Every finding on record at Traverse Care Center

Based on observation, interview and document review, the facility failed to report an allegation of an injury of unknown origin to the State Agency (SA) within two hours for 1 of 1 resident (R1) investigated for injury of unknown origin. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition with no behaviors and rarely socially isolated herself. R1 had impaired lower bilateral extremity range of motion (ROM) and used a walker and wheelchair for mobility. R1 was frequently incontinent of bladder and occasionally incontinent of bowel. R1 required partial/moderate assistance with all transfers and was dependent upon staff for shower/bath and toileting. R1's diagnoses included non-Alzheimer's dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases), anxiety, depression, and poor vision. R1's medications included antidepressants and anticoagulants.R1's care plan dated 7/20/26, identified:-At risk for abuse vulnerability related to cognitive deficit, safer awareness, confusion, and impaired vision. Areas of vulnerability include physical, emotional, and mental. Staff were directed to observe suspected abuse, remove resident from aggressor and relocate to safe location, provide annual vulnerable training by staff, report alleged violations in accordance with community protocol/policy, and notifications to immediate supervisor, unit manager (UM), director of nursing (DON), social worker (SW), nursing home (NH) administrator, and complete paperwork per community protocol/policy. Revised: 9/2/22.Emergency Department (ED) note dated 7/19/26 at 9:54 a.m., identified emergency medical services (EMS) was told R1 had chest pain and she denied chest pain during evaluation. R1 was oriented to self and place but not time. R1 had noticeable and large bruises as well as hematoma on her left upper arm. When asked about this, R1 stated someone grabbed her when they came to help her to the bathroom last night. When asked why they grabbed her she stated that she must have been mad at me. R1 was unable to provide any information about this person, however confirmed that it was someone who came and checked on her frequently at that nursing home. Furthermore, R1 said that when she came into the room she got scared because she was such a snot. When asked several different ways, R1 continued to say that the injury on her arm was caused by another person and denied falls. Physical exam: skin - Significant bruising on left upper arm, appeared to be in patter of a hand gripping the skin tightly. Hematoma is present on upper inner left arm. Neurological: disoriented. Motor: weakness left arm unable to keep lifted against gravity. Clinical Impressions: Hematoma: adult physical abuse suspected. Assessment/Plan/Decision Making: hematoma and adult physical abuse suspected. X-rays negative for signs of fracture. Medical Decision Making: Contacted facility and spoke with lead registered nurse (RN)-A today. I did let her know my concerns for physical abuse based on appearance of bruising. She notes that she shared the same concern and had already reported this to administration and director of nursing (DON) at the care center. RN-A stated she will do her best to ensure that the staff that was on last night and taking care of the patient will not oversee her care today or this evening.ED notes by ED registered nurse (RN)-B dated 7/19/26 at 10:01 a.m., identified R1 arrived with significant bruising and swelling to arm. Per R1, she stated someone was helping her to the bathroom last night, had a temper and then told her to just get her arm checked out in the morning. Minnesota Adult Abuse Reporting Center (MAARC) report was filed. Clinical impressions: hematoma and adult physical abuse suspected. Pictures added to chart.Minnesota Adult Abuse Reporting (MAARC) report received on 7/19/26 at 12 :05 p.m., identified R1 was seen in ED on 7/19/26, for bruising on left upper arm. R1 had a large hematoma on the inside of her left upper arm and significant bruising on the back of the upper arm that extended onto the outer side that bruised in a pattern of hand gripping the arm with significant amount of force. Unable to hold up her left arm against gravity. R1 stated someone grabbed her arm last night when helping her to the bathroom but was unable to say who it was and must have made her mad, when she came into the room she got scared because she is such a snot. This statement was concerning as it means that some abuse may have happened before last night.MAARC report received on 7/19/26 at 12:30 p.m., identified R1 arrived at ED with complaints of left arm pain. Nursing home called to state there was some bruising and no injury reported that staff was aware of. R1 stated whoever put her to bed last night was helping her to the bathroom, had a temper, and was mad at her. R1 was oriented to self, place, situation, unable to tell year. Bruising pictured and added to chart. [NAME] lined up with how a hand would grab R1's arm with finger marks. R1 stated she disliked when this aid helps her because she must hate her job, she had a bad temper.R1's progress noted dated 7/19/26, through 7/24/26, identified:7/19/26 at 10:15 a.m., staff found two areas of purplish bruising on upper left arm, upper one larger with areas of swelling, lower one near elbow also had swelling. R1 complained of pain. Measurements obtained. Per director of nursing instructions R1 was sent via ambulance to local hospital for evaluation.7/19/26 at 10:55 a.m., R1 denied anyone being too rough with her during cares or any other time.7/19/26 at 11:52 a.m., reviewed with staff the current continued use/need for T-bars (upper side railing) while in bed due to recent bruising. Staff, nursing assistants (NA), charge nurse, trained medication administration assistant (TMA) reported yes, she utilized them appropriately and needed for repositioning. Will continue with current plan of care (POC) and monitor.During an observation on 7/23/26 at 11:10 a.m., NA-A assisted R1 out of bed and into a wheelchair. NA-A pushed R1 into the bathroom, transferred her to the toilet and removed her long-sleeved shirt, and completed cares. R1 complained of left arm pain when removed her shirt and stated oh be careful that right arm was sore. R1 had a dark purple solid bruise on the left upper arm from underneath her arm (a straight line) and lateral outer side of the arm down to her wrist area, and a lump/bump located on her left bicep approx. 3 inches in diameter and yellow discoloration that went from the lump to the crease of her arm. NA-A verified the bruise/color, and location. R1 stated to NA-A do you know what person grabbed my arm that lump really hurts and she thought someone may have grabbed her but unable to remember. NA-A stated no he did not and had not worked with/cared for R1 prior to the bruising.Interview on 7/23/26 at 1:20 p.m., trained medication assistant (TMA)-A stated he assisted R1 to the bathroom during the shift worked (7:00 am. to 7:30 p.m.) on 7/18/26 and did not see any bruises. TMA-A stated he worked the same hours on 7/19/26 and completed R1's morning cares. TMA-A stated on the morning of 7/19/26, he removed R1's long-sleeved pajama top, noted dark solid purple bruising on R1's left arm around her bicep, and mostly the outer back side of her upper left arm. TMA-A stated he did not see finger marks on her arm. R1 had a golf ball sized lump located on her bicep, hard to touch, did not compress and caused slight pain according to R1. R1 was unable to identify what happened and it was reported to the day staff nurse, licensed practical nurse (LPN)-A, immediately.Interview on 7/24/26 at 1:34 p.m., the administrator approached surveyor and appeared upset. The administrator stated she was not informed by RN-A how bad R1's bruise was and the report was not filed with the state agency (SA). The administrator stated she was informed on 7/19/26 at 11:26 a.m., R1 had a bruise. The administrator figured R1 had taken a blood thinner twice a day and possibly hit her arm when going to bathroom, on the bar located on the wall. Staff were informed to use their judgement, send to ED if needed. The administrator was informed RN-A would start an investigation to see what was going on and did not feel the need to report this. The administrator stated that today (7/24/26) she looked at documentation in EPIC medical records system, the hospital reported and noted the facility nurse RN-A working shared with the hospital, concern of physical abuse based on the appearance of bruising. The administrator was not aware of RN-A's concerns. The administrator stated the expectation would have been RN-A should have expressed her concerns about possible abuse and the concern would have been reported right away. RN-A filled out the form/questionnaire for the abuse investigation and did not allude she had concerns about abuse. The administrator talked to RN-A on 7/23/26, RN-A did not express concerns about possible abuse nor had any of the staff express concerns about abuse. RN-A was a mandated reporter and if she had thought there was a possibility of abuse she would have been expected to report her concerns to the SA. The administrator stated she was appalled with this information she was made aware of today, it wasn't anything anyone should have taken lightly, ever. The administrator stated R1's bruise was of unknown origin and if staff, including the DON and assistant administrator, did not know what caused the bruise the administrator would have been expected a report was immediately filed with the SA. The administrator stated that when she spoke to the DON and the assistant administrator, they understood the bruise came from being bumped.Interview on 7/24/26 at 2:30 p.m., RN-A stated on 7/19/26, she was made aware of R1's bruise by LPN-A. At approximately at 9:45 a.m., RN-A assessed R1's left arm, asked R1 if anyone had been rough with her and R1 stated no. RN-A verified she observed R1's upper left arm had two areas of purplish bruising, one upper with large areas of swelling and lower one near the elbow also had swelling, R1 complained of pain, and measurements were taken. The DON and the administrator were notified at approximately 10:00 a.m. They were informed bruising was found and R1 complained of left arm pain. RN-A was not asked what caused the bruising during the call. At approximately 10:10 a.m., EMS arrived and transported R1 to the ED. RN-A stated she had no time to investigate the bruising prior to R1 being sent to the ED. RN-A stated she received a phone call from the ED medical doctor (MD), was asked if she was aware of R1's bruising. RN-A informed the MD she was aware. RN-A stated MD informed her she thought the bruises were associated with abuse, RN-A told MD she understood and MD stated as long as we are on the same page. The MD informed RN-A, the staff ED nurse and herself would file an adult abuse report. RN-A stated she understood what MD words conveyed and responded verbally to MD, she understood. RN-A stated there was potential for R1 to have fallen and/or self-transferred. RN-A stated she could not rule out abuse and was unable to identify what happened. RN-A stated she was not expected to call the police department, but thought if R1 was hurt, she would have. RN-A stated she had shared the ED MD concerns with the DON, the same day R1 was sent to ED. RN-A stated the MD asked about night shift and requested the same staff that worked the prior night not care for R1, she informed the MD that would be possible and she would make it happen. RN-A stated she relayed this information to LPN-A. LPN-A verbally responded she would let the evening nurse, LPN-B, know. RN-A stated she assumed it had been taken care of. RN-A stated she did not know if this was reported and probably should have followed up with the DON or the administrator. RN-A stated she did not report this bruise to the SA and should have immediately since it was unknown how R1 received it.Interview on 7/27/26 at 9:30 a.m., ED nurse (RN)-B stated R1 was initially sent to ED for chest pain, but did not have chest pain when she arrived to the ED. The facility staff called and stated she was sent in for bruises. R1's left arm had deep purple bruising that appeared fresh with a large hematoma, three lines located on the outside/lateral backside of her left arm. RN-B stated she placed her hand on R1's left upper arm with her fingers on the three lines located on the lateral side of the upper arm, wrapped her palm of her hand down and around the front of her upper arm. RN-B's thumb lined up with the hematoma located on the bicep. RN-B stated R1 had told her the staff that placed her in bed last night was a snot to her and informed R1 her arm would be fine, and she would have to get it checked out in the a.m. RN-B stated it had to be a hard/firm grab to break blood vessels, it was a pretty deep purple for sure. RN-B stated she had been told by the MD, she talked to facility RN charge nurse and she thought it was abuse also.Interview on 7/28/26 at 12:45 p.m., NP-A stated if R1 was grabbed tightly, R1 would have bruised easily due to her being on Eliquis. R1 had a poor memory. NP-A was unsure if R1 would have been able to recall how her left arm was bruised. Staff would have been expected to follow the facility protocol/procedures regarding reporting.Interview on 7/27/26 at 11:02 a.m., LPN-B stated on 7/19/26, she assessed R1's bruise on her left arm along with RN-A. R1's bruise looked fresh, dark purple, with no yellow areas. The DON was notified by RN-A and sent R1 to the ED. LPN-B stated, We did not know what caused the bruise. According to facility protocol, we should have reported to State Agency right away. Interview on 7/27/26 at 2:50 p.m., the DON stated she was informed on 7/19/26 at 8:20 a.m., a NA noticed a large bruise and a lump on R1's left upper arm. There was no mention of what color it was or of suspected abuse. The DON told RN-A to send R1 to the ED for eval. The DON stated if she had suspected abuse, it would have been reportable within two hours. The DON stated RN-A informed her on 7/19/26, the ED nurse and the MD planned on filing a report with the state. The DON stated it was not reported because the provider and the nurse from the ED, both reported it. The DON stated she was informed by RN-A the area was a bruise. The DON was not made aware the ED MD had concerns of abuse. RN-A completed the questionnaire provided to each staff and indicated a bruise and nothing more.Facility abuse policy dated 5/16/26, identified it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled using technology i.e. social media. The facility will have written procedures to assist staff in identifying the different types of abuse. Possible indicators of abuse include, but are not limited to resident, staff, or family report of abuse, physical marks such as bruises or patterned appearance such as a handprint, belt, or ring mark on a resident's body, physical injury of a resident, of unknown source, and physical abuse of a resident observed. The facility will have written procedures that include reporting of all alleged violations to the administrator or designee, state agency, adult protection service and any other required agencies (i.e., law enforcement when applicable) immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. The administrator or designee will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 days of the incident, as required by the state agencies.

Based on observation, interview, and document review, the facility failed to ensure a call light was within reach for 1 of 3 residents (R5) who had severe cognitive impairment and was at high risk for falling, leaving the resident unable to summon assistance. Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], identified he was admitted to facility on 1/29/26 from an acute hospital setting. R5 had minimal difficulty hearing in some environments, did not wear hearing aids, wore glasses, and had severely impaired cognition. R5 used a walker and wheelchair for mobility. R5 required partial/moderate assistance with toilet transfer, substantial/maximal assistance with toileting hygiene and supervision or touching assistance to walk 10 to 150 feet. R5 was always incontinent of bladder and always continent of bowel. R5's diagnoses included Alzheimer's disease and non-Alzheimer's dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases), anxiety, and depression. R5's care plan dated 2/5/26, identified:Potential for falls related to history of falling and diagnosis of syncope (fainting or passing out). A Call Don't Fall sign was posted in R5's room. Staff were directed to position call light for easy access, reinforce need to use the call light to request assistance, use assistive devices such as walker, gait belt, and staff when walking, encourage proper footwear, check for unmet needs: pain, toileting, hunger, thirst and temperature, ensure environment was free of clutter, and have commonly used articles within easy reach.Activities of Daily Living (ADL) deficit related to history of falls and balance issues and Alzheimer's disease. Staff were directed to use assist of one with gait belt and front wheeled walker 10 to 150 feet, provide supervision with transfers (sit to stand, chair to bed, and toilet), assist of one for personal hygiene, and supervision with toilet hygiene.R5's fall risk assessment dated [DATE] at 5:32 p.m., indicated R5's fall risks included: history of falls; used ambulatory aids such as cane or walker; had impaired gait (difficulty raising from a chair, keeps head down when walking, watches the ground, grasps furniture, person or aid when ambulating, and cannot walk unassisted); and overestimates or forgets limits of his ability to ambulate safely. R5's fall risk score was 90 and determined to be at high risk (low risk 0-24, moderate risk 25-44, high risk 45 and higher).During an observation on 7/27/26 at 10:30 a.m., R5 lay on top of his bed, television was on, eyes were closed, fully dressed, socks on his feet and shoes located on the floor. R5's wheelchair was located across room by the recliner (out of reach), regular call light button was draped over the left arm of the chair and an additional soft vinyl bulb design (required small amount of pressure to activate) call light was clipped up on the call light cord located on the wall across the room, both unreachable to R5 from the bed. During an observation and interview on 7/27/26 at 11:35 a.m., R5 lay awake on his back on the bed fully dressed, with socks on his feet. R5 stated he had a fall a few months ago, slid out of bed, bumped his head, did not have any serious injuries, and was unsure how it happened. R5 stated he had not fallen since. R5 stated he wanted to get up and looked around and commented, I'm not sure how to get someone here to help me. I usually use the call light but I can't to find it right now. R5's call light was observed hung on the wall, out of R5's reach. R5 stated, I could get myself up and into my wheelchair, but I'm not sure I'm supposed to do it on my own. R5 sat himself up on the edge of his bed and was encouraged to wait until staff arrived to assist him. During an interview and observation on 7/27/26 at 11:41 a.m., nursing assistant (NA)-C knocked R5's door, entered R5's room and stated she stopped in to check on him. NA-C stated R5 usually used the call light to get assistance from staff and needed it close by to be able to reach it. NA-C stated staff made rounds and sometimes found him walking by himself and he should not be. NA-C unclipped the call light from the cord that hung from the wall and clipped it to R5's pillowcase. NA-C assisted R5 out of bed as he requested.During an interview on 7/27/26 at 1:55 p.m., NA-C stated R5 occasionally takes himself to the bathroom. Staff frequently remind him to use his call light. R5 liked to walk independently in his room and did not like the call light. Staff were expected to check on him every two hours, were responsible to assure R5 had his call light to prevent falling, and R5 was care planned to have call light. NA-C stated R5 had a call don't fall sign in his room. When staff caught him in his bathroom alone, he joked around and stated he did not see the sign.During an interview on 7/27/26 at 2:50 p.m., the director of nursing (DON) stated R5 was at risk for falls and had one fall since admission. R5 attempted to self-transfer often, staff saw him ambulate independently and he should not. Staff would be expected to provide R5 a call light so that he can call if assistance was needed and would have helped prevent falls.Facility policy Call Lights: Accessibility and Timely Response Policy undated identified a call light should be provided to each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to staff members or centralized locations to ensure appropriate response. All staff will be educated on the proper use of the residents' call system, including how the system works and ensuring resident access to the call light. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secure, as needed.

Based on observation, interview, and document review the facility failed to ensure proper hand hygiene was used after removal of gloves for 1 of 3 residents (R1) during toileting and personal cares. Additionally, the facility failed to ensure appropriate personal protective equipment (PPE) recommendations were followed during a high contact care activity and failed to ensure proper was followed when emptying a urine collection bag for 1 of 1 resident (R4) who required enhanced barrier precautions (EBP).R1R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severely impaired cognition with no behaviors. R1 had lower bilateral extremity range of motion (ROM) impairment and used a walker and wheelchair for mobility. R1 was frequently incontinent of bladder and occasionally incontinent of bowel. R1 required partial/moderate assistance with all transfers and was dependent upon staff for shower/bath and toileting. R1's diagnoses included non-Alzheimer's dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-[NAME] diseases), anxiety, depression, and poor vision.R1's care plan dated 7/20/26, identified:Activities of daily living (ADLS) deficit related to current medical and physical status including depression and anxiety. Staff were directed to provide partial/moderate assistance with transfers, substantial/maximal assistance with personal hygiene, lower body dressing, extensive assistance with toileting, cleaning after elimination to ensure she was clean after each elimination,During an observation on 7/23/26 at 11:10 a.m., nursing assistant (NA)-A assisted R1 to the bathroom. NA-A placed a clean glove on his right hand only. R1 pulled herself up to stand using the bar located on the wall, NA-A pulled down her pants and brief. R1 lowered herself onto the toilet. NA-A removed the transfer belt, brief, pants from R1, placed clean pants and a brief up to R1's thighs. NA-A removed R1's long sleeved shirt, washed her upper body and dried with a towel, placed a clean long-sleeved sweater on, and applied gait belt. R1 voided into the toilet. R1 stood up and NA-A completed R1's personal hygiene his right hand, then pulled up the brief and R1's pants. NA-A held onto R1's waist band while she pivoted and lowered herself into the wheelchair. NA-A grabbed R1's hairbrush and brushed R1's hair with the dirty glove still on his right hand, picked up her glasses, placed them on her face with both hands, then bagged the dirty garbage, placed R1's dirty clothes in a pile, removed the glove from his right hand, and did not complete hand hygiene. NA-A pushed R1 out of the bathroom in the wheelchair, walked over to R1's bedside and made the bed. At 11:35 a.m., NA-A pushed R1, in her wheelchair out of her room, down the hallway, and into the lounge area. NA-A walked back to R1's room gathered R1's dirty clothing, a clear bag of garbage, exited the room, walked down the hallway, opened the soiled utility room door and dropped off clothing and garbage. NA-A immediately came back out to hallway and sanitized hands from a wall mounted sanitizer located across the hall.During interview on 7/23/26 at 2:18 p.m., NA-A stated he placed a clean glove on right only, the glove made his left hand slippery, it was hard to hold onto R1, and pull up her pants. NA-A stated he completed R1's cares, washed her upper body then after she was done on the toilet, wiped her front peri area and bottom with right hand. NA-A stated he left the glove on his right-hand, pulled up R1's clean brief and pants, and assisted her to the wheelchair. NA-A stated he kept the dirty right-hand glove on, combed R1's hair and was unsure when he removed the glove but should have removed it once R1 was safely back into the wheelchair. NA-A bagged the garbage and grabbed the dirty laundry once he returned to R1's room. NA-A stated it would have been important to wash his hands after he removed his gloves, before he touched the resident again, and before leaving R1's room to prevent the spread of germs/bacteria to help prevent infection.R4R4's 5-day MDS (conducted between days one to eight after resident readmission to facility) dated 5/5/26, identified R4 had moderately impaired cognition, impaired bilateral lower extremities and required partial/moderate assistance for toilet transfers, was dependent for toileting hygiene, and used a manual wheelchair for mobility. R4 had an indwelling urinary catheter due to a neurogenic bladder (condition where nerve damage disrupts communication between the brain, spinal cord, and bladder. This leads to urinary control problems). R4 had a history of urinary tract infections (UTI), multidrug-resistant organism (MDRO) (a microbe that has developed the ability to withstand/resistant the effects of multiple antimicrobial drugs, such as antibiotics), and history of septicemia (a serious infection that starts somewhere in your body and spreads throughout the blood stream), and diabetes mellitus (DM). R4 was taking antibiotics, diuretics (pulls fluids to remove excess water and salt from the body), and insulin (7 days a week).Physician orders:Date ordered: 8/7/25, change 16 French Coude (a specialized urinary tube featuring a curved or bent tip used to navigate urethral blockages, strictures, or an enlarged prostate) one time a day every one month starting on 6th for one day related to flaccid neuropathic bladder.Provider office visit dated 4/20/26 at 2:00 p.m., identified Assessment/Plan: Urinary tract infection (UTI) due to urinary indwelling Foley catheter, sepsis due Escherichia coli, unspecified whether acute organ dysfunction present, and bacteremia due to Escherichia coli. Plan: finish antibiotic course, labs to follow, and strict catheter cares as he had urosepsis two times with the catheter being mode of transportation.R4's care plan dated 4/22/26, identified:Risk for infection due to indwelling catheter. Staff were directed to educate R4 on infection control practices, encourage fluids, enhanced barrier precautions (EBP), evaluate urine characteristics, and manage indwelling catheter to minimize risk for infection.Complications with bladder related to diagnoses of flaccid neuropathic bladder and bladder retention. Staff were directed to follow EBP for indwelling catheter and observe for changes in color, consistency, frequency, order, discomfort, distention, fever, or confusion and review changes with medical doctor. During an observation on 7/23/26 at 10:03 a.m., a cart was located outside R4's room with PPE supplies. On the top of the cart was an EBP orange colored sign with two red stop signs on the top left and right hand sides of the sign with the following information: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following High-Contact Resident Care Activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person.During an observation on 7/23/26 at 3:27 p.m., trained medication assistant (TMA)-A brought R4 into his room, did not wash their hands and did not apply PPE before entering. TMA-A washed his hands, applied gloves, and grabbed the urine collection container. TMA-A exposed R4's urine collection leg bag and end of drainage tube, wiped off the end of the tube with an alcohol swab, opened the tube, then laid it inside the container. The drainage tube was touching the inside of the collection container. TMA-A opened the drainage tube and emptied the urine into the collection container. TMA-A closed drainage tube and wiped the end with an alcohol swab. TMA-A emptied the contents of the collection container into the toilet, rinsed container with tap water from the facet, and dumped it in the toilet. TMA-A placed the collection container upside down onto a towel on the bottom shelf in bathroom and removed gloves. TMA-A did not sanitize/wash hands. TMA-A pushed R4, in his wheelchair out of the room, stopped in front the PPE cart located in the hallway outside R4's room, and sanitized his hands. TMA-A did not apply a protection gown during this observation.Interview on 7/23/26 at 3:52 p.m., TMA-A verified R4 was on EBP due to his indwelling catheter. TMA-A stated staff were expected to wear PPE when R4's indwelling catheter was emptied and forgot to wear a gown but he should have, and usually did. TMA-A stated PPE was important to wear and was used to prevent infection being transferred to the resident(s) and staff.Interview on 7/24/26 at 2:44 p.m., TMA-B stated a resident is placed on EBP when they have an indwelling catheter to help prevent the spread of infection. Staff were expected to wear a gown and gloves when they worked with a urinary catheter to help with infection control. The gown and gloves were used to helped prevent splashes of urine from getting on a staff's hands and clothing. TMA-B stated gloves and good hand washing before and after emptying the urine collection bag helped avoid the transfer of germs from one person to another.Interview on 7/27/26 at 11:02 a.m., licensed practical nurse (LPN)-B stated staff would be expected to wear the proper PPE, including a gown and gloves when working with R4's urinary catheter. R4 has had a history of urinary tract infections (UTI), We want to avoid the transfer of germs to prevent infection. LPN-B stated the tip of the catheter, where the urine was drained from the collection bag, should not touch the inside of collection container to avoid bacteria from getting on it, contamination, and can possibly cause an infection such as UTI.Interview on 7/27/36 at 1:55 p.m., NA-C stated R4's indwelling urinary catheter needed to be emptied frequently. Staff were expected to wear PPE (gown and gloves) when indwelling catheter cares and emptying were completed to avoid splashes of urine on their clothes and prevent the spread of infection. NA-C stated staff were expected to wipe off the end of the catheter bag tubing with an alcohol swab and avoid the catheter from touching the inside of the collection container to avoid infection.Interview on 7/27/26 at 2:50 p.m., the director of nursing (DON) stated R4 had an indwelling urinary catheter with a history UTIs and was placed on EBP due to facility policy and guidelines from center of disease and control (CDC). Staff would be expected to wear PPE while working with R4's catheter to avoid contamination, transmission/spread of the multidrug-resistant organism (MDRO) to other residents and staff. DON stated it would be concerning if the end of the urinary catheter drain tube was placed into the collection container without being held onto and could have caused contamination, infection, and increased R4's risk for a UTI. Staff were expected to use good hand hygiene once they completed peri cares, removed gloves, and sanitize/wash hands to prevent infections.Facility policy Enhanced Barrier Precautions (EBP) dated 2024, identified the EBP along with contact precautions will be implemented during high-contact resident care activities when caring for residents that have increased risk of acquiring a multidrug-resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. Definition of EBP was identified as to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP is intended for nursing homes to prevent the spread of novel or targeted MDROs when residents have an infection or colonization with a MDRO or if the resident has a wound or indwelling medical device, regardless of MDRO infection or colonization. When a resident contracts an MDRO, treatment is often limited. The purpose of EBP was to prevent opportunities for transfer of MDROs to employees' hands and clothing during cares, beyond situations in which staff anticipate exposure to blood or bodily fluids. Clear signage would be expected to be posted outside the resident's door/wall of their room and an isolation cart with PPE equipment immediately outside the resident room. PPE equipment was required for all staff providing high-contact resident care activities to include device care or use: central line, urinary catheter, feeding tube, and tracheostomy/ventilator.Facility policy Infection Prevention and Control Manual - Standard Precautions/Gloves dated 2024, identified it was the policy of this facility to don (put on) clean non-sterile gloves in accordance with Standard and transmission-based precautions (TBP) (i.e., when anticipating touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and non-intact skin or when a resident was in TBP). Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. Perform hand hygiene after the removal of gloves, it is always possible that gloves have tiny leaks.

Based on observation, interview, and document review, the facility failed to ensure that nebulizer medications were administered safely for 3 of 3 residents (R14, R1, R2) who were observed to self-administer a nebulizer and had not been approved to self-administer medications.Based on observation, interview, and document review, the facility failed to ensure that nebulizer medications were administered safely for 3 of 3 residents (R14, R1, R24) who were observed to self-administer a nebulizer and had not been approved to self-administer medications. Findings include: R24's annual Minimum Data Set (MDS) identified that R24 was moderately cognitively impaired. R24 had a diagnosis that included diabetes, anxiety, and depression. R24 required assistance with dressing, toileting, and transfers. R24's Care plan revised on 12/16/24, identified R24 had an altered respiratory status and difficulty breathing. Care plan identified staff were to administer medication and treatments as ordered. Additionally care plan identified R24 as not being able to self-administer medications related to dementia and cognitive impairment. R24's signed physician order dated 12/16/25, identified R24 of receiving budesonide inhalation suspension (reducing inflammation in the airway) 0.5 milligrams (mg) /2 milliliters (ml) 1 vial inhale orally one time a day for bronchitis, and Ipratropium-Albuterol inhalation solution (treat chronic obstructive pulmonary disease ) 0.5-2.5mg/3ml 1 application inhale orally three times a day for bronchitis and give prior to budesonide treatment. R24's self-administration of medication assessment dated [DATE] identified R24 of not being capable of administering inhalants or inhalers and the resident was not approved for self-administration of medications. R24's electronic medical administration record (EMAR) dated January 2025, identified R24 received budesonide inhalation suspension 0.5mg/2ml on 1/12/25 at hour of sleep (HS). R24 received Ipratropium-albuterol inhalation solution 0.5-2.5mg/2ml three times on 1/12/25. During an observation on 1/12/26 at 7:45 p.m., R24 was sitting in his room with a nebulizer mask on and a nebulizer machine running. No staff in R24's room, nebulizer treatment appeared to be finished. At 7:47 p.m., trained medical assistant (TMA)-A went to the medication cart and took out budesonide inhalation suspension 0.5mg/2ml and verified medication with the EMAR. TMA went into R24 room and turned off the nebulizer machine and administered budesonide inhalation suspension 0.5mg/2ml to the nebulizer mask, turned on the nebulizer and then left the room. R1's R1's quarterly MDS dated [DATE], identified R1 had severely impaired cognition and had a diagnosis of schizophrenia (mental disorder with hallucinations or delusions), and Alzheimer's disease (neurodegenerative disorder that affects memory). R1 was dependent on staff for dressing, hygiene, and toileting. R1's care plan revised on 2/21/24, identified R1 as not being able to self-administer medications related to dementia and cognitive impairment. Nursing staff to administer all medications per the physician's orders and monitor for side effects of medications. R1's self-administration of medication assessment dated [DATE], identified R1 as not being able to cognitively participate in self-administration of medications. R1's signed physician orders dated 12/2/25, identified R1had orders for Ipratropium-albuterol inhalation solution 0.5-2.5mg/2ml two times a day. R1's orders lacked an order for self-administration of medication. R1's EMAR January 2026 identified R1 received for Ipratropium-albuterol inhalation solution 0.5-2.5mg/2ml two times. During an interview on 1/12/25 at 7:56 p.m., TMA indicated that R24 could have the nebulizer treatment without staff present. During an interview on 1/13/26 at 4:10 p.m., RN-A indicated his normal practice was to place a nebulizer treatment on a resident and return in ten minutes to remove the nebulizer treatment. RN-A indicated that if a resident had a self-administration of medications, it would be in the orders. RN-A verified there were no self-administration orders for R1 and R14. RN-A was unaware if a self-medication assessment was done for R1 or R14. During an interview on 1/13/26 at 4:18 p.m., the administrator indicated a resident could self-administrator medications after a self-administration of medications assessment was completed and a resident was deemed capable of self-administrating medications. If a resident is not able to self-administrate medications, staff should keep the resident in their line of sight when administrating medications. The administrator indication a self-administration assessment is important to ensure a can properly administer the medication. R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses which included: heart failure, chronic obstructive pulmonary disease (COPD), anxiety and bi-polar disease. Identified R2 was dependent on staff for dressing, personal hygiene, toilet hygiene, and transfers. R2's comprehensive care plan revised 11/20/25, identified R2 was not able to self administer medications due to cognitive impairment related to not interested in self administration of medication. Nursing staff to administer all medications per physician orders. R2's Self-Administration of Medication (SAM) assessment dated [DATE], identified R2 was unable to self administer as unable to obtain medications from package due to fine motor need. Not interested in self administration of medications. R2's Medication Review Report signed 12/2/25, identified the following orders: -Budesonide Inhalation Suspension (nebulized medication to decrease inflammation of airways) 1 milligram (MG)/2 milliliters (ML) 1 application inhale orally two times a day by nebulization related to COPD. Rinse mouth with water after use. -Formoterol Fumarate Inhalation Nebulization Solution (nebulized medication to relax airway muscles to ease breathing) 20 micrograms (MCG)/2ML 1 application inhale orally via nebulizer two times a day related to COPD. -Ipratropium-Albuterol Solution (nebulized combined medication that relaxes lung muscles and reduces mucus) 0.5-2.5 (3) MG/3ML 1 unit inhale orally three times a day related to COPD. Rinse mouth after use. R2's Medication Review Report lacked an order to self-administer medications. During observation on 1/12/26 at 7:36 p.m., R2 was sitting in recliner in his room with a nebulizer mask covering his mouth and nose, while the machine was running. Registered nurse (RN)-A had just exited R2's room and left the wing. No other staff were noted in the hallway. At 7:43 p.m., nursing assistant (NA)-A exited a room across the hall from R2's room. NA-A leaned into R2's doorway, looked towards R2 in his recliner, then left the area, and walked down the hallway. At 7:45 p.m., RN-A entered R2's room, checked on R2's roommate. RN-A shut off R2's nebulizer, administered another nebulizer medication into the cup, then replaced the mask and turned on R2's nebulizer machine and left R2's room and area. During interview on 1/13/26 at 4:08 p.m., RN-A verified his usual practice for nebulizer medications, was to start the nebulizer, leave, then return ten minutes later to remove them. RN-A verified R2 received three different nebulizer medications, and he would administer one right after the other. RN-A verified he had administered the three nebulizer medications to R2 on 1/12/26, and had left after set up of each nebulizer medication. RN-A confirmed R2 did not have an order to SAM nebulizer medication. RN-A indicated he was unaware if R2 had a SAM assessment completed. During interview on 1/13/26 at 4:18 pm., with administrator, assistant administrator, nurse consultant and director of nursing the following was discussed. Administrator indicated expectation was if a resident was deemed competent for SAM, an assessment was completed, including what route of medication would be self administered. If a resident did not have a SAM assessment completed and was not deemed competent to administer the nebulizer medication, nursing staff would stay with the resident while the medication was administered. This was to assure proper administration of the medication. Policy title Resident Self-Administration of Medications, not dated, identified that a resident may only self-administer medications after the facility's interdisciplinary team has determined which medication may be self-administered safely.

Based on interview and record review the facility failed to ensure hospital physician's discharge orders for a follow-up appointment with urology was scheduled upon admission from hospital and completed for all necessary care for Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified he re-entered facility on 12/15/24, from a critical access hospital. He had severely impaired cognition, no behaviors, impaired mobility, and required substantial/maximum assistance with bathe/shower, all transfers, upper body dressing, roll left and right, sit to lying, lying to sit, and sit to stand. R1 was dependent for toileting and personal hygiene, and unable to ambulate. He had an indwelling urinary catheter and frequently incontinent of bowel. Diagnoses included neurogenic bladder (nerves that control the bladder are damaged leading to loss of bladder control that can result in urinary incontinence, difficulty emptying the bladder or other urinary problems), renal failure diabetes mellitus (DM), anxiety, and depression. He received antiplatelet (prevents blood clots from forming and inhibits the action of platelets) from medication seven out of seven days. R1's progress notes from 12/8/24 through 12/15/24, identified: -12/9/25 at 10:22 p.m. resident is alert and oriented able to make some of his need known. Resident bladder scan 481 ml. Straight catheterized output was 1000 ml with lots of sediment. -12/10/24 at 2:22 p.m. at 11:50 a.m. was with therapy and t-shirt was soaking wet, clammy, neck and back pain. Temperature 98.2, respirations 40, pulse 91, and oxygen saturation (SaO2) 94 %, blood pressure 70/40 . left with ambulance at 12:30 p.m. -12/10/24 at 2:22 p.m. called hospital for report. Almost septic per nurse, had a urinary tract infection (UTI). -12/15/24 at 11:05 a.m. returned from hospital via ambulance with a foley catheter in place. R1's Hospital Discharge summary dated [DATE] at 8:58 a.m. identified discharge instructions: -Continue Augmentin 875/125 milligrams (mg) two times a day (BID) times 5 days (starter pack sent with, prescription (Rx) to pharmacy). -Continue Flagyl 500 mg three times a day (TID) (starter pack sent with, Rx to pharmacy). -Urine retention/cystitis (inflammation of the bladder usually caused by a UTI). Foley placed and remained in place until follow-up with urology. Change every four weeks. Foley catheter cares. -Follow-up with PCP on Wednesday 12/18/24, 10:00 a.m. with nurse practitioner (NP). R1's hospital follow- up appointment with physician assistant (PA)-A on 12/18/24, identified he had been admitted to hospital with hypotension secondary sepsis secondary to colitis (inflammation of the large intestine (colon), which can lead to inflammation of the large intestine causing diarrhea, abdominal pain and bloody stools), urinary retention, UTI, and rectal stool ball compaction. Foley was in and continued to down drain. This was expectedly a more chronic duration now while we stabilize his bowel regimen and improved constipation. R1's order dated 12/4/24, straight catheterization if amount is greater than 300 ml with bladder scan. Discontinued 12/15/24. R1's order dated 12/5/24, post void bladder scan BID. Discontinued end date 12/15/24. R1's order dated 12/16/24, Foley catheter to remain in until follow-up with urology. Order discontinued on 12/26/24. R1's order revision date 2/26/25, 16 French catheter, 10 milliliter (ml) balloon. Foley Catheter to remain in until follow-up with urology, discontinued/end date 4/23/25. Review of R1's medical records did not identify a follow-up appointment with urology was scheduled and/or completed as ordered on 12/15/24. R1's progress noted from 5/17/25 through 5/19/24, identified: -5/17/25 at 2:15 p.m., no urine noted from Foley catheter since early a.m. irrigation not successful. Catheter changed . -5/19/25 at 1:00 p.m., resident taken to the bathroom and had some bleeding at catheter insertion site, tubing noted to be taught. Had urine flow . 5/19/25 at 2:11 p.m., urine output concentrated, dark amber, very cloudy . 5/19/25 at 4:20 p.m., No urine output in catheter bag . bladder scanned 165 ml . flushed with 30 ml of normal saline. No urine output . attempted to deflate balloon, no saline was obtained when attached . since no saline was obtained from catheter balloon foley catheter was pulled. Balloon noted to be flat and resident had a large amount of red blood from penis. Bleeding slowed down after two to three minutes . daughter requested he be sent to emergency room (ER) . Ambulance arrived and taken to local ER. -5/19/25 at 10:22 p.m., ER called to update on resident status. Was admitted for catheter complications and UTI. Will stay in hospital at least two days. R1's hospital discharge instructions dated 5/22/25 at 7:55 a.m., UTI resolved, catheter care; there is a fissure (also known as penile erosion a tear or split in the skin and/or urethra caused by prolonged pressure or friction from the catheter) that had formed on the right inferior aspect of the glans, this was from the catheter. Had been updated the catheter was not correctly removed, caused trauma during removal on 5/19/25, and resulted in the ER visit. Daily dressing changes and as needed (PRN). Paint with betadine and place gauze over the area. Switch catheter bag to the left leg. Be sure the catheter is not pulling. If issues with catheter, please contact provider, do not change without contacting provider first. Urology referral will contact daughter to schedule. Discussed the possibility of need for a supra-public catheter. R1's care plan reviewed on 5/28/25, identified bladder complications and risk for infection related to indwelling urinary catheter due to flaccid neuropathic bladder. Staff were directed to complete catheter cares a.m. and bedtime (HS), switch night bag to leg bag in a.m. and back to night bag at HS and observe for changes in urine color, consistency, frequency, odor, discomfort, distention, fever, or confusion, review changes with MD, and Foley catheter in place until urology addresses. During an interview on 5/29/25 at 8:30 a.m., physician assistant (PA)-A stated she had examined R1 when he arrived at the hospital on 5/19/25. The fissure identified was not new, located on the right bottom side of the glans penis bleeding and the ABD (abdominal) dressing was saturated with red blood. She inserted another urinary catheter without resistance, moved the catheter tubing to the other side and the bleeding slowed down. He did not see urology at the hospital (was not offered locally) or prior to coming to the hospital. The catheter was changed three times in the beginning of the month at the facility due to not working most likely from constipation. When R1 was discharged from hospital she placed a referral to be seen by the urologist for a possible supra-public (a urinary catheter inserted in the bladder through a small incision in the lower abdomen to drain urine) catheter to be placed. During an interview on 5/29/25 at 9:21 a.m., family member (FM)-A stated she was concerned about everything that happened with his catheter prior to going to the hospital. FM-A was unaware if he was seen by a urologist and unsure if he had seen one and may have been a good idea. During an interview on 5/29/25 at 9:45 a.m., registered nurse (RN)-A stated R1 may have been scheduled to see a urologist. Facility staff did not have easy access to when the appointments were scheduled, the type of calendar had just changed. She had not seen anything in his electronic medical record and not all appointments were documented. During an interview on 5/29/25 at 10:15 a.m., FM-B stated R1 needed a urology consult. Unsure if he had seen the urologist after his last hospitalization in December 2024. We relied on the facility to have scheduled the appointments and then let family know so we could have attended with him. During an interview on 5/29/25 at 12:41 p.m., assistant director of nursing (ADON) stated last time R1 had seen a urologist was 2012. He had not been scheduled for an appointment after the December 2024 hospitalization. We did not follow up with urology and it would have been important to see what was going on with his urine and bladder. His medication may have need to be changed, could have been due to constipation, or bladder muscles not working. During an interview on 5/29/25 at 2:15 p.m., director of nursing (DON) stated R1 has had urinary retention since October 2024 with a trial removal of the indwelling urinary catheter, bladder scans, then had to reinsert it in December 2024. DON indicated R1 was not seen by urology after his readmission to the facility after his hospital stay December 2024, not sure what happened, we dropped the ball. For this circumstance the facility should have followed up with the family and made sure the appointment was scheduled with urology so that he would had received he best care possible, without complications regarding the catheter and constipation, adding placement of a supra pubic catheter would have possibly made a difference. Unable to interview NP-B and medical doctor (MD), both out of office until 6/3/25. Requested facility order/follow-up policy and was not received.

Based on observation, interview and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for 1 of 1 residents (R54) observed for enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) and for 5 of 5 residents (R151, R157, R152, R202, R206) observed for COVID-19 transmission based precautions (TBP). In addition, the facility failed to to provide sanitary catheter care to help prevent the development of infections for 1 of 1 resident (R54) observed who utilized a urinary catheter. Further, the facility failed to maintain an on-going infection control program, which included comprehensive surveillance of resident infections to identify and analyze possible patterns of infection in the facility, including identification of any patterns in residents, locations or pathogens in real time to prevent the spread of communicable disease and infections. This deficient practice had the potential to affect all 29 residents who resided in the facility. Findings Include: PPE Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions (EBP) included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. Review of CDC guidance dated 6/24/24, Infection Control Guidance SARS-COV-2 indicated health care professionals (HCP) who entered the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of CDC guidance dated 5/16/23, How to Use Your N95 Respirator indicated N95 respirators must form a seal to the face to work properly. This was especially important for people at increased risk for severe disease. R54's quarterly Minimum Data Set (MDS) dated [DATE], identified R54 had moderate cognitive impairment, and had diagnoses which included: chronic kidney disease, diabetes mellitus, and anxiety. R54's MDS also identified R54 was always incontinent of urine and did not have a catheter in place. R54's care plan revised 10/23/24, identified R54 had actual complications and deficits with activities of daily living (ADL)s and required assistance with dressing, hygiene, toilet use and transfers. Indicated R54 had use of Foley catheter from 10/22/25 to 10/25/24, then trial of voiding. R54's care plan lacked EBP goals and interventions. R54's Order Recap Report, dated 10/1/24 to 10/31/24, included the following: -Catheter size is 16 french (F) with 10 milliliters (ml) saline needed for balloon inflation. -Change to foley leg bag on every morning. -Change foley night bag every night, at bedtime. -Foley catheter cares two times a day. During an observation on 10/30/24 at 7:41 a.m., R54 was sitting in recliner, covered with a blanket, dressed in street clothes, while his foley night bag was lying on the floor under the raised foot rest, uncovered and folded, with clear yellow urine visible in the bag. R54's doorway had a sign identifying EBP. At 8:02 a.m., R54 remained in recliner, while leg bag remained folded lying on the floor. During an observation on 10/30/24 at 9:08 a.m., nursing assistant (NA)-A was in R54's bathroom, had a gown on and was applying gloves. NA-A applied leg straps to R54's leg, then picked up R54's leg bag from the floor, clamped the tubing, unattached the foley night bag, used alcohol to wipe the tip and tubing of the leg bag and attached the leg bag. NA-A went back to the bathroom and emptied the foley night bag, while measuring the amount in a urinal. NA-A removed gown, and returned to R54, applied R54's leg bag with the straps, adjusted R54's pants legs, removed gloves then sanitized hands. NA-A applied R54's shoes. NA-A informed surveyor I should have kept my gown on. NA-A applied a gait belt to R54 and transferred R54 to wheelchair. NA-A removed R54's gait belt, assisted R54 to position self in wheelchair and transported R54 to tub room to get weighed. During an interview on 10/30/24 at 10:55 a.m., NA-A identified R54's catheter was on the floor, and it should have been up off the floor attached to something since the floor could be dirty. NA-A stated she should not have removed her gown before finishing with R54's catheter leg bag and assisting him to transfer to his wheelchair. NA-A indicated R54 was on EBP, and when she had removed the gown, she should have applied a new gown before finishing with R54's cares. During an interview on 10/30/24 at 1:32 p.m., clinical manager registered nurse (RN)-B stated catheter bags should not be lying on the floor for infection prevention and to prevent tripping. RN-B indicated R54 was on EBP, and a gown and gloves should have been worn when carrying for R54's catheter. RN-B stated would not expect EBP to be followed to only transfer a resident, or make their bed, because the catheter was enclosed, and staff would not come in contact with body fluids. RN-B indicated once staff were done completing the catheter cares, they could remove their gown. 45844 PPE: Review of R151's, R157's , R152's Rapid Covid -19 results revealed the following: R151's Rapid Covid -19 test dated 10/28/24, indicated R151 was positive for Covid-19. Review of R157's Rapid Covid-19 test dated 10/25/24, indicated R157 was positive for Covid-19. Review of R152's Rapid Covid test on 10/25/24, indicated R152 was negative for Covid-19. During an observation on 10/18/24 at 12:00 p.m., R151 and R157's door contained a sign that said Enhanced Respiratory Precautions Keep door closed if able: need to put on a gown, N95 or respirator, eye protection, one pair of gloves before entering room. During an observation on 10/28/24 at 12:05 p.m., Infection Preventionist (IP) -assistant director of nursing (ADON) sanitized hands, donned an N95 over her surgical mask, donned a gown, gloves, and eyewear and entered R 151's room with a lunch tray. During an observation on 10/28/24 at 12:25 IP-ADON sanitized hands and donned an N95 over her surgical mask, donned a gown, gloves, and eyewear and entered R157's room with a lunch tray. IP-ADON stood in R157's room within two ft. of R157 for ten minutes before doffing all PPE and returning to the hallway, sanitized hands and applied a clean surgical mask. During a continuous observation on 10/28/24 at 1:08 p.m., R 151 wheeled out of her room into the hallway past registered nurse (RN)-A, NA-A, one unidentified staff member and a family member until she reached the commons area near the front entrance of the facility. At 1:14 p.m., nursing assistant (NA)-A wheeled R151 back to her room. NA-A entered R151's room wearing an N95, no gown, gloves, or eyewear. NA-A returned to the hallway wearing the same N95 and entered R152's room and talked with R152 while shutting off the call light. NA-A then proceeded down the hall into the employee bathroom. At no time during the above observation did NA-A sanitize her hands. During an interview on 10/28/24 at 1:55 p.m., NA-A stated R151 was positive for Covid-19 and was in the hallway without a mask. NA-A further stated she had wheeled R152 back to her room and pushed her into her room and stood within two feet of R151 while encouraging her to eat her lunch. NA-indicated she should have removed her N95 and sanitized her hands after leaving 151's room and prior to entering R152's room since R152 was negative for Covid to prevent the spread of infections. During an interview on 10/28/24 at 2:03 p.m., registered nurse (RN)-A verified R151 was positive for Covid-19 and R151 had to be in the hallway she should have been wearing a mask. RN-A stated she had not noticed R151 wheel by her in the hallway. RN-A stated her expectation was that R151 would have been wearing a mask in the hallway. 49620 PPE: Review of the facility resident matrix dated 10/28/24, identified R202 and R206 had an active covid infection. During an observation on 10/28/24 at 12:17 p.m., R202 and R206's door contained a sign that said Enhanced Respiratory Precautions Keep door closed if able: need to put on a gown, N95 or respirator, eye protection, one pair of gloves before entering. Hospice staff exited R206's room wearing a gown, gloves and an N95 mask wearing a surgical mask on over the N95 mask. The hospice staff removed the gown, gloves and surgical mask and threw them away. The hospice staff left the N95 mask on and proceeded down the hallway past other staff members and stopped in the hallway outside of R206's room. Hospice staff opened the plastic bin outside of R206's room, put on gloves, gown, goggles and a surgical mask over the N95 mask and entered R206's room. During an observation on 10/28/24 at 12:20 p.m., activity staff walked down the hallway wearing a surgical mask, opened the plastic bin outside of R202's room, put on a gown, gloves and goggles and entered R202's room. Activity staff was not wearing a N95 mask. During continued observation activity staff exited R202's room at 12:36 p.m., removed gown, gloves and goggles and threw them away and sanitized hands. Activity staff continued to have the same surgical mask on and entered R204's room and visited with R204. Activity staff exited R204's room, walked down the hallway with the surgical mask on visiting residents and staff in the hall before returning to the activity office. During an observation on 10/28/24 at 12:35 p.m., hospice staff exited R206's room, removed the gown, gloves, goggles and surgical mask and threw them away. Hospice staff continued to wear the N95 mask and walked to the nurses station, sat down and started typing on the computer. During an observation on 10/28/24 at 2:27 p.m., nursing assistant (NA)-G was standing outside of R206's room wearing a surgical mask, put on a gown, gloves, goggles and a N95 mask over the surgical mask and entered R206's room. During continued observation NA-G exited R206's room wearing the same surgical mask and sanitized hands. NA-G had removed the gown, gloves, goggles and N95 mask in R206's room prior to exiting. During an interview on 10/28/24 at 1:45 p.m., hospice staff stated she used the personal protective equipment (PPE) provided at each facility she entered. Hospice staff verified a fit test for the N95 was completed at this facility but was wearing her own N95 mask as there were not any available in the bins outside of the resident rooms that fit. Hospice staff observed to be wearing surgical mask over N95 mask during interview. Hospice staff stated she was wearing a surgical mask over the N95 mask to protect the residents as she had a cold. Hospice staff stated she was unaware of who to ask at the facility for supplies when the facility did not have them available and stated she was unaware she should not be wearing the same N95 mask from covid positive resident rooms to other rooms and staff areas within the building. During an interview on 10/28/24 at 2:37 p.m., NA-G stated she had not been fit tested for a N95 mask and did not receive training from the facility on how to wear a N95 mask. NA-G stated R202 and R206 were positive for covid and required staff to wear the proper PPE listed on the sign on R202 and R206's door. 48583 SURVEILLANCE Review of the facility's infection control logs within the Peerlytics system (a web-based software for infection management and antibiotic stewardship) included current tracking of residents who were receiving antibiotics, COVID positive, and residents with a fever. Facility infection control mapping within Peerlytics identified residents room numbers and residents with current infections. Facility infection control mapping revealed the following: - R154 had a current urinary tract infection (UTI). - R210 was COVID positive. - R52 was COVID positive. - R202 was COVID positive. - R151 was COVID positive. - R60 was COVID positive. - R159 was COVID positive. - R206 was COVID positive. - R157 was COVID positive. The provided infection control logs lacked any completed process surveillance or comprehensive analysis to demonstrate if any other infections had potentially spread in the facility. There was no recorded assessment of the five identified residents (R52, R151, R206, R154, and R58) who were on enhanced barrier precautions (EBP). Additionally, there was no recorded assessment of one resident (R54) having an active UTI and one resident (R208) having a wound infection (WI). The logs lacked ongoing surveillance and trending of all infections which included food-borne illness, and other illnesses caused by other viruses or infections. Review of Census Traverse Care Center (TCC) dated 10/26/24, listed residents currently in COVID UNIT - droplet precautions / isolation (R157, R210, R60, R202, R159, R206, R151, and R52), residents currently on antibiotic therapy (R156, R154 and R52), residents currently on prophylactic antibiotics (R156 and R59) and residents currently on EBP (R58, R151, R52, R154 and R206). During an interview on 10/30/24 at 1:51 p.m., infection preventionist/assistant director of nursing (IP) confirmed the expectation that catheter bags should not be on floors for infection prevention reasons, as bacteria may be on the floor and come in to contact with the resident's catheter bag. IP indicated the expectation was for staff to wear gown and gloves during working with devices, such as catheters or completing wound cares. IP was unaware of any other CDC guidance for EBP, and would need to check the EBP sign. IP and surveyor went to R54's door, reviewed the sign, ADON confirmed staff should have worn PPE according the sign. IP verified staff should also wear the gown and gloves when completing close contact cares which included transfers. During a follow-up interview on 10/28/24 at 2:11 p.m., IP stated she applied an N95 over her surgical mask prior to entering Covid-19 positive rooms for added protection. IP stated she should not have placed an N95 over a surgical mask because there would not have been a good seal. IP indicated her expectation was that all staff including herself would follow facility policy regarding PPE use. During a follow-up interview on 10/28/24 at 6:15 p.m., IP stated the expectation of staff would be to wear a gown, gloves, eyewear and a N95 mask prior to entering a covid positive room. IP confirmed staff should not wear a surgical mask over or under a N95 mask as the seal could be separated and may spread infection. IP stated the facility was not currently providing audits to ensure PPE was being utilized appropriately. IP verified not all facility staff had been provided training on use or fit tested for a N95 mask. During a follow-up interview on 10/30/24 at 2:25 p.m., IP and registered nurse consultant (RNC) confirmed the above findings and indicated the facility was using Peerlytics. IP indicated the facility began using the program in February/March 2024, and it was a work in progress. IP revealed only infections meeting antibiotic criteria and COVID positive cases were being tracked in the Peerlytics system. IP stated EBP and any additional resident infections were not being tracked in the system. IP and RNC indicated tracking and trending was done within the facility however only for the infections that were uploaded into the Peerlytics system. IP stated she should be going into the Peerlytics system every one to two weeks but does not always get in there right away. During an interview on 10/30/24 at 2:01 p.m., director of nursing (DON) confirmed the expectation was for catheter bags to be off the floor for infection prevention and control reasons DON also confirmed expectation that staff don PPE according to CDC guidance for EBP, which included high contact cares. During an interview on 10/29/24 at 3:42 p.m., DON stated her expectation was that all staff would have worn PPE correctly in Covid -19 rooms and performed hand hygiene before and entering all resident rooms. DON stated staff should be removing all PPE after leaving a Covid-19 room and before entering another resident's room who was not positive for Covid -19. DON indicated it was important to follow CDC guidelines when working with Covid-19 residents to prevent the spread of infections. The facility policy titled Enhanced Barrier Precautions, undated, identified the facility would obtain an order for EBP for residents with any of the following which included residents with indwelling devices including urinary catheters, even if the resident was not known to be infected or colonized with a MDRO. The policy identified gowns and gloves would be worn when performing high-contact care activities, which included: dressing, bathing, transferring, and devise care or use including urinary catheters. The infection preventionist would incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.

Based on observation, interview, and document review, the facility failed to ensure insulin pens were accurately dated when opened for 3 of 5 residents (R54, R152, and R202) who received insulin injections. Further, the facility failed to ensure Tubersol solution (a solution that is injected under the skin to test for tuberculosis) was discarded after 30 days per manufacturer's recommendations. Findings include: R54 R54's quarterly Minimum Data Set (MDS) dated [DATE], indicated R54 had diagnoses which included diabetes mellitus (DM), hypertension (elevated blood pressure) (HTN) and anemia. Indicated R54 required limited to extensive assist with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R54's signed physician orders dated 10/9/24, identified R54 had a physician's order for Glargine insulin 26 units at bedtime. R54's medication administration record (MAR) dated 10/4/24 through 10/30/24, identified R54 had been receiving 26 units of Glargine insulin at bedtime. R152 R152's quarterly MDS dated [DATE], indicated R152 had diagnoses which included DM, HTN, and peripheral vascular disease ( a condition where the blood vessels are narrowed and reduce blood flow to the lower limbs). Identified R152 required extensive assist with ADL's which included bed mobility, transfers, and toileting. R152's signed physician orders dated 10/9/24, identified R152 had a physician order for Troujeo insulin 10 units at bedtime. R152'2 MAR dated 10/4/24 through 10/30/24, identified R152 had been receiving 10 units of Troujeo at bedtime. R202 R202's significant change MDS dated [DATE], indicated R202 had diagnoses which included DM, HTN, and muscle weakness. Identified R202 required extensive assist with ADL's which included bed mobility, transfers, and toileting. R202's signed physician orders dated 10/9/24, identified R202 had a physician order for Humalog insulin 12 units every a.m. R202's MAR dated 10/4/24 through 10/30/24, identified R202 had been receiving 12 units of Humalog insulin every a.m. During an observation and interview on 10/29/24 at 12:55 p.m., while completing medication storage of the medication carts with licensed practical nurse (LPN)-A, the top drawer of the medication cart contained an open insulin Glargine Subcutaneous Solutions 100 units/ml insulin pen for R54 with a fill date of 9/3/24, which was not dated when opened. An insulin pen which contained an open Tresiba Subcutaneous Solution 100 units/ml pen for R152 with a filled date of 8/7/24, which was not dated when opened and an open Humalog Subcutaneous Solution 100 units /ml insulin pen for R202 with a fill date of 9/3/24 which was not dated when opened. Further, the refrigerator in the medication room contained an open multi-dose vial of Tubersol solution which contained an open date of 9/25/24. LPN-A verified the undated insulin pens and Tubersol solution. LPN-A stated R 54, R152, and R202 had current orders for insulin and the facility had been using the undated pens in the medication cart and the Tubersol solution in the medication fridge. LPN-A stated insulin pens and Tubersol solution were good for 30 days and should be discarded after 30 days. LPN-A further stated her expectation was that the insulin pens should have been dated to ensure it was discarded after 30 days and the Tubersol solution should have been discarded after 30 days. During an interview on 10/29/24 at 2:44 p.m., pharmacy consultant (PC) stated the facility should have dated the insulin pens to ensure they were used or discarded within 28 days. PC further stated he believed the Tubersol solution was ok to use until the expiration date because it had a lot of preservatives. PC stated his expectation was that all insulin pens would have been dated once opened . During an interview on 10/29/24 at 3:42 p.m., director of nursing (DON) stated her expectation was that all insulin pens would have been dated to ensure they were not used more than manufacture recommendations. DON further stated her expectation was that Tubersol solution would have been discarded after 30 days per manufacturer's recommendations. During a follow up email on 10/31/24 at 10:28 a.m., PC stated after further review Tubersol solution should have been discarded after 30 days. PC stated he would work with the facility to ensure that happened. Review of manufacturer's specifications for In-use Pen, store the pen you are currently using at room temperature [up to 86 Fahrenheit (F) (30 Celsius (C))] and away from heat and light. Throw away the pen you are using after 28 days, even if it still had insulin left in it. Review of manufacturer's specifications for use, 3 ml single-patient-use insulin glargine in use pen expires 28 days after opening. Review of manufacture's specific use for Tresiba, 3 ml single use insulin pen expires 56 days after opening. Review of manufacturer's specific for use, 3 ml single-patient-use Humalog pen expires 28 days after opening. Review of manufacture's specific use for Tubersol solution multi-dose vial indicated a vial of Tubersol which has been in use for 30 days should be discarded. Review of a facility policy titled Insulin Pen Policy undated, indicated the facility would use insulin pens in order to improve the accuracy of insulin dosing, provide increased resident comfort. Indicated once opened, clearly labeled insulin pens may be stored at room temperature in a locked medication cart. Further indicated insulin pens should be disposed of after 28 days or according to manufacturer's recommendation. A facility policy titled Policy: Storage of Medication Requiring Refrigeration undated, identified it was the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. Further identified staff should observe fro proper storage and remove any expired medications from active stock and discard medication according to facility policy. .

Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for 2 of 3 residents (R53, R206 ) investigated for fall safety. Findings Include: R53 R53's quarterly Minimum Data Set, dated dated dated [DATE], identified R53 was cognitively intact and had diagnoses which included Alzheimer's disease, rib fractures, and hypertension. Indicated R53 had one fall with major injury. R53's comprehensive Care Area Assessment (CAA) dated 4/5/24, identified R53 required assistance with toileting and bed mobility and nursing provided activities of daily living (ADL), mobility, and transfer assistance as needed. R53's CAA identified functional status would be addressed in care plan to slow or minimize decline. R53's Morse Fall Scale assessment dated [DATE], identified R53 had fallen before, and was at high risk for falls. R53's care plan revised 10/15/24, identified R53 was at high fall risk with potential for complications with falls. R53's interventions included: make sure walker was clear of recliner footing with getting up from the chair, assist with toileting needs per plan and Dycem non-slip mat under wheelchair cushion to prevent sliding. R53's care plan also identified R53 required assistance with dressing, toilet use, and transfers. Review or R53's progress notes from 9/30/24 to 10/31/24, identified the following: -10/13/24 at 6:15 p.m., nurse progress note- Late Entry- R53 found on floor parallel to bed. Wheelchair cushion under R53. R53 stated left elbow hurt, no other injuries. -10/14/24 at 3:15 p.m., incident/Huddle- 10/13/24 at 6:00 p.m. R53 was sitting in wheelchair parallel to bed waiting for transfer assist. R53 found on floor. R53 stated wheelchair cushion had slipped out and slid onto floor. No injuries noted. -10/14/24 at 3:29 p.m., nurse progress note-Dycem to be placed between wheelchair cushion and chair. -10/15/24 at 9:09 a.m., RN Incident Root Cause Analysis-identified R53 complained that wheelchair cushion slipped from wheelchair, plan of action to prevent this from further happening with Dycem non-slip mat to be placed under cushion. During an observation on 10/29/24 at 11:58 a.m., R53 was in wheelchair, dressed in street clothes and shoes, being transported to dining room. At 12:57 p.m. R53 was in wheelchair in dining room, drinking from a cup with straw. At 1:31 p.m., R53 was in wheelchair in dining room, same location, and Bingo activity was beginning. At 3:20 p.m. R53 continued in wheelchair in dining room playing Bingo. At 3:45 p.m. R53 received stand by assistance from nursing assistant (NA-B) to pivot transfer from wheelchair to bed. During an interview on 10/29/24 at 3:47 p.m. , NA-B indicated was aware R53 had slid of wheelchair recently, however unaware of any other interventions, except indicated the last time had checked R53 was independent with stand by assistance with transfers. During an observation on 10/30/24 at 8:24 a.m., R53 was seated in her wheelchair in the bathroom, completing oral cares with NA-A in the room with her. R53 was dressed in street clothes. During an interview on 10/30/24 at 10:49 a.m., NA-A stated R53 was at risk for falls, and indicated R53 was supposed to call for assistance with transfers. NA-A indicated she assisted R53 by using a gait belt during transfers. During an observation on 10/30/24 at 12:52 a.m., case manager registered nurse (RN)-B was in R53's room, transferring R53 from the toilet with stand by assist to the wheelchair, then assisted R53 to the sink to wash her hands. At 12:58 p.m., RN-B assisted R53 to bed, using stand by assistance while R53 pivot transferred from wheelchair to bed. RN-B then assisted R53 to put legs into bed. NA-A stated R53's care plan had interventions listed, and that was what they followed. During an interview on 10/30/24 at 1:04 p.m., RN-B stated R53 had a recent fall and RN-B confirmed R53 was to have Dycem under her cushion in her wheelchair. At 1:07 p.m., RN-B entered R53's room and verified R53 did not have a Dycem mat under her cushion. RN-B reviewed R53's electronic medical record (EMR) and confirmed R53 fell on [DATE] at 6:37 p.m., and R53's cushion had slid out of her wheelchair. At that time they added Dycem to be placed under her wheelchair cushion. RN-B indicated had thought it was added to R53's treatment administration record (TAR) to be checked to assure it was in place, however reviewed R53's EMR and verified it had not been added, however it was included on R53's care plan. RN-B indicated expectation was for the Dycem to be under cushion in wheelchair so cushion did not slip and indicated she was concerned it had not been in place as that was a fall prevention intervention. 48583 R206 R206's quarterly MDS, dated [DATE], identified R206 had diagnoses which included Alzheimer's disease, dementia and anxiety. R206 required assistance of one staff for bed mobility and transfers. Requested a copy of R206's most recent CAA however was not provided. R206's care plan revised on 10/15/24, identified R206 was at risk for falls related to impaired cognition secondary to Alzheimer's disease, dementia, anxiety, depression and history of a pelvic fracture. R206 had an actual fall on 9/18/24. A goal was listed for R206 to remain free of falls with major injuries and several interventions were identified to help R206 meet this goal. These interventions included: - Revised 7/14/24, 30 minute checks. - Initiated 9/24/24, staff to assist with ambulation if R206 gets up on own and starts to walk. - Initiated 10/8/24, assist with toileting needs. - Initiated 4/18/24, call light positioned for easy access. Review of R7's progress notes dated 8/3/24 to 10/29/24, revealed the following: - 8/31/2024 on p.m. shift R206 was putting self on the floor in the living room and with cues was able to get self up off the floor. - 9/4/24 R206 purposely laid on floor. - 9/5/24 R206 transferred self to the floor and scooted around room on floor. - 9/5/24 R206 purposely laid down on the floor and requested someone to help her up. - 9/6/24 R206 got out of her wheelchair and placed self on floor. - 9/8/24 R206 had been self-transferring and also transferring with the assist of one. - 9/10/24 R206 laid herself on the floor in the dining room. R206 was assisted back into her wheelchair. - 9/11/24 R206 put herself on the floor two times and would just lie there. - 9/13/24 R206 put herself on the floor. - 9/14/24 R206 was found out in the front lobby, put herself on the floor two times, and was crawling around on the floor. - 9/17/24 R206 put self on floor two times this shift. Resident was able to get self-back into wheelchair with supervision by staff. - 9/18/24 R206 was walking on her own in the morning saying she felt stiff. R206 continued to walk in the hallway hanging onto hand rail with appropriate foot wear. Nursing staff provided walker and resident said that was better. Staff walked R206 to living room and sat in chair. - 9/18/24 R206 had a witnessed fall. R206 was half laying half sitting on the floor next to the receptionist window. R206 was assisted up from the floor with the assistance of two staff and mechanical lift. - 9/19/24 R206 had put self on the floor four times during the shift. - 9/20/24 R206 had put self on the floor and was pushing her wheelchair over. - 9/22/24 R206 scooted to the edge of the chair and crawled down onto the floor. R206 then continued to lay down on the floor. - 9/25/24 R206 was on the floor by the door to her room. R206 got herself up into her wheelchair independently. - 9/28/24 R206 put herself on the floor two times this morning. - 9/29/24 R206 was crawling around on the floor crying. - 9/30/24 R206 put self on floor three times and back into her wheelchair while staff were sitting next to her. - 10/8/24 R206 refused to stand and and required the assistance of two to transfer. - 10/16/24 R206 put herself down on the floor several times. - 10/16/24 R206 had put herself on the floor two times. Progress notes lacked documentation if staff were present with R206 when she transferred herself to the floor as indicated in the progress notes above. Review of R206's safety checks (30 minute) dated 7/18/24 to 10/22/24, revealed the following: - 7/18/24 to 7/24/24, 78 checks were not documented. - 7/25/24 to 7/31/24, no logs. - 8/1/24 to 8/7/24, no logs. - 8/8/24 to 8/12/24, no logs. - 8/13/24 to 8/19/24, no checks were missed. - 8/20/24 to 8/26/24, 28 checks were not documented. - 8/27/24 to 9/2/24, 135 checks were not documented. - 9/3/24 to 9/9/24, 46 checks were not documented. - 9/10/24, no logs. - 9/11/24 to 9/17/24, 85 checks were not documented. - 9/18/24 to 9/24/24, no checks were missed. - 9/25/24 to 10/1/24, no logs. - 10/2/24 to 10/8/24, 169 checks were not documented. - 10/9/24 to 10/15/24, 154 checks were not documented. - 10/16/24 to 10/22/24, 154 checks were not documented. During an observation on 10/30/24 at 7:25 a.m., R206's door was closed as R206 was in isolation precautions. R206 was laying in her bed on her back covered with a quilt. R206's eyes were closed and call light within reach. During continuous observations on 10/30/24 from 8:05 a.m. to 10:40 a.m., revealed the following: -7:25 a.m., R206 door was closed as R206 was in isolation precautions. R206 was laying in her bed on her back covered with a quilt. R206's eyes were closed and call light within reach. -8:05 a.m., no staff were observed to check on R206. -8:57 a.m., no staff were observed to check on R206. -9:19 a.m., no staff were observed to check on R206. -9:45 a.m., no staff were observed to check on R206. -10:13 a.m., no staff were observed to check on R206. -10:24 a.m., R206 family member entered the room and closed the door. No staff were observed to check on R206. -10:40 a.m., no staff were observed to check on R206. Requested registered nurse (RN)-B to enter R206's room to check on R206. R206 had not received 30 minute checks per care plan for a total of two hours and 35 minutes during this continuous observation. During an observation and interview on 10/30/24 at 10:45 a.m., RN-B donned personal protective equipment (PPE) and entered R206's room to check on R206. During an observation and interview on 10/30/24 at 11:04 a.m., RN-B doffed PPE and exited R206's room. RN-B confirmed the above findings and indicated R206 had orders for every 30 minute checks. RN-B was not aware nursing staff did not check on R206. RN-B stated her expectations were for nursing staff to check on R206 every 30 minutes as indicated in care plan. RN-B further stated the checks were to be completed to ensure R206 was not attempting or laying on the floor. RN-B confirmed she did not complete any 30 minute checks on R206. During an interview on 10/30/24 at 11:16 a.m., nursing assistant (NA)-A stated she was in R206's room about 6:30 a.m., and had not been in there again. NA-A further stated she was aware R206 had 30 minute checks and NA-A had not completed any checks on R206. During an interview on 10/30/24 at 12:21 p.m., NA-F stated she was aware R206 had 30 minute checks. NA-F further stated she had not completed any checks on R206. During an interview on 10/30/24 at 1:09 p.m., director of nursing (DON) confirmed the above findings and indicated she was not aware staff had not completed 30 minute checks on R206. DON indicated she was aware R206 had a fall intervention to complete 30 minute checks for safety. DON revealed staff stopped doing 30 minute checks when R206 went on hospice on 10/23/24. DON stated the intervention had not been removed from R206's care plan and staff were expected to continue the 30 minute checks until in had been removed. DON further stated her expectations were staff followed the care plan. During a follow-up interview on 10/30/24 at 2:04 p.m., DON indicated was aware R53 had falls, and stated the facility's usual practice was to have interdisciplinary team meetings (IDT) to discuss resident falls, determine root causes and to put interventions in place. DON stated her expectation was that R53's Dycem to be in place to prevent R53's cushion from moving and R53 from sliding out of her wheelchair again. The facility policy Fall Prevention Program Policy, undated, identified each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy identified fall risk would be included if at risk for falls in the resident's care plan, and the interventions would be monitored for effectiveness.

Based on observation, interview, and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 2 resident (R206) with a history of pressure ulcers and at risk for further development of pressure ulcers. Findings include: R206's quarterly Minimum Data Set (MDS), dated [DATE], identified R206 had diagnoses which included Alzheimer's disease, dementia and anxiety. R206 required assistance of one staff for bed mobility and transfers. R206 required assistance of one staff to roll from left to right. Indicated R206 was at risk for pressure ulcers and currently had an unhealed pressure ulcer on her coccyx. Review of R206's Braden scale (tool used in healthcare to assess a patient's risk of developing pressure ulcers) on 10/23/2024 indicated R206's score was 14 and R206 was at a high risk for developing pressure ulcers. Requested most recent Care Area Assessment (CAA) however was not provided. R206's care plan revised on 10/15/24, identified R206 had the potential for complications with impaired skin integrity related to incontinence and a red area on her coccyx. Indicated R206 was to have skin prep two times a day (BID) and as needed (PRN) to her coccyx. R206 was to have an air mattress overlay. R206 was dependent on staff for all cares. R206's treatment authorization request (TAR) dated 10/30/24, identified R206 was to have a Mepilex (absorbent foam) dressing put on the skin between gluteal folds for an open area: wash with skin wash (soap and water) and put a facility barrier cream with the Mepilex dressing BID and PRN. Review of R7's progress notes dated 8/3/24 to 10/29/24, revealed the following: -10/11/24, reddened area to butt by coccyx with dark area next to it. Intact and not open. Measures 3 x 4 centimeter (cm) red area with a 1.1 x 1 cm dark area. Skin prep being used over area and an air mattress overlay was applied. -10/15/2024, provider also noted and assessed R206's coccyx wound. Provider voiced to continue skin prep and pressure relieving device to bed and chair. -10/25/2024, hospice nurse ordered Mepilex dressing to be put on skin between gluteal fold: wash with skin wash (soap and water) and put a facility barrier cream when completing Mepilex dressing change BID and PRN. -10/27/2024, skin prep to butt crease BID for red area on coccyx area and cover with Mepilex dressing. -10/29/2024, R206 has pressure wound on coccyx measuring 1.7 x 1 cm. Slough (a type of necrotic tissue that accumulates on the surface of a wound) in middle of wound. No pain noted. Mepilex dressing put on skin between gluteal folds: wash with skin wash (soap and water) and put a facility barrier cream with Mepilex dressing PRN. During an observation on 10/30/24 at 7:25 a.m., R206's door was closed as R206 was in isolation precautions. R206 was laying in her bed on her back covered with a quilt. R206's eyes were closed and call light was within reach. During continuous observations on 10/30/24 from 8:05 a.m. to 10:40 a.m., revealed the following: -7:25 a.m., R206's door was closed as R206 was in isolation precautions. R206 was laying in her bed on her back covered with a quilt. R206's eyes were closed and call light within reach. -8:05 a.m., R206's day was closed and R206 remained in the same position as above. -8:57 a.m., R206's day was closed and R206 remained in the same position as above. -9:19 a.m., R206's day was closed and R206 remained in the same position as above. -9:45 a.m., R206's day was closed and R206 remained in the same position as above. -10:13 a.m., R206's day was closed and R206 remained in the same position as above. -10:24 a.m., R206's family member entered the room and closed the door. R206 remained in the same position as above. -10:40 a.m., R206's day was closed and R206 remained in the same position as above. Requested registered nurse (RN)-B to enter R206's room to reposition and measure R206's pressure ulcer on coccyx. During an observation and interview on 10/30/24 at 10:45 a.m., RN-B donned personal protective equipment (PPE) and entered R206's room. R206 remained in the same position as above. RN-B changed R206's brief, measured R206's pressure ulcer on coccyx, checked R206's heels for redness and bogginess (tissue texture abnormality characterized principally by a palpable sense of sponginess in the tissue), and repositioned R206. During an observation and interview on 10/30/24 at 11:04 a.m., RN-B doffed PPE and exited R206's room. RN-B confirmed R206 had a pressure ulcer on her coccyx that measured 2 x 1.4 cm. RN-B further confirmed a small amount of serosanguinous (thin, clear or pink fluid from a wound) drainage coming from the center of the wound. RN-B stated there were no open areas on R206's heels. RN-B indicated R206 should have been turned and repositioned every two hours. RN-B stated her expectations were that nursing assistants (NA)'s should be repositioning R206 every two hours as care planned. RN-B confirmed she did not turn or reposition R206 while providing morning cares to other residents on the unit. RN-B stated it was important to turn and reposition residents every two hours to reduce skin breakdown. R206 had not been repositioned for a total of two hours and 35 minutes during this observation. During an interview on 10/30/24 at 11:16 a.m., nursing assistant (NA)-A, confirmed she had not been in R206's room since about 6:30 a.m. NA-A stated she had other residents who had been putting their call lights on for assistance and NA-A further stated are we supposed to tell the residents who put their call lights on to wait while we reposition other residents? NA-A indicated she was aware R206 had an pressure ulcer on her coccyx and should have been repositioned every two hours to prevent further breakdown. During an interview on 10/30/24 at 12:21 p.m., NA-F indicated she did not remember what time she was in R206's room and stated she does not always watch the time. NA-F stated it was important for residents to be turned and repositioned every two hours to prevent skin breakdown. NA-F further stated R206 should have been turned and repositioned every two hours. During an interview on 10/30/24 at 1:09 p.m., director of nursing (DON) confirmed R206 had a pressure ulcer on her coccyx. DON confirmed the above findings and was not aware nursing staff had not turned and repositioned R206 for two hours and 35 minutes. DON stated her expectations were nursing staff were to reposition residents no more than every two hours to prevent skin breakdown. DON further stated nursing staff were to answer residents call lights, ask if they can come back to help them, try to find help, and get to the resident that needed to be repositioned. Review of facility policy titled Policy: Pressure Injury Prevention and Management, undated, this facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Interventions for Prevention and to Promote Healing, Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.).

Based on observation, interview, and document review, the facility failed to ensure medications were administered in accordance with physician orders and standards of practice related to medication administration for 1 of 1 residents (R210) observed to receive medication. Findings include: According to the National Institute of Health article titled, Crushing tablets or opening capsules: many uncertainties, some established dangers, last updated September 23, 2014, The clinical consequences for the patient of crushing tablets or opening capsules can be serious: alteration of the drug's absorption can result in sometimes fatal overdose, or conversely underdosing, rendering the treatment ineffective. When it disrupts a drug's sustained-release properties, the active ingredient is no longer released and absorbed gradually, resulting in overdose. When a gastro-resistant layer is destroyed by crushing, underdosing is likely. The active ingredient released may degrade on contact with light, moisture or the food with which it is mixed for administration. In practice, there are many drugs that should never be crushed or opened. Before crushing a tablet or opening a capsule, it is better to consider and research the impact it will have on the drug's effects. R210's quarterly Minimum Data Set (MDS) dated [DATE], identified R210 had severe cognitive impairment and diagnoses of type two diabetes, chronic kidney disease stage four (severe irreversible damage to the kidneys), bipolar disorder (mental health condition that cause extreme mood swings), anxiety, borderline personality disorder, depression, congestive heart failure (progressive heart disease affecting pumping action of the heart muscles), hypertension (high blood pressure), anemia (deficiency of healthy red blood cells in blood to carry oxygen to body's tissues). Indicated R210 required extensive assistance of staff with toileting, dressing and personal hygiene. R210's care plan revised 9/26/24, identified R210 had congestive heart failure and coronary artery disease. Facility staff to give cardiac medications as ordered by the physician, monitor and document side effects and report adverse reactions to the doctor as needed. R210's care plan revised 6/27/24, identified R210 had a mood problem related to disease process Bipolar disorder, depression, anxiety, borderline personality disorder. Facility staff to administer medications as ordered and monitor/document for side effects and effectiveness. R210's admission Care Area Assessment (CAA) date 12/7/23, identified R210 received physician ordered antipsychotic and antidepressant medication to manage bipolar disorder. R210 was at risk for adverse reactions to those medications. The pharmacist reviewed medications monthly and made necessary recommendations to the physician and nursing staff. The doctor would be updated with medication refusals. Would proceed to care plan with goal to have no drug related side effects. R210's Medication Review Report signed 8/20/24, identified the following orders: -Abilify 5 milligrams (mg) one time a day related to bipolar disorder. -Calcitriol capsule 0.25 micrograms (mcg) Give 0.5mcg by mouth one time a day every Mon, Tue, Wed, Thu, Fri related to chronnic kidney disease stage four. -Effexor XR capsule 150mg by mouth one time a day. Take with 75mg and 37.5mg for total of 262.5mg. Do not crush, may open capsules as needed related to bipolar disorder, anxiety. -Ferrous Sulfate 325mg by mouth one time a day related to anemia in chronic kidney disease. Do not crush. -Isosorbide Mononitrate extended release (ER) Give 30mg by mouth one time a day related to congestive heart failure. Do not crush. -Metoprolol Succinate ER Give 50mg by mouth one time a day related to congestive heart failure. Do not crush. -Seroquel 25mg Give 0.5 tablet by mouth one time a day related to bipolar disorder. -Torsemide Give 20mg by mouth one time a day related to congestive heart failure. -Tylenol eight hour arthritis pain extended release Give 650mg by mouth three times a day for pain management. Do not crush. During an observation on 10/28/24 at 12:03 p.m., registered nurse (RN)-C was standing next to the medication cart in the hallway outside of R210's room preparing R210's medications. RN-B was in R210's room, opened the door and asked RN-C what medications were being prepared for R210 as R210 did not feel well and RN-B advised RN-C to crush R210's medications. RN-C proceeded to crush R210's medications, mixed with applesauce and handed the plastic medication cup with crushed medications to RN-B to give to R210. RN-B took the medications and closed R210's door behind her as R210 was currently in enhanced respiratory precautions. During an interview on 10/28/24 at 4:57 p.m., RN-C verified she crushed the medications for R210 and opened capsules to sprinkle the powder into the applesauce earlier that day. RN-C stated R210 usually chews medications. RN-C verified R210's facesheet/banner on the electronic health record (EHR) stated medications to be given whole. RN-C confirmed the doctor had not been notified R210 was chewing medications or receiving medications crushed. RN-C stated it would be important to follow the physician orders of 'do not crush' because of how the medications would be absorbed and that R210 was probably not receiving the correct dose of medication due to medications being crushed. During an interview on 10/28/24 at 5:27 p.m., consultant pharmacist verified medications that are extended release would not be crushed as that would change the efficacy of the medication. The consultant pharmacist confirmed the expectation of nursing staff to update the physician and pharmacist if a resident required medications to be crushed or if a resident was not taking medications as ordered like chewing medications. The consultant pharmacist stated this was important to ensure residents were safe receiving medications as the medication was intended to be taken. During an interview on 10/28/24 at 5:51 p.m., RN-B confirmed R210's facesheet/banner in the EHR stated medications to be given whole and stated she was unaware R210 was to have medications taken whole. RN-B stated R210 usually chews medications. RN-B confirmed she gave the crushed medications to R210. RN-B confirmed the physician and pharmacist should be notified when a resident was receiving medications crushed instead of whole as that could affect how the medication acts in the resident's body and that neither the physician nor the pharmacist had been updated on R210 receiving medications crushed or chewing medications. During an interview on 10/28/24 at 5:57 p.m., director of nursing (DON) verified R210's facesheet/banner in the EHR stated medications to be given whole. DON stated medications labeled extended release (ER) should not be crushed as the delivering of the medication would be altered and the resident could adversely be affected. DON confirmed the physician and the pharmacist expected to be updated by facility staff if a resident chewed medications or was receiving medications crushed. DON verified that was important so the right medication dose ordered was given and the timeliness of the medication released is received. A facility policy titled Medications Administration Policy, undated, was provided. It was the policy of this facility that medications were administered by licensed nurses, or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy further identified do not crush medications with 'do not crush' instructions and administer medications as ordered in accordance with manufacturer specifications.

Based on interview and document review, the facility failed to report immediately, no later than 2 hours, to the administrator and the State Agency (SA), in accordance with established policies and procedures, an allegation of staff to resident abuse for 1 of 1 resident (R204) who was reviewed for allegations of abuse. Findings include: R204's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R204 had moderate cognitive impairment and had diagnoses which included heart failure, Diabetes Mellitus (DM), and anxiety disorder. Identified R 204 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R204's care plan revised 10/11/24, identified R204 was at risk for vulnerability related to mobility limitations and ADL needs. Identified R204 maintained the ability to report maltreatment. Care plan directed staff to observe/suspected abuse, remove resident from aggressor and relocate to safe location.- Report alleged violations in accordance to community protocol/Policy- Staff to observe for any changes in mood/behavior or medical changes and notify appropriate personnel. During an interview on 10/29/24 at 11:24 p.m., R204 stated she was scared of nursing assistant (NA)-C. R204 stated there were two incidents in the last month where she felt NA-C was abusive toward her. R204 stated she was not sure of the exact date however, one evening when NA-C was assisting her with cares, NA-C raised his fist to R204. In addition, a few days later while NA-C and NA-E were transferring R204 with the E-Z stand, NA-C raised his voice to R204 which made R204 very scared. R204 stated NA-E witnessed the incident and told R204 that she did not have to put up with that. R204 stated she spoke with assistant director of nursing (ADON) the next morning and told her about the above incidents with NA-C and that she was afraid of NA-C. R204 stated ADON informed her the facility was short staffed and needed the help however, they would make sure NA-C did not work with her anymore. Review of facility reported incidents to the SA lacked documentation of the SA being notified of the allegation of abuse toward R204. During an interview on 10/29/24 at 11:46 a.m., NA-D stated R204 had told her a few weeks ago, NA-E had been rough with her. NA-D stated she had reported those concerns to the ADON recently. During an interview on 10/29/24 at 11:54 a.m., NA-E stated a few weeks ago while she and NA-C were transferring R204 with the EZ - stand, R204's foot slipped off the foot plate and NA-C yelled you need to listen to us because we are the boss of you at R204. NA-E stated she told the ADON the next day about the incident. NA-E stated the ADON told her thank you and stated NA-C would no longer be allowed to work with R204. During a telephone interview on 10/29/24 at 11:59 a.m., NA-C stated he was aware R204 had told administration that he verbally abused R204. NA-C stated administration had told him a week or two ago, R204 was trying to get him fired therefore, he was no longer allowed to care for R204. NA-C stated he had not been removed from the schedule but he had the next few days off after the allegation of verbal abuse was made toward NA-C During an interview on 10/29/24 at 12:58 p.m., ADON stated she was not aware of any concerns with staff being rough with R204 however, she was aware R204 was afraid of NA-C because he had raised his voice to her. ADON stated she had been made aware of the allegation of abuse towards R204 a few weeks ago. ADON stated even though she felt it was an allegation of abuse she did not feel it needed to be reported to the administrator or the SA because the next day R204 had stated it was ok for NA-C to work with her as long as another staff member was present. During an interview on 10/29/24 at 2:36 p.m., director of nursing (DON) stated she had been aware on 10/7/24, NA-C had been loud with R204. DON indicated she had initiated an investigation and asked NA-C to not work with R204. DON stated she followed up with R204 a few days later and R204 had stated she was ok with NA-C working with her as long as another staff member was present. DON stated she was not aware that R204 had been scared of NA-C. DON stated she did not feel it was an allegation of abuse at the time. DON indicated her expectation was that all allegations of abuse would have been reported to the administrator and the SA per facility policy. During an interview on 10/29/24 at 3:20 p.m., administrator stated she was not aware of the allegation of abuse towards R204. Administrator indicated her expectation was that all allegations of abuse would have been reported to the administrator immediately and to the the SA immediately but no more than two hrs per policy. Review of a facility policy titled Abuse, Neglect, and Exploitation Policy undated, identified possible indicators of abuse include, but were not limited to: Verbal abuse of a resident overheard. Further identified, the facility policy includes: Reporting of all alleged violations to the Administrator or designee, state agency, adult protective services and any other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury. . .