Every finding on record at Wellspring Lutheran Services

Based on observation and interview, the facility failed to maintain plumbing and wastewater lines in good repair. This deficient practice increases the likelihood of contamination of the water supply with potential to affect any or all the residents in the facility. Findings include:On 8/26/2025 at 1:39 PM, observed the ice machine on the resident unit to have the wastewater drain line extending down into the bowl of the outgoing sewer drain line. In an interview with the Maintenance Manager C, he stated he had originally had an air gap present on this ice machine, but the gap was allowing the floor drain to overflow and allowing wastewater to splash from the discharge waste line onto the bottom of the cabinet. He stated he added the extension onto the bowl drain to catch the waste and prevent splashing from occurring. On 8/26/2025 at 2:45 PM, while on a tour of the exterior grounds of the building with the Maintenance Manager C, the conduit line on the well casing was observed to be broken and no longer attached to the well cap on top of the well casing, leaving the well exposed to potential contamination.

Based on interview and record review, the facility failed to develop and implement interventions or revise the fall care plan for one Resident (#1) of three residents reviewed for falls. This deficient practice resulted in R1 falling who sustained a skull fracture with subdural hemorrhage. Findings include: Resident #1 (R1) R1 was admitted to the facility on [DATE]. R1 fell on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A nurse's progress note dated [DATE] at 11:34 p.m. documented R1 was found by staff on the floor of his room. The progress note indicated R1 was bleeding from a head injury. Emergency Medical Services (EMS) was contacted and R1 was sent to the hospital Emergency Department (ED). An ED record dated [DATE] documented R1 was diagnosed with a skull fracture with subdural hemorrhage (bleeding under the membrane covering the brain). The ED physician documented, in part: .there does appear to be new acute on chronic bleeding .CT imaging also did reveal a significant skull fracture. I spoke with trauma surgery at [hospital name redacted]. They recommend I talk to neurosurgery. I did have a lengthy discussion with the neurosurgeon stating he believes the patient has a poor outcome which we do agree with. He [the neurosurgeon] deems he [R1] is not a surgical candidate . R1 was discharged back to the facility on [DATE] to resume hospice services. A review of progress notes [DATE] and [DATE] revealed R1 experienced an overall decline in health condition including hypotension as reflected by blood pressure of ,d+[DATE] (documented [DATE]), oxygen saturation levels of 57% (documented [DATE]), and scant intake of food or fluids (documented [DATE]). A hospice progress note dated [DATE] read, in part: [R1] is seen today for a routine nursing visit today. He suffered a fall with head injury the night of [DATE]. Went to ER [emergency room ], required stitches, CT showed new brain bleed and a skull fracture. [R1] was noted to be minimally responsive since . [R1] is placed on daily hospice nursing visits at this time. Progress notes dated [DATE] and [DATE] documented R1 became unable to safely swallow and experienced intermittent terminal (end of life) restlessness. The physician note dated [DATE] at 12:58 p.m. read, in part: .His intake is less than adequate to support life. Apneic breathing [temporary and involuntary cessation of respirations] 12 sec [seconds] apart . A hospice progress note dated [DATE] at 5:05 p.m. documented R1 was minimally responsive, pale and his bilateral lower extremities were mottled (discoloration due to slowed circulation and oxygen flow, typically indicative of approaching death). R1's heart rate was thready and irregular. The hospice note recorded R1 was experiencing terminal restlessness and was provided with Morphine (an opioid pain-relieving medication) and Ativan (an antianxiety medication) every four hours. On [DATE] at 2:08 p.m., the hospice nurse documented R1 was comatose and nonresponsive with ,d+[DATE] second periods of apnea. R1 was pronounced deceased on [DATE]. Review of R1's care plans revealed no new or revised interventions to minimize the risk of injury from a fall or to minimize the risk of fall recurrence after R1's falls on [DATE], [DATE], and [DATE]. The Director of Nursing (DON) was interviewed on [DATE] at 12:31 p.m. The DON was asked what care plan modifications or interventions had the facility put in place for R1 after the falls on [DATE] and [DATE] to prevent or minimize the risk of extensive injury following the fall on [DATE]. The DON said a medication regimen review (MRR) was completed after the fall on [DATE] to determine if medications were contributing to R1's falls. The DON said staff education on R1's fall interventions was completed in response to the fall on [DATE]. When asked what interventions were implemented after the fall on [DATE], the DON said 30-minute checks were implemented when R1 returned from the hospital on [DATE]. A copy of the MRR, staff education, and documentation of 30-minute checks was requested. On [DATE] at 1:15 p.m., the DON provided a MRR dated [DATE]. When asked why the Interdisciplinary Team (IDT) determined a MRR was indicated for the fall on [DATE] if a MRR was completed by the pharmacist the day prior to the fall, the DON responded she would have to review the IDT note. On [DATE] at 1:15 p.m., the DON provided a copy of a form Meeting Attendance Sign-In Sheet Nurses Meeting dated [DATE]. The attendance form contained Certified Nurse Aide (CNA) names and signatures. A second form was provided dated [DATE] that read, in part: This is to inform everyone that room [ROOM NUMBER] (R1's name) is now 30-minute checks . The form was unsigned with no other documentation on the form. The DON was questioned regarding the date on the education form and was again asked when 30-minute visual checks were implemented for R1. The DON reiterated R1 was not placed on visual checks every 30 minutes until after the fall on [DATE] despite the education of staff on [DATE] to provide 30-minute visual checks. The DON said there was a discussion in the daily IDT meeting on [DATE] to provide education to remind staff to visually check R1 for safety. The DON explained R1 fell on the night of [DATE] which was a Friday, so the facility did not review the fall to develop an intervention until [DATE], a Monday. The DON said, On Monday [[DATE]] we talked in the morning meeting and decided he needed official 30-minute checks. The DON provided a CNA task report for the month of [DATE]. The report documented 30-minute visual checks of R1 commencing [DATE]. When asked for documentation prior to [DATE], the DON admitted 30-minute visual check documentation for R1 did not start until [DATE], six days after R1 fell and sustained the skull fracture. R1's care plan was reviewed with the DON. The DON confirmed none of the interventions she had conveyed for the falls on [DATE], [DATE], and [DATE] were on R1's care plan. There was no evidence the fall care plan was reviewed or modified after the falls on [DATE], [DATE], or [DATE]. There were no interventions on the fall care plan for MRR, staff education, or visual checks every 30 minutes. When asked again what interventions were implemented or changes made to the plan of care after the falls on [DATE] and [DATE], the DON said, nothing. When asked if documentation of 30-minute checks commencing [DATE], at which time R1 was documented as being minimally responsive, was a timely and appropriate intervention, the DON said, No. The DON said, I can't disagree with you. I am disappointed. We have a problem with our falls [program]. The DON said fall prevention and management was scheduled as the facility's next QAPI (Quality Assurance Performance Improvement) project. The policy Resident Fall Occurrences dated as revised ,d+[DATE] (no day provided on policy) read, in part: .The facility must implement process improvement systems to reduce the prevalence of falls and significant injury . Objectives: to minimize injurious resident incidents, to minimize repeat resident incidents .The licensed nurse documents . review of care plan and any new preventative measures initiated .The IDT then modifies and implements care plans and the treatment approach to minimize repeat incidents . The policy Fall Management Guidelines dated as revised ,d+[DATE] read, in part: .The IDT will review/modify the plan of care to minimize repeat falls . The facility's undated Fall Management Algorithm directed staff to Update Fall Care Plan after a resident fall.

Based on observation, interview, and record review the facility failed to administer 6 of 32 medications accurately to two residents (#11 and #14) during medication pass, resulting in a medication error rate of 18.75%. Findings include: Resident #14 (R14) During observation of medication administration on 7/9/24 at approximately 7:36 AM, Registered Nurse (RN) D dispensed five medications into medication cups for R14 and took them into R14's room. She proceeded to set them down next to R14's empty breakfast tray, stating she would take the tray and leave the medications. RN D proceeded to walk out and close the resident's door, prior to observing R14 taking her medications. Upon return to the medication cart, an interview was conducted with RN D asking if she often left medication with R14. RN D hesitated sighed, bowed her head and said No. On 7/9/24 at 7:55 AM, during a follow-up interview, R14 stated this was a daily occurrence. Review of the facility's Medication Pass Guidelines policy under procedure, number 6, read as follows: Observe that the resident swallows oral drugs. Do not leave medications with resident to self-administer unless the resident is approved for self-administration of the medication. On 7/9/24 at 9:37 AM, during an interview and record review, the Director of Nursing (DON) reviewed the EMR for R14 and confirmed R14 had not been approved for self-administration. Resident #11 (R11) On 7/9/24 RN D was observed donning a N95 mask to go into room where an aerosol medication had been dispensed per sign on door. RN D did not have a stethoscope to assess R11 post aerosol treatment. While conducting an interview with RN D post exiting R11's room, RN D stated she should assess R11 lungs prior to and after administering the aerosol medication. RN D acknowledged that she had not. Review of the facility's Nebulizer Therapy policy under procedure, number 15 read as follows: Assess therapy for efficacy by: Periodic observation of the amount and color of sputum produced during and immediately after a treatment. Monitoring the resident for adverse reactions such as tachycardia, sudden bronchospasm, nausea, and vomiting. Breath sounds before and after therapy. RN D did not complete number 15 of the Nebulizer Therapy policy.

Based on observation, interview, and record review the facility failed to ensure that medication was administered appropriately, reconciled correctly, documented appropriately, and stored appropriately for one Resident (#20) out of 30 residents reviewed for pharmacy services. Findings include: Resident #20 (R20) On 7/9/24 at 9:25 AM, an observation was made of an unattended medication cup with two pills on top of R20's bedside table. R20 was not in her room at this time. This surveyor attempted to get the nurse working on the hall to bring this observation to their attention and conduct an interview, but they were unable to be located. On 7/9/24 at 9:28 AM, an interview was conducted with Registered Nurse D and was asked if they had seen RN H and replied, (RN H) is with another resident drawing blood for labs. On 7/9/24 at 9:30 AM, an interview was conducted with the Nursing Home Administrator/Director of Nursing (NHA/DON) and was asked to accompany this Surveyor to R20's room. The NHA/DON was directed to R20's room and the unattended medication cup. The Surveyor and the NHA/DON returned to her office and identified the two medications to be trazadone (antidepressant) 50 milligrams (mg) and cyclobenzaprine (muscle relaxant) 10 mg. The NHA/DON reviewed the Medication Administration Record (MAR) and trazadone was ordered to be given at 8:00 PM and the cyclobenzaprine was ordered as an as needed medication. The NHA/DON then stated that it must have been the night shift nurse yesterday evening (7/8/24) that left them in R20's room. Review of R20's MAR, dated July 2024, revealed that the last time the cyclobenzaprine was administered was on 7/7/24 at 8:13 AM. Review of R20's care plan, dated 7/2/24, lacked any care plan/desire to self-administer medications. Review of R20's physician orders, lacked an order to self-administer medications. Review of R20's progress notes, dated 7/8/24 through 7/9/24, lacked any documentation of a medication reconciliation for cyclobenzaprine by LPN E. Review of R20's MAR, dated July 2024, indicated the cyclobenzaprine was administered by LPN E on 7/8/24 at approximately 8:00 PM. On 7/9/24 at 9:38 AM, the NHA/DON and this Surveyor interviewed RN H regarding her morning medication pass. RN H replied that she did not give R20 a cyclobenzaprine and she had passed morning medication to R20 in her room. RN H stated that she did not see the medication cup on R20's bedside with the two pills in it during the time she was in R20's room performing morning medication pass. On 7/9/24 at approximately 10:30 AM, an interview was conducted with the NHA/DON and was asked if R20 had a safe self-administration medication assessment and replied, No. The NHA/DON was asked if medications should be left unattended at the bedside where other wandering residents had access and replied, No. The NHA/DON was asked to confirm that Licensed Practical Nurse (LPN) E had actually been the last nurse to dispense the medications to R20 on the evening of 7/8/24 and confirmed she would follow up with LPN E. On 7/10/24 at 9:00 AM, an interview was conducted with the NHA/DON and was asked if she was able to follow up with LPN E and replied, Yes. I came in at 5:30 AM today and asked her about the medications that were left in R20's room. The NHA/DON stated that LPN E had dispensed the two medications at approximately 8:00 PM on 7/8/24. LPN E initially dropped the cyclobenzaprine and had to dispense a second cyclobenzaprine, and then proceeded to R20's room to dispense both medications (trazadone and the cyclobenzaprine). After LPN E entered R20's room she heard another resident calling out for help and told R20 she would be right back and set the medications on her bedside table. LPN E then proceeded to assist a coworker in the resident's room that was calling out for help. When LPN E had finished assisting her coworker and the resident in another room she returned to her medication cart. LPN E had forgotten all about leaving R20 with the medication. The NHA/DON then stated that the medications should not have been left with R20 unattended, medication should have been signed out correctly, and reconciliation of the dropped medication should have been documented. Review of policy titled, Self-Administration of Medication, dated November 2017, read in part, .If a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate, by completing a self-administration of medication assessment . Review of policy titled, Medication Pass Guidelines, dated September 2023, read in part, Purpose: To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing the administration of drugs in an accurate, safe, timely, and sanitary manner and to systemically distribute medications to residents in accordance with state and federal guidelines .Self-Administration - Residents are allowed to self-administer medications if deemed appropriate after being assessed by the Interdisciplinary Team and specifically authorized by the attending physician and in accordance with the guideline for self-administration of medication .Procedure .6. Observe that the resident swallows oral drugs. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of medication .Documentation: Record the name, dose, route, and time of medication on the Medication Administration Record .

Based on observation, interview, and record review the facility failed to 1) appropriately stage, 2) don personal protective equipment (PPE), 3) consult/involve physician for wound treatment, 4) provide aseptic wound care, 5) perform routine skin assessment, 6) provide accurate wound documentation and 7) implement interventions to prevent the development and worsening of a facility acquired pressure injury for two Residents (#2, #11) out of 2 residents reviewed for pressure ulcers. Findings include: Resident #2 (R2) Review of R2's medical record revealed admission to the facility on [DATE] with diagnoses including multiple sclerosis, diabetes mellitus, dependency on wheelchair, and major depression. Review of the 4/19/24 Minimum Data Set (MDS) assessment revealed she scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) assessment indicating moderately impaired cognition. The MDS revealed she was at risk for pressure ulcer development and had no active/current pressure ulcers. On 7/9/24 at 8:15 AM, an observation was made of R2 in her room lying in her bed on her left side. R2 had a foam boarder dressing observed on the right posterior thigh. On 7/9/24 at 8:16 AM, an observation was made of Certified Nurse Aide (CNA) G and CNA F providing direct care to R2 in her room. CNA G and CNA F were changing linens and both CNAs and failed to don any personal protective equipment (PPE) such as gowns. On 7/9/24 at 8:17 AM, an interview was conducted with CNA G and was asked if she was required to wear a gown while providing direct care to R2 and replied, Not unless I am doing something with her catheter. CNA G was shown the sign hanging on the outer door of R2's room indicating R2 was on enhanced barrier precautions and if providing direct care such as changing linens then gloves and a gown were required to be worn by staff. On 7/9/24 at 8:18 AM, an interview was conducted with CNA F and was asked if she was required to wear a gown while providing direct care to R2 and replied, Oh gosh. I forgot. I should have been wearing a gown. On 7/9/24 at 1:00 PM, an observation was made of R2 sitting in her [brand name] specialized chair with flexible strapping surface, in the dining room, with her right hip directly up against the right side on her chair with a thin pad next to the arm of the chair. On 7/10/24 at 8:30 AM, an observation was made of R2 sitting in her [brand name] chair, in the TV room, with her right hip directly up against the right side on her chair with a thin pad next to the arm of the chair. Review of R2's physician order, dated 4/1/24, revealed Staff to wear gown and gloves (potentially additional PPE, if needed) during all high-contact resident care activities, prevention of transmission of multidrug-resistance organisms. Review of R2's physician order, dated 12/11/23, revealed Weekly skin sweep every day shift every Thu (Thursday). Review of R2's weekly skin assessment, dated 1/4/24, revealed alterations in skin integrity as follows: a.) Site: Left buttocks. Description: Chronic discoloration of the area, b.) Site: Other (specify). Description: Right arm - healing scratch, c.) Site: Abdomen. Description: Scratch to RLQ (right lower quadrant), d.) Site: Other (specify). Description: Healing bruise to RFA (right forearm), e.) Site: Right hand (back). Description: Fading bruise, f.) Site: Other (specify). Description: Fading bruise to L (left) wrist, g.) Site: Right toe(s). Description: MASD (moisture associated skin damage), and h.) Site: Chest. Description: Rt (right) chest blister, see TAR (treatment administration record). Review of R2's electronic medical record for weekly skin assessments from 1/4/24 through 7/4/24, revealed the lack of a weekly skin assessment on the following dates: 1/11/24, 2/1/24, 3/28/24, 4/11/24, 4/18/24, and 6/20/24. Review of physician order, dated 1/9/24, read in part, Skin prep to large fluid blister on right hip daily . Review of R2's weekly skin assessment, dated 1/18/24, revealed alterations in skin integrity as follows: a.) Site: Left buttocks. Description: Chronic discoloration of the area, b.) Site: Other (specify). Description: Right arm - healing scratch, c.) Site: Right iliac crest (front). Description: Blister, d.) Site: Other (specify). Description: Healing bruise to RFA (right forearm), e.) Site: Right toe(s). Description: MASD (moisture associated skin damage) between the great/2nd toes and 4th/5th toes. Blister to side of Great toe, and f.) Site: Chest. Description: Rt (right) chest blister, see TAR. Review of R2's wound assessment, dated 2/1/24, read in part, Wound type: Other. Site: Right trochanter (hip). Description: Open blister. Date of onset: 2/1/24. Depth in cm (centimeters): 0.2, wound measurements - length X width: 7.8 x 4.7, drainage: serosanguinous (blood and fluid mixed), drainage amount: light, wound edges: red .wound bed: granulation (new tissue), was care plan updated? Yes . Review of physician order, dated 2/1/24, read in part, Blister opened on right hip: skin prep peri (skin surrounding wound)-wound, apply calcium alginate ( wound dressing type) to wound bed, cover with comfort foam .every day shift every other day. Review of R2's wound assessment, dated 2/19/24, read in part, Wound type: Other. Site: Right trochanter (hip). Description: Open blister. Date of onset: 2/1/24. Depth in cm: 0.2, wound measurements - length X width: 6.6 x 4.3 cm, drainage: serosanguinous, drainage amount: light, wound edges: red .wound bed: granulation, was care plan updated? Yes . Review of progress note, dated 2/19/24, read in part, .Blister measured as 4.5 x 2.4 x 0.6 cm. Edges unattached to wound base, yellow slough covering > 75 % (percent) of wound bed. Foul smelling. Surrounding skin red and hyperpigmented . Review of R2's wound assessment, dated 2/26/24, read in part, Wound type: Other. Site: Right trochanter (hip). Description: Open blister. Date of onset: 2/1/24. Depth in cm: 0.2, wound measurements - length X width: 6.4 x 4.2, drainage: serosanguinous, drainage amount: light, wound edges: red .wound bed: granulation, was care plan updated? Yes .Comments: Blister opened. Light Review of progress note, dated 2/29/24, read in part, .performed wound care to right hip. Blister measured as 4.5 cm x 2.4 x 0.6 cm. Edges unattached to wound base, yellow slough covering > 75% of wound bed. Foul smelling. Surrounding skin red and hyperpigmented . Review of R2's wound assessment, dated 3/4/24, read in part, Wound type: Other. Site: Right trochanter (hip). Description: Open blister. Date of onset: 2/1/24. Depth in cm: 0.2, wound measurements - length X width: 6 x 4.1, drainage: serosanguinous, drainage amount: light, wound edges: red .wound bed: slough, was care plan updated? Yes . Review of physician order, dated 3/6/24, read in part, Blister opened on right hip: skin prep peri-wound, apply Santyl (wound debriding agent) to wound bed, cover with comfort foam .every day shift day. Review of progress note, dated 3/7/24, read in part, .performed wound care to right hip. Decreased odor this week .applied Santyl to wound bed - nickel thick, covered with comfort foam . Review of progress note, dated 3/14/24, read in part, .Wound care to right hip performed. Dimensions 5 x 2.5 x 0.4 cm. Coordinated with facility nurse .update on wound care performed and wound assessment . Review of progress note, dated 4/4/24, read in part, .All skin assessed and discussed with facility wound care nurse .purple discoloration of right trochanter, open wound on right iliac crest being treated .dimensions (4.5 x 2.5 x 0.3 cm) . Review of physician order, dated 4/8/24, read in part, Blister opened on right hip: skin prep peri-wound, apply iodosorb [dressing containing iodine] to wound bed, cover with comfort foam .every day shift day. Review of progress note, dated 4/11/24, read in part, .Right hip wound assessed. Secondary dressing from 4/10/24 saturated with drainage. Wound care to right hip performed. Dimensions 4.75 x 2.75 x 0.4 cm . Review of progress note, dated 4/17/24, read in part, .Blood glucose 517 . Review of progress note, dated 4/18/24, read in part, .Blood glucose 499 .obtain a .wound culture from Rt (right) hip and coccyx. After culture is completed, start resident on ciprofloxacin [antibiotic] 500 BID (two times daily) x 14 days . Review of progress note, dated 4/19/24, read in part, .Called to .verify antibiotic order and the order in the MAR (medication administration record) for cefalexin [antibiotic] 500 mg BID x 14 days in the correct order. Also notified that unable to obtain wound culture as wound bed is slough . Review of physician order, dated 4/19/24, read in part, Blister opened on right hip: skin prep peri-wound, apply Santyl (nickel thickness) to wound bed, cover with comfort foam .every day shift day. Review of physician progress note, dated 4/23/24, read in part, Patient is seen for wound to right hip, continues ATB (antibiotic) at this time . Review of progress note, dated 4/25/24, read in part, .She continues to have elevated blood sugars despite insulin changes. Facility nurses unable to obtain previously ordered wound culture as wound base is covered in slough .10 units insulin aspart (short acting insulin) administered x 1 at 12:33 PM for BS (blood sugar) = 479 by facility nurse. Recheck at 4:23 PM, BS = 472 . Review of progress note, dated 4/29/24 at 12:46 PM, read in part, Resident continues on ABT r/t (related to) wound infection. Upon assessment .Hypotensive (below normal blood pressure) with elevated HR (heart rate). Resident fatigued and declined am (morning) meal .concern for suspected sepsis r/t wound infection .order to hospital for further evaluation . Review of progress note, dated 4/29/24 at 9:23 PM, read in part, Resident returned from hospital emergency room visit .they gave her fluids and antihistamines and suggested we discontinue the cefalexin . Review of physician order, dated 4/29/24, read in part, Blister opened on right hip: cleanse wound with Dakin's [bleach preparation for wounds] solution, skin prep peri-wound, apply Santyl (nickel thickness) to wound bed, cover with comfort foam .every day shift. Current wound care physician order, dated 5/28/24, read in part, Blister opened on right hip: cleanse wound with Dakin solution, skin prep peri-wound, pack wound with calcium alginate, cover with comfort foam .every day shift. Review of progress note, dated 6/13/24, read in part, .Wound care performed to right trochanter .wound base, dimensions and surrounding skin 3.4 x 2.5 x 1.3 cm . Review of progress note, dated 6/27/24, read in part, .has a chronic stage 3 PI (pressure injury) to her right trochanter . Review of physician notes, dated 1/31/24 through 7/10/24, revealed one physician note regarding R2's pressure injury on 4/23/24 and lacked any other notes. Review of R2's care plan, dated 5/1/2019, read in part, .Focus: I have a history of an alteration in my skin integrity .Goal: I will remain free from infection and areas will heal by next review (target date: 7/19/24) .Interventions .I have an air mattress on my bed to prevent skin breakdown while in bed (date initiated: 12/28/23). I need a weekly skin assessment to be completed by nurse (revision on: 6/6/18) . *Note: Most recent intervention last dated 12/28/23. On 7/10/24 at 12:15 PM, an observation was made of Registered Nurse (RN) C providing wound dressing change on R2's right lateral thigh area in her room. R2's pressure injury was a stage two with a granulated wound bed, and measured 2.2 x 2.1 x 0.9 cm. On 7/10/24 at approximately 3:00 PM, and interview was conducted with Occupational Therapist (OT) R and was asked if R2 had been re-evaluated by therapy for her [brand name] chair after acquiring the pressure injury on her right hip and replied, No. We were never told she had a new pressure injury. I was aware she had a sore on her coccyx. R2 should be assessed with a new pressure injury and I will have to get that approved now that she is on Hospice. On 7/10/24 at 5:00 PM, an interview was conducted with the Nursing Home Administrator/Director of Nursing (NHA/DON) and was asked about R2's pressure injury and replied, We did some research and thought it was a bullous pemphigoid (autoimmune blistering disorder) and asked the physician for a diagnosis because of the blister she developed, but he declined to give us the diagnosis. The NHA/DON was asked if the physician had seen R2's pressure injury initially and replied, I did go back in the notes and look, and he did observe it on 4/23/24 when he was here. He did not observe R2's pressure injury prior to that date. The NHA/DON confirmed no other physician notes were noted for R2's pressure injury. The NHA/DON was asked who determines and over sees the wound care treatment order decisions and replied, R2's wound care is a collaboration between our wound care nurse, the hospice nurse, and the physician. *Note: Progress notes for R2 lacked initial wound identification and physician notification. On 7/10/24 at 5:15 PM, an attempt was made to contact the medical director via telephone and no answer was made. On 7/10/24 at 5:16 PM, an attempt was made to contact the nurse practitioner via telephone and no answer was made. On 7/10/24 at 5:35 PM, an attempt was made to contact the hospice nurse via telephone and no answer was made. On 7/10/24 at 5:44 PM, an interview was conducted with hospice RN S and was asked about R2's wound and the care she provides and replied, I come to the facility to provide care to R2 and usually when I am here, I do the dressing change and assess her skin. RN S was asked if she was wound care certified and replied, No. RN S was asked if she communicated with the physician regarding wound care orders and replied, I discuss R2's wound needs with the facility wound care nurse and they discuss wound needs with the physician. RN S was asked to describe R2's wound initially and currently and replied, Well R2 was admitted to hospice services on 1/12/24. I do not see any wounds in the admitting notes. The first time the blister presented was 2/1/24, but after it opened up it had gotten much deeper than we anticipated. I think there was a pressure element. In my charting we discussed it with the wound nurse of the facility. It was open on a bony prominence, and we (hospice nurse and facility wound care nurse) staged it deeper stage two. On 4/15/24 is when I said that it had evolved to a stage two and at that time, we changed the order to Santyl. There was slough in the wound bed and we debrided the wound. R2 also has a super pubic catheter, and it was intermittently leaking. I think that is how the wound got infected, but she is also incontinent of stool. Her blood sugars were out of control. That wound looked yucky. She did get antibiotics. RN S was asked if the medical director had seen R2's wound and replied, I can give you dates when he did. I have it in my notes. It was either right before 4/20/24 or right after that. I can't find the exact date. I remember he wanted a wound culture, but we could not get a wound culture because the wound bed was all slough. Review of policy titled, Skin Management Facility Guidelines, dated January 2022, read in part, .Documentation should include: Location and staging of ulcer .The licensed nurse will complete a weekly skin assessment . Review of policy titled, Pressure Ulcer Preventive Measures Policy, dated January 2022, read in part, .Residents at risk for development of pressure ulcers receive interventions to reduce the risk of pressure ulcers .Residents identified at risk for pressure sore development will be inspected weekly for skin integrity .Documentation: On the care plan, document approaches and interventions to prevent pressure ulcers. Review of policy titled, Pressure Ulcer Treatment Policy, dated January 2022, read in part, .Resident with pressure ulcers receive necessary treatment and services to promote healing, prevent infection and reduce the likelihood of new ulcers developing .Contact the physician for treatment orders .Do not clean ulcer wound with cytotoxic [solutions causing tissue damage] skin cleaners or antiseptic agents (e.g. povidone iodine, iodophor, sodium hypochlorite solution [Dakin's solution] .protect pressure ulcers from exogenous sources of contamination (e.g. feces) .Documentation: 1. In the nurses notes, record periodically: Results of interventions, care being rendered, and adjustments to interventions. 2. Care plan: Who should provide care, how often, supplies and equipment needed, and how the care is undertaken . 40330 R 11 Review of R11's MDS assessment, dated 6/25/24, revealed R11 was admitted to the facility on [DATE] with diagnoses including cancer, heart failure, and on hospice care. The assessment revealed R11 was dependent for toileting and transfers and was frequently incontinent of bladder and bowel. The skin assessment showed R11 was admitted to the facility with two pressure injuries, one Stage 2 pressure ulcer, and one SDTI (Suspected Deep Tissue Injury). The BIMS assessment revealed a score of 11/15, which showed R11 had moderate cognitive impairment. During an interview on 7/08/24, it was confirmed by a facility wound care nurse, RN C, R11 was admitted with two pressure ulcers, a Stage 2 pressure ulcer on his buttocks, and a DTI (Deep Tissue Injury) on his left heel. RN C reported R11's wound on his buttocks was improving, and the DTI on his left heel remained unchanged, and clarified neither wound had signs of infection. RN C stated R11 wore pressure relieving boots on his bilateral heels to offload his heels and had an air mattress on his bed and chair. During an interview on 7/09/24 at 1:45 p.m., a second wound care nurse, RN B, was observed setting up supplies to treat R11's left heel wound (DTI) outside his room. RN B initially set up R11's wound care supplies on a treatment cart, which included a heel soaker pad, a waterproof foam heel cover in a plastic sleeve, saline wash, gauze pads, skin prep wipes, [brand name] bandage wrap, tape, and a paper measurement ruler. During an interview on 7/09/24 at approximately 1:49 p.m., R11 and his wife both agreed to the wound treatment, and for this Surveyor to observe the treatment by RN B of his left heel wound. During the observation on 7/09/24 at approximately 2:00 p.m., RN B was observed performing hand hygiene, donning gloves, and placed R 11's treatment supplies on his bedside table on two small brown paper towels from his bathroom. The bedside table was not sanitized prior to the observation, and contained a television remote, water container, and a pair of glasses next to the two paper towels of supplies. RN B next moved R11's wastebasket with clean gloved hands next to the bed and began removing R11's blanket from his lower bed and reached to remove R11's left pressure relieving boot. Surveyor asked RN B to stop briefly and privately let them know there was the potential for cross contamination by touching R11's bedding and heel boot prior to completing wound care after they had touched the wastebasket. RN B reported they understood the concern and removed their contaminated gloves, performed hand hygiene, and donned new gloves. RN B completed R11's wound care per physician orders and next removed the soiled supplies and garbage bags, while at the same time picking up a sealed, clean foam heel cup bandage with the same hand which touched the garbage and prepared to leave the room. Surveyor stopped RN B and noted they touched the unused clean heel cover pad clear plastic sheath and were cross contaminating the package as they were removing it from the room. RN B asked if she should put it back in the wound care cart, or leave it in R11's room, since it was dirty, and asked questions regarding how to prevent cross contamination from dirty to clean during wound care. It was also noted after the wound care treatment, RN B removed the two paper towels from R11's table and cleaned the table with water and a paper towel. Surveyor asked if this was a proper way to disinfect R11's table, and RN B stated, No. RN B returned and wiped R11's table with bleach wipes. During the observation, there were no further concerns observed during R11's wound care provision by RN B. The wound observation revealed a small dime-sized oval shaped closed wound on back of R11's heel, which was closed and purple and yellow in color, with irregular borders. There were no signs of infection or odor. R11 verbalized no pain or discomfort during the wound care treatment. After the observation, RN B acknowledged they understood all the concerns and stated this was a learning experience as they were newly wound care certified. RN B reported they did not have a supervisor or anyone providing oversight if they had questions, as they oversaw wound care in the facility along with RN C. During an interview on 7/09/24 at approximately 4:10 p.m., the Assistant Director of Nursing (ADON), RN A, was asked with RN B present if they were RN B's supervisor, and if they had been aware of the observed wound care infection control concerns related to RN B's provision of R11's wound care. ADON A clarified they were the Infection Preventionist nurse, and had been made aware of the infection control concerns by RN B on 7/09/24, and could address the concerns. ADON A reported they understood the concerns regarding the improper barrier, touching the wastebasket prior to wound care, not changing gloves from dirty to clean, and not cleaning R11's bedside table properly. ADON A explained the unused heel cup package was able to be sanitized without compromising the integrity of the heel protector bandage once it was contaminated by the dirty gloves. ADON A conveyed they would ensure use of a proper barrier for wound care and proper glove changes when indicated for facility wound care going forward. RN B reported their measurements on 7/09/24 showed the left heel wound was improving, which was confirmed in the facility wound care documentation. During an interview on 7/10/24 at approximately 6:00 p.m., the NHA/DON reported they had been made aware of the concerns related to infection control regarding the provision of wound care for R11 and acknowledged the concerns. Review of the policies received related to Pressure Ulcer Care and Skin Management did not include a procedure or process related to the provision of wound care infection control measures. Review of the CDC (Centers for Disease Control), Infection Control Assessment and Response (ICAR) tool for General Infection Prevention and Control (IPC) Across Settings, dated 1/27/23, revealed, Section 3: Observation Form - Wound Care: Observation 1: Prior to the start of the procedure, are clean supplies gathered and placed on a clean source in the room? Yes or No. Maintain separation between clean and soiled equipment to prevent cross-contamination Observation 7: Are gloves changed and hand hygiene performed when moving from dirty to clean tasks? Yes or No. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications .e. Before moving from on a soiled body site to a clean body site on the same patient. f. Immediately after glove removal . Observation 8: Does HCP [Health Care Practitioner] maintain separation between clean and dirty supplies? Yes or No. Maintain separation between clean and soiled equipment to prevent cross contamination .During the procedure, separation should be maintained between clean and dirty supplies . Observation 11: What happens to any unused disposable supplies that entered the patient/resident care area? Discarded, returned to clean supply cart or storage for use on another patient/resident, Labeled and dedicated to the patient/resident and stored in a manner to prevent cross-contamination, e.g. in the patient/resident room .Maintain separation between clean and soiled equipment to prevent cross contamination. Any unused disposable supplies that enter the patient/resident's care area should remain dedicated to the patient/resident or be discarded. They should not be returned to the clean supply area. If supplies are dedicated to an individual patient/resident they should be properly labeled and store in a manner to prevent cross-contamination or use on another patient/resident (e.g. in a designated cabinet in the patient/resident's room.). Observation 12: Are potentially contaminated surfaces cleaned and disinfected after wound care activities are completed? Yes or No. 1. Require routine and targeted cleaning of environmental services as indicated by the level of patient contact and degrees of soiling. a. Clean and disinfect surfaces in close proximity to the patient and frequently touched surfaces in the patient care environment on a more frequent schedule compared to other surfaces. b. Promptly clean and decontaminate spills of blood or other potentially infectious materials. 2. Select EPA-registered disinfectants that have microbiocidal activity against the pathogen most likely to contaminate the patient care environment. 3. Follow the manufacturer's instructions for proper use and disinfecting products .

Based on interview, and record review the facility failed to provide adequate supervision to prevent one Resident (R1) of four Residents reviewed for resident-to-resident incidents from initiating an altercation. Findings include: This citation pertains to intake #MI00139599. Review of intake #MI00139599's Incident Summary, dated 8/17/23, read in part, .At time of incident, it was reported to Administrator that Resident 1 [R1] was swinging a coffee mug at Resident 2 [R2] with potential contact .Cameras were reviewed at that time, and it was determined that a resident-to-resident altercation did occur . Review of intake #MI00139599's Investigation Summary, dated 8/23/23, read in part, On 8/16/23 at 16:52 [4:52 PM] [staff name], RN D [registered nurse] notified Administrator of incident involving R1 and R2 at 16:38 [4:38 PM] . CNA E [certified nurse aide] observed R1 swinging coffee cup at R2 with possible contact. R2 was observed to have coffee on his face and shirt . R1 was interviewed by licensed bachelor social worker LBSW B on 8/17/23 at 07:45 [7:45 AM]. R1 stated that he was trying to get through Hall 3 when he noted a resident blocking the way. He voiced that he assisted the resident to move the wheelchair, so he could get by and then moved past R2, when R2 grabbed his left arm and would not let go. He denied calling out for staff and voiced 'I told him to let go or I would hit him. He did not let go, instead he was getting worse.' . 'I swung at him with my coffee mug.' . Administrator . and Social Worker . reviewed camera footage at time of incident . R1 was observed approaching the nurses' station and was unable to continue locomotion due to position of wheelchairs. R1 is seen attempting to move back R2 wheelchair. R1 then proceeds to attempt to get through opening and makes contact with R2 chair three times. He is then able to advance in front of R2 . then reaches forward for R1 left arm. R1 then proceeds to swing his coffee cup at R2 eleven times. R2 is attempting to block strikes using his left arm before CNA E intervenes and separates residents . Review of R1's census, revealed an original admission on 11/30/2022 into the facility and discharged on [DATE] from the facility. Review of R1's progress note, dated 8/16/23 at 4:38 PM, read in part, CNA alerted the nurse of a possible altercation between two residents . Review of R1's care plan, dated 12/05/2022, read in part, . Focus: I have an ADL [activities of daily living] Self Care Performance Deficit r/t [related to] Hemiplegia (paralysis of one side of the body) . Interventions . Mobility - I use a w/c [wheelchair] as my main source of locomotion and am able to propel myself short distances. Staff assist me as needed with reaching my desired location . Review of camera footage with the Nursing Home Administrator (NHA), dated 8/16/23, revealed seven residents sitting in chairs and wheelchairs all around the nurses' station and three staff in the area just prior to the altercation between R1 and R2 and then staff exiting the area where all residents were left unattended. R2 is seen sitting to the left of Hall 3 next to the nurses' station and an unidentified resident sitting on the right of Hall 3 blocking the entrance to Hall 3. R1 is seen attempting to move the unidentified resident to the right of Hall 3 without success and then moves toward R2 and attempts to move him out of the way. After R1 bumps into R2 three times he could proceed forward and turns in front of R2 when R2 reaches out and grabs R1's left arm. R1 is observed swinging his coffee mug at R2 and hits him in the left arm and the left side of his face and continues to swing eleven times. Staff then enters the nurses' station area and then separates both residents. Review of witness statement by CNA E, dated 8/17/23, read in part, . Before dinner I was in the equipment room when I heard a resident yell out, Don't do that! I ran out of the room to see R1 raising his coffee cup up towards R2 who was facing in my direction. I was not able to get in between them in time when R1 cup looked as if it contacted R2 left cheek . Review of witness statement by RN C, dated 8/17/23, read in part, I was in the equipment with CNA E. CNA E was in the doorway and opened it because we heard a louder voice, she then said, 'R2 and R1 are fighting .' Review of witness statement by RN D, dated 8/17/23, read in part, I was in room [ROOM NUMBER] when I heard, [CNA E] yell out my name. I came out of room [ROOM NUMBER] . I noticed R2 had coffee on his shirt and hair. CNA E told me that she seen R1 with his coffee cup up in the air towards R2 . On 5/30/24 at 10:50 AM, an interview was conducted with the NHA, and she was asked if the area around the nurses' station had not been congested if the resident-to-resident altercation would have taken place and replied, No. I have not had any concerns between the two residents until the altercation. The NHA was asked if she felt any of the three staff members that were present at the nurses' station prior to the resident-to-resident altercation should have been supervising the residents and replied, Yes. The NHA was asked if any of the three staff members should have been aware of the congestion at Hall 3 and replied, I guess not. We recognized that activities had just gotten out and they added more residents to the area. Other staff were parking wheelchaired residents in that same area getting them ready to go to the dining room for dinner. Since the incident we have made some changes. On 5/30/24 at 11:12 AM, an interview was conducted with RN D, and she was asked to confirm her witness statement. RN D confirmed her witness statement. RN D stated, I felt like R1 was excessive with his reaction and he could have waited for staff to assist moving other residents out of his way. R1 was aware of what he was doing, and his actions were wrong. After he tried to leave as soon as he could, and I felt he knew he did something wrong and was trying to get away from the situation. Review of policy titled, Safety Interventions, dated April, 2021, read in part, Policy .Safety interventions can also be used to help prevent serious injury .Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents .

Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria in the facility water system. The failure to develop and implement a comprehensive Water Management Plan has the potential for the proliferation and transmission of Legionella in the circulating water of the building and the spread of Legionella infections in all 35 residents. Findings include: On 8/1/23 at 2:00 PM, an interview with Maintenance Director (MD)/ Staff A was conducted to review the facility's WMP for the control of Legionella in the water supply system. Staff A produced a document: Administrative Policy Manual: Water Management Program Dated with Revision Date: April 2019. Staff A stated We are flushing. Staff A stated he was not aware of any Water Management Plan which included parameters and critical limits to be monitored and documented. On 8/2/22 at 9:45 AM, an interview was conducted with the Nursing Home Administrator (NHA) and Staff A, at which time they were informed of the lack of a Water Management Plan. The NHA presented the same document as above, with a revision date of February 2023. No changes were noted between the two documents. The NHA acknowledged she was not aware of any specific assessment, plan or interventions being implemented to reduce the risk of Legionella in the water supply. The following components were absent from the facility WMP: A. Designation of a Water Management Team (WMT). B. An assessment of the facility's water system to identify risk locations. C. Identification of control points where effective mitigation measures can used. D. Identification of set critical limits related to the risk areas identified and which can be controlled. E. Identification of defined control measures and locations related to risk and the critical limits which are set. F. Implementation of regular scheduled mitigation program. G. An evaluation process to determine how the WMP is functioning.

Based on observation, interview, and record review, the facility failed to investigate and notify a resident representative of a skin injury for one Resident (#22) of two residents reviewed for accidents. This deficient practice resulted in the potential for injuries and abuse to remain undetected. Findings include: A review of Resident #22's face sheet revealed an admitted [DATE]. Resident #22 had diagnoses which included [CONDITION(S)] (CHF), [CONDITION(S)] (COPD), kidney failure, and falls. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14/15, which indicated Resident #22 was cognitively intact. Resident #22's face sheet revealed her daugher was named her guardian and decision maker. On 04/13/21 at 11:29 a.m., Resident #22 said her leg had been hurt when Certified Nurse Aide (CNA) D and Licensed Practical Nurse (LPN) C had placed her in a mechanical lift to obtain her weight. Resident #22 was unable to recall when the injury had taken place. On 04/13/21 at 11:32 a.m., Resident #22's right leg was observed with LPN C which revealed a dressing on the lower portion of her right leg. LPN C confirmed Resident #22's leg had been injured while being weighed in the mechanical lift. LPN C reported the lift's hook had come in contact with Resident #22's leg and it had resulted in a skin tear. A review of Resident #22's Electronic Medical Record (EMR) did not contain any progress notes or documentation of Resident #22's injury pertaining to the occurrence, nor notification to the resident representatives or physician. Resident #22's Treatment Administration Report (TAR) for April, 2021 contained the following information, in part, R [Right] shin skin tear, cleanse with NSS [Normal Sterile Saline], cover with [brand name] dressing, then border QOD [every other day] every day shift every other day. Start date 4/4/21 0800 [8:00 a.m.] On 04/15/21 at 9:53 a.m., The Director of Nursing (DON) was asked if there had been an incident report completed for Resident #22's skin tear. The DON reported she was not sure what had happened to Resident #22's leg and had not been notified of any injury. On 04/15/21 at 10:03 a.m., Resident #22's right leg dressing was removed by the DON. An open, irregularly shaped area of skin measuring approximately 0.25 cm. (centimeters) wide by 0.50 cm. long was observed. On 04/15/21 at 10:08 a.m., LPN C notified the DON the strap of the lift had rubbed on Resident #22's leg, causing an abrasion. LPN C was unable to recall when the injury had occurred but thought it was over two weeks ago. LPN C reported the injury had drained heavily initially but now it was almost healed. LPN C said an incident report was not completed but normally one would have been. LPN C said they had not notified Resident #22's family of the injury. LPN C thought they had notified the physician of the injury. On 04/15/21 at 1:17 p.m., the DON verified there had not been an incident report completed for Resident #22's skin injury. The DON reported she had just contacted the family member and verified they had not been notified of Resident #22's injury prior to her contacting them. The DON said the policy was to complete an incident report with any type of injury and to notify the resident representatives. On 4/15/21 at approximately 2:00 p.m., the DON provided a copy of the facility's fall policy and reported the fall policy is what should be followed when any type of resident injury occured. regarding to completing an incident injury report along with notifying resident representatives. A review of the facility's Fall Management Guidelines with the most recent revision date of December, 2011 revealed the following information, in part, .4. The licensed nurse will complete an Accident and Incident Occurrence and Investigation Form. 5. The licensed nurse will communicate resident's incidents to the attending physician and the resident's responsible party immediately .7. The licensed nurse will document in the resident chart all pertinent information regarding the incident including: assessment and follow up, notification of physician and responsible party, review of care plan and any new preventative measures .

Based on interview and record review, the facility failed to appropriately follow a pharmacy recommendation for one Resident (#24) from five residents reviewed for medication review. This deficient practice resulted in the potential for adverse medication side effects. Findings include: According to the 'Face Sheet', print date 4/19/21, Resident #24 was admitted to the facility on [DATE] with diagnoses including: enterocolitis due to [CONDITION(S)] (C-diff, a bacterial infection that causes mild to life-threatening forms of diarrhea) and [CONDITION(S)]. Review of her 3/18/21 Minimum Data Set (MDS) assessment revealed Resident #24 scored a 15/15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of Resident #24's 'Progress Note' dated 3/31/21 written by Pharmacist F' read, Medication Regimen Review .See report for any noted irregularities and/or recommendations. Timing of [MEDICATION(S)] should be away from antimicrobial. Rec (recommendation) sent. Review of the [Company name] Consultation Report [Facility Name] electronically signed by Pharmacist F on 3/31/21 read, (Resident #24) has orders to administer a [MEDICATION(S)] (acidophilus given at 0800 & 1600 (6:00 p.m.)) within 2 hours of an oral antibiotic; [MEDICATION(S)] (0800 & 2000 (10:00 p.m.)). Recommendation: Please update the order to give acidophilus at least 2 hours after the administration of [MEDICATION(S)]. Rational for Recommendation: It is recommended to administer probiotics with a bacterial component 2 hours after oral antibiotics to avoid diminishing the effects of the [MEDICATION(S)]. It was noted the Director of Nursing (DON) signed this document on 4/1/21 and wrote Faxed to physician given to nursing 4/1/21. Below the DON's handwritten comment was Physician Assistant H's signature with the comment Agree w/ (with) times. There was no date written by Physician Assistant H's signature to indicate which day they recommended the medication time change. Review of Resident #24's April 2021 Medication Administration Record (MAR) revealed the following physician orders: [MEDICATION(S)] HCL Capsule 125 mg (milligrams) Give 1 capsule by mouth every 12 hours for cdiff for 7 days. Start date: 3/28/21 Time 08:00 and 20:00 (10:00 p.m.) [MEDICATION(S)] HCL Capsule 125 mg Give 1 capsule by mouth one time a day for cdiff for 7 days. Start Date 4/4/21 Time: 08:00 Acidophilus Capsule Give 2 capsule by mouth two times a day for antibiotic use for 30 days. Start date: 3/23/21 Time: 08:00 and 16:00 (6:00 p.m.) It was noted that neither the time of the [MEDICATION(S)] or the Acidophilus times were changed as of 4/15/21. A phone called was made to Pharmacist F who wrote the recommendation for Resident #24. There was no return phone call by the survey exit date of 4/19/21. A phone interview was conducted with Pharmacist G who had routine visits to the facility on [DATE] at 1:19 p.m. Pharmacist G was asked about the recommendation for Resident #24's medication time changes and stated, These two medications (Acidophilus and [MEDICATION(S)]) can interfere with each other's potency if they are taken too close together, so the recommendation was made to change the time of one of these medications to two to three hours after the other. Pharmacist G confirmed that due to the COVID-19 pandemic, they (pharmacists) were not entering into the facility at this time, but doing Medication Regimen Reviews (MRR) outside of the facility and e-mailing those recommendations to the DON. When asked what time frame this recommendation should have been reviewed and/or changed by the physician, Pharmacist G stated, This is not an urgent matter, but we expect a timely response. An interview was conducted with the DON on 4/15/21 at 1:53 p.m. The DON confirmed the medication times were not changed for Resident #24 after the physician assistant agreed with Pharmacist's F recommendations. There was a breakdown after the physician agreed with changing the medication times. The DON confirmed Resident #24's medication times should have been changed immediately after the physician assistant agreed to the recommendation. Review of the facility's Consulting Pharmacist Monthly Drug Review revised on April 2021 read, .Any medication irregularities noted by the Consultant Pharmacist during the monthly review shall be documented on a separate, written report .The written report shall be sent [via email, fax, etc.] to the Director of Nursing(DON)/Designee who will make sure it is sent/communicated to the resident's attending physician/Medical Director (when attending is unavailable) for review The resident's attending physician must document in the medical record that the identified irregularity has been reviewed, and what, if any action has been taken to address it .

Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria pathogen in the facility water system, in accordance with QSO 17-30 Hospitals/CAHs/NH, Revised 7-6-2018, and failed to Develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential to allow for the proliferation and transmission of the bacteria in the circulating water of the building and the spread of Legionella infections in all 32 residents. Findings include: On 4/14/21 at 10:00 APM, an interview with the facility Administrator and Maintenance Director/ Staff A was conducted to review the facility's WMP for the control of Legionella in the water supply system. It was learned through this interview the facility was served by its own Type I Water Supply (as defined by The Michigan Safe Drinking Water Act, Public Act 399, as amended). It was reported the water supply did not have any added disinfectant treatment prior to or after entering the building. A document titled Administrative Policy Manual: Water Management Program; Revision Date April 2019 was presented as the facility's evidence of a Water Management Plan, and consisted of three pages. When asked about an assessment of risk for the building, Staff A stated that he knew there were a couple of dead legs within the plumbing system which needed to be addressed. When questioned as to the location and documentation of these high risk locations, Staff A stated there was no documentation and could not specify where they were. The following components were absent from any documents provided to the survey team as the facility's WMP: A. No reference to the CDC Toolkit Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings or the ASHRAE 188 standard for mitigation, monitoring and control of the pathogen in the water. B. A quantitative inventory and assessment of plumbing fixtures and the identification of high risk fixtures and areas within the building. C. Identification of set critical limits related to the risk areas identified and which can be controlled. D. Identification of defined control measures and locations related to risk and the critical limits which are set. E. Implementation of regular scheduled and defined mitigation program F. An evaluation process to determine how the WMP is functioning.

Based on observation, interview, and record review, the facility failed to properly maintain infection control practices during a COVID-Infection Control Survey. The facility failed to ensure consistent compliance with facility-wide systems for the prevention, identification, and/or control of infection of residents pertaining to appropriate use of Personal Protective Equipment (PPE). This deficient practice resulted in the potential for staff not wearing the correct PPE and/or wearing PPE incorrectly, increasing the risk of infections which could impact all of the residents in the facility. Findings include: On 04/14/20 at 9:46 a.m., the door to Resident #101's room (room [ROOM NUMBER]) was observed to be closed with a door hanger holding PPE, including gowns, gloves, and red biohazard garbage bags. A contact isolation sign was observed on the door of the room next to Resident #101's room; the room marked with the isolation sign was vacant. Housekeeper /Staff F was in the hallway preparing to clean the room and was asked what the protocol was for cleaning Resident #101's room. Staff F did not know and reported they would have to check with their supervisor. On 04/14/20 at 9:50 a.m., the following observations were made in Resident #101's room: A garbage can containing a red biohazard garbage bag with uncontained contact isolation gowns on the outside of the can. The bed had been stripped of the linen; A clear garbage bag containing soiled linen was on the floor. A plastic glass containing approximately one third of a clear liquid on the over the bed table. A blood pressure cuff, stethoscope, and pulse oximetry monitor (a device used to measure oxygen levels in individuals) was on the shelf in the room. On 04/14/20 at 10:25 a.m., Licensed Practical Nurse (LPN) I observed Resident #101's room with this Surveyor. LPN I did not believe Resident #101 had been in contact precautions prior to being transferred to the hospital. LPN I was asked why the PPE for contact precautions had been placed on the door and used contact gowns were in the garbage can. LPN I replied it was confusing and they weren't sure why the contact gowns had been placed on the door and used in the room. LPN I was not sure why the room had not yet been cleaned. On 04/14/20 10:30 a.m., Staff F and housekeeper (Staff G) were observed in Resident #101's room preparing to clean it Staff F and Staff G were unable to describe what type of PPE should be worn in Resident #101's room, and they were unsure if Resident #101 had been on contact precautions. Staff F and Staff Gstated their understanding was that wearing a gown was not needed in contact isolation rooms when the resident was not present. At this time Staff G's face mask was observed to have a bend in it which prevented it from being directly against their face. This Surveyor was able to visualize openings on both sides of the mask. On 04/14/20 at 10:44 a.m., Housekeeping/laundry Supervisor /Staff H was asked what the expectations were for cleaning of contact precaution rooms. Staff H replied the expectation would be for staff to wear the appropriate PPE for the type of precautions the resident had been on. Staff H stated Resident #101's room was to be treated like a contact precaution room and staff should have been wearing contact gowns. Staff H reported for contact rooms, there should be a laundry barrel with a yellow plastic bag to place the linen in. Staff H was aware Resident #101 had been transferred out on Sunday (April 12, 2020) but was not able to determine why the room had not been cleaned sooner. Staff H admitted it should have been cleaned yesterday (Monday, April 13, 2020). On 04/14/20 at 11:27 a.m., Staff G was asked why gowns were not needed to be worn when cleaning resident rooms if the resident was not present. Staff G confirmed that since the resident was not present in the room coughing, a gown did not need to be worn. Staff G was asked if they thought the resident may have touched surfaces and if germs may remain in the room after the resident was gone. Staff G replied when they thought about it that way, they could see why they should wear a gown. Staff G's mask was observed to have a fold in it and did not rest directly on their face. Staff G reported they had not received training on how to apply their face mask. On 04/14/20 at 12:54 p.m., via a telephone interview, LPN J reported they had taken care of Resident #101 on Saturday, April 11, 2020. Resident #101 had been doing well until evening and then had became pale, short of breath and had developed a fever of 99.1. LPN J notified the medical provider on call and had recieved orders for a chest x-ray and labwork. LPN J left at 6:00 p.m. that day. LPN J reported when they came to work on Sunday (April 12), Resident #101's room had PPE on the door and LPN J believed Resident #101 had been placed on contact precautions. LPN J reported wearing a contact gown when going into Resident #101's room until Resident #101 had been transferred out to the hospital on Sunday afternoon. LPN J could not recall whether or not a contact precaution sign had been posted on Resident #101's room. A review of Resident #101's Electromic Medical Record revealed a progress note written by LPN J on 04/11/20 at 17:20 (5:20 p.m.) which contained the following information: Resident up to w/c (wheelchair). Noted pale and SOB (short of breath). VS (vital signs): 180/80 - HR 120, Respers (respiratory rate) 28, Temp=99.1. O2 sat (oxygen saturation level) on RA (room air)=84% . Placed on O2 @ 2 lpm (oxygen at 2 liters per minute). call placed to on call (Nurse Practioner L) Orders to obtain PCXR (portable chest x-ray), CBC (a blood draw to determine a complete blood count), CMP (a blood draw to determine complete metabolic profile). On 04/14//20 at 1:02 p.m., RN K reported being the nurse manager on call over the weekend of April 11-12th and had received a telephone call from the night nurse regarding Resident #101's condition. RN K reported being notified that Resident #101 had a temperature of 99.0 and had experienced shortness of breath. RN K instructed the night nurse to move Resident #101 into room [ROOM NUMBER] and to hang PPE on the door. During an interview with the Infection Preventionist/RN E on 04/14/20 at 2:06 p.m., RN E reported Resident #101 did not have symptoms that would have warranted contact precautions. RN E stated whenever a resident was placed in contact precautions, the policy was to place a contact precaution sign on the resident's door which would provide information pertaining to what type of PPE was required. When asked if all staff had received training on PPE use along with the correct way to apply masks, RN E reported the entire facility had been educated but it had been a couple of months ago. RN E confirmed Resident #101 had been added to the April line listing for infection monitoring and tracking purposes. On 04//14/20 at 3:05 p.m., The Nursing Home Administrator (NHA), the Director of Nursing (DON), and RN E voiced concerns regarding the housekeeping findings regarding PPE. The DON acknowledged the lack of clarity with the housekeeping staff and manager regarding cleaning procedures on the newly designated isolation unit in discerning the difference between COVID-19 and isolation rooms. The DON reported they had educated Staff Gon proper mask usage the day before (April 13). A review of the Protective Attire Techniques policy with the release date of January 2010 revealed the following information, .Mask Techniques 2. Put mask snuggly over nose and mouth . A review of the facility policies Transmission Precautions: Contact and Transmission Precautions: Droplet, both dated April 2013, contained no information pertaining to contact precaution sign usage to provide information on what type of PPE to wear.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as evidence by: A. Failing to label and date food in a manner that ensured identifying appropriate expiration dates. B. Failing to develop and implement policies on the cleaning of fresh melons prior to cutting and serving to the residents. These deficient practices have the potential to result in food borne illness among any or all of the 39 residents in the facility. Findings include: A. On 7/1/19 at 10:50 AM, the initial tour of the kitchen was conducted with Certified Dietary Manager (CDM) A and included observations of the walk in cooler. Four zipper closed packages of sliced sandwich ham were observed on a shelf in the cooler with black marker marking of 5/3/19. An interview with CDM A was conducted at this time and asked if these packages of ham had been frozen and removed from the freezer, to which A replied Yes. When asked what the original use by date stamped on the original package, CDM A stated I'm not sure. When asked when the packages had been removed from the freezer, CDM A replied I am not sure. The packages of ham were void of information including the original use by date, the date removed from the freezer and the current expiration date based on the two previous conditions and facility policy which CDM A stated it must be used within 7 days. The current expiration date cannot exceed the number of days being placed in the freezer ahead of the original use by date or 7 days, whichever is less. This same condition was noted on a container labeled as Mushrooms with a prepare date of 2/20 and a bag of mozzarella cheese with a use by date of 6/29/19. Also during the initial tour, a tray of glass dishes filled with cottage cheese were observed in the walk in cooler. On the tray was the label prepare 6/30 Use by 7/8. An interview with CDM A was conducted and asked if that was an appropriate amount of time allowed between placing the product in dishes and use by date. CDM A stated, That should only be 7 days. A review of the FDA Food Code 2013: 3-602.12 Other Forms of Information. (A) If required by LAW, CONSUMER warnings shall be provided. (B) FOOD ESTABLISHMENT or manufacturers' dating information on FOODS may not be concealed or altered. B. On 7/1/19 at 10:50 AM during the initial tour observation period, two whole watermelons were observed in the walk in cooler. An interview with CDM A was conducted and requested to describe the process for cleaning the exterior of the melon prior to cutting and serving. CDM A stated We run it under water and rub it with our hands. When asked if staff were instructed to use a brush or disinfectant to fully clean the exterior prior to slicing, CDM A stated No. We don't do that. To prevent the transfer of pathogenic bacteria from the exterior of the melon rind into and onto the flesh of the fruit when cutting, it is imperative to fully cleanse the rind prior slicing. 3-302.15 Washing Fruits and Vegetables. (A) Except as specified in ¶ (B) of this section and except for whole, raw fruits and vegetables that are intended for washing by the CONSUMER before consumption, raw fruits and vegetables shall be thoroughly washed in water to remove soil and other contaminants before being cut, combined with other ingredients, cooked, served, or offered for human consumption in READY-TO-EAT form. (B) Fruits and vegetables may be washed by using chemicals as specified under § 7-204.12.

Based on interview and record review, the facility failed to appropriately track infections on facility mapping. This deficient practice resulted in the potential for the spread of infection to all vulnerable facility residents, and the inability to track the source of infections. Findings include: On 07/03/19 at 9:35 AM, a review of the facility infection control program with Registered Nurse (RN) [NAME] revealed the following: For (MONTH) 2019 infection control reporting, Resident # 101 was not on the facility mapping for infections in the facility. The line listing showed Resident # 101 had a respiratory infection, and was prescribed antibiotics on 5/25/19, after a positive chest x-ray on 5/24/19 showed a right perihilar infiltrate (lung field abnormality indicative of infection). [MEDICATION NAME] 1 gm (gram) x 3 days, and [MEDICATION NAME] 750 mg (milligram) x 7 days was prescribed by physician F. RN [NAME] stated (Resident # 101) went home that day, so I didn't put him on there . When asked when an infection should be counted for the facility, RN [NAME] stated Technically 24-48 hours after admission we own the infection . I see what you mean about having it on there (Infection Control Report) . The nurse rounding with him said (Resident # 101) mentioned having trouble breathing on his right side when the physician was walking out of the room. (Resident # 101) was already scheduled to go home the following day. (Resident # 101) was sent home with home care, and the antibiotics . he also went home on an NIV (Non-Invasive Ventilator). No information on Resident # 101 was reflected in the facility infection control summary. For (MONTH) (YEAR) infection control reporting, - Resident #102 was not on the facility mapping for infections in the facility. The line listing showed Resident #102 was written on the line listing and did not contain information in the fields for site, McGeer's Criteria (infection confirmation tool), organism, or date (infection) cleared. Resident #102 was admitted from the hospital on [DATE] with [MEDICATION NAME] (Antibiotic) 875/125 mg twice daily for four days, and [MEDICATION NAME] (Antibiotic) 750 mg daily for 4 days. RN [NAME] stated, I missed that one.

Based on observation, interview and record review, the facility failed to provide a safe environment for one resident (#24) who was at risk for falls. This deficient practice resulted in increased risk for a fall with the potential for serious injuries. Findings include: On 07/02/19 at 10:48 AM, Resident #24 was observed resting in bed, with no staff in the room. The call light was draped on a towel bar fixture attached to the bedside stand, approximately 18 inches from the bed, out of reach of the Resident. A review of the fall risk care plan revised on 6/22/19 revealed the following: Resident #24 was considered a high risk for falls related to Confusion, Wandering, Incontinence, Poor communication/comprehension, Unaware of environmental factors that can increase . risk for falls. The care plan also included the following intervention with a revised date of 5/8/18: Place my call light in reach and ask me to use it for assistance as needed. A review of the quarterly MDS assessment for Resident # 24 dated 5/20/19 revealed short term and long term memory loss with no memory recall ability. According to the above MDS assessment, Resident # 24 was also moderately impaired, and had poor cognitive skills and decisions which required cues and supervision. A review of an incident report dated 1/19/19 revealed Resident #24 had sustained a fall. The incident report indicated Resident #24 was discovered in the room with a laceration to his eye and Resident # 24 was holding a bed sheet to his forehead. On 07/03/19 at 11:40 AM an interview with the Director of Nursing (DON) revealed the following: When asked if it would be expected that a floor should be mopped and left wet for a sleeping, confused and independently ambulatory resident with a falls history, he DON stated I would think that it (the floor) shouldn't (be left wet), to be honest with you .They should have a wet floor sign put out, but then again he would have no idea what to make of a wet floor sign. On 07/03/19 at 12:22 PM, an interview with Housekeeping Staff B revealed the following: When asked if Staff C should have mopped the room of Resident #24 while resting in bed, and knowing Resident #24 was confused, impulsive and ambulatory, Staff B stated No. When asked if Staff C was familiar with Resident # 24 and his mental status, Staff B stated Yes .

Based on interview and record review, the facility failed to properly reconcile controlled narcotic medication after dispensing for one Resident (#7). This deficient practice resulted in the potential for missing controlled narcotic medication, and the potential for undetected controlled narcotic medication diversion. Findings include: On 07/03/19 at 2:02 PM, controlled narcotic medication reconciliation was reviewed with Licensed Practical Nurse(LPN) D for Hall two. A review of the controlled narcotic medication sheet for Resident #7 revealed a count of 11 [MEDICATION NAME] 0.5 mg tablets. A review of the physical count of the medication revealed 10 tablets remaining. A review of the Medication Administration Record [REDACTED]. When asked when narcotic medications should be reconciled, LPN D stated Immediately after being removed from the cart. On 07/03/19 at 2:20 PM the policy and procedures for narcotic medication reconciliation was requested from the DON. A review of the Controlled Substances Management Policy & Procedure for the facility with a release date of (MONTH) (YEAR), revealed the following: It is the policy of this facility to ensure proper monitoring and management of controlled substances. There was nothing to direct licensed staff on when and how documentation should occur for narcotic medications following removal from the secured drawer in the medication cart.

Based on observation, interview, and record review, the facility failed to discard eye medications that remained open beyond the manufacturers recommended discard date for 2 of 2 medication carts reviewed. This deficient practice resulted in the potential for residents to receive expired eye medications which could cause serious damage to the eye as bacteria may have been introduced. Findings include: On [DATE] at 10:31 AM an observation of medication cart storage was performed with Registered Nurse (RN) A. Azelastine 0.05% eye drops for Resident # 1 was observed in the medication cart with an opened date of [DATE] and no other Azelastine eye drops for Resident #1 were available in the medication cart. Review of the EMR for Resident # 1 revealed she had a current order for Azalastine in her medication profile. According to information found on https://patient.info/medicine/azelastine-eye-drops-for-allergies [REDACTED]. This helps to prevent the risk of eye infections. On [DATE] at 10:58 AM An observation of medication cart storage was performed with Licensed Practical Nurse (LPN) B. [MEDICATION NAME] 0.5% eye drops for Resident # 6 was observed in the medication cart with no date opened observed on box or bottle of eye drops. LPN B was asked if the eye drops should be dated for proper timing of discarding medication, and LPN B stated Yes. Natural Balance Tears for Resident # 6 was observed in the medication cart with no date opened observed on the bottle. A review of the EMR for Resident # 6 revealed he had a current order for Natural Balance tears. When asked about the missing date, LPN B stated, It (eye drop bottle) should be dated. Natural Balance Tears for Resident # 5 was observed in the medication cart with date opened written on [DATE]. According to http://apps.who.int/phint/2017/index.html#p/home Multidose ophthalmic drop preparations may be used for up to 4 weeks after the container is initially opened.

Based on observation, interview, and record review, the facility failed to maintain infection control prevention by: 1) Lack of hand hygiene during wound care, and improper hand hygiene technique, 2) Lack of a barrier provided for blood glucose monitoring machine (machine used to check blood sugar levels) in residents rooms, and improper sanitization of glucose monitoring machine. This deficient practice resulted in the potential for bacteria and blood borne diseases to be spread within the facility. Findings include: On 06/20/18 at 08:10 AM Registered Nurse (RN) C was observed performing hand hygiene (hand washing) before and after a medication administration. RN C was observed turning off the faucet each time without a paper towel barrier to prevent recontamination during a medication observation involving insulin administration. According to https://www.verywellhealth.com/how-to-proper-hand-washing-technique- 10, the standard of practice regarding proper sink operation following hand hygiene is as follows: Dry your hands well, using a clean paper towel or allowing your hands to air dry. Nurses and doctors are trained to turn the faucet off with a paper towel or with an elbow . The faucet was turned on with dirty hands, so you may not want to touch it with your freshly cleaned hands. In fact, some sinks in hospitals use foot pedals to make this process easier. On 06/21/18 at 07:20 AM Licensed Practical Nurse (LPN) B was observed performing a blood glucose level test for Resident #230. No barrier was provided for the blood glucose monitor to rest on in Resident #230's room. The blood glucose monitor machine was observed cleansed with an alcohol wipe from a blue container by LPN B after returning to the medication cart. LPN B, following improper cleansing of the blood glucose monitor, proceeded to test Resident # 6's blood glucose level. On 6/21/18 at 07:30 AM, LPN B was observed performing a blood glucose test for Resident # 6. No barrier was provided for the blood glucose monitor to rest on in Resident #6's room. The blood glucose monitor was observed cleansed again with an alcohol wipe from a blue container by LPN B after returning to the medication cart. On 06/21/18 at 4:36 PM AM RN A was observed performing a blood glucose test for Resident #1. The blood glucose monitor machine was observed cleansed with bleach wipe from a yellow container by RN A after obtaining a blood glucose level from Resident # 1. Regarding proper disinfection of blood glucose monitors: This guidance can be found at the FDA's website: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm 5.htm An excerpt from this guidance reads: The disinfection solvent you choose should be effective [MEDICAL CONDITION].[MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device. A list of Environmental Protection Agency (EPA) registered disinfectants can be found at the following website: https://www.epa.gov/pesticide-registration/selected-epa-registered-disinfectants. On 06/19/18 at 05:02 PM Resident # 22 was observed with a wound vac (continual suction to the wound via vacuum to remove exudate and cellular debris) in place to a diabetic ulcer on her left foot. An order was in the Electronic Medical Record (EMR) to Cleanse wound/apply skin prep to periwound area. Cut sponge to size needed and place in wound, cover with adhesive dressing and apply tubing. Wound vac to be attached with a continuous setting at 125. To change wound vac three times weekly. every day shift every Mon, Wed, Fri for Wound care to left heel. On 06/20/18 at 04:18 PM Registered Nurse (RN) D was observed performing a left foot wound vac dressing change with the assistance of Certified Nurse Aide E. RN D began the dressing change and removed the old dressing. During the removal of the old dressing RN Dstated she forgot to bring the trash can for discarding the old dressing. RN D then proceeded to grab the trash can with her left gloved hand, brought it to the bedside, and then discarded the old dressing. RN D then proceeded to continue the dressing change by cleansing the wound with normal saline and gauze with her left hand, without performing hand hygiene after touching the trash can. CNA E held Resident #22's foot up for RN D to perform the dressing change. During the course of the dressing change Resident #22's foot was set down on a clean brief three separate times by CNA E under the direction of RN D after cleansing the wound and prior to application of the new dressing, potentially contaminating the wound surface (inappropriate barrier for a dressing change). When the dressing change was completed, RN D was observed bringing over the wound vac unit with the canister and tubing attached, and during the process of bringing the wound vac over the tubing tip (which plugs into the drain tube on the dressing side) fell on the ground. RN D was observed hooking up the contaminated canister tubing end to the new dressing tubing end without disinfecting the tubing end. On 06/20/18 at 04:40 PM an interview with RN D revealed the following: When this Surveyor discussed the issues regarding the trash can handling during the cleansing of the wound, RN D stated, I understand, and I want to have feedback so I can do better. Regarding the use of a barrier on the bed not designed for that use, RN D stated, I get it, I was going to use a towel, but I thought it would stick to the wound, and to be honest with you, I have never been observed before performing a dressing change like this. When Surveyor discussed hooking up the wound vac tubing after it touched the floor, RN D stated, After hearing all this, now I feel like I need to go in there and do it over again.

Based on observation and interview, the facility failed to Store, prepare, distribute and serve food in accordance with professional standards for food service safety as evidenced by failing to ensure that proper air gaps were provided on the waste lines of one food preparation sink and two ice machines. This deficient practice has the potential of allowing the back flow of contaminated liquids into the sink and ice machines and resulting in a food borne illness among all 37 residents. Findings include: On 8/16/17 at 7:55 am, the food preparation sink in the kitchen was observed to have its waste line directly connected to the sanitary sewer line. The white plastic piping connecting the waste line to the sewer looked relatively new, compared to adjacent plumbing connections. An air gap between the sink's waste line and the connection to the sanitary sewer was absent. An interview with Dietary Manager (DM) C was conducted at this time and asked if some recent modifications had been made to the drain line of the sink. DM C stated Yes. Within the last 6 months. On 8/17/17 at 9:15 am, observations of the physical plant were made with the Nursing Home Administrator and the Maintenance Director/ Staff B. An ice machine in the dining room and an ice machine behind the nurses' station were observed to a bin type machine, in which the ice cubes were created and dropped and held in a bin. From the bin were 1 waste lines directed to and submerged into sanitary drains and were absent of a gap between the bottom of the elbow and pipe transmitting the draining water to the floor drains. A minimum of a 1 gap between the overflow of the drains and the bottom of the ice machine drain line is required.) Pursuant to the 2009 FDA Food Code: 5-402.11 Backflow Prevention. (A) Except as specified in ¶¶ (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed.

Based on observation, interview, and record review, the facility failed to provide wound care, in accordance with accepted standards of care, to prevent contamination of an existing foot ulceration in one resident (#6) reviewed for wound care practices, from a total sample of 10 residents. This deficient practice had the potential to result in worsened medical condition. Findings include: The medical facesheet and the physician progress notes [REDACTED].#6 is a [AGE] year old woman who was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Progress Note of the referring hospital's Primary Care Provider (PCP) dated 8/11/2017 at 14:53 (2:53 p.m.), revealed Resident #6 was returned to the facility on [DATE] with presence of a percutaneously inserted central catheter (PICC line), through which she was to receive administration of [MEDICATION NAME] (antibiotic) for treatment of [REDACTED]. The referring hospital's consultation note dated 8/8/2017 at 10:07 a.m., revealed Resident #6 had undergone a surgical procedure on 8/8/2017 that included . excisional debridement of ulceration (left foot ulcer) . all the way down through subcutaneous tissue and to deep fascia, left calcaneus to remove all nonviable tissue. The ulceration was reported to measure 5 cm (centimeters length) by 5 cm (width) by 5 cm (depth) and . probes down to deep fascia over calcaneal bone. On return to the facility 8/11/2017, Resident #6 continued intravenous administration of [MEDICATION NAME] (1 gram) every 12 hours, as well as use of a wound vac. Use of the wound vac was discontinued on 8/14/2017. Review of the physician order [REDACTED].#6 was to receive wound care that included cleansing of her left heel ulceration with normal saline, application of a collagen powder, covered with a 4 inch by 4 inch dressing, then secured with a Kerlix wrap. During wound care observation on 8/16/2017 at 2:25 p.m., Resident #6 received care of her left foot ulcer from Licensed Practical Nurse (LPN) A, who removed the Kerlix dressing, in part, with use of bandage scissors, then unwrapped the remainder from the foot. LPN A began to remove the 4 inch by 4 inch dressing from the wound, but experienced resistance as the dressing had embedded into the wound base. LPN A began to use a 10 milliliter normal saline pillow to moisten/irrigate the site in an attempt to remove the dressing while pulling at it. Though the dressing was eventually removed, the process had mechanically pulled part of the dressing which had embedded into the wound; this removed some of the yellow slough at the base of the wound, which lead to bleeding. The old dressing revealed presence of serosanguinous return. The edge of the single thickness wound was white and macerated. LPN A brought the Resident's foot to within 6 to 9 inches of his unmasked face to continue an irrigation process of squirting normal saline from a 10 milliliter saline pillow into the wound. LPN A wore no goggles/eye protection. LPN A continued to converse with Resident #6 throughout the wound care procedure, positioned directly in front of the wound which was now within 6 inches of his unmasked face; the wound continued to be open with beads of blood apparent. This had the potential to contaminate the open, bleeding wound. This Surveyor did not participate in the on-going conversation, but did continue to observe the care provided. During an interview on 8/17/2017 at 1:45 p.m. the Director of Nursing said, No, he (LPN A) shouldn't have talked into the wound. I would've put a mask on. Wasn't safe for him either. The wound's already infected and she's (Resident #6) on [MEDICATION NAME]. Not a good practice. We need to do an inservice with our staff. Review of the Center for Disease Control (CDC) Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings (website: CDC.gov/HAI/pdfs) states, Decisions about PPE use are determined by the type of clinical interaction with the patient . During care for any patient, one should assume that an infectious agent could be present in the patient's blood or body fluids, including all secretions and excretions . therefore appropriate precautions, including use of PPE, must be taken. The guidance included patient care activities, including wound irrigation; indications included use of gloves, gown, and mask/goggles or a face shield.

Based on interview and record review, the facility failed to adequately monitor the PT ([MEDICATION NAME] Time) and INR (International Normalized Ratio) levels for 2 residents (#101, #104) of 3 residents reviewed for appropriate blood thinning levels while receiving the medication, [MEDICATION NAME] ([MEDICATION NAME]) from a total resident sample of 7 residents. This deficient practice resulted in Resident #101 being sent to the hospital with uncontrolled epistaxis (bleeding from the nose) and Resident #104 sent to the hospital for a high probability of uncontrolled bleeding. Findings include: An abbreviated survey was conducted on 2/09/16 - 2/11/16 in response to a complaint filed on 2/03/16 which alleged on 2/27/16 .(Resident #101) went to the hospital with a severe uncontrollable nose bleed .related to an INR of 5.8 .the hospital had to administer Vitamin K and platelets .(plus) PRBC's (packed red blood cells) . (Normal INR values for a person with [MEDICAL CONDITION] - Fibulation (A-Fib) is 2.0 - 3.0. The higher the value the thinner the blood and less clotting factors.) A review was conducted of Resident #101's closed clinical file, including face sheet dated 1/09/16 which revealed an [AGE] year old man who was readmitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #101's Minimum Data Set assessment dated [DATE], facility admit hospital history and progress (H & P) and Discharge Plan of Care dated 1/20/16, 1/31/16, Anticoagulant Care Plan, physician and nursing progress notes, Medication Administration Record [REDACTED]. The evidence from the 1/2016 MAR indicated [REDACTED]. Resident #101's Anticoagulant Therapy Care Plan revised on 1/09/16 read, Antidote is Vitamin K .Have on hand for emergencies .monitor/document/report .s/sx (signs and symptoms) of anticoagulant complications: .black tarry stools . A review was conducted of Resident #101's health status notes dated 1/25/16 - 1/27/16. On 1/25/16: all blood levels were ordered and drawn but PT/INR were omitted. On 1/26/16 at 6:10 p.m., (Resident #101) (had) experienced nose bleed .staunched at this time . On 1/27/16 at 12:47 a.m., .abnormal labs received and reviewed (except for PT/INR) .reviewed with Dr At 10:45 a.m., (Resident #101) observed to have black tarry stools this morning and continues to have nose bleed despite interventions to prevent nasal dryness .verbal orders given to transport (Resident #101) for ER (emergency room ) for further diagnostic testing d/t (due to) uncontrolled epistaxis and [MEDICAL CONDITION]. On 2/11/16 at 4:20 p.m. an interview was conducted with Licensed Practical Nurse (LPN) D regarding his admission note for Resident #101, written on 1/21/16. LPN D stated. we (admitting nurses) are supposed to order a baseline PT/INR for all residents (upon) admission to the facility .I did not order one (PT/INR levels) .I forgot . A review was conducted of Resident #101's Discharge Documents from the hospital to another facility dated 1/31/16. The hospital Discharge Documents revealed Resident #101 was admitted to the hospital on [DATE] with acute upper [MEDICAL CONDITION] secondary to supratherapeutic INR .This is the third potentially life-threatening bleed the patient has had while on [MEDICATION NAME] in the last year .[MEDICATION NAME] stopped .received vitamin K and (2 units of) fresh frozen plasma .it reversed .he improved .his (Resident #101's) [MEDICATION NAME] was stopped .risks .far out weighed the benefits at this time . Resident #101's General Laboratory Coagulation Studies revealed Resident #101's PT/INR levels on 1/27/16 were 61.8/5.8. Normal levels for residents receiving [MEDICATION NAME]/[MEDICATION NAME] for A-Fib are PT - 9.2-13.0 and INR - 2.0-3.0. A review of Resident #104's face sheet dated 5/31/15 revealed a [AGE] year old woman was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #104's MAR indicated [REDACTED]. A review of Resident #104's Anticoagulant Therapy Care Plan revised on 6/01/15 read, Antidote is Vitamin K .Have on hand for emergencies .monitor/document/report .s/sx (signs and symptoms) of anticoagulant complications: .blood tinged or frank blood in urine, black tarry stools, headache . A review of Resident #104's INR Laboratory Draws from 6/01/15 through 6/12/15 revealed: upon admission, 6/01/15, laboratory blood work was ordered, all except - PT/INR levels. There were no orders for PT/INR to be drawn. On 6/12/15, PT/INR were drawn - levels came back PT - 110.8, INR - 9.97. Resident #104 was immediately sent out to the hospital for anticoagulant therapy. There had been no monitoring of Resident #104's PT/INR for 12 days. (Normal PT/INR levels for people at high risk for blood clots are PT - 9.2 13.0 and INR - 2.5-3.5) On 2/10/16 at 1:10 p.m., an interview with LPN F was conducted related to Resident #104's trip to the ER after receiving high PT/INR levels. LPN F said she remembered the event because of the high PT/INR levels. LPN F said when she looked back to when Resident #104 was admitted , someone had forgotten to get a beginning PT/INR, there should have been a PT/INR draw when she was readmitted . On 2/11/16 at 4:30 p.m. an interview with the Director of Nursing (DON) was conducted in reference to the lack of PT/INR level blood draws for Resident #101 and Resident #104. The DON stated, we didn't get a PT/INR level for him (Resident #101) while he was here (that time) .missed getting PT/INR for her (Resident #104) too .(upon her admission). ( )

Based on interview and record review, the facility failed to provide adequate staff supervision and/or assistance devices to prevent injury for 1 Resident (#104) of 2 residents reviewed for falls from a total sample of 5 residents reviewed. This deficient practice resulted in Resident #104 falling from her bed and sustaining a fractured hip requiring surgical repair. Findings include: An investigation was initiated at the facility on 3/3/15 of a fall sustained by Resident #104, in her room early in the morning of 2/24/15, resulting in a fractured left hip. A review of radiology records from 2/24/15, found the following clinical impression "Transverse Fracture of Left Femoral Neck". A radiology report dated 2/25/15, documented an "Operative Reduction Internal Fixation (ORIF) Left Hip" for Resident #104 following her fall. A review of Resident #104's Minimum Data Set (MDS) quarterly assessment prior to her fall dated 12/26/14, revealed Resident #104 demonstrated no evidence of cognitive impairment as evidenced by Brief Interview of Mental Status (BIMS) score of 15. A review of Resident #104's plan of care prior to her fall with injury revealed the following requirements: 2 person assistance with bed mobility and repositioning (initiated 7/22/13), 2 person assistance for personal hygiene (effective 12/11/13), and 2 person assistance with toileting (effective 12/11/13). A care plan intervention dated 7/1/14, revealed Resident #104 frequently used a bedpan at night per her request. An interview with Resident #104 was conducted in her room at the facility on 3/5/15 at 9:15 a.m. Resident #104 was requested to recall the incident leading to her fall. Resident #104 reported her roommate had requested assistance with toileting and she (Resident #104) had asked to be placed on the bedpan while staff was in the room. She reported she frequently used the bedside commode during the day, but preferred to use a bedpan at night as staff have to use a lift to get her in and out of bed. Resident #104 indicated she had little control of her legs and this has been a condition since birth. Resident #104's recollection of the Certified Nurse Aide (CNA) that assisted her was different from staff identified in the incident report (facility identified caregiver as CNA "D"). Resident #104 reported 2 staff usually assist her with her requests to use the bedpan. She stated the CNA rolled her to one side and placed the bedpan under her. Resident #104 indicated she let the CNA know she was done. Resident #104 stated the CNA began to roll her onto her side to remove the bedpan. She reported the CNA pushed her legs to the side to make it easier for her to retrieve the bedpan, and her legs just kept on going over the side of the bed and she fell on to the floor landing on her backside. Resident #104 reported being in pain from the fall, and soon a nurse (Registered Nurse (RN) "C" and CNA "K" came into her room to assist her back into bed. A statement completed by CNA "D", dated 2/26/14, revealed she had entered Resident #104's room around 3:20 a.m in response to a call light being on. CNA "D" reported in her statement she had finished getting resident #104 on and off the bedpan when she realized she needed to get a barrier ointment to complete peri care. She reported the ointment was not on Resident #104's night stand, and she went across the room to retrieve it. CNA "D" reported once she got the ointment and was walking back towards resident #104, she witnessed Resident #104's legs sliding off the bed. CNA "D" reported Resident #104 landed on the floor on her knees with her upper torso facing the bed in a kneeling position. Resident #104 was assessed for injury by RN "C" and transferred into her bed via a Marissa lift. CNA "D" stated the following in her statement, "I realized I should've gotten help from another staff member while completing this task. I had not realize (sic) that she required two assist at this time and felt horrible." An interview with the Director of Nursing (DON) on 3/5/15 at 2:30 p.m. confirmed 2 person assistance was required to roll Resident #104 on/off the bedpan as with most all of her cares. ( )

Based on observation, interview and record review, the facility failed to ensure safe wheelchair transport by omitting the use of an assistive device (leg rest/foot pedal) during a dependent transfer; failed to adequately assess wheelchair dependent residents for the need for leg rest/footpedals; failed to ensure staff followed facility policy for wheelchair transport; and failed to develop plans of care which addressed this safety need for two (Residents #101 and #104) of four residents reviewed for safe locomotion from a facility population of 54 residents. Resident #101 was known (per the admission Minimum Data Set assessment dated [DATE]) to be wheelchair dependent for mobility and required supervision for locomotion. Resident #101's balance, transfer ability, core stability, physical capacity, strength and safety awareness were all decreased. Physician orders [REDACTED]. Resident #101 was also known to be at risk for falls and had limitations in self-care ability due to having a fractured right wrist and sprained right knee. On 11/2/13, Certified Nurse Aide "D" transported Resident #101 via a wheelchair without legs rests (foot pedals). Resident #101 catapulted out of her wheelchair. Resident #101 fell on her right side and face which required acute medical attention and admission into a hospital for a right fractured humerus (upper arm), a fractured pelvis, and a right peri-orbital (eye socket) contusion and hematoma. At the time of the survey, Resident #104 was observed being transported without adequate support/devices to prevent her feet from potentially dragging on the floor, creating friction and a resistive force against her feet and legs placing Residents #101 and #104 in immediate jeopardy to their health and safety. On 11/8/13 at 12:30 p.m., the facility management team was notified of the immediate jeopardy identified on 11/8/13 which began on 11/2/13 when the facility failed to provide safe wheelchair transport for Resident #101 and then failed to ensure a process was in place to provide required interventions and monitor Residents #104's safety needs while using a wheelchair. During the completion of the extended survey on 11/8/13, the immediate jeopardy was removed at 4:16 p.m., when this Surveyor verified through observation, interview and record review the following: -All facility residents utilizing wheelchairs for locomotion have had their wheelchairs assessed to ensure foot pedals (leg rests) are available for use. -Care plans were revised to include "foot pedals applied prior to staff transport" for all facility residents utilizing wheelchair for self locomotion. -Upon admission, quarterly and upon significant change, residents will be assessed for ability to self propel, per updated facility policy. -On 11/8/13 during the time frame of 4:05 to 4:40 p.m., residents were observed being transported by staff with the use of foot pedals and staff were able to verbalize the safe dependent transport of a resident. -The facility's policy titled, "Wheelchair Transport" was revised to reflect the need to apply foot pedals prior to staff transporting residents in wheelchair. -Visitors were notified, by posted signage, to report to nursing staff prior to transporting a facility resident. Nursing will provide education to visitors. -Facility staff currently working were educated on the revised wheelchair transport policy and this surveyor confirmed compliance by interview and observation on 11/8/13. -A plan was implemented to educate all staff members prior to the beginning of their next shift. Although the immediate jeopardy was removed, the facility's deficient practice continues at an isolated level with the potential for more than minimal harm pending: -Continuation of the facility's quality assurance program to review all current resident's care plans ensuring appropriate interventions are documented and monitored to ensure proper implementation of leg rests/foot pedals when transporting a resident. -Validation by State Agency of facility's ability to maintain substantial compliance with providing adequate assistive devices (leg rests/foot pedals) when dependently transporting a resident to prevent an accident. Findings include: The face sheet for Resident #101 revealed she was admitted to the facility on [DATE] for rehabilitation from a fall at home, resulting in closed fractures of the distal end of radius (lower arm) and required a cast applied to the area. The physician orders [REDACTED]. The occupational therapist (OT) had signed physician orders [REDACTED]. The physical therapist (PT) had physician orders [REDACTED]. A review of the fall risk assessment (computer generated and untitled) for Resident #101 dated 10/23/13, determined Resident #101 was at "moderate risk" for falls. Resident #101's care plan (not titled) dated 10/24/13, had the "focus" area which read, "alteration in self care and mobility (due to) (fractured) rt. (right) wrist and sprained rt. knee". The interventions for this "focus" area included the need for one person for transfers, weight bearing and activities of daily living (ADLs). The specific ADLs which included the assistance of one were for bathing, dressing and toileting. This care plan also revealed Resident #101's main source of locomotion was a wheelchair. Resident #101's "fall" focused care plan dated 10/24/13, had an intervention which read, "ensure that I am wearing non-skid foot wear". The nursing "progress notes" dated 11/2/13 (at) 1431 hours (2:31 p.m.) found in Resident #101's medical record read, "...observed resident (#101) on the floor on her back in the hallway close to her room with w/c (wheelchair) next to her feet. She did not lose consciousness... she had her casted right arm in a 90 degree position, c/o (complain of) severe pain in that area.... hematoma on the right side of her forehead, small cut at the bridge of her nose with bruising, bleeding and swelling... received orders to transfer her to hospital...for eval (evaluation) and treatment...". The "Incident/Accident Report-unusual occurrence form" dated 11/2/13, indicated Resident #101 was wearing her "non-skid footwear" at the time she catapulted out of her wheelchair. However, the facility did not identify the root cause of Resident #101's fall which resulted in multiple fractures. An "Emergency Department Report" dated 11/2/13 read, "(Resident #101) held her right arm in complete abduction with her hand placed behind her head, complained of severe pain...X-ray work up demonstrates a proximal humerus fracture...large right cephalohematoma (forehead hematoma). With gentle traction and manipulation, the patient's arm was returned to an abducted and internally rotated position...". The "Orthopedic Surgery Consultation" dated 11/4/13 read, "Treatment: ...patient (Resident #101) could start with weight bearing as tolerated. However, it is going to be difficult task in her case as she has got fracture of proximal humerus and also fracture of right distal radius, so one may have to see what is possible and one may have to wait several days to weeks before this could be done... continue with her pain medications". During an interview on 11/8/13 at 9:10 a.m. with Certified Nurse Aide (CNA) "D", he stated he was the CNA involved in the incident with Resident #101 on 11/2/13. CNA "D" stated, "I was pushing her slowly.... no (foot pedals used)... what happened was (I) noticed she was struggling... she appeared fatigued... I went up to her and asked if she wanted a ride... she appeared alert enough not to put her feet down... yes (she was tired) and slightly fatigued." This Surveyor reviewed the facility's policy titled "Wheelchair Transport" dated 11/2013: "Procedure ...3. For residents dependent on wheelchair for transport, leg rest (foot pedals) will be in place for use...". CNA "D" stated he worked for the facility for 7 years and "...yes I believe it (the "Wheelchair Transport" policy) was shared with me at some point...but it didn't come to mind when I took over (for Resident #101)." CNA "D" admitted he frequently assisted a resident (who normally self propelled) with wheelchair transport by allowing the resident to just lift up their feet. CNA "D" added, "Regardless if its 10, 5, or 3 feet ... they need foot pedals, period." A review of the MDS assessment (dated 8/11/13) for Resident #104 indicated she is a [AGE] year old woman who needed extensive assist with locomotion; in transfers to/from her wheelchair she was not steady, and only able to stabilize with staff assistance. A review of the mobility care plan for Resident #104 (dated 11/28/11) reads in part: "(Resident #104) uses a w/c with foot pegs (foot pedals) for locomotion and does require staff to assist her to her desired destination. She is able to move short distances independently." During an observation on 11/7/13 at 3:30 p.m., Activity Aide "C" took Resident #104 from the dining room by pushing Resident #104 in her wheelchair that did not have foot pedals and provided no instructions to Resident #104 to keep her feet lifted up to prevent her feet from being caught on the floor and potentially propelling her onto the floor. ( ) ( )