidents of abuse (resident to resident) and neglect in 3 (Resident #101, #102, and #103) of 3 residents, when Resident #102 struck Resident #101 multiple times with a closed hand causing bruises, and Resident #103 sustained a fall with multiple fractures after staff failed to provide adequate supervision and assistive devices (gait belt) according to the care plan, resulting in the potential for continued abuse and neglect. Findings include: Resident #101 Review of an Admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: difficulty walking. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 10/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 13, out of a total possible score of 15, which indicated Resident #101 was cognitively intact. Resident #102 Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with behavioral disturbance. Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 11/10/23 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #102 was severely cognitively impaired. Review of a Facility Reported Incident received via online on 10/24/23 at 2:44 PM revealed, .Date of Alleged Event 10/23/23 at 4:10 PM .Per camera review .4:08pm (Resident #101) enters the (dining room) and heads to the drink station then heads to his table located on the right side of the dining room. (Resident #102) is sitting at her table to the left of (Resident #101's) table. (Resident #102) is sitting with two other residents .and was watching the television. 4:10:11 (Resident #101) rolls up to his table. (Resident #102's) back is to (Resident #101). 4:10:19 (Resident #102) begins to look around and looks to be speaking to (another resident), who then points at (Resident #102). 4:10:21 (Resident #102) turns her wheelchair towards (Resident #101). 4:10:26 At this time, it appears (Resident #102 & Resident #101) are speaking to each other. (Resident #102) then raises her right hand & balls up her fist. (Resident #101) raises his left arm in defensive move, and (Resident #102) swings her fist and strikes (Resident #101) on his left forearm several times- this lasts until 4:10:36 (9 seconds total) . The facility reported the incident approximately 26 hours after it occurred. In an interview on 12/6/23 at 1:00 PM, Hospitality Aide (HA) M reported that she was present in the dining room and witnessed the resident to resident altercation between Resident #101 and Resident #102 on 10/23/22 just before dinner. HA M reported that Resident #102 started yelling at Resident #101, and then rolled over to him and started hitting him really hard. HA M reported that the residents were immediately separated and that was the end of it. HA M reported that Resident #102 frequently yelled out and hit staff, but that was the first time that she had ever hit another resident. In an interview on 12/7/23 at 11:44 AM, Director of Social Services (DSS) N reported that she came into the facility on [DATE] to investigate the resident to resident incident between Resident #101 and Resident #102, after she received a call from the nurse. DSS N reported that she called the DON and NHA on her way in to the facility to inform them of the incident that was reported. DSS N reported that after reviewing the cameras and interviewing the residents, she again called the DON to discuss her findings. DSS N reported that Resident #102 was just joking around with Resident #101 about her hat, and that Resident #101 responded by yelling and hitting him; Resident #102 yelled for Resident #101 to stop hitting him and defended himself by raising up his arm, until staff were able to deescalate things. In an interview on 12/7/23 at 11:15 AM, DON reported that she and ADON A are responsible for reportables to the state agency. DON reported that she was made aware of the resident to resident abuse between Resident #101 and Resident #102 late in the evening on 10/23/23, but thought that she 24 hours to report to the state, due to no serious bodily injury. Resident #103 Review of an Admission Record revealed Resident #103 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: alzheimer's disease and muscle weakness. Review of a Facility Reported Incident received via online submission on 11/24/23 at 11:07 PM indicated that Resident #103 fell on [DATE] at 6:24 AM, as the result of a CNA leaving the resident unattended and without use of a gait belt during a transfer. Review of Resident #103's Fall Report dated 11/22/23 at 6:18 AM revealed, .nurse was called to room by CNA upon entering observed resident on floor sitting up with her back towards toilet. CNA was holding a wash cloth against her head which was bleeding. 0.6 x <0.1 laceration noted .Laceration to left forehead cleansed and 3 steri strips (helps to keep the laceration closed) applied No injuries observed post incident .Notes: 11/22/23: On 11/22 at 6:24 AM (Resident #103) had a fall in her bathroom. Per staff interview: The CNA was in her room at the time, she had just assisted (Resident #103) with her post toileting hygiene and pulled her pants up. The CNA stated (Resident #103) was standing with her walker in the bathroom when she (the CNA) stepped out of the bathroom to grab (Resident #103's) w/c (wheelchair) that was by the desk in her room. The CNA then reported as she turned around, (Resident #103) began to lose her balance and fall backwards. Following the fall (Resident #103) began to c/o (complain of) increased pain to her (R) (right) hip area .Mobile xray .No fracture or pneumothorax (abnormal amount of air in chest cavity) seen. 12/1/23: .On 11/24 the nurse observed a yellowing bruised area between her (R) rib and hip area with a moderate section of crepitus (a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone) just under the skin .Hospital radiology report on 11/24 showed: Acute minimally displaced right scapular (shoulder blade) fracture, acute comminuted (multiple bone splinters) and mildly displaced right posterior lateral rib fractures involving 5-10, acute superior endplate compression fracture of the T10 (thoracic (mid back) vertebra (spine) #10) and a small right hydropneumothorax (abnormal presence of air and fluid surrounding the lungs). (Resident #103) requires assist with transfers/ambulation and the CNA that was assisting her did not use a gait belt and stepped away from her to grab the w/c . In an interview on 12/6/23 at 1:31 PM, Certified Nursing Assistant (CNA) F reported that Resident #103 lost her balance and fell on [DATE], after CNA F had assisted her to stand up from the toilet and walked away to retrieve Resident #103's wheelchair. CNA F reported that she had not used a gait belt during the transfer and then left Resident #103 unattended standing up in the bathroom. In an interview on 12/6/23 at 2:31 PM, ADON A reported that the facility had determined immediately that the root cause of Resident #103's fall on 11/22/23 was due to CNA F leaving the resident unattended and without a gait belt on, and the CNA was educated on the spot, and then suspended from working after further review of Resident #103's injuries on 11/24/23. ADON A reported that CNA F had multiple past incidents related to not following resident care plans in the past, and was ultimately terminated on 11/26/23. ADON reported that she reported Resident #103's fall to the state, after the facility received results from the hospital xrays on 11/24/23, which indicated that Resident #103 had sustained multiple fractures from the fall. In an interview on 12/7/23 at 11:15 AM, DON reported that she and ADON A are responsible for reportables to the state agency. DON reported that ADON A did not report Resident #103's 11/22/23 fall, until the resident was hospitalized with multiple fractures on 11/24/23. DON reported that the fall was a result of the CNA not following the care plan, but it was reported to the state due to the resulting serious bodily injury that was identified. In an interview on 12/7/23 at 11:27 AM, RN H reported that she assessed Resident #103 following the fall on 11/22/23, and CNA F reported that Resident #103 fell while CNA F had stepped away from her for a moment to grab the wheelchair. RN H reported that she had discussed the details of the fall with Risk Management-RN B at about 8:00 AM on the morning of the fall. In an interview on 12/7/23 at 12:04 PM, Risk Management-RN B reported that she spoke with CNA F on 11/22/23 and that the CNA reported that she didn't use a gait belt and had left the Resident #103 unattended in the bathroom. RN B reported that CNA F was re-educated at that time, and continued to work the rest of that day. RN B reported that she had provided the fall information to ADON A later that same day, along with CNA F being written up. RN B reported that she did not report the incident to the state, as that was not her responsibility. In an interview on 12/7/23 at 1:33 PM, ADON A reported that when it was discovered that CNA F had not provided the needed assistance, which resulted in Resident #103 falling, the facility did not formally assess all residents in the facility and/or educate all nursing staff and stated, .we terminated the CNA, so there would be no more residents effected .

This citation pertains to Intake # MI00133911. Based on interview, and record review, the facility failed to immediately report an elopement incident (a situation involving possible neglect involving a system failure) to the State Survey Agency in 1 of 3 residents (Resident #101) reviewed for elopement/supervision, resulting in the potential for a delayed/incomplete investigation. Findings include: Review of the policy/procedure Abuse, Neglect and Exploitation, dated 11/2019, revealed .Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .The Abuse Coordinator in the facility is the Administrator, Director of Nursing or facility appointed designee. Report allegations or suspected abuse, neglect or exploitation immediately to .Administrator .State Survey and Certification agency through established procedures .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, must be reported no later than 2 hours after the allegation is made if the events involved abuse or result in serious bodily injury. If the event that caused the allegation did not involve abuse or bodily injury, the report must be made no later than 24 hours to the administrator of the facility and to other officials, including the State Survey Agency, adult protected services, and local law enforcement, in accordance with State law . Review of an Admission Record revealed Resident #101 was a female, originally admitted to the facility on [DATE], with pertinent diagnoses which included dementia with behaviors, anxiety, depression, insomnia, heart disease, anemia (a condition with not enough healthy red blood cells), hypothyroidism, Raynaud's syndrome (a condition that causes small arteries to constrict excessively when exposed to cold temperatures, limiting blood supply), and arthritis. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 12/26/22, revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated severe cognitive impairment. Further review of this MDS assessment revealed Resident #101 had behavioral symptoms which included hallucinations/delusions, physical/verbal behavioral symptoms directed toward others, and wandering. Review of a Care Plan for Resident #101 revealed the focus .I have a diagnosis of Vascular dementia and adjustment disorder with anxiety and depressed mood. I am prescribed medication to help with my anxiety and mood. I may try and bite and try and leave. I am an elopement risk ., with the goal .I will leave the premises only when accompanied by family or staff ., and interventions which included .Wander guard sensor to my left ankle . all initiated 12/22/22. Review of an Elopement Risk Assessment for Resident #101, dated 12/19/22, revealed .Is the resident cognitively impaired and displays poor safety awareness? Yes .Is the resident able to move around independently with or without assistive devices, such as a wheelchair or walker? Yes .Are there relevant factors from the resident's history, such as elopement from previous home, history of leaving the premises unsupervised or without signing out? .Yes .family states she has tried to get out of building at previous facility .Wanderguard to left ankle . Review of an Incident/Accident Report for Resident #101, dated 12/23/22 at 7:27 PM, revealed .At 7:45pm the resident was brought to the (Unit Name) dining room door by two staff members as they found her outside on the ground by the sidewalk in the front parking lot .Resident was assessed for injury, wrapped in warm blankets, and V/S (Vital Signs) were obtained .DON (Director of Nursing) .notified .No Injuries .Recent admission with dementia and behavior issues, wanderguard was in place . Review of a BFNP Note for Resident #101, dated 12/29/22 at 10:10 AM, revealed .On 12/23/22 per camera review resident exited the East Ambulance entrance- after holding the crash bar down for 15 seconds- at 7:30pm. She walked around the building along the side of the road and into the front parking lot, where she attempts to get on he sidewalk, but falls. She is seen attempting to get up on her own when staff come to her and assist at 7:43pm. She re-enters the (Unit Name) dining room door with staff at 7:45pm. They then place her in a w/c (wheelchair) and wrap her in blankets. Staff last visually checked on her at 7:15pm which she was noted to be in bed resting. V/S (Vital Signs) returned to normal limits within 15 minutes of the incident. It was further noted by ADON (Assistant Director of Nursing) that the arial devices (used by staff to identify activated call lights/alarms) were clearing themselves of the egress door alarms for the ambulance entrances only every (2 minutes)- the IT (Information Technology) director was contacted and able to correct this, so that they will continue to show on the devices, this is why staff was not able to see/respond sooner to the door alarm on 12/23/22 as they were in rooms with other residents providing care. Resident did have a wanderguard in place and it was found to be in proper working order on the night of the incident. Resident's individualized plan of care was updated to have the resident be one-on-one within line of sight supervision, (as she) does have aggression towards staff at times. She was also moved to (Room Number) to be closer to the nurse's station and further away from an exit door . In an interview on 10/10/23 at 1:20 PM, Director of Nursing (DON) B reported she was notified of Resident #101's elopement on 12/23/22 at approximately 8:00 PM. DON B reported she completed interviews and reviewed the camera footage to verify what happened. DON B reported Resident #101 was identified as an elopement risk upon admission, and a wanderguard was initiated. DON B reported Resident #101 had only been at the facility for .a few days . prior to her elopement on 12/23/22. DON B reported Resident #101 exited the facility through the East Ambulance Exit, by pushing on the crash bar for 15 seconds to release the door lock. DON B reported an audible alarm sounded at the exit door, however, staff on the unit were in rooms providing resident care at the time. DON B reported an alert was also sent to the staff arial devices, however, the alert cleared automatically after two minutes so staff believed someone had responded. DON B reported the exit door alarm was still sounding when staff completed resident care, and they responded to the alarming door at the same time Resident #101 returned to the building through the dining room door. In an interview on 10/11/23 at 1:22 PM, Administrator A and DON B reported they were both contacted on 12/23/22 in regard to Resident #101's elopement from the facility. DON B stated there was .No harm, no allegation of abuse, no neglect, no major injury . and that was why the incident was not reported to the State Agency.

Based on observation, interview, and record review the facility failed to ensure facilty staff fully implemented the national Centers for Disease Control (CDC) guidance per facility policy for newly admitted /readmitted residents and appropriate staff implementation of PPE (personal protection equipment) while caring for the newly admitted /readmitted residents in 6 of 15 sampled residents (Resident #101, #102, #107, #112, #114, & #115) reviewed for infection control, resulting in an immediate jeopardy when beginning 8/27/20, the facility failed to place newly admitted /readmitted residents in Transmission Based Precautions and ensure staff utilized appropriate person protection equipment (PPE) for staff caring for newly admitted /readmitted residents.This deficient practice placed all residents residing in the observation unit and Covid-19 unit at risk for serious harm and/or death. On 9/11/2020 at 5:45 PM, the Nursing Home Administrator was verbally notified and received written notification of the immediate jeopardy that began on 8/27/2020 due to the facility's failure to implement infection control in the designated COVID-19 unit. A written plan for removal for the immediate jeopardy was received on 9/15/2020 and the following was verified on 9/18/2020: 1. All resident who were newly admitted /readmitted in the last 14 days were placed in quarantine for 14 days on transmission based precautions. 2. On 08/27/20 all residents were asked to remain in their rooms with their doors closed until the outbreak is over. 3. On 08/27/20 all residents' rooms in the outbreak area were cleaned/sanitized and continue to be daily. 4. On 08/27/20 the facility closed to new admissions and remains closed until we have 14 days with no new positive COVID-19 results, 5. On 08/27/20 all rehab staff (nurses, CNA's, housekeepers, dietary staff, and therapy) were instructed to wear a face shield over their surgical mask and an isolation gown. 6. On 08/27/20 rehab staffs as noted above were instructed to use a separate entrance and exit from the rest of the staff. 7. On 08/28/20 all staff that came into contact with the first infected resident were notified that they were exposed to COVID-19 and instructed to: wear a face shield over their surgical mask at all times, eat outside others or in their car, monitor themselves closely for symptoms and report any symptoms immediately, and they continued to be screened upon entrance to the facility for symptoms and temperature checks. 8. On 09/09/20 all staff in the non-affected area of the facility were instructed to wear a face shield over their surgical mask in resident care areas. 9. On 09/10/20 the rehab staff (affected area) was instructed to add wearing an N-95 under their face shields instead of a surgical mask; and to continue to wear face shield, gown, and gloves. 10. On 08/27/20, 09/03/20, 09/08/20, and 09/15/20 the local health department was notified of positive resident results and contact tracing was initiated by the Infection Control Nurse (IC) in collaboration with our local health department. Staff, residents, and resident's responsible parties were notified of residents that tested positive for COVID-19 on 08/27/20, 09/03/20, 09/08/20, and 09/15/20. 11. The facility-initiated retesting of all residents on 08/31/20, 09/04/20, and 09/11/20. All staff have also continued to be tested weekly since 06/29/20. On 09/03/20 the facility initiated Point of Care rapid testing for symptomatic staff and residents to obtain faster results. 12. Staff that have tested positive for COVID-19 have been taken off work for a minimum of 10 days since the beginning of their symptoms in accordance with CDC guidelines and we also collaborate with our local health department for guidance on when the employee can return to work. 13. On 09/16/20 the type of precaution (Droplet +) was added to the signage posted on all doors in the rehab/observation unit. 14. After resolution of our current outbreak, in our rehab/observation unit all newly admitted /readmitted residents will be temporarily quarantined to their individual rooms using Droplet + precautions for the first 14 days and instructed to wear a surgical mask whenever staff enters their room as much for these residents will wear an N-95, face providing care. 15. On 09/14/20 the policy and procedure for COVID-19- Infection Control has been updated by the Director of Nursing (DON) and Infection Control Nurse (ICN) to meet the most current CDC guidelines. All staff will be re-educated on this policy which will include the use of N95 respirator, and will continue to wear a face shield, gown, and gloves when caring for residents that are in our observation/rehab unit. As of 09/15/20, 219 staff members have been educated out of 288, which is 76%. Staff will complete this education at the beginning of their shift and will not be allowed to work until it is completed. 16. The procedure Covid-19 Outbreak was updated on 09/16/20 to include the cleaning of face shields in between resident rooms with an alcohol pad by the Director of Nursing (DON) and Infection Control Nurse and posted on the staff huddle board in the affected unit, and all staff will be re-educated on the changes at the beginning of their shift moving forward. The staff present today 108 out of 288 staff have already been educated. 17. Beginning 9/14/20, The ICN and DON or designee will continue to monitor the CDC website for best practice guidelines for dealing with COVID-19 in the long term care setting. 18. Beginning on 09/16/20 the ICN, Nurse Educator, and the 2nd and 3rd shift Supervisors will complete weekly random live observations of staff for appropriate use of personal protective equipment (PPE) and infection control techniques. These observations will be documented on a QA tool, and any breeches will be corrected immediately, and the staff will sign the form that they have been educated. Although the Immediate Jeopardy was removed on 9/16/20, the facility remained out of compliance at a scope of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and severity of pattern due to not all education had been completed and sustained compliance had not yet been verified by the State Agency. Findings include: Review of the Centers for Disease Control and Prevention-Coronavirus Disease 2019 (COVID-19) last revised April 30, 2020 revealed, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. *All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. *Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. *New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html . Review of facility policy Outbreak Management - COVID 19 dated 3/20, revealed, POLICY: Infection Prevention and Control Management - Outbreak Management Outbreak Investigation Policy: It is the policy of this facility to recognize and contain infectious disease outbreaks and outbreak measures will be instituted whenever there is evidence of an outbreak as outlined below . Definitions: For any given circumstance, the facilities Medical Director and Infection Preventionist, and/or State Guidelines will determine if an outbreak exists. CMS defines an outbreak as the occurrence of more cases than expected in a given area or among a specific group or people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. While a single case of a rare infectious condition or one that has serious health implications may or may not constitute an outbreak, facilities should not wait for the definition of an outbreak to act . According to the CDC, Testing Guidelines in Nursing Homes, dated 7/21/20, A single new case of [DIAGNOSES REDACTED]-CoV-2 infection in any HCP or a nursing home-onset [DIAGNOSES REDACTED]-CoV-2 infection in a resident should be considered an outbreak. When one case is detected in a nursing home, there are often other residents and HCP who are infected with [DIAGNOSES REDACTED]-CoV-2 who can continue to spread the infection, even if they are asymptomatic. Performing [MEDICAL CONDITION] testing of all residents as soon as there is a new confirmed case in the facility will identify infected residents quickly, in order to assist in their clinical management and allow rapid implementation of IPC interventions (e.g., isolation, cohorting, use of personal protective equipment) to prevent [DIAGNOSES REDACTED]-CoV-2 transmission. Review of facility policy COVID-19 Isolation Plan date 4/20, revealed, POLICY: It is the policy of this facility to implement proper infection control plans to prevent the spread of COVID-19. PROCEDURE .5. The antechamber area will be used to apply PPE as follows .f. Apply two pairs of gloves .7. While in the contaminated area outer gloves will be changed when visibly soiled or if they become torn/damaged .11. Prior to leaving the COVID area staff will go to the outside of the antechamber- where a trash can will be located, and remove their PPE in the following order .b. Remove outer layer of gloves . Review of facility policy, COVID-19 - Infection Control Policy revision date 9/9/2020, revealed, POLICY: The facility has established appropriate guidelines pursuant to recommendations from the .MDHHS, and the Federal Centers for Disease Control (CDC). The policy addresses staff and visitor behavior and responsibilities to try to prevent the transmission of communicable diseases, specifically COVID-19. Healthcare personnel (HCP) are on the front lines of caring for patients with confirmed or possible infection with coronavirus disease 2019 (COVID-19) and therefore have an increased risk of exposure to this virus. HCPs can minimize their risk of exposure when caring for confirmed or possible COVID-19 patients by following CDC infection prevention and control guidelines, including use of recommended personal protective equipment (PPE). PROCEDURE: 1. The facility, consistent with federal regulations, implements universal, standard infection control practices. This may include information pertaining to a. Standard Precautions b. Hand hygiene c. Respiratory hygiene .e. Signs and symptoms of common communicable diseases. 2. To prevent the spread of respiratory germs WITHIN the facility .b. If we are in an outbreak situation- (one or more COVID-19 positive resident or staff member) than the staff will be required to wear a surgical mask with face shield when interacting with residents. To conserve PPE staff will use their face shield for one week, and then discard. When not in use they will be stored in a paper bag labeled with the staff member's name in their locker or office. They should be cleaned when visible soiled and at the end of each shift prior to storage in your paper bag. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html h. All admissions or any residents who go to the ED will be temporarily quarantined to their individual rooms for a minimum of 5 days after admission/return, and they will be asked to wear a surgical style mask when staff is in their room. They will also be asked to wear one when they are out in facility for a total of 14 days; to monitor for signs and symptoms of COVID 19. To conserve PPE, these masks will be changed weekly and when visibly soiled as they are used intermittently by the residents .l. When COVID-19 is present in the facility the residents will be isolated to the Rehab unit, which has a 21 bed capacity. The DON will assign designated staff to care for these residents and they will receive additional training .m. The facility monitors the Federal CDC website and state public health sources to understand COVID-19 activity in their community to help inform their evaluation of individuals with unknown respiratory illness. If there is transmission of COVID-19 in the community, in addition to implementing the precautions described above for residents with acute respiratory infection, the facility shall also consult with public health authorities for additional guidance . o. Hand and respiratory hygiene as well as cough etiquette by residents, visitors, and employees is imperative. Everyone is encouraged to wash their hands and to use hand sanitizer frequently. p. Employees are educated and reminded to clean their hands according to CDC guidelines, including before and after contact with residents, after contact with contaminated surfaces or equipment, and after removing personal protective equipment (PPE) .s. Post signage on the door or wall outside of the resident room that clearly describes the type of precautions needed and required PPE and make sure it is readily available. In an effort to conserve PPE the facility will follow the CDC Interim Infection Control Guideline recommendations for COVID-19 in healthcare settings .6. Steps to promote health and safety .f. Wash your hands often with soap and water for at least 20 seconds .7. Violations of these policies shall be reported to the Administrator and/or DON for appropriate enforcement and/or disciplinary actions . It is noted, the facility policy was revised after surveyor entered facility. Surveyor requested facility policy prior to revision on 9/9/2020 which was not provided by exit. During observation and interview on 9/9/2020 at 3:00 PM of the Observation Unit Registered Nurse (RN) F met surveyor at Rehabilitation entrance to assist with donning Personal Protection Equipment (PPE) of gown and face shield. RN F stated, The residents that are on the observation unit are on transmission-based precautions of droplet isolation. The residents on this unit have recently been admitted to the facility and must stay here until there 14-days of observation are done. Observed 7 (seven) residents residing on the unit with transmission-based precaution/droplet isolation signage and isolation hangers on doors. RN F stated, The isolation hangers are missing PPE supplies. When staff sees a PPE item has run out they chip in and help out to replace the items. Yes, one of the residents on droplet isolation has no PPE in their isolation hanger. When a staff enters a resident room, they would have to sanitize their hands and don gloves. They would already be wearing a gown. When the staff leaves a resident room, they would remove (doff) their gloves and sanitize their hands. Staff does not always change gowns when entering or exiting the room. It depends on what kind of care they provide the resident. All the residents on this unit are on droplet isolation for possible COVID-19. Observed CNA I exit Resident #102's room wearing a gown, surgical mask, and face shield. CNA I stated, I wear a face shield and only clean it when I take if off to leave the unit. RN G entered the unit wearing a gown, surgical mask, and face-shield, stating, All residents on this unit are on droplet isolation precautions. They should have PPE in their isolation hangers for the safety of the staff and residents. Some PPE supplies are missing from the hangers and will need to be replaced. During an observation and interview on 9/9/2020 at 3:30 PM of the designated COVID-19 unit (formerly the rehab unit), the surveyor had to enter through the antechamber. In the antechamber were PPE supplies; N95 masks, face shields, gloves, and gowns. No dirty linen bin or garbage can was noted. Upon entered the COVID-19-unit, RN K toured the unit with the surveyor. RN K wore a face shield, N95 mask, gown, and two (2) pairs of gloves. RN K stated, Staff wear two (2) pairs of gloves while working on this unit per the DON. When staff enters a room, they are to use hand sanitizer on the outer pair of gloves. When exiting the room, the outer gloves are to come off and hand sanitizer is to be used on the base pair of gloves and a new pair of gloves go over them. We are to wear the base pair of gloves all day on this unit. CNA L stated, Staff wears two (2) sets of gloves while working on this unit. We use hand sanitizer on the gloves. The gowns we wear stay on all shift and used for all the residents. We do not change it out unless it is visibly soiled. The face shields we wear are also used for all the residents and we do not change it out either unless it is soiled. The resident's doors are to be kept shut to prevent the spread of [MEDICAL CONDITION]. From the time the surveyor entered the hall, Resident #105 door was open with the resident going in and out of the room while in her wheelchair. Two (2) of the three times she entered the hall from her room she was not wearing her mask with CNA L encouraging her to go back into her room. Resident #105 would go back into her room but did not want the door shut. Observed CNA L enter Resident #105's room twice, each time she did not change gown, with one time not changing her outer gloves at all. All residents had signage outside of room designating them to be on transmission-based precautions/droplet isolation. While touring the end of the hall with RN K in front of Resident #105's room, Occupational Therapist (OT) J entered the unit wearing a blue plastic gown, blue surgical mask, face shield, and gloves. OT J was carrying a clear plastic bag with a yellow gown and gloves in it. OT J stated, There was no garbage can to put my gloves in and no dirty linen can to put the gown in. Is it okay that I bring this bag on the unit? Note that OT J had already walked the length of the designated unit carrying the bag with dirty gown and gloves. During this time Resident #105 door to her room was open. She entered the hall while in her wheelchair and held a conversation with RN K. OT J entered Resident #105's room without changing her gloves or gown and began to do therapy her. According to https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/gloves.html Conventional capacity strategies. Continue providing patient care as in usual infection control practice. Note: CDC does not recommend double gloves when providing care to suspected or confirmed COVID-19 patients. Continue use of approved disposable medical gloves in accordance with standard and transmission-based precautions in healthcare settings . According to the CDC, IV. Standard Precautions .IV.B. Personal Protective Equipment (PPE) . IV.B.2.c. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination (see Figure). Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens . IV.B.3.a. ii. Remove gown and perform hand hygiene before leaving the patient's environment. IV.B.3.b. Do not reuse gowns, even for repeated contacts with the same patient (https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html) During an interview on 9/10/2020 at 3:50 PM, DON B stated, The facility is definitely following CDC guidelines, CMS (Centers for Medicaid and Medicare) guidelines, and checking CDC websites. Only in the COVID-19 unit do the staff wear double gloves. The inner pair is treated like the staff's hands. I was not comfortable with staff on the COVID unit just changing gloves and not protecting their hands all the time. CDC recommended to only change gloves if soiled and continue to wear the same gloves if cohorting like COVID residents. I felt more comfortable with staff wearing double gloves. The inner gloves would be treated as skin. I think that over protection is always better than under-protection. Reviewed the CDC infection control guidelines with DON B at this time discussing that staff were not changing their gowns between COVID-19 positive residents. DON B stated, Gowns on the observation unit are being changed between residents. Isolation chambers (hangers) should have supplies in them at all. The staff put a gown on when starting their shift and wear the gown while on the observation unit. When staff go into a resident's room staff wear the gown they had on. Then when staff exit the room they change into another gown. On the observation unit there is no time when a staff should be wearing the same gown and going from one resident's room into another resident's room. After reviewing documents with DON B she stated, I told you wrong about the observation unit, in the beginning staff were told they only needed to change their gowns if they were doing direct-patient care. This is the still the same. Reviewed with DON the directive she gave staff. We are still trying to conserve PPE. In an email correspondence received on 9/11/2020, DON B stated, We started placing people in modified transition-based precautions since the day we were closed to visitors March 12 (2020). To conserve PPE. This included: COVID testing prior to admission, surgical masks for all staff on that unit, isolation to their individual rooms for a minimum of 5 days, surgical masks for residents in that unit for the first 14 days. We also placed anyone suspected/symptomatic of COVID into added droplet precautions until COVID-19 test results could be obtained. In an email correspondence received on 9/11/2020 at 1:58 PM, DON B indicated the facility had on Friday, June 12, 2020 at 2:46 PM, 1,320 Face Masks, 300 Face Shields, and 192 Gowns. Review of facility PPE Inventory Weekly Supply dated 7/1/2020 indicated PPE supplies included .Surgical/ Cone Mask 9,370, allotted 1 case from Medline per month, 1071 expected with FEMA donation. Small N-95 Mask 1,150, Regular N-95 Mask 1,150, Face Shields 2,030, Gowns 3,234, Small Glove Boxes (single gloves) 1,100 Allotted 1 case per month from Medline. Medium Glove Boxes (single gloves)116,500, Large Glove Boxes (single gloves) 34,050. Review of facility PPE Inventory Weekly Supply dated 8/4/2020 indicated PPE supplies included . Surgical/ Cone Mask 10,620, Small N-95 Mask 1,100, Regular N-95 Mask 1,310, Face Shields 2,323, Gowns 3,978, Small Gloves 500, Medium Gloves 163,650, Large Gloves 31,600, Extra Large Glove 22,995. During an interview on 9/11/2020 at 12:53 PM DON B stated, Staff on the rehab observation unit were not wearing gowns until August 27th (2020) because we couldn't get them. There was a shortage of gowns. Staff started wearing gowns when the first resident tested positive for COVID-19 on August 27th (2020). Staff have worn surgical masks on the observation unit from the first day it opened. Staff threw out their masks at the end of their shift each day. Staff are to go by standard precautions. There was never a shortage of gloves. I have 197,000 single gloves as of today (9/11/2020). Staff assigned to the COVID-19 unit have worn double gloves since it opened on April 6th (2020). I put that in my policy. The facility does not have a shortage of gloves. During an interview on 9/10/2020 at 4:42 PM, DON B stated, For any kind of transmission, I use the signage that just says, Transmission Precautions. The sign is on a resident door to tell staff what kind of PPE to wear when giving care. If the sign just says Contact or Droplet precautions staff would get confused and not know what PPE to wear. That is why I don't write what kind of precaution the resident is in; I just tell staff what to do. During an interview on 9/11/2020 at 8:26 AM, Local Health Department RN (LHD) Q stated, I have been working with the ICP at the facility. My recommendations for the facility during the COVID-19 outbreak has been education on cleaning, close admissions to new admits, screening of staff and residents, and the use of PPE. Yesterday, (9/10/2020) I spoke with (DON B) and the facility decided to use fitted-N95 masks on the Covid-19 starting yesterday and using surgical masks and face shields on the other units. The local health department advises to use CDC guidelines for infection control. When told the facility was using double gloves in the positive COVID-19 unit, LHD Q stated, I have not heard the facility is using double gloves on the COVID-19 unit. Staff are only to wear one set of gloves and remove them after resident care and do hand hygiene. That is standard glove use. Why would you sanitize gloves? It would not be my recommendation to use double gloves. For gown use, the health department would recommend the facility follow CDC guidelines. The facility is speculating (Resident #101) had a hard time wearing a mask and at times did not wear a mask while on the observation unit. The facility did not know she was positive COVID-19 at that time. She also was using a [MEDICAL CONDITION] and staff were only wearing surgical masks. This was when (Resident #101) was on the observation unit. During an interview on 9/11/2020 at 1:21 PM CNA CC stated, I am a CNA on the rehab observation unit. The DON told us to wear the surgical masks and that is what I had to wear while working on the observation unit. Staff did not wear gowns. The residents were not on any precautions. When the first resident became positive for COVID-19 (August 27th) that is when staff were told by the DON to wear a gown, and a face shield over the surgical mask. Gloves were worn with direct patient care. After care was done, they were thrown away and hands were cleaned when entering and exiting room. During an interview on 9/11/2020 at 1:33 PM, CNA DD stated, I am a Float CNA on the rehab observation unit. Before the resident (referring to Resident #101) became positive for COVID-19 staff wore surgical masks. The DON told staff to wear them. We did not wear gowns at that time. The residents were isolated to their room for the first 5 days. Not all residents wore their masks. After the resident (Resident #101) became positive, staff wore surgical masks, face shields, and gowns. Staff was told to wear washable gowns. At first staff wore the same gown the entire shift and continued doing so until I went off work with COVID-19. When entering a room, I would sanitize hands and don gloves. When exiting doff gloves and sanitize hands. During an interview on 9/11/2020 at 1:47 PM CNA R stated, I am a Float CNA and got called in to work on the rehab observation unit on August 26 (2020). The next day I was called and told the resident (Resident #101) was COVID-19 positive. I worked the entire weekend on the observation unit and felt like I had a sinus problem with a runny nose and a dry cough. The facility knew I was not feeling well but I did not have a fever, so they let me work. I wore a surgical mask the first day and then the weekend the facility told us to wear surgical mask, face shield, and gown. Gloves were worn in the resident rooms. The gowns were blue plastic and changed when we left the room and put a clean one on before leaving. During an interview on 9/11/2020 at 1:58 PM CNA EE stated, I am a part-time Float CNA over at the Cottages and was told to work on the rehab observation unit Monday, August 24th, August 31, and September 1 (2020). On August 24th I wore the gown, surgical mask, and a face shield. The first week gowns were changed out after each resident contact. The second week they had the isolation hangers on the doors with all the supplies. I wore gloves just when I went in to do resident care and took them off and washed with soap and water and sanitized all day. I washed and wore all the PPE I was told to. During an interview on 9/11/2020 at 2:10 PM CNA FF stated, I am a CNA in the float pool. I was first assigned to the rehab observation unit on August 22nd (2020) I think. On that day I wore a surgical mask. After the resident (Resident #101) was found to be positive then staff was told to wear gown the entire day, surgical mask, and a face shield. The only time I wore gloves was when I toileted a resident. I sanitized my hands going in and out of rooms. During an interview on 9/11/2020 at 2:46 PM Housekeeping GG stated, I work housekeeping on the rehab observation unit. I first started coming down with symptoms on September 1 (2020) and my last day to work was August 30. My first day back to work was today, 9/11/2020. I only ever wore a surgical mask while working the unit. When I was in the first positive resident's room (Resident #101) we both had on surgical masks. During an interview on 9/11/2020 at 2:55 PM CNA HH stated, I am a CNA on the rehab observation unit. Residents are put in quarantine for 14-days after they are first admitted . The DON told staff we had to wear surgical masks and not cloth masks. It is in a policy. Only after the first resident tested positive on August 27th (2020) did staff on that unit start to wear gowns and face shields over the surgical masks. On 9/3/2020 I was tested at the facility and on 9/4/2020 I started having signs and symptoms of COVID-19. During an interview on 9/11/2020 at 3:09 PM, CNA P stated, I am a float pool CNA and was assigned to the rehab observation unit on August 24th (2020). Staff had been wearing masks for a long time, since COVID-19 started but on that unit staff had to always wear a surgical mask. Residents were not on isolation at that time (8/27/2020) just 14-day observation so staff did not wear gowns. I know (Resident #101) was incontinent and I had to change her briefs. I wore a surgical mask and gloves, no gown. During an interview on 9/11/2020 at 3:30 PM, LHD Q stated, The facility should have the observation residents on precautions. I do not think droplet precautions, but they should be on contact precautions. I do not think the facility has had the residents on precautions this entire time. The staff have been wearing gowns, gloves, and surgical masks after the first positive resident. The staff on the observation unit have been wearing surgical masks and should have been wearing the N-95 masks. As far as the double gloves being worn on the COVID-19 unit, I did investigate sanitizing them while being worn if the facility is in a shortage of them. The staff should not be wearing the gloves between residents because of the potential to spread infection but can be worn between tasks of the same resident but only if there is a shortage of the gloves. This recommendation is found on the CDC site Optimizing Supply. I haven't heard the facility has had a shortage of gloves. During an interview on 9/11/2020 at 4:22 PM, ICP C stated, Staff is wearing the appropriate mask; surgical. The preferred mask would be a N-95 but CDC guidelines say staff can wear surgical on the 14-day observation unit. During an interview on 9/16/2020 at 10:45 AM, DON B stated, Currently there is no specific Transmission-Based Precautions on the observation unit just general precautions because with droplet precautions staff does not have to wear gowns. During an interview on 9/16/2020 at 11:01 AM ICP C stated, I refer to the CDC guidelines more than anything and it will take me over to the SA (State Agency) guidelines. Before COVID-19, the facility used surgical masks. N-95 mask should be worn by all staff in the 14-day observation unit as well as the COVID-19 unit. During an interview on 9/16/2020 at 12: (TRUNCATED)

This citation pertains to MI 132 and MI 224. Based on observation, interview, and record review, the facility failed to provide adequate supervision and use the correct assistive device for 1 of 5 residents reviewed for falls (Resident #1), from a total of 5 sampled residents, resulting in an avoidable fall from a mechanical lift for Resident #1, on [DATE] at approximately 11:25 AM, when she sustained a skull fracture, internal hemorrhaging, and subsequent death (on [DATE]), and the potential for 39 residents, who were identified by the facility as using total mechanical lifts, at risk for serious harm, injury, and/or death. Findings include: On [DATE] at 10:56 AM, Administrator A was notified of Immediate Jeopardy identified at F-323 on [DATE]. Immediate Jeopardy is due to the facility's failure to ensure that proper technique and equipment was used while transferring Resident #1 with a total mechanical lift, resulting in a fall, sustained skull fracture, internal hemorrhaging, and subsequent death. This deficient practice places 39 residents, who were identified by the facility as using total mechanical lifts, at risk for serious harm, injury, and/or death. Review of the Minimum Data Set (MDS), dated [DATE], revealed that Resident #1 was a [AGE] year-old female, who was originally admitted to the facility on [DATE], who had severe cognitive impairment, needed 2 + persons physical assist with transfers/total dependence on staff, and [DIAGNOSES REDACTED]. Review of the facility's 5 Day Investigation/Summary, not dated, revealed, On [DATE] at approximately 11:20 (AM) CNAs (Nurse Aides E, F , and G) went in to (sic) (Resident #1's) room to finish dressing her and getting her up for lunch .she had a (lift) sling underneath her because (Nurse Aide G) had just given (Resident #1) a bath .(Nurse Aide E) hooked the (lift) sling to the (lift) . (Nurse Aide E) was operating the (lift) and (Nurse Aide F) had turned to retrieve (Resident #1's) wheelchair from by her desk. At that time (Nurse Aide G) had entered the room to ask if they needed help .All three CNAs state that as (Nurse Aide E) raised the (lift) up and maneuvered it away from the bed when a sling strap disconnected from the (Lift) causing (resident #1) to fall .(Resident #1) was assessed at the hospital and diagnosed with [REDACTED]. (Resident #1) returned (to the facility) unresponsive to the facility per family request and is on hospice . According to the emergency room report, dated [DATE], .s/p (after) fall from a Hoyer lift; a strap malfunctioned and pt (Resident #1) fell to floor and hit back of head . According to admission orders [REDACTED]. According to Resident #1's ADL/Activities of Daily Living Care Plan, dated [DATE], .Transfers - Hoyer (total mechanical lift) - Med (medium) sling & leave under her in W/C (wheelchair) . The Care Plan did not specify how many staff were to physically assist with Resident #1's transfers. According to Resident #1's Safety Care Plan, dated [DATE], I have poor sitting balance (sic) and decreased safety awareness r/t (related to my [DIAGNOSES REDACTED].Seat belt on W/C to be worn at all times when up in W/C to allow proper seating and positioning . According to Resident #1's Communication Care Plan, dated [DATE], I am unable to verbally express my needs . According to Resident #1's Kardex/Nurse Aide Care Guide, print date [DATE], Transfers - Hoyer - Med sling and leave under her in W/C. The Kardex did not specify how many staff were to physically assist with Resident #1's transfers. According to a Witness Statement, dated [DATE] (sic) (not timed), Nurse Aide E documented, When getting (Resident #1) up for lunch, her Hoyer sling must have come undone. She had a bath and was already dressed except for pants. She already had a Hoyer (lift) sling under her, that (Nurse Aide G put under her after her bath. I didn't realize it was a large sling. The left leg sling strap came undone while (Nurse Aide F) was grabbing her chair to put her in. According to Nursing Progress Notes, dated [DATE] at 16:15, RN/Registered Nurse J documented, .I walked into room to see bed up, (lift) sling hooked onto arms (hanger bar of lift) x 3, the fourth unhooked and elevated. (Resident #1) was noted to be laying on her left side, under (lift) and sling with head at the direction of end of bed. (Resident #1) was grunting and moaning .found a hematoma on the back of head measuring 3 cm x 5 cm, intact without bleeding .sent to (emergency room ) . According to an ER (emergency room ) imaging report Resident #1, dated [DATE], [AGE] year Old Female fell out of Hoyer (total mechanical) lift .Significant acute (new) closed head injury with small/moderate amounts of subdural hemorrhage tracking along the peripheral margins of the cerebral hemispheres as well as along the falx (internal brain bleeding). There is also some acute subarachnoid blood interdigitating into the sulci of both cerebral hemispheres (internal brain bleeding) and also a moderate size right frontal lobe contusion (bruise). Non depressed linear fracture of the left occipital bone extending anteriorly into the temporal bone (fractured skull), some probable related hemotympanum .(blood accumulation behind the eardrum) .CM Intraparenchymal hemorrhage in the left temporal occipital region (bleeding in additional areas of the brain) and related traumatic pneumocephalus (air or gas in the brain associated with trauma). In an interview, on [DATE] at 12:20 PM, Nurse Aide G reported on the morning of [DATE], she had given Resident #1 a shower using a mesh shower sling, and upon return from the shower room, took the regular cloth lift sling that was already in Resident #1's wheelchair and placed it under Resident #1 before she placed Resident #1 back into bed. Nurse Aide G stated she entered the room to ask if her assistance was needed, and was still standing by the door, when she observed Resident #1 fall head first from the sling. When asked what she thought could have prevented the fall, Nurse Aide G reported she thought Resident #1's wheelchair could have been positioned near the bed before Resident #1 was lifted so that Nurse Aide F would not have to retrieve it and therefore been possibly able to prevent or lessen the fall. On [DATE] at 1:15 PM, this Surveyor observed Resident #1's room; there was a sign on the wall with Resident #1's name on it, but the room was void of Resident #1's belongings. An anonymous Nurse Aide reported, (Resident #1) died last week. According to Nursing Progress Notes, dated [DATE] at 2:57 AM, Res. (Resident #1) passed away. On [DATE] at 1:15 PM, this Surveyor observed a Vander-Lift (total mechanical lift/referred to the facility as Hoyer) in the 200 Hallway, the Unit where Resident #1 had resided. It was observed one of the hanger clips did not snap back to the metal as it appeared to be designed to do; leaving a ,[DATE] inch gap in the area where the sling strap was to be attached. In an interview, on [DATE] at 2:00 PM, ADON/Assistant Director of Nursing reported facility's analysis of the incident revealed the fall was due to human error .the sling was not attached to the bar of the (lift) correctly .we could not determine that it was the wrong pad that cause the incident. According to the Vander-Lift manufacturer's Operating Manual, dated ,[DATE], .It is also required that a nurse or professional rehabilitation staff member inspects all (lift) slings .monthly. A permanent record of each of these inspections and actions taken should be kept by the facility .Make sure you understand which size sling and which method of connecting the sling to the hanger bars is to be used .Connect the sling loops to the hanger bar hooks to transfer the patient .Double check the sling loop connection to the hanger bar hooks to make sure the sling is securely attached with the loops in the bottom of the hanger bar hooks .The (lift) must be inspected by qualified maintenance staff at least monthly .A permanent record of each of these inspections and repairs made should be kept by the facility . It is important that qualified maintenance staff inspect all (lifts) monthly . The manufacturer's Operating Manual contained a Skills Observation Assessment; (evidence that Nurse Aide E had been assessed with [REDACTED]. In an interview, on [DATE] at 1:45 PM, Maintenance Staff I reported the facility did not have a contract for Vander-Lift representatives to conduct routine inspections of the facility Vander-Lifts nor did he call VanderCare Inc. (the manufacturer of the Vander-Lift) to report the incident. Maintenance Staff I reported he inspected lift #10 on [DATE], and just changed the bars (hanger rod where the sling attaches) after the incident (with Resident #1) on lift #10, did not keep the one that was from the machine that failed, and put lift #10 back on the unit for use. Towards the end of the interview, Maintenance Staff I retracted his statement and said he was mistaken, that the hanger rod on lift #10 was not replaced because it was functioning correctly on [DATE]. Maintenance Staff I presented a hanger rod he had replaced from a lift (could not remember which lift it came from). The hanger rod's hanger clip was floppy/did not spring back. Maintenance Staff I stated he was aware the manufacturer recommended monthly lift inspections, and maintenance of an accompanying record of the inspections, but he did not record the dates he inspected the lifts, rather he looked at them as he passed by them daily. Maintenance Staff I reported the manufacturer's educational video instructed staff to manually move the hanger clips on the hanger bar of the Vander-Lift back to the metal to assure straps are secured. Review of the manufacturer's Monthly (lift) Inspection Checklist forms revealed entries were not signed and the check marks were identical for January, 2016 (listed first), then August - [DATE] listed afterward. There was one sheet for each 14 facility Vander-Lift total mechanical lifts (the facility did not have any actual Hoyer/trade name lifts) and all the checkmarks from every month were identical, suggestive they were all checked off at one time, not during individual inspections. In an interview, on [DATE] at 2:00 PM, ADON/Assistant Director of Nursing C reported no photographs taken of lift #10's hanger rod (where there was a failure of the strap attaching) on [DATE]. In an interview, on [DATE] at 2:10 PM, Risk Manager D reported, After the investigation, we didn't feel it was a machine error .I don't believe the sling had anything to do with it; it was a factor, not a cause. Risk Manager D reported during reenactments, the only way they were able to get the sling to fail, was by not attaching it properly. Risk Manager D reported the investigation did not include finding which staff member originally placed the incorrect sling in Resident #1's wheelchair or an analysis as to why a large sling (rather than medium) was used in the first place. Risk Manager D reported Nurse Aides E, F, and G were suspended for 3 days, but were currently employed. Also, Risk Manager D reported the total lift machine (#10) was being used in the facility, although the facility did not contact the manufacturer or the Federal Food and Drug Administration/Medical Device Act. In an interview, on [DATE] at 3:45 PM, DON B reported Resident #1 fell from a total mechanical lift 2 years ago, and at that time, the facility replaced it's total mechanical lifts (brand not mentioned) with the VanderCare lifts currently in use. DON B reported lift slings were checked/assessed quarterly (not monthly as recommended by the manufacturer) when Quarterly Assessments are performed. Review of Employee Disciplinary Forms, all dated [DATE], revealed Nurse Aide E, F, and G received Written Warning for, (Resident #1) was transferred with wrong size (lift) pad, which may have contributed to fall resulting in resident injury; care guide not followed. Nurse Aide E was not disciplined for failure to attach sling properly, although an Employee Evaluation Record, dated 2015, revealed Nurse Aide E needed to slow down; to pay attention .could slow down, she is very fast and sometimes overlooks small things. In an interview, on [DATE] at 11:10 AM, ADON C reported she spoke with the coroner's office at approximately 8:30 AM that day and it was reported to her that the cause of death listed on Resident #1's death certificate was, 'Complications of blunt force injuries of the head; manner - accident'. In an interview, on [DATE] at 9:00 AM, Nurse Aide E reported Resident #1 was a 1 person assist with transfers according to her Care Guide .It will say 2 person if she needs 2. Nurse Aide E reported Resident #1 didn't get up for breakfast that on [DATE] and was not transferred on the midnight shift the night before, therefore, whomever placed the large sling in Resident #1's chair was likely someone who worked first or second shift on [DATE]. Nurse Aide E reported that Resident #1's sling was typically changed daily due to soiled almost on a daily basis with urine or food. Nurse Aide E reported Resident #1 fell out of the left side of the sling head first, the sling came unhooked, and said Resident #1 tips from side-to-side .that's why she has a seatbelt when she's in her wheelchair .(Resident #1) was a Weeble-Wobble and liked to lean over all the time. In an interview, on [DATE] at 9:41 AM, ADON C reported total mechanical lift transfers are, Only a 1 person transfer if the Care Guide says 1 person; otherwise a 2 person (this was opposite of what Nurse Adie E said). ADON C reported although there were 3 Nurse Aides in the room at the time of the fall, They couldn't catch her. They were too far away. ADON C stated, I wish we would of had a hand on her. ADON C was unaware that Resident #1 needed a seat belt for balance while in a wheelchair and reported that after Resident #1 fell on [DATE] she changed her Care Plan to make her a 3 person assist with transfers. In an interview, on [DATE] at 10:12 AM, RN J reported when she entered Resident #1's room on [DATE] when she was called STAT to the room, she saw one of the leg straps not attached to the hanger bar of the Vander-Lift. RN J stated she knew Resident #1 well and referred to her as a, Weeble-Wobble .no control over the top part of her body. RN J reported she did not inspect at the hanger bar or the sling at the time of the fall; rather she called Risk Manager D, and Manager D placed the Vander-Lift in the hallway. In an interview, on [DATE] at 10:50 AM, Occupational Therapist K reported she thought the reason the incident occurred was because, The Aide (Nurse Aide E) was not focused. The only way for it (sling) to come off would be for it to never have been in the bar hook in the first place. In an interview, on [DATE] at 3:30 PM, DON B reported lift #10 was being used by staff after Resident #1 fell on [DATE] (for approximately 3 hours) until ADON C removed it from service on ,[DATE] at 2:20 PM. Immediacy was removed from the facility on [DATE] at 5:00 PM due to the facility having the following in place: · On [DATE] at approximately 1:00 PM, Risk Manager D, Occupational Therapist K, Restorative Registered Nurse L, ADON C, Education Nurses RN M and Oand Director of Therapy N attempted for approximately 30 minutes to recreate the incident as it was described to us by Nurse Aides E, F, and G. (The only way we could get the sling strap to come undone, while a person was suspended in the Vander-Lift sling, even when shifting weight back and forth.) It was concluded the incident occurred because the sling strap was to not properly attach the Vander-Lift at the time of the incident; not due to a defect of the Vander-Lift. · On [DATE] at 2:00 PM, Nurse Aides were disciplined and then suspended while the investigation was ongoing, and had competency skills checks completed by RN O prior to returning to work on [DATE]. · Beginning on [DATE] at 2:00 PM, re-educated on the proper use of Vander-Lifts with return demonstration and review of the manufacturers guidelines to include double checking the sling attachment to the lift began. As of [DATE] at 4:00 PM, 173 of the 183 nursing staff had been re-educated; the remaining 10 nursing staff will educated prior to being allowed to return to work. · On [DATE] at 2:20 PM, lift #10 was pulled from service. · On [DATE] at approximately 3:00 PM, all residents that use a Vander-Lift for transfers were inspected for the correct size sling being used per resident's individualized plan of care. · On [DATE] at 4:00 PM, all 14 Vander-Lifts were inspected by Maintenance Staff I for proper function and repair, and lift #10 was returned to service. · On [DATE] at 4:00 PM, the Therapy Department completed a screen on all 39 residents that use a Vander-Lift for transfers to ensure necessity of use, appropriate sling size, and correct number of staff needed to safely complete transfer. Changes required were made in the residents individual plans of care and direct care staff was educated of changes made. · On [DATE] by 4:00 PM, DON B notified the FDA and Vander-Lift manufacturer via phone and/or e-mail regarding the incident. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance with scope of isolated and severity of no acutal harm with potential for more than minimal harm that is not immediate jeopardy as sustained compliance had not been verified by the state agency. ( )

This citation pertains to intake MI 186. This citation has 2 Deficiency Practice Statements Deficiency Practice Statement #1 Based on interview and record review, the facility failed to ensure that residents were free from significant medication errors, and prevent a significant medication error in 1 of 6 sampled residents (Resident #101) reviewed for medication errors, from a total sample of 6 residents, resulting in an Immediate Jeopardy when, on 11/9/14 at 7:07 am, Resident #101 was administered all of Resident #102's morning medications and then subsequently her own medications on 11/9/14 at 9:15 am, resulting in Resident #101 having a decreased level of consciousness, decreased blood pressure, and decreased blood sugar levels, which required hospitalization and admission to the Intensive Care Unit (ICU) for medical stabilization and supportive care. This deficient practice places all residents who receive medications, at risk for serious harm, injury and/or death. Findings include: Review of facility "Administration of Medications" policy (undated), revealed "7. Residents are identified before medication is administered. Methods of identification include: a. checking identification band (not used at facility), b. checking photograph attached to medical record, c. calling resident by name, d. if necessary, verifying resident identification with other facility personnel." The policy also indicated, "12. Medications supplied for one resident are never administered to another resident." The six rights of medication administration include: 1) the right medication, 2) the right dose, 3) the right client, 4) the right route, 5) the right time, 6) the right documentation. Medication errors often occur because one client gets a drug intended for another client. To identify a client correctly, the nurse checks the medication administration form against the client identification bracelet. When asking the client name, the nurse should not merely speak the name and assume that the client's response indicates that he or she is the right person. Instead, the nurse asks the client to state his or her name. (Fundamentals of Nursing, 6th edition, 2005, pgs. 841-842.) Review of the Face Sheet, dated 11/10/14, revealed Resident #101 was a [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated , 10/10/14, indicated Resident #101 had moderately impaired cognitive skills, and no documented behaviors. Her facility November 2014 "Medication Review Report" listed allergies [REDACTED]. In an interview on 11/13/14 at 11:25 am, Licensed Practical Nurse/Risk Manager (LPRM) #2 stated she was passing medications on 11/9/14 at breakfast time and did not know who Resident #101 was, so she asked a Certified Nurse Aide (CNA) while pointing at Resident #101 in the dining room if that was (name of Resident #102). LPRM #2 stated the CNA stated yes, so LPRM #2 stated she then prepared Resident #102's medications. LPRM #2 stated Resident #101 then wheeled out of the dining room to her medication cart and requested pain medication for her leg. LPRM #2 stated she administered Tylenol and all Resident #102's morning medications crushed in applesauce, to Resident #101. LPRM #2 stated she did not, at any time, identify Resident #101 by asking her what her name was or call her by name. LPRM #2 stated at approximately 2 hours later around 9:15 am, she noticed on Resident #101's electronic Medication Administration Record [REDACTED]. LPRM #2 reported that she did not notice that Resident #101 was the same resident, she had identified earlier as Resident #102, and had administered Resident #102's medications. LPRM #2 stated Resident #101 left the facility and went to church with a friend and when she returned, the friend reported to the CNA's that Resident #101 was sleepier than normal and was slurring her words. LPRM #2 stated Resident #101's vitals were stable so the aides took her to the dining room for lunch. During the interview on 11/13/14 at 11:25 am, LPRM #2 reported that at lunch time, when she observed Resident #102 in her room to give her medications, she realized she had not seen Resident #102 before and she may have made a mistake. LPRM #2 stated at that time the CNA's were putting Resident #101 in her bed, because she was falling asleep on the table in the dining room, and they could not obtain a blood pressure. LPRM #2 stated Resident #101 was sent to the hospital because she (LPRM #2) administered both Resident #101's and Resident #102's medications to Resident #101 on the morning of 11/9/14. LPRM #2 stated she did not follow facility policy and give the correct medication to the correct resident. LPRM #2 stated the facility did have a policy/procedure to identify a resident prior to administering medications, but she wasn't sure what that procedure was. LPRM #2 stated Resident #101's morning medications on the 11/9/14 Medication Administration Record [REDACTED]#101 at 7:07 am. Review of November 2014 Medication Administration Record [REDACTED]. Review of November 2014 Medication Administration Record [REDACTED]. Review of the nurse's note, dated 11/9/14 at 1:15 pm, indicated Resident #101 returned to the facility from church and Resident #101's friend reported to a CNA Resident #101 seemed more tired and slurred her words. The note indicated CNA was instructed to take Resident #101 to the dining room, where Resident #101 became increasingly tired, fell asleep during the meal and was then taken to her room. The nurse's note indicated Resident #101 reported feeling "dizzy", the Nurse Practitioner was notified of "all meds" resident received that morning and Resident #101 was transferred to the hospital via ambulance. Review of the Nurse's note dated 11/9/14 at 1:39 pm indicated Resident #101's manual blood pressure was 94/62, very difficult to hear and the nurse was unable to obtain a blood oxygen level. The note indicated when asked questions Resident #101 gave one word slurred responses and would not open her eyes. Review of Facility "Medication Related Incident Report" for Resident #101, dated 11/9/14, revealed that at 7:07 am, Resident #101 received the wrong medications and was sent to the hospital via ambulance. The report indicated the incident type to be "wrong resident" with contributing factors to be "no resident photo-photos look the same", "failure to follow policy", and "staff agreed that was who resident was at time of med pass". The report indicated the error necessitated additional testing or procedures and an adverse reaction did occur as a result of the medication error. Review of facility video recordings on 11/14/14 revealed that on 11/9/14, LPRM #2 was standing near the medication cart (near nurse's station) at 6:53 a.m., pointed to the dining room when Certified Nurse Aide (CNA) #5 walked by and CNA #5 looked into the dining room. The video then showed LPRM #2 prepared medications from the medication cart and administer those medications to a different resident (Resident #103) at 6:56 am. The video revealed LPRM #2 prepared and administered Resident #102's medications and administered them to Resident #101 while Resident #101 sat in her wheelchair near the medication cart at 7:07 am. Further review of the video revealed Resident #101 attempted to leave the dining room at one time but was returned by a CNA, where she remained until LPRM #2 administered her own medications to her at 9:18 am. Review of hospital emergency room physician note dated 11/9/14 (no time) revealed Resident #101 was "given another resident's medications along with her own and came into the emergency room with decreased responsiveness". The noted indicated Resident #101 was given fluid boluses (fluid infusion) to control [MEDICAL CONDITION] (low blood pressure) and her blood sugars continued to drop into the 30's and 40's (normal 80 to 120). The note indicated Resident #101 was given [MEDICATION NAME] of D50 (glucose) per IV in response to low blood sugars. Resident #101 continued to be unresponsive to verbal stimuli even after her blood sugar rose to 150. Review of the hospital History and Physical report revealed Resident #101's [DIAGNOSES REDACTED]. The report indicated Resident #101 had an Iatrogenic multiple drug overdose (caused by a medical provider) and the patient had resulting somnolence, [MEDICAL CONDITION], and [DIAGNOSES REDACTED] with a status classified as "medically guarded". Review of the hospital Physician Note dated 11/11/14 indicated Resident #101 was very weak with [DIAGNOSES REDACTED]. Accidental overdose with patient to have IV fluids of ? normal saline with D5 (glucose), cardiac monitoring, to be placed in ICU and hold her own medications. 2. [MEDICAL CONDITION] congestion (evidence of [MEDICAL CONDITION] congestion and [MEDICAL CONDITION]) 3. [MEDICAL CONDITION]. 4. Altered mental status. The note indicated Resident #101 was to receive [MEDICATION NAME] (diuretic medication) 20 mg IV on 11/11/14 with cautious administration secondary to impaired renal function and [MEDICATION NAME] 40 mg on 11/12/14. On 11/14/14 at 3:54 p.m., Administrator (ADM) #3 was notified of the Immediate Jeopardy that was identified on November 13, 2014 and began on November 9, 2014 as a result of the facility's failure to prevent a significant medication error causing harm for Resident #101, who was administered Resident #102's mediations at 7:07 am and then her own medications at 9:15 am, resulting in a decreased level of consciousness, decreased blood pressure, and decreased level of blood sugar, which caused Resident #101 to be transferred to the hospital and subsequently admitted to the intensive care unit. On 11/17/14, this surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy: 1. Resident #1 is being readmitted to the facility and will be admitted to a separate neighborhood to prevent misidentification with Resident #102. 2. All residents will have a temporary identification band placed upon their left arm to ensure proper identification until all nurses have been properly trained on resident identification policy and procedures. This will be completed on 11/14/14. 3. The medication pass identification policy and procedure was reviewed and revised as appropriate on 11/14/14. 4. All nursing staff in the building have been in-serviced on resident identification policy and procedures on 11/14/14. Eight RN's of 29 were in-serviced and 6 LPN's of 20 were in-serviced. All other nursing staff will be in-serviced on the policy and procedure to identify residents prior to beginning their shift. No Nursing staff, including on call staff, will not be allowed to pass medications until they have been in-serviced on the medication pass identification policy and procedure. 7. The nursing supervisors will ensure nurses are in-serviced prior to passing medications by conducting a return demonstration with all nurses on all shifts beginning 11/14/14. Although the Immediate Jeopardy was removed on 11/14/14, the facility remained out of compliance as a scope of no actual harm with potential for more than minimal harm that is not Immediate jeopardy and severity of widespread due to the fact that not all facility staff had received education and sustained compliance had not yet been verified by the State Agency. Deficiency Practice Statement #2 Based on observation, interview and record review, the facility failed to ensure medications were administered in a manner which would prevent significant medication errors in 2 of 6 sampled residents (#107 and #108) observed during medication pass, from a total sample of 6 residents, resulting in the potential for Residents #107 and #108 to have missed medications, take their medications incorrectly, or for another resident to take the medication left unsupervised for Residents #107 and and Resident #108 on the table in the dining room at breakfast time. Findings include: Review of facility "Administration of Medication Policy" revealed "15. The resident is always observed after administration to ensure that the dose was completely ingested." During an observation of medication pass on 11/14/14 at 7:24 am, the surveyor observed Licensed Practical Nurse (LPN) #8 prepare the following medications for Resident #107: Aspirin 81 mg (chewable), [MEDICATION NAME] 240 mg capsule (for high blood pressure), [MEDICATION NAME] XL 400 mg (for pain and swelling), Potassium 10 mEq 2 tablets, [MEDICATION NAME] 20 mg (for blood pressure), [MEDICATION NAME] 300 mg (for nerve pain), [MEDICATION NAME] 5 mg (treats blood pressure and chest pain), [MEDICATION NAME]-M, and [MEDICATION NAME] XL 50 mg (for high blood pressure and chest pain). LPN #8 placed the pills in a small (30 milliliter) clear medication cup, took the cup of pills into the dining room where Resident #107 was sitting at a table with 2 other residents, and put the cup on the table in front of Resident #107. LPN #8 then instructed Resident #107 that those were her morning medications and left the dining room and the medications unattended by a licensed nurse at 7:31 am, before Resident #107 took the medications. LPN #8 then went back to the medication cart and began to prepare medications for another resident. During an observation of medication pass on 11/14/14 at 7:34 am, the surveyor observed LPN #8 prepare the following medications for Resident #108: [MEDICATION NAME] 100 mg (to treat gout), aspirin 81 mg, CoQ-10 100 mg (supplement for heart function), cranberry 425 mg, [MEDICATION NAME]-M. LPN #8 placed the medications in a 30 ml medication cup, walked into the dining room where Resident #108 was sitting with 2 other residents, and put the cup of medications on the table next to Resident #108. LPN #8 instructed Resident #108 that those were her medications and then left the dining room before Resident #108 took the pills leaving the medications unattended by a licensed staff. LPN #8 then went back to the medication cart and began to prepare medications for another resident. After LPN #8 left Resident #107 and #108 with the medications in the cups and went back to the medication cart, the surveyor observed Resident #108 take the pills out of the medication cup, place them on the table in front of her, and take each pill, one at a time off from the table surface, with a drink from her breakfast. During the medication pass the surveyor observed multiple residents self propel their wheelchairs in and out of the dining room for breakfast. It was also noted during the observation that multiple residents were observed self propelling around the dining room during breakfast. In an interview on 11/17/14 at 9:15 am, Assistant Director of Nursing (ADON) #11 stated nurses are supposed to stay with a resident and supervise the resident taking medication during medication administration. ADON #11 stated there are no residents in the facility at that time that are able to self administer medications. The surveyor asked ADON #11 who was responsible for ensuring another resident did not take Resident #107 and #108's medications and ADON #11 stated the nurse was. ADON #11 stated the nurse should have stayed in the dining room. #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ASSESS COGNITIVELY IMPAIRED RESIDENTS FOR RISK OF ELOPEMENT, PROVIDE ADEQUATE SUPERVISION AND MONITOR WANDERGUARD DEVICES RESULTING IN THE ELOPEMENT OF 3 OF 4 RESIDENTS (#6, 19, 20) REVIEWED FOR ELOPEMENT RISK IN A TOTAL SAMPLE OF 24 RESIDENTS PUTTING ALL 3 RESIDENTS (#6, 19, 20) IN IMMEDIATE JEOPARY DUE TO INCREASED RISK OF INJURY OR DEATH. FINDINGS INCLUDE: RESIDENT #19 ELOPED FROM THE FACILITY AND WAS OBSERVED OUTSIDE NEAR THE ENTRANCE LEADING TO THE STAFF PARKING LOT LOOKING FOR HIS WIFE WITH THE POTENTIAL OF BEING HIT BY A CAR. RESIDENT #20 ELOPED FROM THE FACILITY AND WAS OBSERVED OUTSIDE THE FRONT DOOR SEATED ON BENCH WITH FACILITY STAFF WHO STATED THAT RESIDENT #20 "HAD MADE IT TO THE END OF THE SIDEWALK." RESIDENT #6 ELOPED FROM THE FACILITY AFTER SELF PROPELLING HER WHEELCHAIR ACROSS THE THRESHOLD OF THE FRONT MAIN DOOR AND WAS ASSISTED BY A VISITOR OVER THE THRESHOLD. RESIDENT #19 PROCEEDED OUT THE FRONT DOOR TOWARD THE MAIN PARKING LOT. AN OBSERVATION OF THE EXTERIOR GEOGRAPHICAL PLACEMENT OF THE FACILITY WAS DONE 08/01/2012. OUTSIDE OF THE FACILITY FRONT DOORS IS THE MAIN PARKING LOT WITH A COVERED PAVILION DRIVE. THE MAIN PARKING LOT SLOPES DOWNWARD TO A 45 MILE PER HOUR TWO LANE ROAD WITH A BLIND CURVE. ON THE OTHER SIDE OF THE TWO LANE ROAD THERE IS A SIGNIFICANT DOWNWARD SLOPE TO A RIVER. THESE ELOPEMENT INCIDENTS RESULTED IN AN IMMEDIATE JEOPARDY FOR THE RESIDENTS AT RISK OF ELOPEMENT THAT BEGAN ON 06/11/2012 AT 6:31 PM WITH THE ELOPEMENT OF RESIDENT #19. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY SITUATION ON 08/03/2012 AT 11:05 AM. THE IMMEDIATE JEOPARDY WAS REMOVED ON 08/03/2012 AT 5:00 PM WHEN THE FACILITY ADMINISTRATOR PROVIDED THE CORRECTIVE ACTION PLAN TO REMOVE THE IMMEDIATE JEOPARDY. THE CORRECTIVE ACTION PLAN IMPLEMENTED TO REMOVE THE IMMEDIATE JEOPARDY CONSISTED OF THE FOLLOWING: 1) ALL IN-HOUSE RESIDENTS WILL HAVE AN ELOPEMENT RISK ASSESSMENT COMPLETED. 2) WANDER GUARDS (AN ELECTRONIC DEVICE THAT IS PLACED ON THE RESIDENT'S PERSON OR WHEELCHAIR AND SOUNDS AN ALARM IF THE RESIDENT ATTEMPTS TO EXIT THE FACILITY WITHOUT SUPERVISION) WILL BE PLACED WHERE APPROPRIATE BASED UPON THE ELOPEMENT RISK ASSESSMENTS. 3) LETTERS WILL BE SENT VIA MAIL TO RESIDENT'S FAMILIES, VOLUNTEERS AND ADDED TO THE ADMISSION PACKET ADVISING THEM NOT TO ASSIST A RESIDENT OUT OF THE BUILDING AND BE AWARE OF RESIDENTS WHEN ENTERING OR EXITING THE BUILDING. 4) SIGNAGE WILL BE PLACED AT THE MAIN ENTRANCE AND AT THE "REHAB" ENTRANCE ASKING VISITORS NOT TO ASSIST ANY INDIVIDUALS OUT OF THE DOOR. 5) A WANDER GUARD DETECTOR WAS INSTALLED AT THE START OF THE HALLWAY LEADING TO THE "REHAB" ENTRANCE. 6) WANDER GUARDS PLACED ON RESIDENTS WILL BE MONITORED BY THE CHARGE NURSES EVERY SHIFT FOR PLACEMENT, FUNCTIONALITY AND (SIC) WILL BE CHECKED BY RESTORATIVE NURSING WEEKLY. 7) THE DIRECTOR OF NURSING (DON)/DESIGNEE WILL MONITOR THE ELECTRONIC DOCUMENTATION FOR COMPLIANCE WEEKLY OF AT LEAST 25% OF RESIDENTS WITH WANDER GUARDS. 8) THE DOUBLE DOORS LEADING TO THE FRONT LOBBY WILL BE CLOSED WHEN THE BUSINESS OFFICE IS CLOSED. THE "OVER HOUSE" (SHIFT CHARGE NURSE) NURSE WILL BE RESPONSIBLE FOR MONITORING THOSE DOORS. THE SURVEYOR TEAM CONFIRMED THE INITIATION OF THE "CORRECTIVE ACTION PLAN" WITH OBSERVATION AND RECORD REVIEW. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY DEFICIENT PRACTICE AT SUSTAINED COMPLIANCE COULD NOT BE VERIFIED AND REMAINED AT A PATTERN OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY. INITIALLY, ON 08/01/2012 AT 3:40 PM THE DIRECTOR OF NURSING STATED THE FACILITY DID NOT HAVE AN ELOPEMENT ASSESSMENT FOR RESIDENT #6. ADDITIONALLY ON 08/02/2012 AT 2:00 PM, THE DIRECTOR OF NURSING CONFIRMED THAT NO ELOPEMENT RISK ASSESSMENTS WERE COMPLETED ON COGNITIVELY IMPAIRED RESIDENTS. THE DIRECTOR OF NURSING STATED THE FACILITY RELIES ON HISTORY OBTAINED FROM THE ADMITTING FACILITY AND/OR THE RESIDENT'S FAMILY AND THE MINIMUM DATA SET (MDS) ASSESSMENT FOR "WANDERING". ACCORDING TO THE ADMISSION FACE SHEET DATED 06/05/2012, RESIDENT #19 WAS A [AGE] year OLD COGNITIVELY IMPAIRED MALE admitted to the facility on [DATE]. RESIDENT'S [DIAGNOSES REDACTED]. RESIDENT #19'S BRIEF INTERVIEW MENTAL FOR STATUS (BIMS) SCORE WAS 4 OUT OF 15 ON THE MDS (MINIMUM DATA SET) ADMISSION assessment dated [DATE], REFLECTING SEVERE COGNITIVE IMPAIRMENT AND POOR MEMORY RECALL. NO ELOPEMENT RISK ASSESSMENT WAS COMPLETED FOR RESIDENT #19 PRIOR TO THE ELOPEMENT ON 06/11/2012. REVIEW OF THE INCIDENT/ACCIDENT REPORT DATED 06/11/2012 AT 6:31 PM AND REVISED DATE 07/20/2012 AT 9:29 PM, 39 DAYS LATER, REVEALED RESIDENT #19 WAS BROUGHT BACK INSIDE OF FACILITY AFTER RESIDENT WAS OUTSIDE NEAR THE STAFF ENTRANCE LEADING TO THE STAFF PARKING LOT. NURSING DESCRIPTION OF THE INCIDENT "SUGARBUSH NURSE CALLED COLDWATER CREEK NURSE OVER WALKIE TALKIE AND STATED THAT THERE WAS A RESIDENT OUTSIDE NEAR STAFF ENTRANCE. NURSE WENT OUTSIDE AND FOUND RES (RESIDENT) BY STAFF ENTRANCE IN STAFF PARKING LOT. RES STATES THAT HE WAS SUPPOSED TO BE PICKED UP BY HIS WIFE BY NOW AND SO HE WENT OUTSIDE TO LOOK FOR HER". RESIDENT WAS IN A WHEELCHAIR ON THE SIDEWALK LOOKING FOR HIS WIFE. THERE WAS NO INVESTIGATION DOCUMENT RELATED TO DETERMINING HOW LONG THE RESIDENT WAS OUTSIDE AND IF STAFF WAS ACTIVELY LOOKING FOR THE RESIDENT. FURTHER REVIEW OF NURSING NOTES DATED 06/11/2012 AT 6:51 PM REVEALED "RES (RESIDENT) WIFE CALLED AND NOTIFIED PHYSICIAN NOTIFIED. WANDER GUARD PLACED ON L. (LEFT) EXTREMITY". REVIEW OF THE MDS dated [DATE], THE DAY AFTER RESIDENT #19'S ELOPEMENT, REFLECTED SECTION E 0900 WANDERING - PRESENCE & FREQUENCY "0" WITH "BEHAVIOR NOT EXHIBITED." DURING A FAMILY INTERVIEW ON 08/02/2012 AT 2:10 PM, RESIDENT #19'S WIFE STATED, "I ALWAYS VISIT EVERY DAY FROM 1 PM TO 5 PM, HE HAD A ROOM CHANGE IN THE REHAB UNIT A FEW DAYS AFTER HE WAS IN ANOTHER ROOM ON THIS UNIT. I DO NOT KNOW IF HE WAS JUST CONFUSED WITH THE ROOM CHANGE OR IF HE WAS LOOKING FOR ME. HE WANTS ME TO TAKE HIM HOME. WHEN THEY CALLED ME ABOUT HIM BEING OUTSIDE, I ASKED THEM, HOW DID HE GET THROUGH THE DOORS? CONSIDERING HE CANNOT PUSH OR PULL THE DOORS FROM HIS WHEELCHAIR AND THEY TOLD ME HE WENT OUT THE AUTOMATIC DOORS IN THE REHAB UNIT AND WAS OUTSIDE ON THE SIDEWALK. THEY ALSO TOLD ME THEY NEEDED TO PUT A THING ON HIS ANKLE FOR ALARMING STAFF AND I AM OK WITH THAT EQUIPMENT". RESIDENT # 19'S WIFE STATED "HE CANNOT DO REHAB ANYMORE BECAUSE HE CANNOT REMEMBER ANYTHING AND I WANTED TO TAKE HIM BACK HOME BUT NOW I AM LOOKING AT A LONG TERM PLACEMENT. MY HUSBAND IS VERY CONFUSED". ON 08/02/2012 AT 2:09 PM IN THE 200 HALL, REGISTERED NURSE STAFF "A" AND LICENSED PRACTICAL NURSE STAFF "B" BOTH STATED WE DO HAVE PICTURES OF "AMBULATORY" RESIDENTS THAT WANDER AND WE KEEP THE PAPER AT THE DESK, BUT IT HAS BEEN HERE A LONG TIME (REFERRING TO UPDATING OF THE LIST). WHEN ASKED ABOUT THE COGNITIVELY IMPAIRED RESIDENTS WHO WANDER IN A WHEELCHAIR AND THEIR PICTURES ARE NOT ON THE PAPER AT THE NURSES DESK, THEY HAD NO RESPONSE. ON 08/02/2012 AT 2:20 PM, RESTORATIVE CERTIFIED NURSE AIDE STAFF "C" STATED RELATED TO THE AUTOMATIC DOORS IN THE REHAB UNIT, "THE DOORS DO NOT OPEN IN THAT UNIT IF THEY HAVE A WANDER GUARD ON". ON 08/03/2012 BETWEEN 2:15 AND 2:19 PM, WITH THE REHABILITATION DEPARTMENT (REHAB) STAFF "Q", THE SHORT HALLWAY OUTSIDE OF THE GYM DOOR AND LEADING TO THE REHAB LOBBY WAS OBSERVED GETTING A NEW WANDER GUARD DETECTOR PLACEMENT, THIS AREA IS BEFORE THE REHAB DOUBLE AUTOMATIC DOORS. ON 08/03/2012 DURING AN INTERVIEW WITH "IT (INFORMATION TECHNOLOGY) DEPARTMENT" STAFF "F" AT 2:20 PM IN THE REHAB LOBBY, STAFF "F" STATED, "AFTER THE OTHER WANDER GUARD IS FUNCTIONING IN A FEW MINUTES, RESIDENTS WOULD HAVE TO CLEAR BOTH SYSTEMS BEFORE THEY REACHED THE AUTOMATIC DOORS AND THEN IF THEY DID REACH THESE DOORS THE POWER IS SHUT OFF TO THESE DOORS, IF THEY HAVE A WANDER GUARD". ( )( ) RESIDENT #6 WAS A [AGE] year OLD FEMALE WITH AN ORIGINAL admission date of [DATE] AND [DIAGNOSES REDACTED]. A REVIEW OF RESIDENT #6'S NURSING "PROGRESS NOTES" DATED 07/15/2012 AT 3:46 PM REFLECTED "NURSE WAS INFORMED BY ANOTHER NURSE THAT RES (RESIDENT) WAS OUTSIDE ON SIDEWALK. RES STATED THAT SHE WAS GOING HOME. BROUGHT RES BACK IN BUILDING, ASSESSED VITALS, AND WANDERGUARD PLACED ON WHEELCHAIR..." ON 07/31/2012 AT 4:30 PM AN OBSERVATION WAS MADE OF RESIDENT #6 SITTING IN HER WHEELCHAIR WHEELING HERSELF SLOWLY FROM THE SUGARBUSH DINING ROOM. RESIDENT #6'S CONVERSATION WAS DIFFICULT TO FOLLOW BECAUSE SHE WOULD SPEAK OF ONE TOPIC AND "JUMP" TO ANOTHER IN MID-SENTENCE. A REVIEW OF RESIDENT #6'S MOST CURRENT QUARTERLY MINIMUM DATA SET ((MDS) dated [DATE] REFLECTED A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) OF 3 OUT OF 15 (3= SEVERELY COGNITIVELY IMPAIRED). SECTION E0900 "WANDERING-PRESENCE & FREQUENCY" WAS CODED "0" "BEHAVIOR NOT EXHIBITED". RESIDENT #6'S COMPREHENSIVE ANNUAL MDS dated [DATE] WAS REVIEWED AND SECTION E0900 "WANDERING-PRESENCE & FREQUENCY" WAS CODED "0" "BEHAVIOR NOT EXHIBITED". OBSERVATION OF THE FACILITY VIDEO SURVEILLANCE OF 07/15/2012 AT 3:23 PM WAS OBSERVED ON 08/01/2012 AT 3:15 PM IN THE "IT" (INFORMATION TECHNOLOGY) STAFF "I" OFFICE. ON THE OBSERVED VIDEO SURVEILLANCE AT 3:23 PM ON 07/15/2012, THE FRONT DOOR TO THE FACILITY OPENED AND RESIDENT #6 SELF PROPELLED HER WHEELCHAIR ACROSS THE THRESHOLD OF THE DOOR. THE REAR WHEELS OF RESIDENT #6'S WHEELCHAIR WERE STOPPED BY THE THRESHOLD AND A FEMALE VISITOR ON THE OUTSIDE OF THE DOOR PULLED RESIDENT #6 OVER THE THRESHOLD. RESIDENT #6'S WHEELCHAIR DISAPPEARED FROM THE VIDEO AS RESIDENT #6 SELF PROPELLED AWAY FROM THE DOORS TOWARD THE MAIN PARKING LOT. AT 3:24 CERTIFIED NURSING ASSISTANT (CNA) "Z" IS OBSERVED GOING OUT THE FRONT DOORS WITH ANOTHER STAFF MEMBER. AT 3:25 PM CNA "Z" IS OBSERVED PUSHING RESIDENT #6 BACK INSIDE THE BUILDING. AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING ON 08/01/2012 AT 3:40 PM RELATED TO RESIDENT #6'S ELOPEMENT. THE DIRECTOR OF NURSING STATED THE "ELOPEMENT" INCIDENT DESCRIPTION FORM, INITIALLY COMPLETED BY REGISTERED NURSE CHARGE NURSE "BB", HAD BEEN "DELETED AFTER I (THE DIRECTOR OF NURSING) WATCHED THE VIDEO BECAUSE IT WASN'T AN ELOPEMENT IN MY MIND BECAUSE A FAMILY MEMBER HELPED HER (RESIDENT #6) OUT THE DOOR." THE DIRECTOR OF NURSING STATED "IF IT HAD BEEN WINTER, I WOULD HAVE REPORTED IT (THE ELOPEMENT TO THE STATE AGENCY)." THE DIRECTOR OF NURSING FURTHER DEFINED HER CRITERIA OF ELOPEMENT AS "...GETTING TO THE ROAD...", "...LOOKING IN AND AROUND CARS (IN THE PARKING LOT)...", "...GOING UP AND DOWN THE SIDEWALK...", AND/OR "IF SOMEBODY GOT HURT" OR IF THE RESIDENT MAKES REPEATED STATEMENTS "ABOUT WANTING TO GO HOME OR (GO) SOMEWHERE ELSE". THE DIRECTOR OF NURSING FAILED TO IDENTIFY A COGNITIVELY IMPAIRED RESIDENT BEING OUTSIDE A SAFE AREA WITTHOUT SUPERVISION AS AN ELOPEMENT. A REVIEW OF THE FACILITY POLICY WITH A REVISION DATE OF 11/2007 AND TITLED "INCIDENT REPORT ANALYSIS" DEFINED ELOPEMENT AS "..A RESIDENT NEEDS SUPERVISION BUT LEAVES A SAFE AREA WITHOUT SUPERVISION". RESIDENT #6'S"ELOPEMENT" INCIDENT DESCRIPTION FORM, PROVIDED BY THE SOCIAL WORKER, DATED 07/15/2012 REFLECTED THAT "...THE RESIDENT (#6) WAS OUTSIDE ON THE SIDEWALK." RESIDENT #6'S "MENTAL STATUS" INDICATED RESIDENT WAS ORIENTED ONLY TO HERSELF. "PREDISPOSING PHYSIOLOGICAL FACTORS" INDICATED ON THE "ELOPEMENT" INCIDENT DESCRIPTION FORM INCLUDED "CONFUSED" AND "IMPAIRED MEMORY". "PREDISPOSING SITUATION FACTORS" INDICATED "WANDERER". THE (UNTITLED) INVESTIGATION, DATED 07/16/2012, AUTHORED BY SOCIAL WORKER "AA" REFLECTED "STAFF DID PLACE WANDER GUARD ON HER (RESIDENT#6'S) PERSON AS SHE IS NOW AT RISK FOR ELOPEMENT." NO ELOPEMENT RISK ASSESSMENT WAS FOUND IN RESIDENT #6'S MEDICAL RECORD PRIOR TO THE ELOPEMENT ON 07/15/2012. ( ) ACCORDING TO THE 12/18/11 ADMISSION MINIMUM DATA SET (MDS, AN ASSESSMENT TOOL) RESIDENT #20 WAS A [AGE] year OLD FEMALE admitted TO THE FACILITY 12/5/11 WITH [DIAGNOSES REDACTED]. THE MDS RECORDED RESIDENT #20 WITH A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SCORE OF 2 OUT OF A POSSIBLE 15, REPRESENTING A SEVERE COGNITIVE IMPAIRMENT. ADDITIONALLY, RESIDENT #20 WAS INDEPENDENT IN AMBULATION, BUT NEEDED SUPERVISION (OVERSIGHT) FOR MOVING ABOUT THE CORRIDORS AND OFF THE UNIT. A WANDER GUARD HAD BEEN INSTITUTED, PER THE physician's orders [REDACTED]. A REVIEW OF RESIDENT #20'S CARE PLANS INITIATED ON ADMISSION (12/15/11) REFLECTED A CARE PLAN ON "HOW TO MEET RESIDENT #20'S NEEDS" REFLECTED UNDER INTERVENTIONS THE USE OF A "WANDER GUARD TO (RESIDENT #20'S) RIGHT ANKLE R/T (RELATED TO) STATEMENTS OF WANTING TO FIND THE CAR. THE DATE THE WANDER GUARD WAS INITIATED WAS RECORDED AS 12/15/11. A REVIEW OF RESIDENT #20'S ACCIDENT/INCIDENT RECORD DATED 7/6/12 REFLECTED THAT ON ON 7/6/12, AT 6:03 PM RESIDENT #20 WAS OBSERVED OUTSIDE THE FRONT DOOR SEATED ON A BENCH WITH ANOTHER STAFF WHO STATED THAT RESIDENT #20, "HAD MADE IT TO THE END OF THE SIDE WALK." ACCORDING TO THE INVESTIGATION CONDUCTED BY SOCIAL WORKER "G" ON 7/9/12, RESIDENT #20 HAD NO RECALL OF BEING OUTDOORS. THE INVESTIGATION FURTHER REFLECTED, AN INTERVIEW WITH REGISTERED NURSE STAFF "H". STAFF "H" WAS IN HER OFFICE AND SAW RESIDENT #20 OUTDOORS ON THE FRONT SIDEWALK WALKING TOWARDS MILL POND POINT. THERE WAS NO DOCUMENTATION THAT NURSE "H" OR ANY FACILITY STAFF WAS ACTIVELY LOOKING FOR RESIDENT #20. THE ELOPEMENT INCIDENT REPORT REFLECTED A REVISION DATE OF 7/16/12, 10 DAYS AFTER THE ELOPEMENT, WHICH DESCRIBED "STAFF NOTICED THAT THE FRONT DOOR EGRESS WAS GOING OFF, STAFF WENT TO THE FRONT DOOR WHERE RES (RESIDENT) WAS SITTING ON THE BENCH WITH ANOTHER STAFF MEMBER." THE SAME REPORT CONTINUED WITH, "STAFF MEMBER STATED THAT SHE (REFERRING TO RESIDENT #20) HAD MADE IT TO THE END OF THE SIDEWALK, THERE WAS NO MAIN HALL ALARMS GOING OFF AROUND THE TIME SHE HAD REACHED THE DOOR. UPON COMING BACK TO HALL THE MAIN HALL ALARMS DID NOT SOUND AS WE WENT THROUGH. WE CHANGED WANDERGUARD..." ( )