Every finding on record at West Bloomfield Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area and failed to ensure food brought in from family/visitors was properly handled resulting in the potential to spread foodborne illness to all residents that consume food at the facility. Findings Include: On 7/6/2026 at 9:00 AM on an initial kitchen tour with the dietary manager (DM) L observed the following soiled food contact surfaces: (2) table mounted can openers with accumulated debris on the blades and mounts, and the interior top surface of the microwave oven on the cookline coated with food debris. On 7/6/2026 at 9:05 AM the floor area under the center food holding unit (steam table and adjacent cold holding unit) was observed heavily soiled with dark, wet accumulated build up. A clear plastic container was observed collecting water from a leak in the steam table. During this observation, DM L said that this area is scheduled for a repair this week. On 7/6/2026 at 9:08 AM observed the floor and wall area near the dish machine and around the booster heater unit soiled with accumulated build up. On 7/6/2026 at 9:10 AM observed approximately half of the supply of resident meal service trays worn and damaged with cracked surfaces and broken corners. At this time DM L concurred and indicated that they would work on ordering replacements. On 7/6/2026 at 9:13 AM at the entrance to the dry storage room observed a white plastic hanging pest control device (marked as dichlorvos). Five more of the same products were observed hanging throughout the kitchen on the drainpipes under several sinks. When asked about the product use instructions, DM L showed the product packaging, which indicated the product was restricted from use in enclosed areas and not for use in food service areas. DM L was not aware of these use instructions and removed the devices from use. On 7/6/2026 at 9:30 AM observed (2) sanitation buckets- one with detergent and the other for sanitizer- stored on the prep table immediately adjacent to a serving tray of uncovered portioned dessert cups. When asked where they should be stored, DM L relocated the buckets to a location below the table. On 7/6/2026 at 10:10 AM observed breakfast dishes being cleaned at the high temperature dish machine. When asked when and how the sanitizing temperature was checked, staff V indicated the test strip log and that a 160 degrees F color changing test strip had been run in the morning at 6:00 AM at the start of the shift. At this time, the wash temperature gauge indicated 135 degrees F. An unidentified dietary staff member was asked to verify sanitizing temperatures. They ran temperature indicating strips through the cycle 2 times with no color change which indicated the sanitizing temperature was not being reached. The 2 staff members operating the dish machine continued to load and unload dishes at this time. DM L indicated they would call for service and request the maintenance director come to look. DM L indicated they could use the 3-compartment sink sanitizing for back up. On 7/6/2026 at 10:17 AM when asked about the frequency of checking the dish machine temperatures, DM L indicated once in the morning then again later before lunch dishes. When asked about the required wash temperature, DM L indicated they were not certain what the required wash temperature was. On 7/6/2026 at 10:20 AM Maintenance Director (MD) T arrived and concurred the wash temperature was lower than required. After a several minute pause in running the machine, another temperature indicating strip was affixed to a plate and the color changed, indicating the effective sanitizing temperature was reached. On 7/6/2026 at 4:20 PM observed the dish machine wash water temperature was again 135 degrees F. At this time MD T indicated a service call would be scheduled. On 7/8/2026 at 10:00 AM observed the dish machine wash water temperature was again at 135 degrees F and MD T ran the temperature indicating test strip with no color change. After the dishwashing was paused for approximately 10 minutes, the wash water temperature was observed at 150 degrees F. Another temperature indicating strip was affixed to a utensil and the color changed, indicating the effective sanitizing temperature was reached. Facility policies for kitchen physical facility cleaning and food service equipment cleaning were requested but not made available for review by the time of survey exit. Record review of policy titled Dish Machine- Testing dated 11/11/2014 states: the dish machine temperature is to be checked before each use. This is to be done three times per day, before cleaning breakfast, lunch, and dinner meal dishes and trays. According to the 2022 FDA Food Code: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch .(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 4-202.16 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 7-202.12 Conditions of Use. POISONOUS OR TOXIC MATERIALS shall be: (A) Used according to: (1) LAW and this Code, (2) Manufacturer's use directions included in labeling, and, for a pesticide, manufacturer's label instructions that state that use is allowed in a FOOD ESTABLISHMENT, 7-201.11 Separation. Poisonous or toxic materials shall be stored so they cannot contaminate food, equipment, utensils, linens, and single-service and single-use articles by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning . 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); (2) For a stationary rack, dual temperature machine, 66oC (150oF); (3) For a single tank, conveyor, dual temperature machine, 71oC (160oF); or (4) For a multitank, conveyor, multitemperature machine, 66oC (150oF). 4-703.11 Sanitization of Equipment and Utensils, Methods, Hot Water and Chemical. After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: .(B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 degrees C (160 degrees F) as measured by an irreversible registering temperature indicator; or(C) Chemical manual or mechanical operations, including the application of SANITIZING chemicals .using a solution as specified under 4-501.114. On 7/6/26 at 10:53 AM, an initial screening of residents on the 600 unit was conducted. It was noted there were personal refrigerators in rooms 600-A, 600-B, 602-B, and 612-B. A brief observation of the refrigerators revealed numerous food items contained in the refrigerators in various types of storage containers. It was noted many of the items did not have a date they were placed into the refrigerator. On 7/8/26 at 8:50 AM, a more thorough observation of the refrigerator in room [ROOM NUMBER]-A revealed a black carry out container with a clear lid. The container was not dated and contained a hot dog and hamburger. On 7/8/26 at 8:52 AM, an observation of the refrigerator in 600-B revealed a carry out container with potato salad, a container with a piece of cake, and a cup of soup. None of the food items had dates of when they were placed in the refrigerator. On 7/8/26 at 8:54 AM, an observation of the refrigerator in 602-B was conducted. The fridge was observed to contain a freezer bag of ham chunks, a freezer bag containing a chicken leg and a biscuit, a black plastic container with no lid that contained dinner rolls, and a foam carry out container with chicken tenders and fries. None of the food items had dates of when they were placed in the refrigerator. On 7/8/26 at 9:01 AM, an observation of the refrigerator in 612-B was conducted. The refrigerator revealed three paper bowls with unknown food content covered with aluminum foil, a plastic tub of pre-prepared potato salad that was re-used and contained cherries, a plastic carry out container with a clear lid that contained shredded meat, and a plastic freezer bag that contained several unidentifiable ball shaped food items. None of the food items listed were observed to have dates of when they were placed in the refrigerator. A review of a facility policy titled, Use and Storage of Food Brought in by Family or Visitors dated 8/2024 was conducted and read, .It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident .5. All food items brought in that are already prepared by the family or visitor must be labeled with the date the food was brought in .b. Prepared food must be consumed by the resident within 3 days. c. After 3 days, unconsumed food will be thrown away by facility staff . On 7/8/26 at 10:57 AM, an interview with the facility's Administrator was conducted and they were asked who was responsible for monitoring compliance with the facility's policy for food brought from home. They indicated the managers on the unit were supposed to round every day and remove undated food items or items that had been in the refrigerators more than three days.

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for two (R36 and R60) of two residents reviewed for dignity and four of five residents that participated in the confidential group interview. Findings include:R36:On 7/6/26 at 9:55 AM, Certified Nursing Assistant (CNA 'O') was observed entering in and out of the room occupied by R36 and R60 multiple times without knocking or announcing themselves before entering.On 7/6/26 at 9:58 AM, during an interview with R36 in which the privacy curtain was pulled, CNA 'O' appeared from behind the curtain with a cup of water and began to place the cup on the overbed table without knocking, announcing themselves, or awaiting permission to come over. When R36 was asked if staff usually announced they wanted to enter the room and knock or verbalize their presence/intentions the resident reported there were some that did and some that did not. The resident wanted to wait until CNA 'O' left to continue the interview and asked if they had left the room yet.Review of the clinical record revealed R36 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute cholecystitis, adjustment disorder with depressed mood, and adjustment insomnia. According to the Minimum Data Set (MDS) assessment dated [DATE], R36 had intact cognition. R60:On 7/6/26 at 10:10 AM, CNA 'O' was observed walking in and out of multiple resident rooms, including R60's room without knocking or announcing themselves before entering.On 7/6/26 at 10:22 AM, R60 was attempted to be interviewed but appeared confused and was able to respond only to simple questions. At 12:12 PM, R60 was observed still lying in bed and CNA 'O' was observed seated directly on the bed next to the resident while providing feeding assistance with their lunch meal. CNA 'O' was not observed to seek an alternate seating arrangement.Review of the clinical record revealed R60 was initially admitted into the facility on 1/4/22 with diagnoses that included: Parkinson's disease without dyskinesia, dementia in other diseases classified elsewhere, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and neurocognitive disorder with lewy bodies. According to the MDS assessment dated [DATE], R60 had severe cognitive impairment and was dependent upon assistance with most activities of daily living.Additional observations on 7/6/26 from 12:15 - 12:30 PM revealed continued dignity concerns. CNA 'O' was observed entering multiple resident rooms on the unit without knocking or announcing themselves before entering the rooms.On 7/6/26 at 12:32 PM, an interview was conducted with CNA 'O'. They reported they had worked at the facility for about a month and a half and had been certified for about a year. When asked if they had received any training on dignity and respect during care, CNA 'O' reported they did and it was for things like making sure the call light was on the bed, residents were positioned, and had fresh water. When asked if they should be knocking and/or announcing themselves before entering the rooms, CNA 'O' reported they should. When asked why that had not been done and reminded about their sudden interruption while talking with R36 earlier and the multiple observations for other residents, CNA 'O' reported they were told as part of their training to knock and announce themselves before entering resident rooms and further reported, Ok, that's my fault. Thanks for letting me know. Resident Group Interview:On 7/7/26 at 10:10 AM, a confidential group interview was conducted with five residents. When asked if they felt the staff treated them with respect and dignity, several residents expressed concerns that there were some staff that did not. When asked if they could give details, several residents expressed concerns with staff not knocking/announcing themselves before entering their rooms. Responses included:Not all of them do that, but some they just walk right in.It's part of our rights as residents they should be knocking. Who knows what we could be doing or if we are not decent!On 7/7/26 at 11:38 AM, an interview was conducted with the Director of Nursing (DON). When asked about the facility's process for ensuring residents were treated with dignity and respect and what should be done before entering their rooms, the DON reported staff should be knocking, saying hi can I come in, nursing should definitely be knocking and announcing themselves before coming in. When asked about whether staff should be sitting on the resident's bed while providing feeding assistance, the DON reported that should not happen and was also an infection control concern. The DON was informed of the multiple observations from 7/6/26 and concerns discussed in the confidential resident group interview and acknowledged that should not have occurred.According to the facility's policy titled, Promoting and Maintaining Resident Dignity dated 4/11/2025: .Staff members that are involved in providing care to residents are to promote and maintain resident dignity, and to respect resident rights . There was nothing identified specific to knocking/announcing self before entering the room.Review of the facility's policy titled, Resident Rights under the Michigan Public Health Code dated 9/3/2019: .Each nursing home patient may associate and communicate privately with persons of his or her choice .The facility shall treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility shall protect and promote the rights of the resident .

Based on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the showers and laundry areas. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for all residents that use the unit showers. Findings Include: On 07/06/2026 at 11:25 AM observed accumulated black build up on the tiled floors and walls of the showers in both central shower rooms near nurse station 4. In the shower room to the right, the shower was observed dripping at both the shower head and at the hose attachment near the wall with the handle in the off position. On 07/06/2026 at 2:10 PM observed (2) plastic carts for soiled laundry in the soiled laundry sorting room both with damaged/broken rim area with sharp edges and the false floor spring fabric coverings were frayed or missing. The same carts had debris build up across the inside bottom surface beneath the false floor. At this time when pointed out to the housekeeping director (HK) Q she concurred with this observation. On 07/06/2026 at 2:15 PM when interviewed regarding the cleaning protocols for central shower areas, HK Q indicated being aware of the black build up on central shower tiled areas and that the Sunday floor care staff deep clean in those areas weekly, but it continues to come back.On 07/06/2026 at 4:10 PM during an environmental tour with maintenance director (MD) T observed black build up on tiled floors and walls of the showers in the central shower rooms near nurse stations 1, 2, 3 and 4. MD T indicated that the housekeeping floor care team is responsible for the cleaning of these surfaces and also indicated that the facility is in the process of completing central shower remodeling/resurfacing and some of the tiled areas will be replaced.Record review of a provided document Floor Care Daily Duties indicated that the floor care team is responsible to scrub all shower rooms on Sundays of each week.

Based on observation, interview and record review, the facility failed to ensure a resident was assessed for the safe self-administration of medication for one (R4) of one resident reviewed for self-administration of medication. Findings include:On 7/6/26 at 4:00 PM, R4 was observed seated upright in bed holding a nebulizer mask that was actively in use (a fine mist was coming out of mask). R4 began pulling away the mask and repeatedly yelled more medicine. During this time, R4 was observed to have the nebulizer machine on their bed next to them and repeatedly turned the machine off and on.On 7/6/26 at 4:03 PM, R4's assigned nurse (Nurse 'U') was observed at a medication cart with another nurse a few doors down from R4's room. At that time, the Director of Nursing (DON) approached and asked if they could help with anything. They were asked to come into R4's room and confirmed R4 was self-administering their own medication via nebulizer. The DON proceeded to call for Nurse 'U' to come immediately and informed the nurse they needed to stay with the resident during the nebulizer treatment and not to leave the resident. Nurse 'U' indicated they had initially, but something else had come up. Nurse 'U' then stated to the DON the medication was done, however the DON reported there was still medication in the nebulizer. During this time, R4 repeatedly kept removing their nebulizer mask and stating they needed more medicine.Review of the clinical record revealed R4 was initially admitted into the facility on 5/20/24 and readmitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease (COPD), noninfective gastroenteritis and colitis, unspecified dementia unspecified severity with mood disturbance, anxiety disorder, heart failure, and chronic respiratory failure with hypoxia. According to the Minimum Data Set (MDS) assessment dated [DATE], R4 had a Brief Interview for Mental Status exam (BIMS) score of 11 which indicated moderate cognitive impairment.Review of the physician orders included:Start date 7/1/26: Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG (Milligrams)/3ML (Milliliters)) 0.083% (Albuterol Sulfate) 3 ml inhale orally via nebulizer every 6 hours as needed for sob (shortness of breath).Start date 6/30/26: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 8 hours for COPD EXACERBATION.Further review of the clinical record revealed there was no assessment, care plan or physician's order completed that identified R4 was able to safely self-administer medication via nebulizer.On 7/7/26 at 11:38 AM, an interview was conducted with the DON. When asked about the facility's process for having residents self-administer their own medication, the DON reported there would be an assessment but R4 was not assessed to be able to self-administer their medication via the nebulizer and reported the nurse should have remained with the resident during the treatment.According to the facility's policy titled, Self Administration of Medication dated 2/2023: .Based on the interdisciplinary team's review, a decision is made as to whether or not the resident is a candidate for self-administration. This will be recorded on the Self-Administration of Medication Assessment .if the resident's BIMS - (mental exam) is less than 13 this will also deem the resident inappropriate to self-administer medications .If it is recommended that the resident self-administer their medications, the nurse will obtain a physician's order, care plan, and document in the resident's EMR (Electronic Medical Record) for the patient to self-administer medications .For Nebulizer treatments .The MAR (Medication Administration Record) will note that the resident may self-administer the nebulizer treatment under the Protocol. The nurse will obtain a physician's order, care plan, and document in the resident's EMR for the patient to self-administer .If at any time it is determined that the patient becomes unable to appropriately self-administer the nebulizer treatment the nurse must administer and stay with patient during treatment .

Based on interview and record review, the facility failed to follow physician's orders and notify the physician of a change of condition for one resident (R10) of one resident reviewed for a change of condition. Findings include:On 7/6/26 at 12:42 PM, an interview was conducted with R10. They were asked if they had any concerns with their stay at the facility and said the only thing that bothered them was when their blood sugar levels were up and down. On 7/7/26 at 10:17 AM, a review of R10's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: diabetes, peripheral vascular disease, chronic kidney disease, and urinary retention. R10's most recent Minimum Data Set assessment dated [DATE] indicated R10 had intact cognition. Continued review of the record revealed an order dated 7/1/26 that read, Obtain Blood Sugar TID (three times a day) Notify MD (medical Doctor) if less than 60 or greater than 250. A review of R10's blood sugar levels was conducted and revealed the following: 7/6/26 at 8:13 AM, blood sugar documented as 430 (normal glucose levels are between 60-100) by Nurse 'C'. The record did not indicate Nurse 'C' contacted the physician. 7/6/26 at 4:13 PM, blood sugar documented as 481 by Nurse 'D'. The record did not indicate Nurse 'D' contacted the physician. 7/6/26 at 10:31 PM, blood sugar documented as 461 by Nurse 'D'. The record did not indicate Nurse 'D' contacted the physician. A review of the medication administration record was conducted, and it was discovered Nurse 'C' and Nurse 'D' documented the elevated blood sugar levels on the medication administration record that accompanied the order that indicated the physician was to be notified for levels less than 60 or greater than 250. On 7/7/26 at 12:03 PM, a telephone interview was conducted with Nurse 'D'. They confirmed R10's blood sugars were high on their shift. They were asked if they contacted the physician per the order to report levels less that 60 or greater than 250 and said they did not. On 7/7/26 at 12:14 PM, a telephone interview was conducted with Nurse 'C'. They confirmed R10's blood sugars were high on their shift. They were asked if they contacted the physician per the order to report levels less that 60 or greater than 250 and said they did not. On 7/7/26 at 12:32 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the physician not being contacted about the high blood sugar levels and the DON said they should have read the order and contacted the physician when they documented the levels on the medication administration record. A request for a policy on following physician's orders was requested, however; the facility reported they did not have a policy.

Based on observation, interview and record review, the facility failed to ensure treatment of a cholecystostomy drainage tube was completed in accordance with professional standards of practice for one (R36) of one resident reviewed for drainage tube, resulting in the resident not receiving treatment as ordered, nursing staff inaccurately documenting treatment had been completed, and the potential for further clinical complications. Findings include On 7/6/26 at 9:58 AM, R36 was observed lying in bed and agreed to an interview. When asked if they had any concerns with their care, R36 pulled up their gown and revealed a drainage tube which extended from their right abdomen that had a white bandage dated 7/4. R36 further reported the treatment was supposed to be done daily but the nurses were not doing that. R36 reported they had been very sick and did not want to end up back in the hospital again.Review of the clinical record revealed R36 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute cholecystitis, other cholangitis, acute embolism and thrombosis of left axillary vein, and adjustment disorder with depressed mood.According to the Minimum Data Set (MDS) assessment dated [DATE], R36 had intact cognition.Review of the care plans included, Cholecystostomy drain tubes date initiated 3/23/26, revision on 4/3/26. The only intervention was for enhanced barrier precautions. There was no identification about the monitoring/assessment of the area/tube. Review of the physician orders included:Start date 3/30/26, Cleanse Cholecystostomy drain site with mild soap and water, pat dry, apply 4x4 split gauze around the tube site, then cover with non split 4x4 on top, secure with tape, once daily and prn (as needed) every day shift AND as needed.On 7/6/26 at 12:05 PM, review of R36's Treatment Administration Record (TAR) revealed nursing staff documented the above physician order for the cholecystostomy drain site had been completed (via a check mark and nurse initials) on 7/5 by Nurse 'H' and on 7/6 by Nurse 'F'.On 7/6/26 at 12:38 PM, Unit Manager (Nurse 'I') and Quality Assurance (QA) Nurse (Nurse 'G') were asked to observe R36's cholecystostomy drainage site. R36 gave permission to observe the drainage site and at that time both Nurse 'I' and Nurse 'G' confirmed the dressing was dated 7/4. When asked how that could be since the TAR documentation reflected the treatment had been completed on 7/5 and 7/6, Nurse 'I' reported that was not right and would have to follow-up.On 7/6/26 at 12:41 PM, an interview was conducted with Nurse 'F' who confirmed they were assigned to R36 today. When asked why they had documented the treatment to the cholecystostomy drain site was completed when it was not, Nurse 'F' reported they had planned to do it. When asked to explain the process for administering medications/treatments, Nurse 'F' reported they should do it first, then mark it as completed and was unable to offer any further explanation.Multiple attempts were made to contact Nurse 'H' but there was no return call by the end of the survey.On 7/7/26 at 11:38 AM, an interview was conducted with the Director of Nursing (DON). When asked if they had been informed of the concern with treatments being documented as completed when they were not, the DON reported they had been aware and expressed concern that it could be considered falsification regarding the five rites of medication and confirmed the process was to document the completion once the task is completed. The DON further reported they had attempted to contact Nurse 'H' but had not received any response.According to the facility's policy titled, Professional Standards: Provision of Physician Ordered Services dated 10/22/2021, the policy did not address the nurse's documentation of medication and/or treatments.According to the facility's Charge Nurse job description, .Prepares and administers medications as per physicians' orders .Performs wound treatments as per physicians' orders .Provides direct care skills .

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for tube feeding for one resident (R46), of one resident reviewed for tube feeding, resulting in the potential for unplanned weight loss. On 7/6/26 at 10:30 AM, R46 was observed in bed asleep. A pole with a tube feeding pump was observed at the bedside with no tube feeding formula or water for hydration on the pole. On 7/6/26 at 1:36 PM, a second observation of R46's bedside revealed the pole with tube feeding pump, a bag of water for hydration, and a bag of tube feeding formula. The label on the tube feeding formula bag indicated it had been placed on the pole at 10 AM, despite an observation at 10:30 AM where there was no tube feeding formula or water hanging on the pole. On 7/7/26 at 8:46 AM, a review of R46's clinical record revealed they most recently re-admitted to the facility on [DATE] with diagnoses that included: Parkinson's Disease, high blood pressure, dysphagia, presence of a feeding tube, heart failure and Alzheimer's Disease. R46's most recent Minimum Data Set assessment dated [DATE] revealed R46 had severe cognitive impairment and was dependent on staff for all activities of daily living. A review of R46's clinical record revealed an order for tube feeding formula to be delivered at 70 mL (milliliters) per hour for 16 hours for a total delivery of 1,120 mL's of formula. A review of the medication administration record revealed an order for nursing staff to document the total amount of tube feeding delivered on their shift for days, afternoons, and midnights. The totals for each shift were added together and revealed the following: 7/1/26- 1051 mL of tube feeding formula delivered. 7/2/26- 963 mL of tube feeding formula delivered. 7/3/26- 618 mL of tube feeding formula delivered. 7/5/26- 834 mL of tube feeding formula delivered. 7/6/26- 695 mL of tube feeding formula delivered. 6/1/26- 713 mL of tube feeding formula delivered. 6/2/26- 575 mL of tube feeding formula delivered. 6/3/26- 799 mL of tube feeding formula delivered. 6/7/26- 821 mL of tube feeding formula delivered. 6/8/26- 995 mL of tube feeding formula delivered. 6/9/26- 871 mL of tube feeding formula delivered. 6/10/26- 503 mL of tube feeding formula delivered. 6/11/26- 922 mL of tube feeding formula delivered. 6/14/26- 589 mL of tube feeding formula delivered. 6/17/26- 516 mL of tube feeding formula delivered. 6/18/26- 874 mL of tube feeding formula delivered. 6/19/26- 970 mL of tube feeding formula delivered. 6/20/26- 969 mL of tube feeding formula delivered. 6/22/26- 904 mL of tube feeding formula delivered. 6/24/26- 759 mL of tube feeding formula delivered. 6/25/26- 923 mL of tube feeding formula delivered. 6/26/26-944 mL of tube feeding formula delivered. 6/28/26- 767 mL of tube feeding formula delivered. 6/29/26- 795 mL of tube feeding formula delivered. 6/30/26- 620 mL of tube feeding formula delivered. On 7/7/26 at 10:34 AM, an interview was conducted with Registered Dietician (RD) 'B'. They were asked how they ensured R46 received their entire 1,120 mL dose of tube feeding and said they did not add up the shift totals documented by the nurses, rather; they assessed nutritional needs based on weight changes, physical assessment, and labs. At that time, they were made aware the nursing documentation did not indicate R46 received their full 1,120 mL dose most days through June and July. RD 'B' went on to say they believed R46 was receiving the full dose and nursing were documenting their shift totals incorrectly. They further said they would have to consult with the facility's Director of Nursing (DON) regarding nursing documentation. On 7/7/26 at 11:30 AM, 12:45 PM, and 2:15 PM, an observation of R46 and their room revealed the pole with the tube feeding pump, water for hydration and tube feeding formula hanging. The tubing delivering the water and formula were hooked up to R46's feeding tube, however; upon closer inspection of the pump, it could not be heard delivering the water and formula down the line and the information screen on the pump read, TF (tube feeding) pump flow error clog in line downstream of pump. On 7/7/26 11:42 AM, an interview was conducted with the Facility's DON regarding the documented shift totals of tube feeding delivered to R46 and they agreed the math did not add up. They further reported they would look into why the totals did not add up and indicated re-education would probably be needed for the nurses. On 7/7/26 at 2:34 PM, R36's tube feeding pump was observed with the facility's DON and they acknowledged the pump had a clog in the line and it should have been addressed. A review of a facility provided policy for following physician's orders and tube feeding were requested, however; the policy provided, titled, Tubefeeding Hang-Time dated 9/2019 did not address the concern.

Based on interview and record review, the facility failed to ensure one (R4) of one resident reviewed for food allergies received food that accommodated the resident's food allergy. Findings include:Review of the clinical record revealed R4 was initially admitted into the facility on 5/20/24 and readmitted on [DATE] with diagnoses that included: noninfective gastroenteritis and colitis, unspecified dementia unspecified severity with mood disturbance, moderate protein-calorie malnutrition, and type 2 diabetes mellitus without complications.According to the Minimum Data Set (MDS) assessment dated [DATE], R4 had moderate cognitive impairment, required setup or clean-up assistance with eating, and received a therapeutic diet while a resident.Further review of the clinical record identified multiple allergies which included fish-derived product.Review of the care plans revealed there was a nutritional care plan initiated 7/9/24, revised 7/1/26, however there were no allergies included within that documentation. Interventions included:Provide, serve diet as ordered. Monitor intake and record q (every) meal.Review of the progress notes included an entry on 7/5/26 at 7:05 PM by Nurse 'M' which read:Resident received fish for dinner. Resident has a fish allergy. Resident consumed a small amount. Resident is not having any adverse effects.Review of the most recent dietary assessment by Registered Dietitian (RD 'K') read: .admitted on a Diabetic diet. Will clarify order to Consistent carbohydrate, NAS (No Added Salt). Missing some teeth on top/bottom.Allergies .fish - kitchen aware.On 7/7/26 at 10:48 AM an interview was conducted with RD 'B' who alternates their visits to the facility with RD 'K'. When asked what the facility's process was for serving food for residents with food allergies, RD 'B' reported if a resident has a food allergy that would go on a ticket and the ticket is flagged with the allergies. RD 'B' further reported the dietary staff put a specific sticker for people on the tray line and they (dietary staff) should always be reading and there should be a red strip, and explained they extra flag it to stand out more. RD 'B' reported they would see if they could provide R4's dinner meal ticket from 7/5/26.On 7/7/26 at 11:33 AM, an interview was conducted with the Director of Nursing (DON) who began in their role at the facility on 3/2/26. When asked about R4's incident from 7/5/26 in which they received food they were allergic to, the DON reported there should have been a couple checks between the dietary staff, especially the person preparing the tray and the nursing staff who gave it to her.On 7/8/26 at 1:08 PM, an interview was conducted with the Dietary Manager (Staff 'L'). Staff 'L' reported they were not able to print the meal ticket from 7/5/26, but was able to show it from the computer and reviewed the red stickered allergy label. Staff 'L' further reported it showed it was highlighted in red but their printer doesn't print in color so they used an orange sticker on the actual meal tickets. Staff 'L' reported they were the actual cook for dinner on 7/5/26 and had informed their dietary staff to review their residents with allergies and was not able to explain how R4 received the fish for dinner.According to the facility's policy titled, Menus Nutrition and Preferences dated 7/2024: .Each resident's dietary orders and tray card will reflect interventions to accommodate nutritional and/or medical needs (i.e. food allergies) .

Based on interview and record review, the facility failed to maintain complete and readily accessible medical records for two (R6 and R7) of two residents reviewed for medical records. Findings include: R6:Review of the clinical record revealed R6 was initially admitted into the facility on 7/11/22 and readmitted on [DATE] with diagnoses that included: other heart failure, unspecified severe protein-calorie malnutrition, dysphagia, type 2 diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, and adjustment disorder with anxiety.Review of the monthly pharmacy medication regimen reviews (MRRs) revealed there were four reviews from 10/22/25, 11/17/25, 12/19/25 and 2/6/26 that were documented to see the report for any recommendations.Review of the scanned documentation in the electronic health record (EHR) revealed there was no documentation available for review of the identified irregularities, recommendations or physician responses. R7:Review of the clinical record revealed R7 was admitted into the facility on 6/19/24 and readmitted on [DATE] with diagnoses that included: bilateral primary osteoarthritis of knee, atrioventricular block second degree, bradycardia, primary osteoarthritis left shoulder, anemia, chronic diastolic heart failure, and primary osteoarthritis right shoulder.Review of the MRRs revealed there were two reviews from 8/21/25 and 12/19/25 that were documented to see the report for any recommendations.Review of the scanned documentation in the EHR revealed there was no documentation available for review of the identified irregularities, recommendations or physician responses.On 7/7/26 at 9:30 AM, the Director of Nursing (DON) was asked about where to find the pharmacy recommendations and physician responses and reported the MRR recommendations should be scanned under the documents tab in the EHR. At that time, the DON was asked to review the documents tab and confirmed there was no documentation available and would follow-up.On 7/7/26 at 9:44 AM, the facility was requested to provide the MRRs for R6 and R7 for the above dates. At 11:11 AM, the Administrator reported that for requests prior to May 2026, they were looking from their prior contracted pharmacy. The Administrator confirmed their current contracted pharmacy started on 5/1/26. There was no further documentation provided for the MRR documentation prior to the end of the survey.According to the facility's policy titled, Medication Regimen Reviews - Pharmacy Services dated 10/8/2018: .When irregularities are noted during the MRR, these irregularities are documented on a separate report including, at a minimum, the resident's name, relevant drug, and the irregularity the pharmacist identified .The Consultant Pharmacist will provide copies of the MRR irregularities and recommendations within 3 business days of completion .The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it .If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record .MRRs will be scanned into the EHR via Medical Records after completion and sign off.

This citation pertains to intake 3002054Based on interview and record review, the facility failed to ensure interventions to prevent falls were completed and in place for one resident (R801) of two residents reviewed for falls. Findings include:On 5/12/26 a concern submitted to the State Agency was reviewed which alleged the facility failed to implement interventions to prevent a fall for R801. On 5/12/26 the medical record for R801 was reviewed and revealed the following: R801 was initially admitted to the facility on [DATE] and passed away on 4/29/26 with diagnoses including Neoplasm of Cardia and Neoplasm of Bladder. A review of R9801's MDS (minimum data set) with an ARD (assessment reference date) of 3/21/26 revealed R801 needed assistance from facility staff with most of their activities of daily living. R801's BIMS score (brief interview for mental status) was 13 indicating intact cognition.A review of R801's careplan revealed the following: Focus-admission .Fall Risk r/t (related to) Risk for Falls R/T Weakness. Date Initiated: 03/15/2026 .Interventions-Dycem to wheelchairDate Initiated: 04/26/2026 .PT (Physical therapy) Evaluate and Treat as necessary proper positioning in wheelchair Date Initiated: 04/26/2026 .A Physician's order dated 4/26/26 revealed the following: PT evaluate and treat as necessary proper positioning in wheelchair.A progress note dated 3/15/26 revealed the following: Fall Risk Evaluation Fall Risk: History of falls (past 3 months): No falls in past 3 months. Level of consciousness / mental status: Intermittent confusion. Resident is ambulatory / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. Resident did not have a change in condition in the last 14 days. Recent hospitalization history in last 30 days: Yes. Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Medication: Takes 1-2 of these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 15.0 .A Nurses note dated 4/26/2026 at14:45 revealed the following: CNA (Certified Nursing Assistant) called writer to room to report skin tear directly under right shoulder blade- 8cm(centimeter) long x lcm wide. Patient lying in bed when writer arrived. Writer took note of patient up in wheelchair most of the previous day and patient kept sliding down in chair leading staff to frequently correct patient's position in chair. Writer noted a correlation between where skin tear is located and where back of wheelchair touches just beneath Right shoulder blade. Writer was asked how skin tear happened or if patient had any fears or concerns about incident Patient denies any concerns and stated she did not remember how skin tear happened. Patient shook her head No when asked if anyone purposefully hurt her. Provider called and notified about incident. Cleaned tear- applied 5 steri-strips to close tear, applied triple antibiotic ointment and covered with ABT (abdominal) pad and secured with tape. monitor daily. Son called and notified of incident. Order placed for PT/OT to check wheelchair positioning. call light within reach. Will continue monitor.A Nurses note dated 4/28/2026 at 13:57 revealed the following: CNA called writer to come to patient's room. Patient lying on face on floor- on right side of bed. Patient is fully clothed and has socks and shoes on feet. Patient has dry, intact brief on. Patient was seen by CNA 20 mins (minutes) prior to fall sitting in wheelchair speaking with visiting hospice nurse. Patient was assessed for injury's and then picked up off floor and placed into bed. Call light is laying on patient's bed attached to the bed covers inactivated. Wheelchair was sitting behind patient next to bed with breaks on. Patient stated she was unable to stop from falling forward. Patient denies pain and discomfort. Neuro (neurological) checks started. Grip is equal, pupils are reactive, Patient denies nausea .Patient agreed she would use call light when needing something. Will continue to monitor.A Nurses note dated 4/28/2026 at 15:35 revealed the following: wheelchair taken from patient d/t (due to) safety reasons- Geri (geriatric)-chair obtained for patient.An incident report dated 4/26/26 at 10:30 revealed the following: Notes: Around 10:30 a.m., CNA called nurse to resident's room to report skin tear/abrasion directly under right shoulder blade-8cm long x 1cm wide .Investigation: Resident was lying in bed when nurse arrived. Nurse took note of patient being up in wheelchair most of the previous day, per her preference, and she kept sliding down in w/c (wheelchair) leading staff to frequently re-adjust resident's position in w/c. Nurse noted a correlation between where skin tear is located and where back of wheelchair comes in contact with area of the skin just beneath the right shoulder blade. Nurse asked how kin tear happened or if patient had any fears or concerns about incident-resident denies any concerns and stated, 'she did not remember how skin tear happened.' .Interventions-Dycem anti-skid pad to above and below w/c cushion PT/OT eval (evaluation) for positioning in w/c .An incident reported dated 4/28/26 at 11:00 revealed the following: Un-witnessed Fall .Notes: Around 11 a.m., CNA summoned nurse into resident's room. Resident was obseved lying on her face on the floor of her room-to the right side of the bed Resident was previously observed by the staff 20 minutes (minutes) prior to fall-she sitting in her w/c speaking with hospice nurse .Resident stated she was unable to stop from falling forward off the w/c Investigation: Resident was observed by the staff sliding down out of her w/c during several previous shifts .Intervention: Status changed to Geri-chair .Further review of the medical record did not reveal any PT/OT evaluations per Physician's order on 4/26/26. On 5/12/26 at approximately 11:28 a.m., R801's medical record was reviewed with Therapy Director B (TD B). TD B was asked if they were aware of the Physician's order for R801 to be evaluated by therapy for wheelchair positioning and they indicated it was processed on 4/27 because no one was available to read the orders on 4/26/26. TD B indicated that R801 went on hospice on 4/28 and did not know what happened to the order or communication of the order after that. TD B indicated they did not know if the order was ever communicated to hospice for approval. TD B was asked if the therapy department had ever assessed R801 for positioning and they reported that nobody had and the last time the therapy department had worked with R801 was on 4/16/26. On 5/12/26 at approximately 12:25 p.m., Nurse A was interviewed regarding R801's fall on 4/28/26 and they reported they were notified by a CNA and had gone into to assess R801 when they were on the floor. Nurse A reported R801 was on the floor next to the bed. Nurse A was queried regarding R801's wheelchair and they indicated it was a standard wheelchair with a standard cushion and the brakes were locked. Nurse A was asked if R801 had any anti-skid plastic (dycem) on their cushion and they indicated they did not, and that it was added to R801's wheelchair after their fall. Nurse A was queried reading their note on 4/26 that indicated a PT order for evaluation of wheelchair positioning, and they said they wrote it because they felt R801's w/c was inappropriate for them and to assess for a different chair. 5/12/26 at approximately 1:43 p.m., the ADON (Assistant Director of Nursing) and DON (Director of Nursing) were queried regarding R801's fall. The ADON reported they fell in their room and the resident stated they were unable to stop from falling forward out of wheelchair. The ADON indicated that R801 was observed by sliding out of wheelchair multiple times during several previous shifts. The DON was queried regarding the interventions for R801 to have been assessed for positioning and the dycem to the cushion that was not present when they fell and they reported that all fall interventions on the careplan should have been implemented. On 5/12/26 at approximately 2:58 p.m., during a follow-up conversation with the DON, the DON was queried regarding falls in the facility, and they indicated they had developed an action plan for falls including identifying Past noncompliance with a compliance date of 5/1/26 and had been doing weekly audits Including audits of R801's fall interventions with the week ending of 5/1/26.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included weekly audits of fall interventions and staff education. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake 2696425 .Based on interview and record review, the facility failed to ensure medication was available for administration per Physician's order, utilize the reserve supply of medication for administration and accurately document administration of medication in the medical record for one resident (R903) of two residents reviewed for medication administration. Findings include:On 3/9/26 a concern submitted to the State Agency was reviewed which alleged R903 was not provided their medications according to the Physician's order. On 3/9/26 the medical record for R903 was reviewed and revealed the following: R903 was initially admitted to the facility on [DATE] and had diagnose including Muscle weakness and Low back pain. A review of R903's MDS (minimum data set) with an ARD (assessment reference date) of 11/23/25 revealed R903 needed assistance from facility staff with most of their activities of daily living. R903's BIMS score was 15 indicating intact cognition.A review of R903's care plan revealed the following: Focus-admission #5 Alteration in Comfort / Pain Chronic Pain R/T (related to):, Acute Pain R/T: RA (arthritis), Chronic pain in his back and both shoulders on Tylenol #3 and Lidoderm patch Date Initiated: 11/17/2025 .Interventions-Administer pain medication(s) as ordered, monitor for effectiveness within 30 to 60 minutes. Date Initiated: 10/22/2025 .A Physician's order with a state date of 11/19/25 revealed the following: Acetaminophen-Codeine Oral Tablet 300-30 MG (milligram) (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 4 hours for pain -Start Date- 11/19/2025.A Nursing progress note dated 11/27/25 at 11:30 revealed the following: Health Status Note-Upon arrival of shift Writer was informed in report that resident was in pain due to not receiving scheduled Tylenol #3 r/t (related to) prescription not being refilled. writer spoke with supervisor on duty to notify of situation b/c (because) resident was dissatisfied and (in) excruciating pain. NM (Nurse Manager) contacted MD (Medical Doctor) for authorization code to pull medication from backup. Writer was able to obtain medication from backup, resident consumed medication @apprx 1130. @Apprx 1400 writer went to check on resident's pain level and resident (said) that he is no longer in pain and that the pain medication was effective .An EMAR (electronic medication administration record) note dated 11/27/2025 at 05:23 revealed the following: eMar - Medication Administration Note-Acetaminophen-Codeine Oral Tablet 300-30 MG Give 1 tablet by mouth every 4 hours for pain-waiting on pharmacyA second EMAR note dated 11/27/2025 at 08:46 revealed the following:eMar - Medication Administration Note-Acetaminophen-Codeine Oral Tablet 300-30 MG Give 1 tablet by mouth every 4 hours for pain- on orderA review of R903's controlled substance log for their Acetaminophen-Codeine pain medication revealed R903's last pill from the pharmacy was administered on 11/27/25 at midnight resulting in zero medications remaining for the rest of the doses on 11/27/26. A review of the backup supply medication dispensing system's dispensing log revealed no codeine pills were removed on 11/27/25 until 7:33 a.m., indicating no medications were removed from the backup supply for the 0400 scheduled dose. A review of R903's November 2025 Medication Administration Record (MAR) revealed the 0400 dose was documented as being administered by Nurse A. Further review of the paper Acetaminophen-Codeine controlled log and the electronic backup supply dispensing log did not reveal any documentation that Nurse A had documented removal and administered R903's 0400 dose. On 3/9/26 at approximately 2:15 p.m., the Director of Nursing (DON) was queried regarding the process for ensuring uninterrupted medication administration. The DON reported the facility Nursing staff should be reordering the medications a few days prior to running out, so that the delivery is made before the last dose is given from the previous pack. The DON indicated that if the Nursing staff run out of a medication they should contact the pharmacy and the medical provider to ensure that the medication ban be dispensed from the backup supply to ensure administration in a timely manner. The DON was queried regarding R903's acetaminophen-Codeine controlled logs that indicated no Codeine was given for the 0400 dose and it was missed. The DON indicated that Nurse A documented they gave the 8:00 AM dose, as they had documented evidence that they had pulled it from the backup supply at 733 AM to administer. The DON was queried regarding the scheduled 4:00 AM dose and they indicated that it was documented in the MAR as administered but was not removed on the controlled substance sheet or the backup supply. The DON indicated they attempted to call Nurse A but did not receive an answer. The DON indicated that since no codeine was available in the pack and nothing was dispensed from the backup supply, Nurse A probably made a documentation error on the MAR. The DON indicated that Nurse A should have pulled the medication from the backup supply and administered the codeine at the scheduled dose and time per the Physician's order. The DON indicated that Nurse A did not follow the facility procedures pertaining to the steps to take when medication is not available for administration. On 3/9/26 a facility document titled Medication Orders and Timely Administration was reviewed and revealed the following: .C. PROCEDURE: WHAT TO DO IF A MEDICATION IS NOT AVAILABLE FOR ADMINISTRATION:1. When an ordered medication is not available for administration, the nurse needs to determine why the medication is not available and then check the Electronic Backup Machine inventory list to determine if the medication is available in the Electronic Backup Machine. If so, he/she should retrieve the medication and administer as ordered. The nurse must then call the pharmacy and request the medication be sent on the next delivery.2. If the medication is not available in the backup Electronic Backup Machine, the nurse must call the pharmacy and request the medication be sent on the next delivery or ASAP (as soon as possible) as determined by the particular medication ordered.3. The nurse should ask the pharmacy to provide an expected time of delivery of the medication. If, based on the projected delivery time, the resident will miss an ordered dose of a medication, the nurse should do the following: a. Notify the physician of the expected delay in treatment; b. Document physician recommendations/comments in the interdisciplinary progress note section of the resident's medical record. Additional physician recommendations may include: 1. an order for an alternate medication that is available in the Electronic Backup Machine or available for immediate delivery from the pharmacy; 2. an order to hold the medication or change the administration time; e an order to discharge the resident to the hospital if necessary; or 3. an order for a stock med. c. The nurse should write any new or adjusted physician orders in the physician order section of the resident's medical record and proceed with processing the order. 4. At no time should there be more than one dose of the same medication not administered without the nurse responding to the situation by following this policy. The nurse should notify the Director of Nursing or designee of the situation, if appropriate. 5. If the medication is not available and was not given, the nurse must document as such. Do not document a medication was given, prior to administration of the medication to the resident .

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: 04/09/25 11:20 AM, during an observation of the kitchen with Food Service Director (FSD) B, the following items were observed: The ceiling vent cover near dish machine and above a clean dishware rack, was observed with a thick layer of dust. There were 2 trays of clean coffee cups, with the open side facing up, on the rack underneath the soiled vent. Wen queried as to why the cups were stored uncovered with the open side up, FSD B stated we're getting ready to use them According to the 2017 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. According to the 2017 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, (A) Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. There was a continuous drip of water coming from a pipe underneath the soiled drainboard of the dish machine. There was standing water observed on the floor. FSD B stated she would let Maintenance know. According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and(B) Maintained in good repair. There were 3 male staff members observed with beards, but were not wearing beard restraints. Dietary Staff I was observed serving lunch at the steam table, Dietary Staff J was observed washing dishes and delivering carts to units, and Dietary Staff K was observed preparing food for the dinner meal. When queried about the lack of beard restraints, FSM B stated staff don't wear beard restraints. Review of a policy posted on the bulletin board in the Dietary Department noted: Uniform Policy-Hygiene (Dietary) 4. Mustaches are allowed but must be neatly trimmed. Beards must be well trimmed and covered with effective hair restraint. According to the 2017 FDA Food Code section 2-402.11 Effectiveness, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. The exhaust vent cover in the walk-in cooler was coated with dust. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The ventilation hood was observed with a buildup of grease and dust. The tag on the hood noted it was last serviced 2/2025. When queried, FSD B stated they had just cleaned it 2 weeks ago. The Traulsen refrigerator was observed with black stains on the door gasket. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. There were no red sanitizer buckets set up anywhere in the kitchen. There were several wiping rags observed lying on the counters. Staff was observed using the rags to wipe down counters. FSD B provided no explanation for why the wiping cloths were not being stored in a chemical sanitization solution. According to the 2017 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; On 4/9/25 at 11:50 AM, Dietary Staff L was observed cutting fruit on a cutting board. When finished, Dietary Staff L took the cutting board and knife and washed it with detergent in the food prep sink, and rinsed it under running water. Dietary Staff L then placed the knife back in the holder and placed the wet cutting board on top of a stack of cutting boards on the clean dishware shelf. When queried, FSD B stated the items should have been brought to the dish machine area. According to the 2017 FDA Food Code section 4-701.10 Food-Contact Surfaces and Utensils, Equipment food-contact surfaces and utensils shall be sanitized. On 4/9/25 at 12:05 PM, Dietary Staff J was observed washing a soiled sheet pan in the wash compartment of the 3 compartment sink. The rinse compartment of the 3 compartment sink was not filled with rinse water. Dietary Staff J took the soapy pan, dipped the pan in the sanitizer bin of the 3 compartment sink, and then carried the sheet pan into the kitchen area for use. On 4/9/25 at 12:35 PM, Dietary Staff K was observed draining the sanitizer from the 3 compartment sink, and re-filling with fresh quaternary ammonia sanitizer. When finished, Dietary Staff K began using the sanitizer without testing the concentration with a test strip. When queried about the use of test strips, Dietary Staff K located some quaternary ammonia test strips, which were missing the color wheel and were wet and damaged. According to the 2017 FDA Food Code section 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration, Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device.

Based on observation, interview and record review the facility failed to ensure timely and accurate advanced directive documentation were in place for four (R29, R47, R48 and R71) out of eight reviewed for advanced directives. Findings include: R47 On 4/8/25 at approximately 10:31 AM, R 47 was observed in their room. The resident was alert and able to answer questions appropriately and noted that they had been at the facility for a few years and expressed no concerns. A review of R47's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: chronic kidney disease and congestive heart failure. A review of R47's Minimum Data Set (MDS) (1/2/25) revealed the resident had a BIMS score of 12/15 (moderately impaired cognition). The resident was noted as FULL CODE. Continued review of R47's clinical record revealed the following: 8/4/22: Advanced Directive: Patient received a packet of information about Advanced Directives .An Advanced Directive Information & Acknowledgement Form was signed upon receipt of the above information. Additional information will be provided by the Social Work department and/or physician. *It should be noted that there were no documentations titled Advanced Directives following the packet provided to the resident. 3/25/24: Physician Certification of Resident Capacity: .R47 .As of this date, the above-named resident has been assessed to be .Incompetent to participate in medical treatment, care, and custody decision-making .The reason that the resident is unable to participate is: Moderate cognitive impairment limits capacity for decision-making . 7/5/24: Psychosocial Note: Social Work has completed a quarterly interview .Resident has been here for long term care since 10/13/22. Social Work completed a cognitive screening, and prior Brief Interview for Mental Status (BIMS) score was 14/15. Current BIMS score is 9/15 .Residents current code status is FULL CODE .Does Resident have Medical and/or Financial DPOA: None .Residents dtr states that pt has always refused (for years) to sign DPOA .Dtr states that she will file for guardianship. Resident has been deemed incompetent . *It should be noted that there were no further documents that indicated R47's daughter had applied for Guardianship as noted in the note above. 3/21/25: Physician Certification of Resident Capacity: .R47 .As of this date (3/21/25), the above-named resident has been assessed to be .Competent to designate a DPOA only .Resident understands the function of the DPOA only (resident understands the function of the DPOA and is comfortable with their choice.) *Incompetent to make medical treatment and care decisions .Two (2) Physician signatures are required .The reason resident is unable to participate is lack of knowledge, understanding and appreciation of her med<sic> .without medical status, medications and cognitive deficits . *It should be noted that the document was only signed by a psychologist on 3/21/25. There was no signature by a second party/Physician. 3/24/25: Psychosocial Note: Capacity eval was done on 3/21/25 stating that resident is competent to designate a DPOA, although still incompetent to make medical treatment and care decisions. Writer spoke to residents dtr (daughter-name redacted) .and states that she will complete Medical DPOA paperwork with resident and provide the complete paperwork to our facility by Mon 3/31/24 . On 4/10/25 at approximately 12:49 PM, R47 interviewed about end of life wishes. When asked who made decisions for them, they noted they make their own choices. When asked about end-of-life decisions regarding code status, R47 reported that they would not want to be resuscitated as it was up to God to make their choice. R71 On 4/8/25 at approximately 11:13 AM, R71 was observed lying in bed. The resident was alert, but unable to answer questions asked. R71's son was interviewed at the facility and reported that the resident had been at the facility for over four years and did not express concerns about the resident's care. A review of the resident's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Schizoaffective Disorder, Type II diabetes and Bipolar disease. A review of the resident MDS dated noted the resident had a BIMS score of 9/15 (moderately intact cognition). The resident was noted as FULL CODE. Continued review of the resident's clinical record revealed the following: 4/9/24: Physician Certification of Resident Capacity: .R71 .As of this date (4/9/24) the above-named resident has been assessed to be . Incompetent to participate in medical treatment, care and custody decision-making .The reason the resident is unable to participate is: unable to participate fully in interview .Patient is unaware of his diagnoses . 3/10/25: Physician Certification of Resident Capacity: .R71 .As of this date, the above-named resident has been assessed to be (check one) .Competent to designate a DPOA only .Resident understands the function of a DPOA and is comfortable with their choice. *Incompetent to make medical treatment and care decisions .The reason the resident is unable to participate is lack of knowledge, understanding and appreciation of medical hx (history) .medical status and medications, cognitive impairments and dementia . R29 On 4/8/25 at approximately 10:32 AM, R 29 was observed lying in bed yelling loudly. The resident was alert, but not able to answer questions asked. A review of their clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that include: Alzheimer's disease, type II diabetes and delusional disorders. A review of the Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 3/15 (severely impaired cognition). The resident was noted to be FULL CODE and did not have any documents indicating they had a DPOA (Durable Power of Attorney) paperwork and/or Guardianship paperwork. Continued review of the R29's clinical record revealed the following: 10/12/23: Advanced Directive Information and Acknowledgement: Resident Name: R29 .you are being provided with a packet providing you with more information about DPOA, Legal Guardianship, Living Will, MI-POST, and Do Not Resuscitate (DNR) orders .I am declining the Advanced Directive packet at this time . The document was signed by R29' Responsible Party. *There were no further documents in the resident's clinical record that noted the facility worked with the resident while they were deemed competent to be given the opportunity to form an advanced directive. 3/19/24: Physician Certification of Resident Capacity: .Resident name: R29 .As of this date, the above-named resident has been assessed to be .Incompetent to participate in medical treatment, care, and custody decision-making .The reason that the resident is unable to participate is: Alzheimer's Disease with severe cognitive impairment . 4/2/25: Psychiatry: .The resident was last seen on 3/26/25 .The resident has been experiencing crying episodes and yelling out during the day .The nursing staff notes that the resident's mood varies .Plan: Change Seroquel dosage 75 mg (milligrams) .to 50 mg QHS (once per day at bedtime) and 25 mg daily in the morning; involve family in care . 4/2/25: Order: Seroquel 50 MG .give one tablet by mouth at bedtime for delusions associated with dementia . 4/2/25: Order: Seroquel 25 MG .give one tablet by mouth one time a day for delusions associated with dementia . R48 On 4/8/25 at approximately 10:18 AM, R48 was observed lying in bed. The resident was alert, but not able to answer any questions asked. A review of R48's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease and Parkinsons. A review of the residents MDS noted the resident had a BIMS score of 00/15 (severely cognitively impaired). The resident was noted as FULL CODE. Continued review of R48's clinical record revealed the following: 1/25/21: Physician Certification of Capacity: R48 .As of this date (1/25/21), this resident is: Incompetent to participate in medical treatment, care and custody decision-making .The reason that the resident is unable to participate is: impaired memory .If the resident has executed a Durable Power of Attorney for Medical Decision-Making .the DPOA or Patient Advocate is not in effect (there was no check to indicate the resident had a DPOA at that time) . 11/10/22: Psychosocial Note: SW spoke to pt's son (name redacted) re: advanced directives. Pt does not have a DPOA or legal Guardian and has severe cognitive impairments. SW talked to son about filing for guardianship SW will continue to remain available as indicated . 1/12/24: Psychosocial note: .Current BIMS score is 0/15 .severely impaired .code status: FULL CODE .Does resident have a DPOA: No .SW has talked to resident's son .Son states that he still plans to file for guardianship of resident . 10/11/24: Psychosocial note: Social work has completed quarterly review .Psychotropic Medications: Remeron .DPOA: No .SW has talked to resident's son several times .Son states that he plans to file for guardianship of resident . 3/14/25: Psychosocial note: .Son has still not filed the guardianship paperwork .started the process of petitioning for guardianship . On 4/9/25 at approximately 11:25 AM, an interview was conducted with Social Service Director (SSD) C. SSD C reported they had been employed by the facility for over ten years and was not a licensed social worker, but did work with another social worker that was licensed. SSD C was asked as to the facility protocol pertaining to residents advanced directives. SSD C reported that when residents are admitted to the facility, they are provided with a package that provides information on Advanced Directives including, but not limited to, DPOA forms and information about Guardianship. SSDC was asked about those residents who do not complete or provide legal advanced directive documentation. SSD C noted that they have been working with families/residents that were provided the package, but did not have the paperwork and/or would not complete the forms. SSD C was asked about the forms noted in some of the residents' charts that noted they were competent to appoint a DPOA only but were not competent to make medical treatment and care decisions. SSD C reported that they realized that they had some long-term care residents that had been deemed incompetent and did not have either legal guardianship or DPOA representatives. SSD C noted that for residents they believe might be competent to appoint a DPOA only they followed a Webinar presented by the State's [NAME] (Licensing and Regulatory Affairs) division that noted competency is flexible and that at times and for some residents they can address who they would want to act on their behalf. A continued interview was conducted with SSD C who was asked specifically about certain residents as noted below: SSD C was asked about R47 who was admitted into the facility in 2022 with a BIMS score of 15/15 and never completed and/or provided advanced directive paperwork and then deemed incompetent in 2024. SSD C was asked about the documented dated 3/21/25 that indicated that R47 was deemed competent only to appoint a DPOA. SSD C reported they had been working with this resident and their family regarding guardianship and never received any paperwork. Following a Webinar provided by [NAME] they determined the resident was competent enough to appoint their daughter as their DPOA. *It should be noted that there were no notes in the resident's clinical record that documented the discussion as to who to appoint as the DPOA and why the document had still not been signed by the physician. SSD C was asked about R29 who had been residing in the facility since 2023 and had no legal representative and had been deemed incompetent in 2024. SSD C stated they are now in the process of applying for Guardianship. *It should be noted that the facility did not have any court documentations but did provide an e-mail that indicated that the process was to be started. No further documentation was provided before the end of the Survey. SSD C was then asked about R48 who had been admitted to the facility in 2020 and did not complete and/or provide advanced directive documentation. SSD C reported that for several years they have been asking the family to apply for Guardianship, but they did not. SSD C noted that they are in the process of applying for Guardianship. SSD C and was only able to provide an email note that indicated Guardianship should be started. No further documents were provided by the end of the Survey. SSD C was asked as to why R48's family member was able to consent to their antipsychotic medication Seroquel when they were not the resident's legal representative. SSD C reported that the Psychiatrist did address the situation with the family member. SSD C was asked about R71 who was admitted to the facility in 2020 and did not provide any advanced directive paperwork and then was deemed incompetent in 2024 and later deemed competent to appoint a DPOA in 2025. Again, SSD C reported they were aware of the delay and had made attempt to have the family provide the necessary paperwork and/or apply for Guardianship. Following the Webinar provided by [NAME], the facility determined the resident was competent to appoint a DPOA. On 4/9/25 at approximately 3:02PM, an interview was conducted with Infection Control Nurse/Assistant Director of Nursing (ADON) M. It was determined that R29, R47, R48 and R71 had not been offered vaccinations, including pneumonia, influenza and Covid 19 after being deemed incompetent. The DON reported that as these residents did not have a legal representative at the time the vaccinations were offered and going forward the residents who now have a legal guardian or have been deemed competent only to appoint a DPOA will receive offers for the vaccination. On 4/10/25 at approximately 12:41 PM, an interview was conducted with the Administrator regarding residents who did not have Advanced Directives and/or Guardianship. The Administrator reported that they were aware that they had several residents who did not have Advanced Directives in place timely and were continuing to work on the issue. When asked about the forms that noted residents were competent only to appoint a DPOA, the Administrator reported that they attended a Webinar provided by [NAME] and felt their new approach was appropriate. The facility policy titled, Advanced Directive (3/2024) was reviewed and documented, in part: .Each nursing home resident has the right to be fully informed in advance about his/her care and treatment .the right to participate in planning/his/her care and treatment, unless adjudged incompetent or otherwise found to be incapacitated under State law, the right to formulate an Advanced Directive .A Durable Power of Attorney for Health Care (DPOA-HC) is a document delegating authority to an agent (person) to make heath care decisions in case the individual delegating that authority subsequently becomes incapacitated .A Patient Advocates authority is not activated until the individual is deemed by two doctors to be unable to make medical decisions .Legal representative is a person designated and authorized by an advanced directive or State law to make a treatment decision for another person .Resident Representative .the resident may appoint a person to act as their Resident Representative. Once appointed, the Representative shall have the power to perform the following acts for the Resident: A. Review and execute the Admission Contract .B. make payments to the Facility out of the resident's funds .C. Act as a liaison between the Facility, the Resident and the Resident's family .A Resident Representative does not have legal authority to act form if they cannot make their own medical decisions .A complete Advance Directive or guardianship would need to be completed appointing a Representative as the DPOA-HC .

Based on observation, interview and record review, the facility failed to maintain the confidentiality of medical information for one (R110) of four residents reviewed for dignity. Findings include: On 4/8/25 at 12:02 PM, R110 was observed sitting in a wheelchair in a sitting/dining room located behind the nurse station. Another resident was observed sitting in the area of the nurse station. Licensed Practical Nurse (LPN) G was observed standing between the other resident and the nurse station and projecting loudly, asking R110 if they wanted a Tylenol. R110 explained they did. On 4/8/25 at 12:05 PM, LPN G was observed sitting in front of a computer at the nurse station and appeared to be having a conversation with R110, who was still seated in the room behind the nurse station. LPN G said loudly, It's your Colchicine, for your gout. R110 asked if they had gout. LPN G replied, Yes. During the entire exchange, the other resident was sitting in the hallway between LPN G at the nurse station and R110 in the room behind the station. Review of the clinical record revealed R110 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: gout, heart failure and kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R110 had moderately impaired cognition. Review of R110's April 2025 Medication Administration Record (MAR) revealed R110 received Colchicine 0.6 mg (milligrams) and Tylenol 500 mg at 12:00 PM by LPN G. On 4/11/25 at 9:05 AM, the Director of Nursing was interviewed and informed of the observation between LPN G and R110. The DON explained she was embarrassed by the exchange, and LPN G should have been talking to R110 privately. Review of a facility policy titled, Promoting and Maintaining Resident Dignity dated 9/3/19 read in part, .Speak respectfully to residents; avoid discussion about residents that me be overheard .

Based on observation, interview, and record review, the facility failed to ensure two (R273 and R272) of four residents reviewed for dietary services, received meals according to their preferences. Findings include: R273 On 4/8/25 at 9:27 AM, R273 was observed lying on their bed. A meal tray, consisting of a plate of untouched scrambled eggs, a broken up blueberry muffin and a bowl of oatmeal was observed on the over-bed table across R273. R273 was asked about their mostly untouched breakfast. R273 explained they did not like eggs. Observation of the meal ticket revealed near the top of the ticket NO EGGS was highlighted in yellow. On 4/8/25 at 12:32 PM, observation of R273's lunch tray revealed a bowl of mixed vegetables, milk, coffee and a cookie. R273 was asked if that was all they had received for lunch. R273 explained they had received an egg salad sandwich and the aide had removed it. Observation of R273's lunch meal ticket revealed NO EGGS highlighted in yellow and 1 Egg Salad S/W was listed. R273 was asked if the aide was going to bring something else for them to eat. R273 explained their family had brought them some food the day before, so they would probably eat that. Review of the clinical record revealed R273 was admitted into the facility on [DATE] with diagnoses that included: wedge compression fracture of vertebra, heart disease and glaucoma. According to the Minimum Data Set (MDS) assessment dated [DATE], R273 was cognitively intact. Review of R273's nutritional care plan revealed an intervention initiated 3/3/25 that read, Provide, serve diet as ordered . R272 On 4/8/25 at 10:47 AM, R272 was observed lying on the bed. R272 was asked about food at the facility. R272 explained they were a strict vegetarian and their meals at the facility always had meat. Their family was bringing them food daily for them to eat since they could not eat what was being served to them. On 4/8/25 at 12:34 PM, R272 was observed sitting in a wheelchair in their room. No lunch tray was observed in their room. R272 was asked about their lunch. R272 explained they had brought meat, so the aid had ordered something else. R272's Certified Nursing Assistant (CNA) was observed on the phone ordering a grilled cheese sandwich and a salad for R272. Observation of the tray cart in the hall outside of R272's room revealed R272's tray. The meal ticket read in part, Corned Beef & Swiss on Rye . Review of the clinical record revealed R272 was admitted into the facility on [DATE] with diagnoses that included: malnutrition, diabetes and major depressive disorder. According to a Brief Interview for Mental Status (BIMS) exam dated 4/8/25, R272 was cognitively intact. Review of physician orders revealed a diet order with a start date of 4/1/25 that read, Order: 1800 ADA (American Diabetes Association), Regular texture, Thin consistency; Directions: Vegetarian OVO (does eat eggs) LACTO (dairy products), 2GM (grams) K+ (potassium); Active. On 4/9/25 at 9:08 AM, R272 was observed sitting in a wheelchair in their room. R272 was asked about their dinner the night before. R272 explained they had received a grilled cheese sandwich, the same thing they had for lunch. On 4/9/25 at 11:45 AM, Registered Dietician (RD) A was interviewed and asked about R272 receiving meat when they had a vegetarian diet ordered. RD A explained the order had not been entered correctly, it had only said vegetarian in the directions, not the order itself, so the kitchen must no have seen the vegetarian order. When informed of R273 missing two meals, breakfast and lunch on 4/8/25, because of receiving eggs when no eggs was highlighted on the ticket, RD A had no explanation. On 4/9/25 at 1:55 PM, the Kitchen Manager (KM) was interviewed and asked about R273 receiving eggs twice on 4/8/25. The KM explained it was not on the ticket. When informed the ticket had NO EGGS highlighted in yellow at the top, the KM had no explanation. The KM was asked about R272 receiving meat. The KM explained they did not know R272 was a vegetarian. When informed the diet had been ordered as vegetarian, the KM had no explanation. On 4/10/25 at 12:00 PM, the Administrator was interviewed and informed of R273 missing two meals on 4/8/25 and R272 not receiving their vegetarian diet. The Administrator explained residents should be served food according to their preferences. Review of a facility policy titled, Menus, Nutrition, and Preferences dated 7/2024 read in part, .Resident preferences, including likes and dislikes, will be documented in the resident's chart or try card, and shall be reviewed when planning menus . Each resident's dietary orders and tray card will reflect interventions to accommodate nutritional needs when their preferences exclude a food group (i.e. vegetarian, does not eat daily, etc.) .

This citation pertains to intake #'s MI00147219 and MI00149909 Based on observation, interview and record review, the facility failed to ensure multiple allegations of verbal and physical employee to resident abuse were reported to the State Agency (SA) for two (R404 and R401) of three residents reviewed for abuse. Findings include: R404 A complaint was filed with the SA that read in part, .on 1/27/25, (R404) got into a fight with a nurse's aide possibly named (Certified Nursing Assistant - CNA D) . (R404) was hit with a fist on the top of the head, shoulder, and in (their) chest area during the incident . the nurse's aide got scratched while (R404) was trying to defend (themselves) . other staff were made aware of this incident . On 2/11/25 at 9:30 AM, R404 was observed lying in their bed. R404 was asked if there had been an incident between themselves and an employee at the facility. R404 explained when they were first admitted into the facility and did not know how things were done there, they had asked their aid for a shower on Sunday . the aid told them they did not do showers on Sundays . then a supervisor told the aid to give them a shower . three aides came and called them Bitch because they had told the supervisor and now they had to give them a shower on Sunday . the next evening the aide wanted them to go to bed early and pushed their wheelchair into the bathroom where there was another aide in the bathroom . the aid in the bathroom then hit them on the head, shoulder and chest area . they were in a wheelchair and could only defend themselves by grabbing the aids arm and scratching her . the nurse came and said they all needed to listen to each other . they did not know how they could listen to someone when they were hitting them . later two supervisors came and talked to them about what happened . Review of the clinical record revealed R404 was admitted into the facility on [DATE] with diagnoses that included: arthritis, diabetes and kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R404 scored 15/15, indicating intact cognition, and required the assistance of staff for activities of daily living (ADL's). Review of R404's progress notes revealed: A Health Status Note dated 1/26/25 at 10:02 PM by Licensed Practical Nurse (LPN) B read in part, .Resident was very anxious and combative towards staff while providing ADL this evening . A Health Status Note dated 1/27/25 at 10:11 AM by the Director of Nursing (DON) read in part, .the patient requested a shower which was arranged by the nurse supervisor so (they were) given shower [sic] Sunday. Plus, Sunday evening the patient was being taken by 2 CNAs and a supervisor to the toilet. Patient accused one CNA hitting (them) to (their) forehead (their) chest, so (they) scratched CNA's face, hand and pulled her necklace. The writer and UM (Unit Manager) visited the patient to address issues . On 2/11/25 at 12:25 PM, LPN B was interviewed by phone and asked about the incident between R404 and CNA D. LPN B explained two CNA's were taking R404 to the bathroom . CNA C flagged her down, when she got closer could hear R404 could be heard loudly talking . R404 said CNA D had hit them three or four times . R404 had CNA D's necklace in their hand and CNA D had scratches up her arm . asked CNA D to leave and helped CNA C with the rest of R404's care . tried to calm R404 down, but R404 was upset and also told her about a CNA on the day shift who called them a Bitch . told her Supervisor, LPN F, about what happened . LPN B was asked if she had notified the Abuse Coordinator about R404's allegations of abuse. LPN B explained they were supposed to report all allegations to their Supervisors. When asked if she had ever made a written statement about the incident, LPN B explained she had actually written two statements, because she had forgotten to mention certain details in the first one. On 2/11/25 at 1:48 PM, LPN F , who was the Nursing Supervisor on 1/27/25, was interviewed by phone and asked about the incident involving R404. LPN F explained LPN B told her R404 had said CNA D had hit them . went and talked to R404 who also alleged a day shift CNA had called them a Bitch . called the DON and let her know what had happened. LPN F was asked who was the facility Abuse Coordinator. LPN F explained it was the Administrator. When asked if she had called the Administrator, LPN F explained she did not, she called the DON. Review of a facility provided OCCURRENCE INVESTIGATION for R404 read in part, .Occurrence Date: 01/26/2025 - Afternoon shift . OCCURRENCE: .resident stated to Nurse Supervisor (LPN F ) on the afternoon shift (01/26/2025) that CENA - (CNA D ) hit (them) during a toileting transfer . Occurrence Date: 01/26/2025 - Dayshift Reported by resident the evening of the afternoon shift . OCCURRENCE: Resident stated to nurse supervisor (LPN F ) on the evening of 01/26/2025 that CENA - (CNA E ) had called (them) a bitch regarding (them) taking a shower that morning . On 2/11/25 at 3:06 PM, the DON was interviewed and asked why the incidents between R404 and CNA E and CNA D were not reported to the Administrator and the SA. The DON explained it had been reported to her that CNA C was in the room at the time of the incident, and did not find out until later that CNA C had not been in the room at the time R404 alleged CNA D hit them. On 2/11/25 at 3:30 PM, the Administrator was interviewed and asked why R404 ' s verbal and physical abuse allegations had not been reported to the SA. The Administrator agreed the allegations should have been reported. 38271 R401 On 2/11/25 a concern submitted to the State Agency was reviewed and alleged R401 was slapped at the Nursing station multiple times by a staff member. A review of the MIFRI (Michigan-facility reported incidents) reporting system for Nursing facilities did not reveal any allegation or investigations pertaining to R401 allegedly being slapped by facility staff. On 2/11/25 the medical record for R401 was reviewed and revealed the following: R401 was initially admitted to the facility on [DATE] and had diagnoses including Muscle weakness and Fracture of Lumbar Vertebra and was discharged from the facility on 9/25/24 to the hospital. On 2/11/25 at approximately 9:32 a.m., family member G (FM G) was contacted regarding the allegation and indicated that one of the facility staff had called them at around 3:00 AM (because their mother was agitated) to assist in helping to calm them down. FM G indicated that during that time, R401 informed them that someone had slapped them at the Nursing station and that they had multiple conversations with the Administrator regarding to the allegation. On 2/11/25 at approximately 10:50 a.m., during a conversation with the Administrator, the Administrator was queried pertaining to the allegation of R401 being slapped and they reported they could not remember the incident, but that they would check for documentation of the allegation investigation. On 2/11/25 at approximately 3:08 p.m., the Administrator provided a facility investigation pertaining to the allegation that R401 had been slapped. A review of the investigation revealed the following: Occurrence Investigation .Occurrence Date: 9/24/24-afternoon shift .Family called stating resident informed them that staff hit her arm during the time of her fall. Resident had fall on 09/24/24 and was sent to hospital . On 2/11/25 at approximately 3:14 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the investigation and their conclusion. The DON indicated the resident could not provide any information pertaining to the allegation including any potential perpetrators. The DON indicated that the staff were interviewed and nobody witnessed anything and a skin assessment was done without any new identification of bruising indicating they were slapped. On 2/11/25 at approximately 3:29 p.m., during a follow-up conversation with the Administrator, the Administrator was queried why the allegation and investigation had not been reported to the State Agency and they indicated that it it should have been and would look to report unsubstantiated allegations in the future. On 2/11/25 a facility document titled Abuse Program was reviewed and revealed the following: Policy: It is our policy to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants, clinicians, volunteers, staff or other agencies servicing the resident, family members or legal guardians, friends or other individuals. The focus on the resident and supporting the resident in making their own choices and having control of their daily lives is the approach of person-centered care Component 7: Reporting/Response 7. The facility shall: a. In accordance with CFR 483.12 (c) the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident's property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury

This citation pertains to Intake MI00146824 Based on interview and record review, the facility failed to report an allegation of abuse (from R902) to the State Agency within the required timeframe for one (R905) of one residents reviewed for abuse, resulting in the potential for unidentified or continued abuse. Findings include: A complaint was filed with the State Agency alleging R902 was permitted to sign themself out of the facility after being evaluated as a threat to themself and others. Clinical record review revealed R902 was admitted to the facility on [DATE] with the medical diagnoses: Multiple Sclerosis (nerve damage to the spinal cord and brain), generalized muscle weakness, hypertension, atrial fibrillation (abnormal heart rate). R902 has a self-care deficit related to their musculoskeletal impairment and right hemiplegia (weakness) and uses a motorized wheelchair. R902 Psychological diagnoses include schizoaffective disorder, (a mix of schizophrenia symptoms includes hallucinations, delusions, and mania), personality disorder, anxiety, and depression. A careplan revised on 2/20/2024 documented R902 presents as cognitively intact and current BIMS (Brief Interview for Mental Status) score is 15/15 indicating cognitively intact, however, R902 had an active court appointed Guardian. On 9/17/24 at 9:05 AM, an interview was conducted with R902's assigned Certified Nurse Assistant (CNA) E who acknowledged R902 is easily triggered to become angry and leaves the facility. CNA E mentioned an incident when R902 came out of their room and threw a metal bar directly at CNA D and R905. On 9/17/24 at 9:10 AM, an interview was conducted with CNA D regarding the statement and confirmed not too long ago, R902 came out on their motorized wheelchair, started coming down the hall towards room [ROOM NUMBER] where themself and R905 were positioned. R902 had a metal bar in their hand, pulled it up into the air and threw it towards CNA D and R905. CNA Dsaid it did not hit either of them, but was very close to hitting R905. CNA D confirmed a statement was taken by a charge nurse regarding the incident, but no further interviews were conducted afterwards by the facility. CNA D was inquired if R905 was interviewable, and stated they were not cognively intact and would not have remembered the incident. CNA D had no recollection if the facility notified R905's family of the incident. On 9/17/24 at 2:30 PM, An interview was conducted with Nursing Home Administrator (NHA) and informed of the incident as told by CNA D and CNA E. The NHA acknowledged the incident was not reported by the staff and was not aware. The NHA was informed that CNA D claimed a statement was taken by their charge nurse, but the NHA had no knowledge of the incident. Review of the facilities policy title; Abuse dated 6/2021 documented: Staff shall immediately report abuse/suspected abuse to their supervisor. The supervisor will immediately assess the situation and report the abuse/suspected abuse to the Director of Nursing and/or Administrator .

This citation pertains to Intake MI00146824. Based on interview and record review, the facility failed to ensure additional and revised interventions were in place for one (R902) of one reviewed for behavior, resulting in the potential to exacerbate and further disrupt other residents (including R903, R904). Findings include: A complaint was filed with the State Agency alleging R902 was permitted to sign themselves out of the facility after being evaluated as a threat to themselves and others. Clinical record review revealed R902 was admitted to the facility on [DATE] with the medical diagnoses: Multiple Sclerosis (nerve damage to the spinal cord and brain), generalized muscle weakness, hypertension, atrial fibrillation (abnormal heart rate). R902 has a self-care deficit related to their musculoskeletal impairment and right hemiplegia (weakness) and uses a motorized wheelchair. R902 Psychological diagnoses include schizoaffective disorder, (a mix of schizophrenia symptoms includes hallucinations, delusions, and mania), personality disorder, anxiety, and depression. A careplan revised on 2/20/2024 documented R902 presents as cognitively intact and current BIMS (Brief Interview for Mental Status) score is 15/15 indicating cognitively intact, however R902 had an active court appointed Guardian. On 9/17/24 at 9:25 AM, an interview was conducted with R904 who resides in the room next to R902. R904 acknowledged R902 is aggressively loud, daily hits the wall they share and at times hits the wall so hard and loud, that their personal items fall (off the wall on) to the floor. R904 stated, I was so scared, I would shake .Who knows what is coming next R904 mentioned while visiting with their daughter F, R902 was so hostile hitting the wall and slamming the door it was scary for them both. On 9/17/24 at 10:05 AM, A telephone interview with R904's family member F confirmed approximately five weeks ago on a Sunday afternoon while visiting with R904, R902 was banging on the wall and slamming the door so forcefully, it was terrifying. Family member F went out into the hallway where they observed the staff were ignoring the behaviors from R902. F said they asked the staff if they were going to do anything about what R902 was doing, and the staff commented R902 does this all the time. A charge nurse came over and commented that the facility was trying to evict him, and further acknowledged the aggressive behaviors happens a lot. Family member F commented that the situation was so frightening they (F and R904) were visibly shook up and angry. Family member F remarked that the place where their parent resides should never be that frightening. On 9/17/24 at 10:55 AM, R903 (resident on the side of R902) confirmed R902 drives the motorized wheelchair into the walls, bangs on the walls, slams the door, it is frightening. R902 replied, Scares the hell out me and they (R902) should not be living in this place. On 9/17/24 at 2:30 PM, the Nursing Home Administrator (NHA) was informed of the interviews and commented that they were unaware of these reports from R904's Family member F and R903. Record review of R902's Careplan last revised on 2/20/2024 identifies having .verbally aggressive behaviors .physical aggression episodes such as hitting/banging doors/walls .ineffective coping skills, poor impulse control. All listed interventions for this Focus were created on 10/19/2020 and do not identify any revised interventions for these behaviors.

This citation pertains to Intake MI00146824 Based on interview and record review, the facility failed to maintain and provide complete clinical records for one (R902) reviewed of one, resulting in the facility staff and providers not having access to all pertinent information to care for the resident. Findings include: A complaint was filed with the State Agency alleging R902 was permitted to sign themselves out of the facility after being evaluated as a threat to themselves and others. Clinical record review revealed R902 was admitted to the facility on [DATE] with the medical diagnoses: Multiple Sclerosis (nerve damage to the spinal cord and brain), generalized muscle weakness, hypertension, atrial fibrillation (abnormal heart rate). R902 has a self-care deficit related to their musculoskeletal impairment and right hemiplegia (weakness) and uses a motorized wheelchair. R902's Psychological diagnoses include schizoaffective disorder, (a mix of schizophrenia symptoms includes hallucinations, delusions, and mania), personality disorder, anxiety, and depression. A careplan revised on 2/20/2024 documented R902 presents as cognitively intact and current BIMS (Brief Interview for Mental Status) score is 15/15 indicating cognitively intact, however had an active court appointed Guardian. On 9/17/24 at 2:30 PM, an interview was conducted with the Nursing Home Administrator (NHA)and Social Work Director A. When questioned if there was consent from R902's Guardian for Leave of Absences (LOA) both confirmed there was no consent. Social Worker A acknowledged there is documentation of conversations with R902's Guardian, but they are not available in the electronic medical record. Social Worker A stated there is soft file that has R902's clinical records and documentation, however, it is currently not accessible for other staff to read. A record review of the soft file for R902 was requested and was not provided by the end of the survey.

This citaiton pertains to intake #MI00144557. Based on interview and record review, the facility failed to ensure appropriate consents for treatment were made for one resident (R801) of three residents reviewed for consents, resulting in feelings of frustration. Findings include: On 5/29/24 at 11:47 AM, a review of R801's clinical record was conducted and revealed they originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. R801's diagnoses included: multiple sclerosis, anorexia, chronic ulcer of foot, and a left ischium/buttock pressure ulcer (diagnosis added 4/14/24). Continued review of R801's record revealed a progress note dated 3/19/24 that read, .Capacity eval (evaluation) done today and pt (patient) was deemed incompetent (not able to make complex medical decisions). Pt's DPOA (Durable Power of Attorney) is now in effect . A review of R801's Skin/Wound Notes by Wound Care Nurse Practitioner 'B' revealed the following: A note dated 4/23/24 which indicated a surgical wound debridement (removal of dead or unhealthy tissue from a wound) was done on their left ischium pressure ulcer. The note read, .Patient consent: Patient . A note dated 5/22/24 which indicated a surgical wound debridement was done on their left heel vascular wound. The note read, .Patient consent: Patient . On 5/29/24 at 12:33 PM, an interview with the complainant was conducted. They said they had been made R801's DPOA for healthcare effective 3/19/24. They further went on to explain R801 transferred to the hospital on 5/3/24 and while R801 was in the hospital they were made aware of the pressure wound on R801's hip. They further explained the hospital had to surgically debride the wound, a bone biopsy was performed, osteomyelitis had been discovered, and R801 had been placed on intravenous antibiotics. The complainant said the facility never made them aware of the wound. They further explained when R801 returned to the facility, the staff commented the wound looked better than when it was debrided in the facility. They said they were not aware R801 had any debridement done in the facility and further questioned, Why wasn't I notified as the DPOA? On 5/29/24 at 2:26 PM, an interview was conducted with Wound Care Nurse Practitioner 'B' regarding obtaining consents for R801's debridement procedures. They said they had obtained R801's consent prior to the procedure and it was documented in their notes. They were asked if they were aware R801 had a DPOA for health care as they had been deemed incompetent effective 3/19/24 and said they were not aware. On 5/29/24 at 2:56 PM, an interview was conducted with the facility's Assistant Director of Nursing 'A' and Administrator. They acknowledged the concern and indicated they would be putting a system in place for outside consultants to ensure they were obtaining proper consents. A review of a facility provided Admission packet was reviewed and read, .B. EXERCISE OF RIGHTS .3 .The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative .4. The facility shall treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law . A review of a facility provided policy titled, Condition Changes to Report to Physician Nurses Responsibility for Condition Change dated 4/2020 was reviewed, however; the policy did not contain information pertaining to notifcation of changes.

This citation pertains to intake: MI00143972. Based on interviews and record reviews the facility failed to ensure the required assistance level for care was provided for one (R404) of two residents reviewed for falls, resulting in the resident to have fell from their bed, required a transfer to the hospital due to pain, and admitted with a lateral angulated fracture of the right femoral neck and multiple left rib fractures. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . During the evening shift, the medical professional was changing her (R404's) undergarments. This activity required (R404's name) to be repositioned in the bed and required by protocol to have 2 people present to assist. The second person was unavailable at this time and the medical professional attending to (R404's name) took it upon herself to proceed without the additional member to assist her . The medical bed was positioned at the highest point and the medical professional commence the movement of (R404's name) where she fell from the highest point of the bed to the floor fracturing her hip and ribs . As a result of this incident, (R404's name) required a hip replacement (Right Hip) . Review of the medical record revealed R404 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease with dyskinesia, syncope, and collapse. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 12, which indicated moderately impaired cognition and required staff assistance for all activities of daily livings (ADLs). Review of a Nurse's note dated 4/8/24 at 11:04 PM, documented in part . Resident transferred to the hospital after rolling out of the bed onto the floor during pericare <sic>. Writer called into the room after resident had been picked up off the floor and placed into wheelchair. Resident was crying stating that her right leg was in pain and told staff nurse that she was seeing stars. (Medical Doctor name) informed and stated it was fine to send resident out to hospital . Review of a facility incident report dated 4/8/24 at 10:47 PM, documented in part . Writer given report by staff nurse, stated he was called into the room by cna (certified nursing assistant), when he walked in resident was on the left side of her bed lying on her back leaning towards her right side in between the bed and the wall, can stated resident was being changed for the night and rolled off the bed while the cna was walking to the other side of the bed. Nurse and cna (Certified Nursing Assistant) assisted resident back into bed . resident screaming in pain stating that her right leg was hurting when moved/touched and that she was seeing stars . Per ER (emergency room ) . Imaging results: - Lateral angulated fracture of the right femoral neck. - Minimally displaced left rib fractures . Review of the hospital documentation revealed the following: A Hospitalist Medicine H&P (History & Physical) note dated 4/9/24, documented in part . Right Femoral Fracture . Patient presented to the emergency department via EMS (Emergency Medical Services) . for evaluation of right hip pain status post fall . Family stated that staff at the facility where <sic> changing the patient when she rolled off the bed and landed on her right hip. They stated the patient needed 2 person assist however only 1 person was attending to the patient at the time of fall . right hip x-ray: Lateral angulated fracture of the right femoral neck . Question avulsion injury at the left lesser trochanter. CT (Computed tomography) lumber spine: Chest: Nondisplaced subtle fracture deformity of the left 3rd-1th <sic> rib, laterally/anterolaterally as well as the left 9th rib posterolaterally . management per orthopedic surgery team . Review of the care plans revealed no documentation of the required staff assistance level needed for bed mobility. Review of the facility's Task documentation by the facility's certified nursing assistants for April 2024, documented the following for R404 . ADL- Dressing- hoyer lift x2 extensive assist . Personal Hygiene-x2 extensive assist . Bathing . x2 extensive assist . Locomotion off unit - x2 extensive assist . Bed Mobility- x2 extensive assist . Transferring hoyer lift with extensive 2 person assist minimal . Review of a Physical Therapy PT Evaluation & Plan of Treatment for the certification period of 3/25/24 to 4/23/24, documented the following in part, . Bed Mobility . Total Dependence . Transfers . Total Dependence . Initial Assessment/Current Level of Function & Underlying Impairments . Sitting Balance- Static Sitting = Poor; Dynamic Sitting = Poor, Standing Balance- Static Standing = Poor; Dynamic Standing = Unable . Bed Mobility = Total Dependence . Transfers = Total Dependence . Level Surfaces = Total Dependence . Gross Motor Coordination = Impaired . A history of present problem w (with)/3 or more personal factors and/or comorbidities that impact the plan of care . An examination of 3 or more body structures and functions, activity limitations and/or participation restrictions using standardized tests . Moderate Complexity . This indicated R404 required an extensive, two person assist for transferring, bed mobility and personal hygiene. The aide who provided care to R404 when the fall occurred was identified as Certified Nursing Assistant (CNA) C. On 4/29/24 at 12:07 PM, an interview was conducted with CNA C. When asked about the fall that occurred with R404 on 4/8/24, CNA C replied R404 required a hoyer to transfer into the bed. Once that was done, the CNA that helped them stepped out of the room. CNA C stated they knew R404 was a two person assist for brief changes and bed mobility, however decided to proceed by themselves to provide care for R404. CNA C was asked if they decided to proceed with R404's care due to a lack of staff and CNA C stated in part . No, it was a personal decision . I didn't expect this to happen . We have more than enough (staff) . It should have been two (staff members) . I took full accountability . this is one of my biggest mistakes . CNA C went on to say they were interviewed by the facility Administration staff regarding the incident and informed them of their mistake and took full responsibility for their actions. CNA C stated they received a write up for not following the assistance level implemented for R404's care. Review of a EMPLOYEE COUNSELING & CORRECTIVE ACTION RECORD dated 4/9/24 for CNA C documented in part . 3rd Final Written Warning . Description of Work Rule Violation:_ Failure to complete assigned task and carelessness in the performance of the job assignment . On 4/08/24 around 10pm, employee was changing resident's (R404 facility number) brief while resident was lying in bed. Resident's bed mobility status is Ax2 (assist times two). Employee was changing a resident by herself, which led to resident's accidental roll-off the bed onto the floor and a subsequent right hip fracture. Employee failed to verify resident's bed mobility status via PT (physical therapy)/OT (occupational therapy)/ST (speech therapy) recommendations poster prior to proving <sic> ADLs to a resident, which led to fall . the form was signed by the facility's Assistant Director of Nursing (ADON) and CNA C. A one-on-one education form was attached to the disciplinary action and signed by both the ADON and CNA C. On 4/29/24 at 12:14 PM, the Director of Nursing (DON) and the ADON was interviewed and asked about the fall that occurred with R404 under CNA C's care and the DON stated the CNA (CNA C) failed to follow protocol with the resident's plan of care. The DON stated a final education (disciplinary action) was given to CNA C for the incident that occurred. On 4/29/24 at 12:22 PM, the Administrator was interviewed and asked about the incident that occurred with R404 on 4/8/24 when CNA C was providing care, and the Administrator stated the CNA had done everything right up until the point of the fall. The Administrator acknowledged CNA C failed to follow R404's plan of care and stated it was an unfortunate situation. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake # 9 Based on interview and record review the facility failed to ensure appropriate catheter care was provided for one resident (R#701) of three residents reviewed for catheter care, resulting in pain, acute transfer to hospital and subsequent needle aspiration of the catheter bulb through the skin. Findings include: On 3/11/20 at approximately 10:09 a.m., during a conversation with complainant A (CA), CA indicated that R#701 had been sent to the hospital because the facility Nurse B had inflated their catheter balloon while the catheter was not yet in the bladder and still in the Urethra. CA further indicated that Nurse B was supposed to have used a straight catheter( a soft, thin tube used to pass urine from the body. Straight catheters are usually made of plastic and are only used one time and then thrown away) but had told them that they couldn't find one in the facility and so they ended up using a Foley indwelling catheter (a tube with a balloon that drains urine from your bladder into a bag outside your body). On 3/11/20 the medical record for R#701 was reviewed and revealed the following: R#701 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. disease. A review of R#701 MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/20/19 revealed R#701 had impairments of upper and lower extremities and had an indwelling catheter. A nursing note dated 12/20/19 at 12:09 a.m., revealed the following: Resident complaint <sic> on lower abdominal pain at about 10:43 PM just as skin assessment was being performed, scaled pain 10/10. Call (Physician) and new orders obtained to performed PVR (Post Void Residual) and insert 16Fr (French) Foley (indwelling catheter) if Urine is above 250cc (cubic centimeters) in the bladder, PVR was performed and 378cc Urine retained in Bladder, Catheter inserted and Procedure explained to resident and he verbalize understanding, Catheter placed all the way inside till resistance was felt, no returns noted, 10cc fluid pump in to catheter to encourage returns as resident continues to complain of pain, still no Urine returns, Unable to retract 10cc fluid, call (Physician) and resident ordered to be sent out to (local hospital) Out Via 911 as regular ambulance ETA (estimated time of arrival) was over 2 hours and resident was in excruciating pain. A hospital transfer form dated 12/20/19 revealed the following: Key Clinical Information-ABD (abdominal) and back pain 10/10 spasms .Reason for transfer: Urinary catheter balloon malfunction placement by covering nurse catheter in urethra unable to insert or d/c (discontinue) catheter . A hospital emergency room report dated 12/20/19 revealed the following: History-Patient (R#701 demographics) who is currently residing at (name of nursing home) facility after sustaining compression fractures from a fall. Tonight he was complaining of suprapubic pressure with noted decreased urine output. He was noted to be retaining urine with bladder scan shower <sic> 357cc .Foley was placed but no output was appreciated. Staff inflated balloon with 10 cc of fluid with no urine return. Staff was apparently unable to deflate the balloon or remove the Foley. He was complaining of increased pain so was sent to the ED (emergency department) for further evaluation .ED course .Patient with noted Foley unable to move and with inflated bulb of around 30 cc's verified on imaging of pelvis recommendations by Urology for bedside needle aspiration of the Foley catheter bulb .Review of other clinical data .CT abdomen pelvis without IV contrast: Impression-1. A Foley catheter appears to terminate at the bulbar urethra. Repositioning is recommended .Patient was sent from rehab facility after unsuccessful Foley placement for [MEDICAL CONDITION]. Per patient staff was unable to deflate the balloon catheter or remove the Foley catheter. Patient started experiencing increased pressure and pain in the suprapubic area .CT abdomen and pelvis shows a Foley catheter appears to terminate at the bulbar urethra .Discussed with (name of Physician) recommended palpate the balloon catheter and sticking the balloon with 25 gage needle though the skin .palpated the balloon and confirmed with ultrasound, ER (emergency room } physicians were able to deflate the balloon under aseptic technique sticking 25 gage needle through the skin . On 3/11/20 at approximately 3:35 p.m., during a conversation with Nurse B, Nurse B was queried regarding the catheter insertion procedure for R#701. Nurse B indicated that R#701 was having pain and they asked one of the nursing aides if R#701 had been toileted and they reported they hadn't. Nurse B indicated they called the Doctor and the Doctor ordered PVR and if they were over a certain amount then to insert a catheter. Nurse B reported a bladder scan was done and R#701 had retained urine over the parameter set by the Physician. Nurse B then reported they inserted a Foley indwelling catheter up R#701's Urethra until they felt resistance. At that time no urine output was noted. Nurse B indicated they had 1-2 inches left of the catheter outside the penis. Nurse B then indicated that since no urine output was observed they pumped approximately 10cc of fluid into the catheter to stimulate the bladder. Nurse B was queried if that was a standard procedure for stimulating the bladder when no output was observed and they reported that there were multiple ways to stimulate the bladder and that was the one they had tried. On 3/12/20 at approximately 8:48 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding their knowledge of the procedure that Nurse B used when inserting R#701's catheter and what happened that caused R#701 to be sent to the hospital. The DON stated he inflated the balloon. The DON was queried if Nurse B should have inflated the balloon when no urine return was observed and they had felt resistance and they stated, that's not standard procedure. The DON was queried what Nurse B should have done instead of inflating the catheter balloon when no return was observed and resistance was felt and they indicated they would not have inflated the balloon if no return was observed and resistance was felt. The DON further indicated they would not have inflated the balloon and would have withdrawn the catheter. The DON was queried if any education or inservices on appropriate catheter care was provided to Nurse B and the DON indicated that Nurse B was inserviced on general catheter care and so were the rest of the nurses. The DON was queried if Nurse B was inserviced on not inflating the balloon when no urine return and resistance was felt and they stated, that's nursing 101. At that time the DON was queried for documentation of the education/inservices for catheter care. On 3/12/20 at approximately 9:50 a.m., the DON indicated they knew Nurse B was inserviced on catheter care after R#701's catheter incident but did not have any documentation. On 3/12/20 a facility document titled Facility Infection Control Manual dated 9/26/17 was reviewed and did not reveal any information pertaining to the deficient practice. A reivew of a Nursing Process Manual titled Taylor's Clinical Nursing Skills-5th Edition was reviewed and revealed the following: Insert indwelling catheters to the catheter bifurcation (the 'y' level created by the balloon filling and urinary drainage ports) to assure the balloon is within the bladder to avoid inadvertent inflation of the balloon in the urethra (ANA, 2014; Suna, 2015c) .inproper inflation can cause patient discomfort and malpositioning of catheter .

Based on observation, interview and record review, the facility failed to ensure a resident was not served food that contained an known allergen (wheat/gluten) for one (R#70) of three residents reviewed for allergies, resulting in an Immediate Jeopardy (IJ) when R#70 was served food containing wheat/gluten on 11/4/19 and 11/27/19, with subsequent anaphylactic reaction (tongue and throat swelling, difficulty breathing and difficulty talking) which required administration of an [MEDICATION NAME] injection after each instance. This deficient practice placed R#70 at risk of serious injury, serious harm, and/or death. Findings include: The IJ began on 11/4/19. The IJ was identified on 12/3/19. The Administrator was notified of the IJ on 12/3/19 at 3:25 PM in person and by email. A plan to remove the immediacy was requested. The immediacy was removed on 12/4/19 at approximately 5:00 PM, based on an acceptable plan of removal verified onsite by the survey team. Although the IJ was removed on 12/4/19, the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not yet been verified by the State Agency. On 12/2/19 at 10:40 AM, R#70 was observed seated on the side of the bed with oxygen in use via nasal cannula. When asked about general life in the facility, and whether there were any concerns regarding the facility's food, R#70 reported, I have a gluten and flour allergy, and I have Celiac's disease (an immune reaction to eating gluten, a protein found in wheat, barley, and rye). They had to use the ([MEDICATION NAME] injection). When asked what prompted the facility to have to administer an [MEDICATION NAME] injection, R#70 further reported, They gave me a croissant that wasn't gluten free and it wasn't the first time. I've been working with (name of Registered Dietitian/RD B which obviously doesn't work. When asked if anyone from administration had followed up regarding these incidents, R#70 reported, No. On 12/3/19 at 8:00 AM, R#70's assigned nurse (Licensed Practical Nurse/LPN M) was asked about whether she had ever administered R#70 with an [MEDICATION NAME] injection and reported, I saw another nurse (Nurse Manager L) use from the back up last week. On 12/3/19 at 8:10 AM, R#70 was asked to provide some additional information regarding the facility not providing meals that were gluten free or did not contain flour/wheat and reported, The first time (11/4/19), she (RD B) said she was going to (name of local food supply company) and thought the bun they gave me was gluten free. So I cut in half and I ate the half and started feeling that feeling in my mouth. Just cause it says gluten free all over the ticket, it's not what it is .The second time (11/27/19) was a seafood sandwich. It had a croissant which first made me leery. The girl (unknown Certified Nursing Assistant/CNA) said 'It says gluten free on ticket'. She picked it (croissant) up and dusted off the plate with her hand and I figured a little crumb wouldn't hurt. It (seafood salad) wasn't in it (croissant) but was on it (plate). She (unknown CNA) removed the croissant. I ate it (seafood salad) and started feeling my throat closing up. I had to ask for ([MEDICATION NAME] injection). It was like they didn't believe me. When asked if she could recall any specific names, R#70 was unable to recall any specific staff names. R#70 further reported, It was imitation seafood and that has wheat in it. Now I call to confirm if item (food) is really gluten free .It's really scary . R#70's clinical record was reviewed and revealed R#70 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the face sheet identified R#70's allergies included, Celiac .Gluten Protein .Wheat Containing Prod (product). According to the Minimum Data Set (MDS) assessment dated [DATE], R#70 was cognitively intact (scored 15/15 on the brief interview for mental status exam), had no behavior concerns, and required set up assistance with supervision for eating. Review of R#70's physician orders [REDACTED].>([MEDICATION NAME] injection) 0.3 mg (milligrams)/0.3 mL (milliliters) injection, auto-injector inject 0.3 mg by intramuscular route once as needed for [MEDICATION NAME] .Call 911 with administration .11/04/2019 . Review of R#70's interdisciplinary progress notes included: An entry on 11/4/19 at 1:14 PM by Nurse Practitioner (NP G) read, .epi injection 0.3 mg (milligram) in L (left) lateral muscle thigh. Administered by RN (Registered Nurse) with myself present at the bedside. Tongue was swollen and throat was closing up. Pt (patient) could not breath and could not talk to us. After administered within a few minutes could talk much better and breath freely again .no need for 911. Pt is A&Ox3 (alert and oriented to person, place and time) and stable. PRN (as needed) for any allergic rxn (reaction) again . An entry on 11/27/19 at 1:40 PM by Nurse Manager L read, .Writer was notified by CNA that resident stated she is having allergic reaction. Writer went to resident room, on assessment resident is speaking but in a high pitched tone, wheezing, states that her throat is closing up and tongue is swelling .([MEDICATION NAME] injection) given left thigh. NP arrived in room, also assessed resident. After giving ([MEDICATION NAME] injection) resident states she feels better, symptoms have resolved . Review of R#70's care plans included a focus for Allergies Etiology: Alteration in Immune response R/T (related to) allergies. As Evidenced By: [MEDICAL CONDITION] <sic> ([MEDICAL CONDITION] - swelling of the subcutaneous tissues caused by exposure to drug, venom, dietary, pollen, or animal dander allergens) initiated 10/31/2019 by Nurse Manager L which documented a goal of Resident will be free from allergic reactions while at this facility. Interventions included did not address food served from the kitchen. On 12/3/19 at 2:40 PM, the Administrator was requested to provide any incident/investigation reports for R#70. Review of the documentation provided by the Administrator included a one page document dated 11/27/19, titled NON FALL RELATED TEAM REPORT signed by (illegible signature) and NP G which read, .Patient developed allergic reaction with symptoms of [MEDICAL CONDITION], nurse administered ([MEDICATION NAME] injection) L thigh, in presence of the NP. After the shot, patient developed redness and some bleeding in that area . There was no documentation provided for R#70's incident and/or investigation from 11/4/19. There was no documentation provided that the facility had further investigated either of these incidents. A review of R#70's psychology consultation dated 11/22/19 with Contracted Psychologist HH documented, in part: .referred by SW (social work) and PCP (primary care physician) to assess and treat mood, for purposes of treatment and discharge planning .Resident is referred to follow-up on mood and treat for anxiety, depression and other distress related to placement and medical issues .Resident remains stable with behavior and mood . No documentation pertaining to food allergies was noted in the record. On 12/3/19 at 9:15 AM, an interview was conducted with Nurse Manager [MI] When asked for further details about R#70's incidents which required [MEDICATION NAME] injections on 11/4/19 and 11/27/19, Nurse Manager L reported, The CNA came out and said she (R#70) felt like she was having an allergic reaction. I was here at the desk. I went there and she said she felt like her throat was closing. Was talking a little weird too. She told me that she had eaten the seafood salad and I didn't know about gluten free. The Nurse Practitioner (NP G) was here. She came down .I went and got ([MEDICATION NAME] injection). When asked if this incident had been documented, Nurse Manager L reported, I didn't personally, I remember talking to the DON (Director of Nursing). When asked if there was any education or training regarding R#70 receiving non-gluten free food from the kitchen, Nurse Manager L stated, Not that I'm aware of. I did speak with (name of Certified Dietary Manager/CDM K) and RD [NAME] We did talk about it in our daily meeting the next day and discussed she (R#70) received the ([MEDICATION NAME] injection) and that she was given the salad. I'm not sure as far as a plan going forward. On 12/3/19 at 9:30 AM, an interview was conducted with RD [NAME] When asked about R#70's incidents of allergic reactions to food provided by the facility, RD A reported, I was not present for both times. I do know (CDM K) talked to staff to check ticket. On 12/3/19 at 9:52 AM, an interview was conducted with CDM K. When asked to provide details of R#70's incidents of allergic reactions to food provided by the facility, CDM K reported, I recall we had grilled chicken on a bun. Her ticket said grilled chicken only. When I questioned my staff, that person did not pay attention to the tag. After that (first occurrence on 11/4/19), everyone (dietary staff) was in-serviced and informed. (Dietary Aide/DA Y) is on his final write-up. We now have a posting of for sure what they (resident's with allergies) can and cannot have. Put in on the 4th after the day of the incident. When asked if interventions were implemented following the first time, how did the second occurrence happen, CDM K reported, Another incident happened, I believe it was immitation crab salad that had hidden wheat in the crab. When asked if R#70 should not have received a croissant as well, CDM K reported, I was not aware R#70 was served a croissant. (R#70's) would be served on the gluten free bread. That was an error. I wasn't notified until after an hour after (second occurrence) and they (nursing staff) called down and said yes she (R#70) had a reaction to it. When asked what had been implemented following the second occurrence, CDM K reported, We just talked about it cause they're (dietary staff) used to just the bread and not the crab. Since happened, now it's (seafood salad) changed to a seafood salad without the crab. We didn't do another in-service with staff regarding the crab incident, just changed the menu. CDM K provided a disciplinary record for DA Y which documented, Employee Counseling & Corrective Action Record .11-4-19 .Description of Work Rule Violation: (DA Y) was scheduled as the checker on 11/4. He put a plate with a bun on the tray, her menu option was grilled chicken breast. The ticket stated Allergy as gluten free. The resident consumed the sandwich on a regular bun. and had a <sic> allergic reaction. When asked about this resident, (DA Y) stated that he asked the cook. The cook denied that the allergy was called. Then he added that he thought the bun was GF (gluten free), but the menu clearly stated Grilled Chicken Breast vs on a bun . This document was signed by the DA Y and CDM K on 11/6/19. Review of an additional document attached to this disciplinary form was a meal ticket for R#70 for Monday 11/04/19 which documented, .DIET Menu: Gluten Free .ALLERGENS Gluten Wheat .NOTES GLUTEN FREE EXTRA BUTTER HONEY WITH TEA .03 ENTREES Grilled Chix (chicken) Breast - 3 ounce . On 12/4/19 at 10:00 AM, an interview was conducted in person with CNA [NAME] When asked about R#70's food allergies and whether she was aware of any occurrences following receiving food from the kitchen, CNA J reported, I gave (R#70) the tray. She put her light on and said 'I don't think I can have it. It might have gluten.' She got salad with a croissant. I said I could call the kitchen and got new bread (gluten free) for her. I said don't touch it (croissant) and called (kitchen) to see if she can have the salad and was told yes. On 12/4/19 at 10:45 AM, an interview was conducted with NP [NAME] When asked to recall R#70's occurrences which required [MEDICATION NAME] injections, NP G reported, First time, they paged me and I immediately assessed. She was wheezing. I think it was a regular hamburger bun. She is gluten free and has allergy. To my recollection the kitchen knew about it (allergy). She was wheezing, tongue was swollen, redness on chest and face .Her throat was closing. At that time, I saw the nurse administer the ([MEDICATION NAME] injection). The second time, I happened to be walking by it was the same wheezing, tongue swollen and they (nursing staff) had already began to administer the ([MEDICATION NAME] injection). I was told there was a bruise. Right away I saw red at administration site .It was actual anaphylactic reaction given swollen tongue and throat. When asked if there was any concern that R#70 may not be having actual reaction from food, could it be a behavior and/or acting out, NP G stated, Given my observation and symptoms she was having, it was an actual anaphylactic reaction. She is a person who has high anxiety. Upon admission, she did say (to NP G) 'It's a pretty severe allergy and allergic to wheat.'. When asked if there would be any additional documentation following these occurrences by herself, or the attending Physician, NP G reported, There is no other documentation anywhere else. (Physician F) assesses upon admission, and then I follow thereafter. According to an Nutritional Quality of Fake Crabmeat. Healthy Eating | SF Gate, http://healthyeating.sfgate.com/nutritional-quality-fake-crabmeat-1119.html. 20 (MONTH) (YEAR), .Fake crabe meat, also called imitation crab, does not contain any crab meat at all. Its Japanese name, surimi, actually means ground meat .Fake crab meat contains more than ground fish. To create a paste that holds its shape, food manufacturers also add starch from wheat .If you are gluten- or wheat - intolerant or have celiac disease, surimi is not a safe alternative for you . Review of the facility's Select Menu policy dated 10/2019 documented, in part: .Each facility will provide alternatives for residents with food allergies, intolerances .Menus will be assigned that correspond to the diet order, allergy or food preference as follows: a. Gluten allergy or intolerance-gluten free regular menu . The facility submitted the following plan to remove the immediacy on 12/4/19: I am requesting an abatement of the Immediate Jeopardy of F-692. Please see the following submission of immediate corrective actions taken to address F-692 at the level of Immediate Jeopardy. Also included are actions taken to prevent a similar occurrence in the future. 1. [NAME] 11/04/19 occurrence: Resident #70 has a gluten/wheat allergy and requires a gluten/wheat free diet. On 11/04/19 the resident received a non-gluten free sandwich bun on her lunch tray. The resident took a bite of the bun which triggered an allergic reaction. At the time of the allergic reaction, the resident was assessed by nursing and received an epi injection. The dietary employee responsible for checking resident meal trays on was re-educated on proper checking of trays on the meal tray line (with emphasis on food allergies) on 11/04/2019 and also received written disciplinary action. Dietary staff were in-serviced on 11/04/2019 regarding the proper checking of tray contents during the meal tray line. B. 11/27/2019 occurrence: Resident #70 received a crab salad sandwich with a croissant for lunch which caused an allergic reaction. At the time of the allergic reaction, the resident was assessed by nursing and received an epi injection. The dietary manager reviewed all foods on the gluten free menu for gluten/wheat ingredients on 12/03/2019. Any foods found with gluten/wheat were removed from the gluten free menu and replaced with appropriate foods. The menu was changed accordingly. The Dietary Consultant that created the gluten free menu was notified of the occurrence and verbally in-serviced on 12/03/2019. 2. On 12/03/2019, the Dietitian reviewed the food/ingredients in all of the facility's allergy diets to ensure they were appropriate for each specific diet. No other issues were found. An audit was completed of current residents with food allergies to ensure each resident's diet reflected their specific food allergies. The meal trays of residents with food allergies were audited for accuracy. No other issues were found. On 12/04/2019 an immediate hold was placed on admission of residents to the facility with any food allergies. The hold on admissions will remain in effect until substantial compliance is achieved as deemed though <sic> the facility's QA/QAPI committee. 3. The dietary manager and assistant manager will personally monitor and check the food trays of all residents with food allergies to ensure compliance for all three meals daily. On the managers day off a specified dietary employee will be responsible for checking the trays and ensuring compliance. The person checking the meal trays for accuracy will log their audit results for each meal on all residents with allergies. The Administrator and/or designee will randomly audit the dietary staff member assigned to check resident meal trays for accuracy. This will be completed for one meal daily. A list of all residents with food allergies will be posted on the tray line and at the end to notify staff of residents' dietary allergy needs. All dietary staff will be re-educated on proper assembly of resident food trays and the checking of tray items against any food allergies listed on the residents' meal ticket. All nursing staff will be in-serviced on delivery of meal trays to residents with food allergies and how to address resident questions and concerns. If a resident with food allergies questions the food on their meal tray, nursing staff will be in-service to hold the resident's tray, immediately notify dietary, and dietary will immediately see the resident, deliver their tray, and answer any questions regarding their food. Snacks will be labeled with regards to each type of food allergies, so staff will be able to identify which snacks are appropriate for each resident with food allergies.

Deficient Practice #1 Based on observation, interview and record review, the facility failed to ensure 70% Isopropyl Alcohol (a known toxic substance) was not accessible to two (#712 and #715) sampled residents reviewed for accident hazards who were cognitively impaired, from a total sample of 15, and five (#61, #77, #78, #91, and #92) supplemental sampled residents who were cognitively impaired, resulting in Resident #715 ingesting Isopropyl Alcohol and the potential ingestion by six additional residents which could result in intoxication, nausea, vomiting, [DIAGNOSES REDACTED], over-sedation, respiratory depression, and falls with injury, serious harm, or death. This results in an immediate jeopardy (IJ) to the health and safety of these residents. The immediate jeopardy was identified at 9:25 A.M. on 5/23/16. The administrator was notified of the immediate jeopardy on 5/23/16 at 1:05 p.m. and a plan of correction was requested to remove the immediacy. The IJ was removed on 5/24/16 at 8:30 a.m., when the facility submitted the acceptable plan of correction that was implemented and verified on site by the survey team. Although the IJ was removed, the facility's deficient practice was not corrected and remained at a pattern, no actual harm but the potential for more than minimal harm that is not an immediate jeopardy. Findings Include: On 5/22/16 at 5:00 p.m., Resident #715 was observed sitting in the dining room with family members. The Resident and family members were queried about life in the facility. One family member stated, We do have some concerns. It is mostly about staff and the lack of it, we can discuss this is more detail on the phone. Please feel free to contact us for more information. On 5/23/16 at 8:30 a.m., Resident #715's clinical record was reviewed and documented that the Resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum (MDS) data set [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score of three (3) severely cognitively impaired and required extensive assistance for transfers. Further review of the Resident's clinical record revealed, in part, the following: Progress Note dated 5/21/16 10:56 p.m. and authored by Nurse (K); CNA (certified nursing assistant) reported seeing resident drinking rubbing alcohol that was sitting on table in small dining room. Resident states took 1-2 sips of it. No discomfort noted. Resident observed rest of the day with no adverse effects. No distress noted. Spoke to nurse practitioner. Nurse (K) called and asked writer to call poison control. Poison control called and said it wasn't enough alcohol ingested to cause distress or damage. Poison control called back a couple of hours later to check on resident. Spoke with dtr (daughter) and informed. Vitals were in range for the resident to continue to monitor. On 5/23/16 at 9:00 a.m., the Administrator was asked to provide all Incident and Accident (I&A) Reports pertaining to resident #715. At 10:00 a.m., the Acting Director of Nursing (ADON) T reported that there were no I & A reports pertaining to Resident #715. On 5/23/16 at 9:25 a.m., approximately one half of a 16 ounce (oz.) bottle of clear 70% isopropyl alcohol was observed on the top of Resident #712's dresser. On 5/23/16 at 11:40 a.m. a tour of all the rooms occupied by 112 resident's residing in the facility was conducted. During the tour the following observations were made on Unit Three: Room occupied by resident #712 revealed a 16 oz. of 70% Isopropyl Alcohol sitting on the resident's dresser. A review of the Resident's clinical record revealed that Resident #712 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS revealed that the Resident was cognitively impaired. Room occupied by resident #61 revealed a 16 oz. bottle of green dyed 70 % Isopropyl Alcohol, approximately one quarter full, sitting on the resident's dresser, placed among three other unopened bottles of cranberry and apple juice. A review of the resident's clinical record revealed that resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] revealed the Resident had moderately impaired cognition. Room occupied by resident (s) #77 & #78 revealed a 16 oz. bottle of clear 70% Isopropyl Alcohol, approximately half full, was placed in a wash basin on the resident's #78's night stand. A review of the resident's clinical record revealed that resident #77 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] revealed the Resident had moderately impaired cognition. A review of the resident's clinical record revealed that resident #78 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] revealed the Resident had severely impaired cognition. Room occupied by resident (s) #91 and #92 revealed a 16 oz. bottle of clear 70% Isopropyl Alcohol sitting on the resident #91's dresser. A review of the resident's clinical record revealed that resident #91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] revealed the Resident had severely impaired cognition. A review of the resident's clinical record revealed that resident #92 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] revealed the Resident had moderately impaired cognition. On 5/23/16 at 12:15 p.m., ADON T provided a document titled I & A Report that stated, in part, the following: Resident Name: #715 Date/Time of Incident: 5/21/16 9:30 a.m. Location: Station 3 small dining room Statement by resident: I took 2 sips of this bottle Statement by staff (CNA Y): Smelled alcohol on resident's breath On 5/23/16 at 12:10 p.m., Resident #715 was queried about the incident that occurred on 5/21/16. Resident #715 was not able to recall the incident. On 5/23/16 at 1:10 p.m., an interview was conducted with CNA Y regarding the incident pertaining to the ingestion of Isopropyl Alcohol by resident #715. CNA Y stated, I was working the day shift on 5/21/16. I walked into the dining room and Resident #715 and Resident #719 were sitting at a table. Resident #719 was getting her nails done by Nurse Z. As soon as I walked in I smelled alcohol. I went over to the resident and smelled it on her breath. I saw a bottle of rubbing alcohol on the table near her with the cap off. I moved the bottle of alcohol. Resident #715 told me that she had two sips. I went and got her some water and then some milk because that is what Unit Manager F told me to do. We removed the alcohol from the room and also removed the resident. CNA Y was asked if she was aware of bottles of Isopropyl Alcohol in other resident's rooms, Nurse Y stated, No. They are supposed to be locked up. On 5/23/15 at 1:20 p.m., an interview was conducted with Nurse Z regarding the incident involving resident #715. Nurse Z stated, I was assigned to clip resident's fingernails in Unit 3. I am not usually assigned to do this, it is usually done by the CNAs. I brought in some supplies including a bottle of alcohol to clean the nail clipper. I got it (the alcohol) from the locked medication cart. I had completed resident #715's nails and moved over to assist resident #719. CNA Y came into the room and smelled alcohol on resident #715's breath. I never saw her drink from the bottle, but I know the top was off. I told Nurse K about what happened. Today (5/23/16), I was told by ADON T and ADON N that I needed to write a statement. I wrote one this morning. When further queried as to whether Nurse Z was aware that bottles of alcohol were found in other resident's rooms, Nurse Z stated, No. I thought it was supposed to be locked up. On 5/23/16 at 3:25 during a third tour of the resident's rooms on Nursing Station Three was conducted. During the tour the bottles of Isopropyl Alcohol remained present in Resident #61, #77, #78, #91 and #92's rooms. On 5/23/16 at 5:20 p.m., an interview was conducted with Nurse K regarding the incident that occurred involving resident #715 and the storage of toxic substances, including, Isopropyl alcohol. Nurse K stated, I was informed by CNA Y that Resident #715 smelled like alcohol. I informed Unit Manager (UM) F and me to call the Nurse Practitioner (NP) and the family. I did all that. The NP told me to call Poison Control, I did that. We gave the resident water and milk and took her vitals. She appeared fine. I know that UM F never reported this to Administration. When further queried as to whether she was aware of Isopropyl Alcohol in other resident's rooms, Nurse K stated, It is not supposed to be there. It should be locked up either in the medication room or on the medication cart. On 5/24/16 at 10:00 a.m., an interview was conducted with UM F regarding the incident involving Resident #715 on 5/21/16. UM F stated, I was working the day shift that day. I was with another patient and got paged and was told Resident #715 ingested rubbing alcohol. I instructed Nurse K to contact the physician and family. I do know that she did that as well as contacting poison control. The resident was assessed and appeared fine. I never reported this to my supervisor(s) ADON T or the Administrator. I should have. I was given education on reporting. When further queried as to whether she was aware of bottles of alcohol in other resident's rooms on unit three and the facility policy regarding hazardous substances, UM F stated, I was not aware. We do not leave them in the resident's rooms. They should be locked up on the medication cart or in the medication room. On 5/24/16 at 11:30 a.m., an interview was conducted with ADON T regarding the incident that occurred with Resident #715 on 5/21/16 and the facility policy on handling hazardous products. ADON T stated, As far as Resident #715, we are still investigating the incident. I am not sure why the alcohol was used during nail clipping. It is generally done by CNAs who do not even have access to isopropyl alcohol. It was just a mix-up and I was not made aware over the weekend. We are working on in-servicing our staff. As far as the bottles of alcohol in the resident's rooms on Unit Three, I am not sure why they are there. They should be locked up to prevent situations like what happened over the weekend. On 5/24/16 at 2:00 p.m., an interview was conducted with the Medical Director regarding the incident involving Resident #715 on 5/21/16. The Medical Director stated, I became aware of the incident on 5/23/16. I was informed that the Resident was monitored and showed no signs or symptoms of distress. I was made aware that poison control was contacted. I did see the Resident yesterday (5/23/16) and she showed no signs of distress. As far as the bottles of alcohol found in the other resident's rooms, I am not sure why they were there, perhaps family brought them. They should be locked up. On 5/24/1 at 4:00 p.m., a Quality Assurance (QA) interview was conducted with the Administrator and the incident pertaining to Resident #715 and the observation of alcohol in resident (#712, #61, #77, #78, #91, and #92) rooms was discussed. The Administrator stated, I found out on Sunday night (5/22/16) what had happened. I should have been called on 5/21/16, but there was a breakdown with UM F not reporting. It should not have happened. We are working on educating those involved and other staff. As far as the bottles of alcohol found in the resident's rooms, it was just an oversite. All toxic and hazardous substances should be locked up. We have now removed all items containing alcohol from resident's rooms. I believe there was an initial mix-up when we first became aware and that is why they were not removed earlier. We are going to have to educate staff as well as residents and family members about how those items need to be locked up and stored. On 5/24/16 at 10:00 a.m., the facility policy titled, Environmental Hazards dated 1/2015 was reviewed and revealed, in part, the following: Policy: To prevent an environment that is safe with no risk to the health and well-being of the facility residents, staff and visitors. Procedures: 1. Hazardous machinery, chemicals, and activities which are likely to cause potential danger will not be used or undertaken while residents, staff or visitors are in the location where the injury could occur. 2. All potential dangerous products such as cleaning materials, disinfectants, flammable, poisonous and other dangerous substances, tools and medications will be stored in the appropriate containers, clearly labeled and stored in the designated secured area. The facility submitted the following IJ removal plan on 5/24/2016: 1: Residents #715 & #712 were being supervised by a nurse at the time of the incident on 5/21/2016. Nail care was being rendered, to the residents, at the time of the incident on 5/21/2016 at 9:30am. The lsopropyl Alcohol was immediately removed from resident #715.Resident #712 did not ingest isopropyl alcohol and had no further access to the bottle. Resident #715 was immediately assessed by the nurse. Vital signs were stable. Resident had no respiratory symptoms, no GI symptoms, and denied pain and discomfort. Physician Assistant, Stephanie DalBianco, was on call for the attending physician Ryan Barrish MD. She was immediately notified at 9:35am, on 5/21/2016, of the incident. She instructed resident #715's nurse to call Poison Control. Immediately after calling physician extender, the residents nurse called Poison Control. Poison Control indicated that no action was necessary. Poison Control representative told the nurse that they would call the facility back to get an update on the patient's status. Resident #715 continued to be monitored for post exposure signs and symptoms, safety, and complications. 5/23/2016 at 11:43am the incident was brought to attention of the facility medical director. The medical director indicated that the facility took appropriate action and steps following the incident. The medical director assessed resident #715. Resident is free of complications from incident of 5/21/2016. Medical director indicates vital signs are stable, oral cavity is fine, chest is clear to auscultation, no epigastric tenderness and her appetite has been fine over the past two days. The nurse involved in the incident was educated on proper nail care and hazards in the environment 5/23/2016 at 11:00am. 2. The rooms of Residents #61, #77, #78, #91 #92 #715 and #712 have been audited by the nurse manager for any items containing lsopropyl Alcohol that could be ingested. lsopropyl Alcohol and items with lsopropyl Alcohol have been removed from their rooms. The facility nurse managers were educated regarding securing potential hazards in the environment. The facility Medical Director assessed resident #61, #77, #78, #92 #715 and #712. The residents were free of any complications of the potential of lsopropyl Alcohol. Resident #91 is out of the facility on a leave of absence with her son. She will be assessed by the medical director on 5/24/2016. 3. All available nursing staff in the building were educated on keeping the resident's environment safe and free of hazards. Specific emphasis was placed on items that contain isopropyl alcohol. A policy was developed to address 70% lsopropyl Alcohol storage. This was covered in the policy. ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Deficient Practice #2 This deficient practice is actual harm that is isolated. Based on observation, interview, and record review, the facility failed to provide adequate supervision and transferring assistance for two residents (Resident #704 and #712) out of thirteen residents who were reviewed for falls, out of a total sample of twenty-six residents, resulting in falls causing pain, a skin tear, a fractured leg, and a fractured finger. Findings include: Resident #712 On 5/23/16 at 1:35 pm, a review of a facility document titled, NON FALL RELATED TEAM REPORT was reviewed. During the review the following was discovered: Resident #712 had sustained a skin tear to her left knee and fracture to her left tibia. Further review of the report read, On 2/28/16 at 2240 the resident was transferred from Geri-chair to bed by one CNA (Certified Nurse Assistant) with a gait belt. resident sustained [REDACTED]. An x-ray was ordered and showed a Lateral Tibial plateau fracture .Pain medication was increased .Resident is a Hoyer lift for transfers with two person assist . A review of the Director Of Nursing's (DON) summary of the incident, dated 3/3/16 read, .CENA (Certified Nursing Assistant) who was assigned to the resident upon interviewed <sic> stated that she did not want to ask Nurse to assist her with the Hoyer lift transfer and used her clinical judgement to transfer the resident herself with the gate <sic> belt. Per CENA resident sustained [REDACTED]. At that time, a review of the nurses progress note was also conducted. The progress note dated 2/29/16 at 12:20 am read, .This writer notified by assigned CENA that resident has a wound on the left leg. A skin tear was noted .with moderate bleeding. But Resident also complains of pain when her left knee was moved. Redness and swelling was also noted on the lateral side of the left knee .Resident shows hurts a little more level at Wong scale (a pain scale with facial expressions often used in assessment of pain for children or cognitively impaired individuals who are not able to effectively communicate pain with the the traditional 1-10 pain scale), every time this writer gently do <sic> slight ROM (range of motion) on the left knee . At that time a review of the on call Nurse Practitioner's (NP) notes was also conducted. The NP's note on 2/28/16 at 11:15 pm, read, .Knee was bumped with transfer to the bed there is a skin tear with some redness and edema with complaint of pain, XRAY of knee ASAP (as soon as possible). At that time a review of the physician's evaluation progress note dated 3/6/16 indicated an evaluation of the resident was done on 3/1/16 and read, ' .patient's left knee was accidentally bumped onto side of bed while transfer to the bed with development of skin tear with some redness and edema with acute left knee pain. Imaging of left knee showed .fracture along the lateral tibial plateau . On 5/23/16 at 3:10 pm, an interview with Resident #712 was attempted, however; due to Resident #712's cognitive status, she was unable to recall the incident. On 5/23/16 at 3:25 pm, an interview with the facility's Assistant Director of Nursing (ADON) 'T' and ADON/Safety Nurse 'N' was conducted. During the interview the ADON and Safety nurse were asked about the incident. ADON 'T' indicated that the expectation is for the CNA's to follow the Nursing Instructions (instructions on residents functional abilities) on the computer kiosks and the Happy Feet charts (charts hanging in resident rooms that indicate transfer and or ambulation status) for transferring residents. She reiterated that Resident #712 was a two person Hoyer lift for transfer, and stated, The CNA unfortunately used poor clinical judgement when she transferred her by herself with a gait belt. On 5/22/16 at 12:25 pm a review of Resident #712's medical record was conducted. It was noted that Resident #712 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #712's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated severely impaired cognition and total assist of two staff members for transferring. A review of the Nursing Instructions indicated that Resident #712 was a two person Hoyer lift for transfer. On 5/24/16 at 1:20 pm, a review of the facility's policy titled, Happy Feet Transfer Program dated 2/10/11 read, .The safest method of transfer .shall be posted in the resident's room . A request for a policy regarding CNA's expectation to follow nursing instructions for transferring was not provided by the end of the survey, and the facility was asked if they had any other documentation to provide surrounding the concern with Resident #712's improper transfer, and none was provided. ( ) On 5/22/16 at 12:30 pm, Resident #704 was observed in her room. Resident #704 eyes were closed, and the bed was in a low position with bedside mats on the floor on either side of the bed. During an interview at that time, Resident #704's granddaughter stated Resident #704 had a fall at the facility which resulted in a broken fifth finger on the right hand. Review of the clinical record on 5/22/16 at 1:30 pm revealed the following: Resident #704 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set resident assessment instrument, dated 11/15/15, for Resident #704, reflected Resident #704 had severely impaired cognition and had total dependance on staff for transfer, dressing and eating, and was at high risk for falls related to unsteady gait, cognitive deficits, impaired safety awareness and impaired mobility and history of falls. The care plan, updated 2/28/16, reflected 'Star Program' (facility program for management of residents at high risk for falls.) The 'Resident accident/incident reports' for Resident #704, reflected the following. On 2/27/16 at 12:30 pm, the resident was observed sitting on the floor next to her bed No injuries noted. On 3/9/16 at 12:30 pm, the resident was observed sitting on the floor mat next to her bed .No injuries noted. On 3/28/16 at 4:20 pm resident was observed in her room sitting in front of her wheel chair .No injuries noted. On 3/29/16 at 3:30 pm resident was in the station three dining room safety group. The resident slid out of her chair and onto the floor. The resident complained of pain to the right hand. No visible injuries noted. X-ray ordered for right hand and shows a fracture of the right fifth finger. The X-ray report, dated 3/29/16 reflected, 'Acute nondisplaced fracture at the base of the proximal phalanx of the fifth digit .' The facility 'Accident/Incident Investigation, dated 3/29/16, reflected 'Nurse was in charge of safety group. Nurse was standing in the door to the dining room with her back to the residents and one of the residents (Resident #704) fell sustaining a fracture.' On 5/23/26 at 4:00 pm, the assistant director of nursing 'N' explained that the nurse had not properly monitored the residents in the safety room to limit the potential for falls and injuries. ( )

REFER TO INTAKE #MI 464 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE A SAFE ENVIRONMENT TO 4 (#101, #103, #105 AND #106) OF 6 RESIDENTS REVIEWED FOR FALLS FROM A TOTAL SAMPLE OF 6 WHEN RESIDENTS #105 AND #106 WHO NEEDED TO BE SUPERVISED fell AFTER NURSING STAFF LEFT THEM UNSUPERVISED, WHEN RESIDENT #101 WAS INJURED DURING A TRANSFER AND WHEN RESIDENT #103 DID NOT HAVE A FUNCTIONING ALARM ON HER WHEELCHAIR, RESULTING IN INJURY (FRACTURES AND LACERATIONS) AND THE POTENTIAL FOR INJURY. FINDINGS INCLUDE: RESIDENT #101: RESIDENT #101 WAS ALERT AND ORIENTED AND ABLE TO MAKE HER NEEDS KNOWN. SHE WAS admitted INto the facility on [DATE], AFTER A RIGHT HIP ARTHROPLASTY. SHE WAS ABLE TO BEAR WEIGHT AS TOLERATED WITH HIP PRECAUTIONS. ACCORDING TO THE RESIDENT ACCIDENT/INCIDENT REPORT DATED 8/30/12, AN INCIDENT INVOLVING RESIDENT #101 OCCURRED ON 8/20/12 AROUND 9:00 AM. ACCORDING TO THE I/A REPORT'S RESIDENT STATEMENT, "I TWISTED MY LEG IN THE SHOWER." THE FACILITY DID NOT START THE INVESTIGATION UNTIL 8/30/12 (10 DAYS AFTER THE INCIDENT OCCURRED).THE PHYSICIAN WAS CALLED ON 8/29/12 (9 DAYS AFTER THE INCIDENT) AT 4:20 PM AND ORDERED AN X-RAY. AN X-RAY OF THE RIGHT HIP WAS PERFORMED ON 8/29/12 AT 4:20 PM. THE X-RAY RESULTS RECEIVED ON 8/30/12, REVEALED THAT RESIDENT #101 HAD SUSTAINED AN ACUTE COMPLETE GREATER TROCHANTERIC FRACTURE. THE PHYSICIAN WAS NOTIFIED OF THE X-RAY RESULTS AND ORDERED IMMEDIATE TRANSFER TO THE HOSPITAL FOR FURTHER EVALUATION AND TREATMENT. CLINICAL RECORD REVIEW OF NURSES NOTES AND PHYSICAL/OCCUPATIONAL THERAPY DOCUMENTATION DATED 8/20/12-8/30/12, DOCUMENTED THAT RESIDENT #101 PERSISTENTLY COMPLAINED OF SEVERE PAIN (WITH THE PAIN SCALE LEVEL OF 9 OR 10 OUT OF 10) AFTER THE SHOWER TRANSFER INCIDENT OCCURRED. CNA #4 WAS INTERVIEWED ON 10/31/12 AT 4:40 PM. CNA #4 STATED, "I WITNESSED THE TRANSFER ON 8/20/12. (RESIDENT #101'S) RIGHT LEG, ANKLE AND FOOT WERE CAUGHT ON A BATH BLANKET AND WERE PULLED UNDER THE WHEEL DURING THE TRANSFER." ACCORDING TO CNA #4, SHE (#4) OBSERVED CNA #3 PULL RESIDENT #101'S RIGHT LEG OUT FROM THE WHEEL. ACCORDING TO CNA #4, CNA #3 DID NOT CAREFULLY OR GENTLY RELEASE THE RESIDENT'S RIGHT LEG, "IT LOOKED LIKE SHE YANKED IT OUT AND THE RESIDENT SCREAMED." CNA #4 WENT ON TO SAY THAT CNA #3 WAS NEW AND WAS IN TRAINING AT THAT TIME. CNA #4 SAID THAT SHE (#4) DID NOT THINK THAT CNA #3 WAS AWARE THAT RESIDENT #101 RECENTLY HAD SURGERY ON THE RIGHT HIP. THE INCIDENT WAS REPORTED TO THE CHARGE NURSE. CNA #5 WAS INTERVIEWED BY TELEPHONE ON 11/7/12 AT 3:25 PM. CNA #5 SAID THAT SHE RECALLED LEAVING CNA #3 IN THE SHOWER ROOM WITH RESIDENT #101. AS CNA #5 CAME BACK INTO THE SHOWER ROOM, SHE SAW CNA #4 (ON RESIDENT #101'S LEFT SIDE) AND CNA #3 AT HER (#101) RIGHT SIDE, PERFORMING THE TRANSFER. CNA #5 ADDED, "DURING THE TRANSFER, I SAW THE RESIDENT'S (#101) FOOT TWISTED AND GET CAUGHT INTO THE WHEEL OF THE CHAIR. (CNA #3) PULLED THE RIGHT LEG OUT AS THE RESIDENT SCREAMED IN PAIN." CNA #3 WAS NOT EMPLOYED BY THE FACILITY AT THE TIME OF THE INVESTIGATION. LPN #6 STATED THAT CNA #3 REPORTED THE INCIDENT ON 8/20/12. LPN #6 SAID THAT SHE (#6) INSTRUCTED THE CNAS TO LAY RESIDENT #101 DOWN IN BED. NURSE # 6 admitted THAT SHE EXAMINED RESIDENT #101'S RIGHT KNEE AND RIGHT ANKLE AND FOUND NO PAIN, NO SWELLING NO DISCOLORATION AT THAT TIME. LPN #6 DID NOT MAKE AN INCIDENT REPORT AND DID NOT REPORT THE INCIDENT TO THE NEXT SHIFT. RESIDENT #105: RESIDENT #105 WAS A [AGE] years OLD FEMALE, WHO WAS admitted to the facility on [DATE]. ACCORDING TO THE HOSPITAL DISCHARGE SUMMARY DATED 8/24/12, RESIDENT #105 HAD A FALL ON 8/19/12 THAT CAUSED CERVICAL SPINE FRACTURES AND A CLAVICLE FRACTURE. SHE UNDERWENT surgery for [REDACTED]. AFTER SURGERY, SHE WAS PLACED IN A CERVICAL COLLAR AND WORE A SLING TO SUPPORT HER RIGHT UPPER EXTREMITY. ACCORDING TO THE MINIMUM DATA SET (MDS) ASSESSMENT, DATED 9/20/12, RESIDENT #105 HAD SEVERELY IMPAIRED COGNITIVE SKILLS AND REQUIRED EXTENSIVE ASSISTANCE DURING TRANSFER AND TOILETING WITH 2 PERSON ASSISTANCE. RESIDENT #105 WAS IN THE STAR PROGRAM (INDICATING FALL RISK). ACCORDING TO AN INCIDENT REPORT DATED 10/1/12 AT 7:30 PM, THE NURSE AIDE (CNA #7) LEFT RESIDENT #105 SITTING ON THE TOILET AND TOLD THE FAMILY MEMBER THAT SHE WOULD BE RIGHT BACK. WHEN CNA #7 RETURNED, RESIDENT #105 WAS OBSERVED LYING ON THE FLOOR, HAVING SUSTAINED A 2.2 CENTIMETER LACERATION TO HER EYEBROW. RESIDENT #105 WAS SENT TO THE HOSPITAL FOR FURTHER EVALUATION AND treatment for [REDACTED]. ACCORDING TO LICENSED PRACTICAL NURSE (LPN) #6 ON 11/2/12 AT 3:15 PM, RESIDENT #105 WAS CONFUSED AND WAS NOT ABLE TO COMMUNICATE HER NEEDS DUE TO A LANGUAGE BARRIER. RESIDENT #105 WAS A 2 PERSON ASSIST DURING TRANSFERS AND TOILETING. CERTIFIED NURSE AIDE (CNA) #7 LEFT RESIDENT #105 SITTING ON THE TOILET WITH THE FAMILY MEMBER IN THE ROOM TO GET WASH CLOTHS FROM A CART OUTSIDE THE RESIDENT'S ROOM. THE FAMILY MEMBER SPOKE MINIMAL ENGLISH. THERE WERE NO OTHER STAFF MEMBERS ASSISTING RESIDENT #105 WHEN SHE fell . RESIDENT #105 fell on THE FLOOR AND SUSTAINED A LACERATION TO HER EYEBROW. CNA #7 WAS INTERVIEWED ON 10/31/12 AT 1:25 PM. CNA #7 STATED THAT RESIDENT #105 WAS A 2 PERSON ASSIST AND THE FAMILY MEMBER WAS THERE TO HELP. CNA #7 admitted THAT SHE GET ANOTHER STAFF MEMBER TO TOILET RESIDENT #105 BECAUSE SHE RELIED ON THE FAMILY MEMBER. ADDITIONALLY, ACCORDING TO CNA #7, THERE WERE NO OTHER CNAS OR NURSES AVAILABLE AT THAT TIME. WHEN SHE CAME BACK, SHE HEARD THE FAMILY MEMBER SCREAM AND FOUND RESIDENT ON THE FLOOR WITH BLOOD COMING FROM THE RIGHT SIDE OF HER HEAD. THE NURSE CAME IMMEDIATELY TO ASSESS AND SENT RESIDENT #105 TO THE HOSPITAL. THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED ON 10/31/12 AT 2:00 PM. ACCORDING TO THE DON, ACCORDING TO FACILITY POLICY, TWO-PERSON ASSIST MEANS THAT 2 NURSING STAFF ARE INVOLVED IN THE TASK. FAMILY MEMBERS ARE NOT CONSIDERED NURSING STAFF. THE DON AGREED THAT CNA #7 DID NOT FOLLOW THE 2 PERSON ASSISTANCE EXPECTATION AND THAT WITH SUPERVISION, THIS FALL WITH INJURY COULD HAVE BEEN AVOIDED. RESIDENT #106: RESIDENT #106 WAS AN [AGE] year-OLD FEMALE, admitted to the facility on [DATE]. RESIDENT #106 HAD A FALL AT HOME THAT RESULTED WITH IN A LEFT-SIDED HUMERAL HEAD FRACTURE. ACCORDING TO THE MDS dated [DATE], RESIDENT #106 REQUIRED EXTENSIVE ASSISTANCE WITH ACTIVITIES OF DAILY LIVING, PARTICULARLY DURING TRANSFERS, TOILET USE AND HYGIENE. RESIDENT #106 WAS NON-AMBULATORY. RESIDENT #106 HAD SEVERE COGNITIVE IMPAIRMENT AND A LANGUAGE BARRIER. REVIEW OF PHYSICIAN ORDERS [REDACTED].#106'S WHEELCHAIR AND BED WERE ordered on [DATE]; HOWEVER, THEY WERE DISCONTINUED ON 9/5/12. ACCORDING TO THE CARE PLAN FOR COGNITIVE LOSS DUE TO DEMENTIA DATED 9/5/12, ALARMS WERE ORDERED TO PROMOTE SAFETY AND THE RESIDENT WAS STARTED IN THE STAR PROGRAM. A REVIEW OF THE PROGRESS NOTES, REVEALED THAT ON 10/20/12 AT 8:31 AM, A NURSE WROTE, "RESIDENT (#106) IS HAVING EPISODES OF CONFUSION WITH SOME MILD AGITATION. RESIDENT WILL CONTINUE TO BE MONITORED...SHE HAS PERIODIC EPISODES OF STANDING WITH ATTEMPTS TO WALK FROM WHEELCHAIR..." THE NEXT ENTRY, DATED 10/22/12, DOCUMENTED, "RESIDENT #106 FALL TODAY IN SMALL DINING ROOM DIFFICULT TO COMMUNICATE WITH TO DO WITH LANGUAGE BARRIER RESIDENT HAS PAIN ON THE RIGHT HAND, RIGHT PINKY FINGER AND RIGHT RING FINGER... XRAY WAS ORDERED." THERE WAS NO EVIDENCE THAT THE FACILITY HAD IMPLEMENTED INTERVENTIONS TO ADDRESS RESIDENT #106'S NEW BEHAVIORS OF CONFUSIONS AND AGITATION AND HER ATTEMPTS TO STAND AND AMBULATE. ACCORDING TO THE RESIDENT ACCIDENT/INCIDENT REPORT DATED 10/22/12 AT 12:40 PM, CNA (#9) "FOUND RESIDENT (#106) IN DINING ROOM IN FRONT OF WHEELCHAIR" AND THAT RESIDENT #106 HAD COMPLAINTS OF "PAIN (IN) RIGHT WRIST, RIGHT RING FINGER AND RIGHT PINKY FINGER." ACCORDING TO AN X-RAY RESULT DATED 10/23/2012, THE IMPRESSION WAS "ACUTE FRACTURE INVOLVING THE 5TH METACARPAL BONE WITH MILD DISPLACEMENT AND MILD ANGULATION." CNA # 8 WAS INTERVIEWED ON 11/2/12 AT 1:09 PM. CNA #8 STATED THAT SHE DRESSED RESIDENT #106, BROUGHT HER TO THE SMALL DINING ROOM AND LEFT HER WITH OTHER RESIDENTS. SHE EXPLAINED THAT SHE WAS RESPONSIBLE FOR THE CARE OF OTHER RESIDENTS AND NEEDED TO GET THEM UP AND INTO THE DINING ROOM. CNA #8 STATED THAT SHE WAS NOT SURE IF RESIDENT #106 HAD AN ALARM ON HER CHAIR. ACCORDING TO CNA #8, WHEN SHE RETURNED TO THE DINING ROOM, SHE FOUND RESIDENT #106 ON THE FLOOR. THE FALL WAS UNWITNESSED AS THERE WERE NO OTHER STAFF MEMBERS IN THE DINING ROOM. CNA #9 WAS INTERVIEWED ON 11/2/12 AT 1:35 PM. ACCORDING TO CNA #9, SHE (#9) STEPPED OUT OF THE DINING ROOM TO ASSIST WITH BRINGING OTHER RESIDENTS IN THE DINING ROOM AND DID NOT WITNESS THE FALL. CNA #9 SAID THAT RESIDENT #106 MUST HAVE UNLOCKED HER CHAIR AND TRIED TO STAND AND WALK. THERE WAS NO ALARM ON HER (#106) WHEELCHAIR. NO ALARM SOUNDED. THE FALL WAS UNWITNESSED. THERE WAS NO OTHER CNAS OR OTHER STAFF PRESENT WHEN RESIDENT #106 fell . ACCORDING TO THE DON, THE FACILITY DID NOT BELIEVE THAT AN ALARM COULD HAVE PREVENTED THE FALL. THE FALL TEAM DISCONTINUED RESIDENT #106'S CHAIR ALARM ON 9/5/12. THE DON WAS NOT ABLE TO EXPLAIN WHY THERE WERE NO STAFF MEMBERS PRESENT IN THE DINING ROOM WHEN RESIDENT #106 fell . RESIDENT #103: DURING THE INITIAL TOUR WITH THE DON ON 11/2/12 AT 1:25 PM, RESIDENT #103 WAS OBSERVED SEATED IN A WHEEL CHAIR IN THE ACTIVITY ROOM. THERE WAS A SENSOR PAD ON THE WHEELCHAIR, BUT IT WAS NOT ATTACHED TO AN ALARM UNIT. REVIEW OF THE CLINICAL RECORD REVEALED THAT RESIDENT #103 HAD FALLEN ON 9/25/12, WHILE ATTEMPTING TO GET OUT OF THE WHEELCHAIR. RESIDENT #103 HAD AN UNSTEADY GAIT AND WAS ENROLLED IN THE STAR DUE TO HER FALL RISK. FURTHER RECORD REVIEW REVEALED THAT THE PHYSICIAN HAD WRITTEN AN ORDER 10/25/12 FOR A CHAIR ALARM THAT WAS TO HAVE ITS FUNCTION MONITORED EVERY SHIFT. THE DON WAS NOT ABLE TO EXPLAIN WHY THE SENSOR WAS NOT ATTACHED TO AN ALARM UNIT. ( )

This citation pertains to Intake #MI 566. Based on observation, interviews and record review, the facility failed to provide adequate supervision and fall precautions for two (#103, #104) of five sampled residents, resulting in a subdural hematoma and laceration on the back of his head and forearm (#103) and laceration to the top of his head (#104). Findings include: Resident #103: According to the facility's transfer sheet dated 12/12/10 (No time), resident #103 was transferred to a local area hospital by emergency medical services after a fall that resulted in a laceration to his forehead, the back of his head and his forearm. A review of resident #103's hospital medical record on 1/19/11 at 10:00 a.m. revealed a computed tomography (CT) of resident #103's head dated 12/15/10. According to the CT scan resident #103 had a left frontal intraparenchymal hemorrhage measuring approximately 3 centimeters (cm) by 2.1 cm resulting from status [REDACTED]. The ventricles were described as slitlike with suspicion of diffuse cerebral edema. There was a small adjacent left subdural hemorrhage along the interhemispheric fissure. Resident #103 was transferred to the neurological intensive care unit with a [DIAGNOSES REDACTED]. On 1/14/11 at 11:14 a.m., a review of the facility's accident/incident (A/I) report dated 12/12/10 at 6:40 a.m., revealed resident #103 was found in his room next to the bed on the floor. According to the accident/incident report resident #103 was trying to get up. The roommate of resident #103 put on his call light to notify staff that resident #103 was on the floor. Resident #103 had a safety assessment score of 17. (Score >15 = High). The safety assessment dated [DATE] for resident #103 revealed reduced vision/hearing, some impulsiveness, history of falls, intermittent confusion, ability to follow one step commands were inconsistent, his [DIAGNOSES REDACTED]. The recommendations on his safety assessment included bed & chair pressure sensitive alarms, however, other recommendations include the following interventions: 1. Bed & chair mobility/tab alarm Not offered to family as an alternative when discussing fall precautions. 2. Low bed with mats CNA not aware of fall and Nurse #D not sure if bed was placed in the low position at the time of resident #103's fall. There was no documented evidence in the nurse's notes. 3. Defined perimeter mattress Not offered to the family as a alternative when discussing fall precautions. Resident #103 did not have a defined perimeter mattress on his bed at the time of his second fall, according to the accident/incident report the DPM mattress was going to be placed on resident #103's bed when he returned to the facility s/p fall. 4. Posey roll guard Not offered to family as an alternative when discussing fall precautions. A review of resident #103's care plan entitled "Risk for falls" dated 12/8/10 revealed no documented evidence of the low bed intervention for resident #103. The updated care plan entitled "Risk for falls" dated 12/9/10 revealed no documented evidence of the low bed intervention for resident #103. The facility care plans entitled "Risk for falls" were standardized care plans and were not individualized with specific falls interventions for resident #103. On 1/19/11 at 12:26 p.m., during an interview with certified nursing assistant (CNA)#F, CNA #F stated, "I don't why the facility gave you my name. I don't know anything about this." When CNA #F was informed her name was listed on the accident/incident report as the CNA assigned to resident #103 on 12/12/10 when he fell . CNA #F stated, "I don't know anything about that and I don't know why you were given my name and asked to call me, I don't remember that resident (#103)." The CNA (#F) was unable to state how often resident #103 was monitored by staff during the night on 12/11/10 through 12/12/10 or when was the last time resident #103 was monitored by staff prior to his fall on 12/12/10. During a family interview on 1/20/11 at 10:31 a.m., the facility was informed of resident #103's history and risk for falls. After resident #103's first fall, the family discussed with the Director of Nursing methods available to assist resident #103 from falling. The family requested to have side rails placed on resident #103's bed, however, after being informed of the risk factors, the family declined the side rails. According to the family, no other safety recommendations were made and/or suggested by the Director of Nursing, such as a low bed, mats or defined perimeter mattress. Review of the consent for the side rails dated 12/10/10, revealed the question "Does the resident require the use of bed rails while in the facility?" Response was "Yes, resident requires the use of bed rails." Question: "If requires the use of bed rails, indicate reasoning:" Response was "Bed Mobility." Other recommendations was blank. On 1/20/11 at 4:12 p.m., during an interview with Nurse #D, Nurse #D stated, resident #103 fell during medication pass on 12/12/10. According to Nurse #D, the roommate of resident #103 put on his light to request help for resident #103. Nurse #D stated, she observed resident #103 to have a laceration to the back of his head, the doctor and emergency medical services were called related to his injuries. During the interview with Nurse #D, she also stated, CNA #F was listed on the accident/incident report dated 12/12/10 because she (CNA #F) was the assigned CNA and it was her (CNA #F) responsibility to check on him (#103) every two hours and as the call lights come on per the facility protocol. Nurse #D stated, the facility protocol was to recommend and/or place floor mats on the side of the resident's bed when resident are identified at risk for falls to cushion the falls and decrease injury. Nurse #D stated, she couldn't remember if resident #103 had mats on the floor or not. During an interview on 1/18/11 at 1:19 p.m., with the Director of Nursing (DON), the DON stated, resident #103 did not have any mats on the floor because of the fear of tripping. The DON also stated, sensor alarms were placed on resident #103 after he fell on [DATE] to alert the staff of his movements. The nurse's note dated 12/12/10 was reviewed with the Director of Nursing (DON), it was revealed the nurse's notes did not mention the sensor alarms were sounding. The DON responded, "it's not on the nurse's note but on the incident report." The DON could not explain why the nurse did not documented the sensor alarms were sounding and alerted staff to resident #103's fall on the nurse's notes. On 1/19/11 at 12:05 p.m., during an interview with nurse #E, nurse #E stated, when resident's are admitted and identified high risk for falls, it is the facility protocol to initiate fall precautions upon admission, including interventions such as applying an alarm, low bed, defined perimeter mattress, and mats on the floor for protection. Nurse #E stated, it is the facility's protocol to initiate these interventions upon admission and/or when the family informs the facility the resident is at risk for falls. According to the facility policy entitled "Accident & Incident Report" dated 4/9/2010" the nurse must document in the medical record after an incident/accident "what you observed at the scene." The nurse's note dated 12/12/10 at 8:10 a.m. revealed "resident (#103) was on the floor in resident room (#103) next to his bed. Injury to back of his head, laceration approximately 4 cm and laceration to left forearm bandage applied. Notified medical doctor and family. Ambulance notified. Incident report complete. Will continue to monitor." There was no documented evidence the nurse observed the sensor alarms in place, sounding and resident #103's bed in a low position. The facility's accident/incident report also revealed resident #103 had a left forearm laceration measuring 5 centimeters (cm) and a laceration to the back of his head measuring 4 cm that was bleeding. The Corrective action revealed on the accident/incident report included "DPM (Defined Perimeter) mattress" would be placed on resident #103's bed when he returned from the hospital. There was no documented evidence why the DPM mattress was not placed on resident #103's bed prior to his fall. Nurse #D, Nurse #E, or the DON could explain why the DPM mattress had not placed on resident #103's bed. A review of the ADL flow record revealed documentation that resident #103 received limited assistance with bed mobility dated 12/13/10, however, resident #103 had been admitted to the hospital on [DATE] at 8:45 a.m. The DON could not explain why the CNA documented assisting resident #103 on 12/13/10. According to the clinical record review, resident #103 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimal Data Set (MDS) assessment dated [DATE], resident #103 had impaired cognition and required extensive assistance with activities of daily living. The MDS revealed resident #103 would wake up during the night and had a history of [REDACTED]. Resident #104: On 1/19/11 at 12:45 p.m. observed revealed resident #104 was alert and oriented to his surrounding with some confusion, eating lunch, it was observed resident #104 had an injury to the top of his head. Review of the medical record from a local area hospital dated 12/22/10 revealed resident #104 was admitted to the hospital after a s/p fall at the facility with scalp laceration measuring 9 centimeters (cm) by 9 cm that was sutured in the emergency room . According to the physician progress notes [REDACTED]. He was sent to the hospital and was admitted for ,[DATE] days. On 1/19/11, review of resident #104's accident/incident (A/I) report revealed on 12/20/10 at 11:15 a.m. resident #104 was located on the right side of his bed. According to the A/I report resident #104 was trying to get his pillow to put it in his wheelchair. During a family interview on 1/19/11 at 12:30 p.m., it was revealed resident #104 had been left in his room unattended and without assistance when he returns from appointments. Resident #104 tried to get his own pillow to sit on when he didn't assistance, resulting in his falling out of his wheelchair and hitting his head on the side of the bed hitting the bedframe. Resident #104 required sutures in the top of his head. According to the family resident #104 had alarms placed on his bed and wheelchair two weeks ago. The family interview for resident #104 also revealed he had a history of [REDACTED]. According to the A/I report resident #104 did not have an alarm or any safety device in place at the time of his fall According to the nurse's notes dated 12/20/10 at 12:00 p.m., patient (resident #104) was alert and oriented times 2-3 with some confusion, patient (#104) was observed on right side of bed on the floor with his head bleeding. According to the care plan for resident #104 entitled "Risk for Falls" related to cognitive impairment dated 12/10/10, revealed resident #104 had a resident safety assessment score of 16. (Score >15 = High). Review of the care plan for resident #104 entitled "Risk for Falls" dated 12/10/10 the interventions included: 1. Monitor resident when call light is not available. There was no documented evidence resident #104's call light was within reach. 2. Ensure personal items of need are within reach at bedside. Resident #104 was not assessed or assisted with his need for the pillow in his wheelchair. The facility care plans entitled "Risk for Falls" were a standardized care plan and was not individualized with specific falls interventions for resident #104. On 1/19/11 at 12:05 p.m., during an interview with nurse #E, nurse #E stated, when resident's are admitted and identified high risk for falls, it is the facility protocol to initiate fall precautions upon admission, including interventions such as applying an alarm, low bed, defined perimeter mattress, and mats on the floor for protection. Nurse #E stated, it is the facility's protocol to initiate these interventions upon admission and/or when the family informs the facility the resident is at risk for falls. On 1/20/11 at 4:12 p.m., during an interview with Nurse #D stated, she stated the facility protocol was to recommend and/or place floor mats on the side of the resident's bed when resident are identified at risk for falls to cushion the falls and decrease injury. Nurse #D also stated, it was the assigned certified nursing assistant's responsibility to check on the resident's every two hours and as the call lights come on per the facility protocol. On 1/13/11 at 2:20 p.m., review of resident #104's clinical record revealed he was admitted to the facility on [DATE]. He was re-admitted to the facility on [DATE] s/p hospitalization for head laceration with [DIAGNOSES REDACTED]. According to the Minimum Data Set assessment dated [DATE], resident #104 had cognitive impairment and required extensive assistance with activities of daily living. resident had a history of [REDACTED].