Every finding on record at Windemere Park Health and Rehabilitation Center

This citation pertains to Intake number 3003145. Based on observation, interview, and record review, the facility failed to maintain resident's right to privacy for five residents (R6, R5, and anonymous resident (AR B) of five reviewed for privacy. Findings include: R6 A review of an Intake called into the State Agency revealed, Complainant states for the past several months resident [R6] has been wandering in and out of [R13's] and other residents' rooms and taking their personal belongings . [R6] took [R13's] roommate [R4's] dentures twice, [R6] took an unknown (resident's) . bible, [R6] steals food from residents' trays and other items. The complainant states [R6] will also get into other residents' beds when they aren't in their rooms .residents have complained to nursing staff and they said nothing can be done because the resident [R6] has dementia. Complainant states staff make excuses for [R6] and said [R6] has the right to wander. The complainant states [R6] is allowed to violate [other residents] . right to privacy. On 6/09/2026 at 9:47 AM, 10:51 AM, R6 was observed walking up and down the hallway entering rooms not assigned to R6. Multiple rooms were observed with stop signs across the entry to resident's rooms. Staff were not observed to redirect R6 out of the unassigned rooms. On 6/09/2026 at 11:12 AM, R6 was observed with a cup of juice in their hand, walking in and out of rooms that were not assigned to them. R6 walked into an unassigned room, placed the cup of juice down, on an overbed table while an unknown staff member walked past the resident without addressing or redirecting them. On 6/10/2026 at 3:39 PM, R6 was observed walking in and out of unassigned resident's rooms without staff awareness. At 12:39 PM, R4 was interviewed and reported R6 has taken their dentures out of the water cup two times and has woken up with R6 standing over them. A review of R6's medical record noted, R6 was admitted to the facility on [DATE] with diagnoses Adjustment disorder, Dementia, Mood disorder, Cognitive deficits, and non-verbal. A review of R6's Minimum Data Set (MDS) assessment dated [DATE] revealed R6 with a severely impaired-never/rarely made decisions and required assistance from staff for activities of daily living. A review of R6's care plan noted, I am at risk for elopement R/T (related to): Dementia wanders in and out of other resident's rooms. Date Initiated: 1/30/26. Goal: I will not leave unit/facility unattended thru next review date. Interventions: Provide frequent visual checks/supervision. Provide redirection/reorientation as needed. Supervise me when wandering about unit/facility. I am at risk for decreased leisure activity participation due to; Adjustment, Mood D/O (disorder), cognitive defects, Dementia, Mood D/O, is non-verbal. Date Initiated: 2/16/26. Goal: I will accept 1:1 visits through next review date. Interventions: Provide 1:1 room visits as I choose. Provide audio/tactile stimuli as I am able to tolerate . On 6/11/2026 at 12:27 PM, the Activities Director (AD) was asked about the services they provide to R6 AND reported R6 does not participate with the group or other individual activities. Further review of R6's medical record progress notes revealed, 6/8/26 17:36 (5:36 PM) Health Status Note: Resident was sleeping at start of shift, resident at 100% of [their] meal, has been walking in and out of residents rooms and at times is lying in their beds and eating their food resident is on a puree diet, resident is nonverbal and cannot communicate with staff well, is not easily redirected, will continue plan of care. 6/11/26 13:27 (1:27 PM) Behavior note; resident is alert to self and pleasant. Resident wanders up and down hall and room to room taking applesauce and medication cups from nursing cart. Care is ongoing. A review of R6 admission documentation dated 1/27/26 revealed, The IDT (interdisciplinary) team met to review an incident involving the resident [R6], who was observed being kicked on the buttocks by another resident . A root cause analysis determined that environmental factors contributed to the incident, as the resident independently ambulates and may unintentionally enter other resident's personal spaces; shared living areas and open room access increased the likelihood of unplanned resident to resident contact. Supervision challenges were also identified, as the event occurred during routine resident movement under standard supervision, indicating the need for enhanced environmental strategies, visual cue interventions, and staff redirection . On 6/11/2026 at 2:52 PM, the Social Service Director (SW D) was asked about R6 and reported the resident had been at a previous facility where other residents retaliated when R6 entered their space. SW D confirmed R6 was being followed by psych services quarterly and as needed. On 6/11/2026 at 2:33 PM, the Nursing Home Administrator (NHA) asked about R6's wondering behaviors and confirmed they use the stop signs and staff are to redirect the resident. The NHA explained they will look revisiting the interventions that are in place to ensure other resident's privacy. A review of the facility's policy titled, Resident Rights dated December 2016, revealed, Policy Statement. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: 1. a dignified existence; 2. be treated with respect, kindness, and dignity; 3. be free from abuse, neglect, misappropriation of property, and exploitation . 20. privacy and confidentiality; 21. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal . AR B On 06/09/2026 at 9:31 AM, AR B reported they heard a commotion in the hall about a resident (R6) who wanders into everyone's room. They reported the resident moves fast and is a thief taking drinking cups and looking into closets taken things out. AR B reported they have yelled or cuss at the resident (R6) to get them to leave but the resident (R6) simply stares at them and just ignores you. AR B confirmed staff dismiss their concerns as the wandering resident has dementia and may not know what they are doing. AR B reports this has gone on for weeks and weeks. From 06/09-06/11/26 observations of R6 were made. R6 walked the hallways of the fifth floor and repetitively entering and exiting the rooms of other residents for up to 10 minutes at a time and leave with an item and sit in an armchair. On 06/10/2026 at 3:47 PM, R5 reported R6 had been walking in and out of their room since they arrived at the facility on 1/2/23 and described R6 as a nuisance. R5 recounted a day when R6 sat in an armchair at the foot of their roommate's bed for a long while until two staff members came in and attempted to remove R6 from the room. R5 was admitted into the facility with diagnoses that included Adjustment Disorder, Stroke and Dementia. The Minimum Data Set (MDS) dated [DATE] documented impaired cognition and the need for substantial/maximal assistance for bed mobility and dependent on staff for transfers. R5 was conversational and could make their needs known.

This citation pertains to intake 2800927:Based on observation, interview, and record review, the facility failed to implement fall care plan interventions for one resident (R902) of three residents reviewed for falls. Findings include:Review of a concern called into the State Agency documented concerns pertaining to R902's bed height, mechanical functioning of the bed, and the facility's management of the resident's risk for falls.Review of the facility record for R902 revealed a most recent admission date of 01/15/26 with pertinent diagnoses including Dementia and Muscle Weakness. The Brief Interview for Mental Status (BIMS) dated 02/02/26 indicated moderate cognitive impairment. The baseline care plan dated 01/16/26 revealed a fall risk reduction focus area that included the interventions Bed in lowest position when occupied (initiated 01/16/26) and Bilateral fall mats on floor when in bed (initiated 01/28/26 in response to a fall from the bed).On 04/07/26 at 11:15 AM, R902 was observed in bed. The bed was positioned with the mattress surface at a height of approximately three feet from the floor and not appearing to be in a lowered or lowest position available. There were no fall mats in place on either side of the bed.On 04/07/26 at 11:50 AM, Licensed Practical Nurse (LPN) A accompanied the surveyor to R902's room and demonstrated the bed was functioning properly including raising and lowering of the bed height. Prior to operating the bed, the bed height remained at approximately three feet from the floor as observed previously. No fall mats were in place on the floor and upon further observation of the room, fall mats were observed folded up and resting in the corner of the room. On 04/07/26 at 1:40 PM, R902 was observed in bed. The bed remained at a height of approximately three feet from the floor, and no fall mats were present on the floor. The fall mats remained in the corner of the room as previously observed. R902 was interviewed and asked if they mind if staff lower their bed closer to the floor and they reported they did not mind and could not recollect if fall mats are kept on the floor. On 04/07/26 at 3:00 PM, the facility's Director of Nursing (DON) was queried about the observations of R902 not having fall mats in place and not having the bed lowered as care planned and reported they should be in place when the resident is in bed as indicated in care plan.Review of the facility policy Fall Management dated 04/28/25 revealed the Procedure item 2. Residents identified at risk for falls will have a care plan developed and fall prevention interventions will be implemented as needed based on their assessment.

This citation pertains to Intake number 2716304.Based on interview and record review, the facility failed to provide scheduled showers for one resident (R700) of four residents reviewed for Activities of Daily Living (ADL's). Findings include: A review of a complaint allegation called into the state agency alleged, .the resident isn't provided with appropriate showers since admission.On 2/18/26 at 10:25 AM, a review of R700's Electronic Health Record (EHR) documented the resident was admitted into the facility on 1/07/26 with diagnoses that included congestive heart failure and emphysema. A review of R700's shower schedule noted, Bathing: Tuesday and Friday.A review of R700's shower record for the last 30 days revealed R700 received showers or bed bath on the following days, Thursday 1/8/26; Tuesday 1/13/26; Monday 1/19/26; and 1/26/26 (missing 3 showers).On 2/18/2026 at 2:00 PM, the Nursing Home Administrator (NHA) was asked about R700's missing showers and stated they were aware of the concern and reviewed the charting for documentation of refusals. NHA confirmed there were missing shower days for R700 and provided no explanation saying, the residents are to receive their showers as scheduled.A review of the Bath, Shower and Tub policy only discussed the procedure of giving a bath.

Based on observation, interview, and record review, the facility failed to store resident food items in accordance with professional standards for food service safety. This deficient practice had the potential to result in food borne illness among all 49 residents that potentially store food in the resident refrigerators. Findings include: On [DATE] at 10:20 AM, the 4th floor resident refrigerator was observed with Certified Dietary Manager (CDM) B. There were 4 expired cartons of milk, an undated deli sandwich, an undated brown bag lunch, 2 undated bowls of cooked oatmeal, an undated bowl of chili, and a moldy container of raspberries. On [DATE] at 10:30 AM, the 5th floor resident refrigerator was observed with CDM B. There was an undated foam container with chicken and rice. When queried, CDM B stated that nursing staff was responsible for ensuring the food items in the resident refrigerators were dated and discarded when expired. Review of the facility's policy Foods Brought by Family/Visitors revised [DATE] noted: 7. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food . b. Perishable foods must be stored in re-sealable containers with tight-fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. 8. The nursing staff will discard perishable foods on or before the use by date.

Based on observation, interview, and record review, the facility failed to ensure call light accessibility for one (R13) of seven residents reviewed for call light accessibility. Findings include: Review of the facility record for R13 revealed an admitted [DATE] with diagnoses including History of Falls and Chronic Heel Ulcers. R13's Brief Interview for Mental Status (BIMS) score of 10/15 indicated Moderate cognitive impairment. On 04/28/25 at 2:15 PM, R13 was observed laying in bed. The call light was observed on the floor under the bed out of the resident's reach. The resident was alert and able to communicate in a functional manner. Further review of R13's record revealed the Care Plan Focus area statement I have alteration in Activities of Daily Living self-care function related to dependence on staff for care needs and weakness associated with medical condition. This focus area included the Intervention item Call light to be kept in reach. Provide prompt response to requests for assistance. On 04/30/25 at 10:46 AM, R13 was interviewed in their room. The call light was observed wrapped around the headboard hardware near the floor out of the resident's reach. R13 was asked about the call light being out of reach and they indicated there are regularly times when they attempt to call for assistance and are not able to locate the call light. R13 was asked if this has caused delays in receiving care from staff and they stated, oh yeah. On 04/30/25 at 10:52 AM, a staff member was observed entering R13's room to check on the resident. The resident was observed after this interaction and the call light had not been placed in reach. On 04/30/25 at 12:25 PM, R13's call light was observed to remain under the bed wrapped around the headboard hardware out of the resident's reach. On 04/30/25 at 1:05 PM, the facility Administrator (NHA) reported the expectation is all resident's call lights should be within reach at all times. Review of the facility policy Call Lights: Accessibility and Timely Response dated 11/22/24 revealed the policy statement The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet and bathing facility. The policy explanation includes the entries: .5. Staff will ensure the call is within reach of resident and secured, as needed .6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview, and record review, the facility failed to ensure one resident (R35) of two residents reviewed for altered diet consistency, received the prescribed therapeutic diet. Findings include: On 4/28/25 at 01:02 PM, R35's spouse was observed feeding R35 a pureed textured main course foods. Also on the tray was regular textured fruit cocktail in a covered container. On 4/29/25 at 12:33 PM, an observation was made of Certified Nursing Assistant (CNA) A taking R35's tray into room to assist R35 with feeding. The main dish was pureed and there was a cup of regular textured pineapple chunks in a covered dish. There was also a half peanut butter and jelly sandwich. A review of the Electronic Medical Record (EMR) revealed R35 was most recently admitted on [DATE] with pertinent diagnoses of Alzheimer's Disease and Dysphagia (difficulty swallowing). Further review of the EMR revealed R35 has a Brief Interview for Mental Status (BIMS) score of 99 indicating R35 is rarely/never understood. Further review indicated R35 is dependent on staff for all activities of daily living and mobility. Further review of the EMR revealed an active order dated 1/3/2025 for PB and J (peanutbutter and jelly) sandwiches daily to add additional calories. On 4/16/2025 an order was written for a regular diet, pureed texture, Thin Liquids consistency. On 4/29/2025, an interview with the Dietary Manager (DM) B revealed the line checker (Dietary Worker (DW) F) should have noted the wrong textured dessert (pineapple chunks) was on the tray. DW F was interviewed and confirmed an error was made regarding the pineapple chunks. On 4/29/2025, an interview with the Nursing Home Administrator (NHA) revealed R35 had recently received an order for hospice and that the hospice nurse had written the order for pureed diet and may have not seen the peanut butter and jelly order to increase caloric intake. On 4/30/2025 an interview with the Clinical Dietary Manager (CDM) D revealed they were unaware of the PB and J order, and indicated they would cancel the order.

This citation pertains to Intake: MI00147215 Based on interview and record review, the facility failed to report and investigate an allegation of misappropriation of narcotic medicaitons to the State Agency for two residents, (R605 and R606) of five residents reviewed for misappropriation of property. Findings include: On [DATE] at 10:42 AM, an interview was completed with Regeistered Nurse (RN) G regarding the Director of Nursing (DON) handling of medications that needed to be destroyed. RN G explained on [DATE], the DON stood at the nurses' station with a white container that is used to destroy medications along with a bag of narcotics. The nurse said the DON began punching medications out of blister packets onto the desk at the nurses' station making it difficult to identify what packet the medications were coming from. RN G explained they were able to organize and count the medications, they identified that 17 Hydrocodone pills were missing for R605 and R606. RN G said the DON had a new Licensed Practical Nurse (LPN) I sign documents presented to them by the DON regarding the destruction of the medications, and the DON said they would notify the Medical Director about the missing medications. RN G confirmed they reported the missing medications to the Nursing Home Administrator (NHA). R605 A review of R605's medical record revealed they were admitted into the facility on [DATE], and expired on [DATE]. The resident was admitted with diagnoses that included Alzheimer's Disease, Diabetes, and Hypertension. Further review of the medical record revealed the resident was prescribed the following order on [DATE], Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (milligrams). Give 5.325 mg by mouth every 6 hours as needed for Moderate Pain. R606 A review of R606's medical record revealed that they were admitted into the facility on [DATE] under hospice care, and expired on [DATE]. A review of the resident's diagnoses includes Chronic Pain and Malignant Neoplasm of the Esophagus. Further review of the medical record revealed that the resident had the following physician order on [DATE], Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE]MG. Give 1 tablet via Percutaneous Gastrostomy Tube (PEG-tube for foods, liquids and medication)-every 6 hours for Pain. On [DATE] at 1:09 PM, an interview was completed with LPN I regarding the day they and the DON disposed of medication. LPN I confirmed they did sign off on a few narcotic sheets, but refused to sign the sheets that were missing medications. LPN I explained they didn't think they were able to assist the DON in the destruction of medications, but the DON insisted it was fine. On [DATE] at 11:45 AM, the Nursing Home Administrator (NHA) was asked if they reported the allegations of missing narcotics brought to they're attention by RN G on [DATE]. The NHA confirmed awareness of the concern and spoke to the DON about it, however, were not able to provide an explanation as to why the incident was not investigated or report to the State Agency. A review of the facility's Unusual Occurrent Reporting policy which was undated revealed the following, Our facility will report the following events to appropriate agencies .g. Allegations of abuse, neglect and misappropriation of resident property; h. other occurrences that interfere with facility operations and affect the welfare, safety, and health of residents, employees or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations .

This citation pertains to Intake: MI00147215. Based on observation, interview, and record review the facility failed to prevent incidents of misappropriation of narcotic pain medication for three residents (R604, R605, R606) of five residents reviewed for misappropriation of property. Findings include: A review of the Facility Reported Incident revealed the following, Incident Summary: Missing Medication: Lorazepam (Anti-anxiety) 0.5 MG (milligrams) 30 Tabs (tablets). On [DATE] at approximately 8:45am [Licensed Practical Nurse (LPN) F], removed 5 controlled substances from her medication cart and handed off to [Director of Nursing (DON)] for destruction. At approximately 9:15(am), the pack of Lorazepam 0.5 MG 30 Tabs was missing from the DON's possession. During the investigation, the information did not line up. The Director of Nursing has been suspended pending investigation . On [DATE] at 10:04 AM, an interview was completed with LPN F via phone, and was asked about the day they provided medications to the DON for destruction. LPN F explained the facility recently began working with a new pharmacy, and she had a number of as needed medications from the previous pharmacy in her fifth floor medication cart, that needed to be discarded for two residents, one of them being R604. LPN F explained they handed off a total of five cards (blister packets, unit dose packaging for pharmaceutical drugs), two cards which contained Ativan, and three cards of Tramadol, all which were full containing about 30 pills to the DON. LPN F indicated she signed the narcotic count sheet when doing so however, the DON did not sign the Controlled Substance Proof of Use sheet for removal from the medication cart. LPN F explained Registered Nurse (RN) G was present at the time she handed the medications to the DON and this was the last time she saw the DON with the medications. LPN F explained the DON later called back to the unit indicating she misplaced the medication, and didn't know what she had done with them. On [DATE] at 10:42 AM, an interview was completed with RN G regarding the missing medications. RN G explained LPN F called the DON to the 5th floor and informed them that they had medications that needed to be destroyed. RN G confirmed witnessing LPN G provide the medications to the DON, and together they rode the elevator to the 4th floor where the medications were to be destroyed in the DON's office. RN G explained as soon as they arrived to the 4th floor, the DON said there were residents on the floor that needed assistance to be fed, and proceeded to entered into room [ROOM NUMBER] where a Certified Nursing Assistant (CNA H) was feeding a resident. RN G explained they observed the DON lay the cards of narcotic medication down on the resident's nightstand, inform CNA H they could leave, and she (the DON) would assist the resident with eating. RN G said that they made attempts to get the DON to leave and destroy the medications, as their morning meeting was scheduled to begin in approximately 5 minutes, however, the DON stayed in the room and continued to feed the resident. RN G explained they left the room to obtain water for the 4th floor residents, returning back to room [ROOM NUMBER] approximately ,d+[DATE] minutes later. RN G explained upon entering the room, they observed the resident's food tray looked as though it had not been touched since the duration the DON was in the room. RN G said that upon returning to room [ROOM NUMBER], they and the DON went to destroy the medications however, upon counting the cards, the DON only had four cards, and not five. RN G explained the DON attributed it to LPN F not giving her five cards, and then started to indicate that maybe she had dropped the 5th card. RN G explained the missing card was for R604, and was later identified as Ativan. RN G said they told the DON they needed to retrace their steps and go back to room [ROOM NUMBER] however, the DON stated it wasn't necessary, and began to frantically look for the medication. RN G explained that they went to the Nursing Home Administrator (NHA), and provided them with the controlled substance record for the missing medication. RN G was asked if she had witnessed any other incidents of missing medications, and she explained on [DATE], the DON stood at the nurses' station with the white container used to destroy medications along with a bag of narcotics. RN G said the DON began punching medications out of blister packets onto the desk at the nurses' station making it difficult to identify what packet the medications were coming from. RN G went on to say, after they were able to organize and count the medications, and 17 Hydrocodone pills were missing for [R605 and R606]. RN G said the DON had a new LPN ( LPN I ) sign documents presented to her by the DON regarding the destruction of the medications, and said they would notify the medical director about the missing medications. On [DATE] at 11:18 AM, CNA H was interviewed regarding the day they assisted the resident in room [ROOM NUMBER] with breakfast. CNA H confirmed the DON entered into the room and explained that they would assist the resident, so they subsequently left the room to collect trays. CNA H explained to the DON that they only had one other resident that needed assistance with meals, but that resident was asleep. CNA H confirmed upon returning to room [ROOM NUMBER], the residents plate of food looked the same as it had when they had left the DON in the room to assist. On [DATE] at 11:37 AM, an attempt to contact the DON via phone was unsuccessful. On [DATE] at 1:09 PM, an interview was completed with LPN I regarding the day they and the DON disposed of medication. LPN I confirmed they did sign off on a few narcotic sheets, but refused to sign the sheets that were missing medications. LPN I explained they didn't think they were able to assist the DON in the destruction of medications, but the DON insisted that it was fine. R604 A review of R604's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Alzheimer's Disease, Chronic Kidney Disease, Diabetes and Anxiety. Further review revealed the resident was severely cognitively impaired, and had three separate PRN (as needed) orders dated for [DATE], [DATE] and [DATE], and are as follows,Lorazepam Oral Tablet 0.5 MG (Lorazepam). Give 1 tablet by mouth every 6 hours as needed for Anxiety . R605 A review of R605's medical record revealed they were admitted into the facility on [DATE], and expired on [DATE]. The resident was admitted with diagnoses that included Alzheimer's Disease, Diabetes, and Hypertension. Further review of the medical record revealed the resident was prescribed the following order on [DATE], Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE] MG (milligrams). Give 5.325 mg by mouth every 6 hours as needed for Moderate Pain. R606 A review of R606's medical record revealed they were admitted into the facility on [DATE] under hospice care, and expired on [DATE]. A review of the resident's diagnoses include Chronic Pain and Malignant Neoplasm of the Esophagus. Further review of the medical record revealed the resident had the following physician order on [DATE], Hydrocodone-Acetaminophen Oral Tablet ,d+[DATE]MG. Give 1 tablet via Percutaneous Gastrostomy Tube (PEG-tube for foods, liquids and medication)-every 6 hours for Pain. On [DATE] at 11:45 AM, the Nursing Home Administrator (NHA) was asked about they're investigation regarding the DON, and she explained when the DON was interviewed about the missing medications, the DON could not provide an explanation for the missing medications, and said they did not have any destruction logs for medications that had been destroyed during the course of her employment. On [DATE] at 2:37 PM, an interview was completed with LPN J regarding the process for medications needing to be destroyed. LPN J explained there isn't a schedule for when medications are to be destroyed, it's as needed however, the nurse further explained there have been so many different nurses in the role of Director of Nursing (DON), and they all had a different procedure for how they wanted things done, so they really was not sure what the procedure is. A review of a partial destruction log binder was reviewed revealing multiple unorganized and incomplete documents titled Controlled Drug Record and Control Substance Record that were missing signatures and witnesses however, RN E's name and signature was noted on a number of the incomplete documents. On [DATE] at 3:36 PM, an interview was completed with Minimum Data Set Assessment (MDS) nurse, RN E and was asked about the number of times they were involved in the destruction of medications with the DON. RN E explained they were not very involved and disposed of narcotic medications one time with the DON. RN E was shown the partial log binder with their name listed on multiple incomplete documents, however, the nurse could not explain why their name or initials were on the sheets. On [DATE] at 4:00pm, Pharmacist K was interviewed via phone regarding the process of narcotic delivery and storage to the facility, and explained the nurse signs for the medications when they are delivered and the nurse signs them into their inventory. Regarding facility advisement of controlled substance destruction, Pharmacist K explained the facility should have their own controlled systems and guidelines with a nurse and a witness. A review of the Discarding and Destroying Medications policy which was undated revealed the following, 1. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of .7. For unused, non-hazardous controlled substances that are disposed of by an authorized collector, the Environmental Protection Agency (EPA) recommends destruction an disposal of the substance with other solid waste following the steps below: .d. Document the disposal on the medication disposition record. e. Include the signatures(s) of at least two witnesses .12. Completed medication disposition records shall be kept on file in the facility for at least (2) two years, or as mandated by state law governing the retention and storage of such records .

This citation pertains to Intake MI00145241. Based on interview and record review, the facility failed to schedule a follow up appointment for one resident (R701) of three reveiwed for quality of care. Findings include: A review of the intake allegation noted, [They] has been in the facility for approx (approximately). 2.5 wks (weeks). Staff were supposed to schedule [their] a follow-up appt. (appointment) with [their] cancer doctor, which hasn't been done. [They] . supposed to have a CAT scan (CT-Computed tomography is a noninvasive medical examination or procedure that uses specialized X-ray equipment to produce cross-sectional images of the body)w (with)/contrast done of [their] left lobe . A review of R701's medical record noted, R701 was admitted to the facility on [DATE] and readmitted [DATE] and then discharged on [DATE]. A review of R701's admission Minimum Data Set (MDS) dated [DATE], revealed R701 with an intact cognition, used a walker, and required some assistance with activities of daily living. Further review of R701's medical record revealed, progress notes, 6/12/2024 10:40 (AM) Physician Progress Note . History and Physical . this patient was recently treated for COPD (Chronic obstructive pulmonary disease). [R701] reports [R701] does have lung cancer diagnosed in the past and recommended for follow-up CT with contrast .I called oncology radiation and clinic staff reports they will fax a prescription for patient to do CAT scan of the lungs . ASSESSMENT/PLANS: Left lung primary malignant neoplasm. Placed a call to clinic of [local] oncology . spoke with clinic staff, will fax prescription for CT with contrast needed for patient before follow-up visit. Patient agreeable to do CAT scan in [local hospital] . 6/14/2024 08:20 (AM) Physician Progress Note: [local] Consultants . Placed a call to clinic of [local]/radiation oncology . spoke with clinic staff, will fax prescription for CT with contrast needed for patient before follow-up visit. Patient agreeable to do CATscan in [local hospital] . 6/25/2024 10:00 (AM) Physician Progress Note: Placed a call to clinic of [local]/radiation oncology . spoke with clinic staff, will fax prescription for CT with contrast needed for patient before follow-up visit. Patient agreeable to do CATscan in [local hospital] . 6/18: Placed a call to oncology clinic again, clinic staff and gave a prescription for CT scan of the lungs with contrast 6/20. Awaiting scripts for CT scan from radiation oncology clinic . 6/27/2024 08:00 (AM) Physician Progress Note: [local hospital] . Left lung primary malignant neoplasm. Placed a call to clinic of [local]/radiation oncology . spoke with clinic staff, will fax prescription for CT with contrast needed for patient before follow-up visit. Patient agreeable to do CAT scan in [local hospital] .6/18: Placed a call to oncology clinic again, clinic staff and gave A prescription for CT scan of the lungs with contrast .6/20: Awaiting scripts for CT scan from radiation oncology clinic . On 7/16/24 at 1:45 PM, the appointment clerk was asked about R701's appointments. The clerk stated [R701] didn't have any (outside) appointments .I never knew that [R701] had any appointments. I don't see any orders from the doctor. The clerk was asked about the process for outside appointments. The clerk explained, she reviews the hospital discharge summary, then talks to the resident/responsible party to find out how they want to handle any follow up appointments. If it is a new order, the clerk explained, that she would get the order from the nurse and make the appointment. On 7/16/24 at 2:15 PM, The Nursing Home Administrator (NHA) was asked about the appointments that were not made for R701. The NHA explained, she was not sure why the appointments were not made for R701, but she would look into the issue. A review of the facility's policy titled Outside Appointments/Consults undated, revealed, Residents may require outside specialty appointments, outside consults, ancillary services or any other services that require the resident to receive additional care outside of the facility. External appointments require a physician's order before the appointment can be scheduled. Once the order is obtained, the order will be forwarded to the Medical Records Department for scheduling. Medical Records will contact the Resident/Responsible Party to communicate the appointment. Once the appointments are scheduled, the appointment will be placed on the dashboard. The day prior to the appointment, the appointment will be placed on the communication board. A packet of information will accompany the resident to the appointment. All documents and recommendations will be provided to the nurse upon return from the appointment. The nurse will contact the attending physician and review recommendations. Any changes in the residents' plan of care will be reviewed by the physician. The physician will provide orders as indicated. Medical Records will review the documents for further information to determine if there is a need for a follow-up appointment.

Based on observation, interview, and record review, the facility failed to clean and maintain food service equipment and maintain sanitary kitchen practices effecting 45 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 04/02/24 at 12:40 P.M., An environmental tour of the 5th Floor Dining Room was conducted by this surveyor. The following items were noted: The stainless steel non-insulated transport cart steering handles were observed bent and curved. 1 of 2 handles were also observed covered with black electrical tape. The worn and fragmented black electrical tape was also observed heavily soiled with accumulated and encrusted food residue. The ice and water dispensing machine (chutes) were observed heavily soiled with accumulated and encrusted mineral (lime and calcium) deposits. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 04/02/24 at 12:58 P.M., An environmental tour of the 4th Floor Dining Room was conducted by this surveyor. The following items were noted: The stainless steel non-insulated transport cart steering handles were observed bent and curved. 1 of 2 handles were also observed covered with gray duct tape. The worn and fragmented gray duct tape was also observed heavily soiled with accumulated and encrusted food residue. The ice and water dispensing machine (chutes) were observed heavily soiled with accumulated and encrusted mineral (lime and calcium) deposits. The water dispensing sensor was also observed loose-to-mount, located within the machine cabinetry. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The drywall surface was observed (etched, scored, particulate), adjacent to the General Electric refrigerator/freezer unit. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. On 04/02/24 at 02:19 P.M., A comprehensive tour of the food service was conducted with Dietary Manager B. The following items were noted: The Panasonic Microwave Oven interior door surface was observed (etched, scored, particulate). The damaged door surface measured approximately 1-inch-wide by 2-inches-long. The ANETS Golden Grill support legs (2 of 4) were observed bent inward approximately 45 degrees, creating an increased likelihood for staff accidental injury. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The [NAME] Commercial Toaster was observed with accumulated and encrusted food residue (breadcrumbs). The Ice Machine interior basin white resin retention was observed soiled with accumulated and encrusted black residue. The black watery residue measured approximately 2-inches-wide by 14-inches-long. The Juice Machine interior and exterior surfaces were observed with accumulated and encrusted food residue. The backsplash, undersplash, and drip tray were also observed soiled with accumulated and encrusted food residue. The Coffee Machine undersplash and dispensing spouts were observed soiled with accumulated and encrusted food residue. Dietary Manager B indicated she would have staff thoroughly clean and sanitize the soiled food service equipment as soon as possible. The [NAME] commercial mixer was observed soiled with accumulated and encrusted food residue. The undersplash, spindle gear, and safety guard shield were observed soiled with food residue. The [NAME] commercial mixer was additionally observed with exterior chipped and flaking paint. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The [NAME] commercial mixer electrical pig tail cord was observed worn, frayed, and split. The [NAME] commercial mixer on/off switch was further observed non-functional. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The Mechanical Storage Room was observed in disarray. The entrance door lockset was also observed loose-to-mount and non-functional. The overhead light assembly plastic light lens cover was further observed with numerous dead insect carcasses. On 04/03/24 at 02:42 P.M., A comprehensive tour of the Walk-In Freezer was conducted with Dietary Manager B. The following items were noted: The primary freezer temperature was observed to read 22 degrees Fahrenheit on the external manufacturer thermometer. The internal secondary freezer was also observed to read 32 degrees Fahrenheit on the manufacturer thermometer. Food products in both freezer units were further observed to be thawing and supple. Dietary Manager B indicated she would contact the refrigeration contractual vendor for immediate assessment and repairs of the unit. The 2017 FDA Model Food Code section 3-501.11 states: Stored frozen FOODS shall be maintained frozen. On 04/04/24 at 11:30 A.M., Record review of the Policy/Procedure entitled: Sanitization dated 10/2008 revealed under Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Record review of the Policy/Procedure entitled: Sanitization dated 10/2008 further revealed under Policy Interpretation and Implementation: (1) All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. (2) All utensils, counters, shelves, and equipment, shall be kept clean, maintained in good repair, and shall be free from breaks, corrosion, open seams, cracks, and chipped areas, that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair. (3) All equipment, food contact surfaces, and utensils, shall be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. On 04/04/24 at 11:45 A.M., Record review of the Policy/Procedure entitled: Ice Machines dated (no date) revealed under Instructions: Ice Machines: Check filters (if present), clean coils, sanitize interior, and delime (if necessary). On 04/04/24 at 12:00 P.M., Record review of the Policy/Procedure entitled: Cleaning Procedure - Food Processor/Blender dated (no date) revealed under Policy: The Food Processor/Blender is maintained in a clean, sanitary condition. On 04/04/24 at 12:15 P.M., Record review of the Policy/Procedure entitled: Cleaning Procedure - Coffee Maker dated (no date) revealed under Policy: The Coffee Maker is maintained in a clean, sanitary condition. On 04/04/24 at 12:30 P.M., Record review of the Policy/Procedure entitled: Cleaning Procedure - Toaster dated (no date) revealed under Policy: The Toaster is maintained in a clean, sanitary condition. 32220 On 04/02/24 at 7:39 AM, an initial observation of the kitchen with the dietary staff D and the Dietary Manager revealed: -The external temperature of the [NAME] freezer was 26 degrees Fahrenheit (F). The internal thermometer reading was between 26 and 28 degrees F; The secondary (internal) [NAME] freezer read 32 degrees F on the external thermometer. The freezer did not have an internal thermometer. The freezer did not feel cold. -A bag of chicken tenders and a bag of shredded meat were open and did not have an open date or label. They did not feel frozen solid. -Food holding pans trays on the rack outside the freezer had a greasy substance on it and three others were wet in between the pans. Dietary staff D and Dietary Manager indicated they should be clean and dry before they are placed on the shelf. -The [NAME] refrigerator was 32 degrees on the external thermometer. Cucumbers had visible green and white mold; -The holding bins for the rice, oats and flour were not dated bins; multiple packages of bread were open and loosely knoted; -The meat slicer had dry dust like debris under and in the tray of the slicer. The stand mixer had chipped and peeling paint on the housing above the bowl; The splatter guard was covered side to side with a dried batter mixture though the unit was not in use; -10 ladels, spoons or straining spoons hanging on the storage rack had dried food debris on them; -The dish machine log posted was for December 2023 and was not filled out. The dietary staff reported mulitple staff run the dish machine and were not sure if daily temperature checks were completed; -The four slot toaster had crumbs which covered the bottom of the toaster. It was reported that the toaster may be cleaned once a week. On 04/02/24 at 11:34 AM, an observation of the tray line for lunch revealed: -A female staff had strands of hair that were not fully covered by their hair net; -A gnat/fuit fly was hovering around the microwave; -Cook E was observed to placed food onto a few plates with the service utensils and adjusted the food on the plate with gloved hands and wiped the gloved hands on a dishcloth resting on the counter which had sanitizer on it and then returned to dispensing food with the utensils and adjusting the food on the plates with the same gloved hands; The cook then removed the gloves and put on a new pair without washing in between; The cook the returned to preparing plates and upon stepping away to pull an item from the oven touched their hat and sides of their pants and returned to the steam table with the item from the oven; The cook resumed plating the food; The gloves were not observed to be changed; the cooked then placed a food item into the micrwave and turned back to the food; The cook then went to check the temperature of the item from the microwave, removed a glove from the left hand, checked the temperature and placed a new glove on and during the process pulled their pants up from the back and returned to plating the food and making placement adjustments with the same gloved hands. No hand hygiene was observed. On 04/04/24 at 10:55 AM, the outside temp for the [NAME] freezer read 31 degrees F; the internal thermometer read between 28 and 30 degrees F; -Tubes of ground meat were not frozen; a box of ham and a box of ground beef did not feel frozen; -Liquid items/juices dated 3/15 and 4/2 were not frozen-the container could be squeezed; -muffins and biscuits dated 4/1 were soft to the touch; -The internal freezer read 34 degrees on the external temperature gauge-there was no internal thermometer; -The unlabeled shredded meat and chicken strips were soft and not labeled with a date opened; Pastry sheets, pulled pork, pie crusts, seasoned beef, seasoned beef patties, cooked meatballs, breaded fish dated 4/1, magic (ice cream) cups, chocolate chip cookie dough, and bacon felt soft to the touch and not frozen; The bacon was open to the air in the freezer; Two boxes of whipped topping had four tubs of whipped dairy topping on top which were soft to the touch and the writing on the box advised to maintain at zero or below. The Dietary Manager reported the cook called off for the day and was the only staff preparing food.

Based on interview and record review the facility failed to ensure all elements of the facility infection control program (ICP) were implemented and documented potentially affecting all 45 residents of the facility. Findings include: On 04/03/24 at 3:07 PM, a review of the infection control program was initiated with the Infection Control Preventionist Nurse. The ICP reported they had started in their role for the facility in Novembers of 2023. A review of the elements included a monthly summary of facility infections, the facility acquired rate of infection, the line list of resident infection, mapping the location of resident infections, documentation of the use of McGreer's Criteria, radiology reports, labs for culture and sensitivity for antibiotic use, a pharmacy report on the antibiotic use by the facility, staff education on infection control processes, and correlation of staff and resident illness. On 04/04/24 at 7:54 AM, a review of the documented elements was conducted. -January 2023 had a line list and mapping no other elements were included. -February 2023 had a line list and mapping, no other elements were included. Eight resident had antibiotic use. -March had mapping and a summary of infections and facility acquired rates for January 2023 and February 2023. The January facility acquired rate of infection was 7.68% vs the 5% threshold rate for infection. -April 2023 had no documented elements for the program. -May 2023 through October 2023 had no rate for facility acquired infections and no documentation for correlation of staff and resident illness. -October did not have a summary. On 04/04/24 at 9:42 AM, the findings were reviewed the Administrator. The Administrator noted a consultant provided a report on processes dated April 2023. The report did not include any elements missing from the program for January 2023 through April 2023. The Administrator indicated there was lapse in having a defined ICP during some months in 2023. At 1:31 PM, the Administrator confirmed the missing elements could not be located. A review of the facility policy titled, Antibiotic Stewardship revised December 2016, revealed, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program .The purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents . A review of the facility policy titled, Monitoring Compliance with Infection Control revised August 2019, revealed, Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and practices . A review of the facility policy titled, Surveillance for Infections revised September 2017, revealed, .The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare Associated Infections, to guide appropriate interventions and to prevent future infections .

Based on observation, interview, and record review, the facility failed to clean and maintain the physical plant effecting 45 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and reduced air quality. Findings include: On 04/03/24 at 09:36 A.M., Record review of the Maintenance Work Orders generated for the last 90 days revealed no specific entries related to the documented maintenance concerns. On 04/03/24 at 09:50 A.M., An environmental tour of the facility Laundry Service was conducted with Director of Maintenance A. The following item was noted: Laundry Room: The flooring surface was observed missing numerous 12-inch-wide by 12-inch-long vinyl tiles. The damaged flooring surface measured approximately 10-feet-wide by 24-feet-long. The damaged flooring surface was also observed extremely moist, due to excessive water exposure from the washing machine discharge pipes. On 04/03/24 at 10:08 A.M., An environmental tour of the facility Central Supply was conducted with Director of Maintenance A. The following item was noted: 3 of 4 overhead light assemblies were observed non-functional. The entire room was also observed in complete disarray. On 04/03/24 at 10:20 A.M., A common area environmental tour was conducted with Director of Maintenance A. The following items were noted: Entrance Lobby: The flooring surface was observed (etched, scored, worn), directly behind and beneath the receptionist chair perimeter. The damaged flooring surface measured approximately 4-feet wide by 5-feet-long. Director of Maintenance A indicated he would have staff replace the worn vinyl planking as soon as possible. Rehabilitation Gym: 1 of 6 stools were observed (etched, scored, particulate), exposing the inner Styrofoam padding. 2 of 4 chairs were also observed (etched, scored, particulate), exposing the inner Styrofoam padding. 4th Floor [NAME] Nursing Station: 1 chair was observed (etched, scored, particulate), exposing the inner Styrofoam padding. 1 of 2 stools were also observed (etched, scored, particulate), exposing the inner Styrofoam padding. The desk surface edge was further observed missing the laminate veneer. The damaged laminate surface measured approximately 2-inches-wide by 13-feet-long. Staff Restroom: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust and dirt deposits. The hand sink faucet assembly was also observed loose-to-mount. [NAME] Nursing Station: The desk surface edge was observed missing the laminate veneer. The damaged laminate surface measured approximately 2-inches-wide by 13-feet-long. 5th Floor [NAME] Nursing Station: 1 of 2 chairs were observed (etched, scored, particulate), exposing the inner Styrofoam padding. Staff Restroom: The return-air-exhaust ventilation inner baffles and plenum were observed with accumulated and encrusted dust and dirt deposits. The hand sink faucet assembly was also observed loose-to-mount. The Polar Wind desk fan, located on the [NAME] Unit Medication Cart was observed heavily soiled with accumulated and encrusted dust and dirt deposits. Soiled Utility Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust and dirt deposits. Janitor Closet: The mop sink basin drain cover was observed loose-to-mount. The mop sink basin was also observed soiled with accumulated and encrusted dirt deposits. Tub/Beauty Room: 2 of 2 brooms were observed severely worn and damaged. The broom bristles were also observed sporadically bent and frayed pointing in numerous directions. The dust/dirt collection pan was also observed heavily soiled with accumulated and encrusted dirt/debris. Director of Maintenance A indicated he would have housekeeping replace the severely worn brooms as soon as possible. On 04/03/24 at 11:25 A.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance A. The following items were noted: 413: The restroom return-air-exhaust ventilation grill was observed soiled with dust and dirt deposits. 420: 1 of 2 windowpanes were observed severely fogged and clouded from a damaged seal. The damaged windowpane measured approximately 3-feet-wide by 5-feet-long. 518: The Bed A bi-lateral landing strip pads were observed heavily soiled with accumulated and encrusted dirt deposits. 1 of 2 landing strip pads were also observed (etched, scored, particulate), exposing the inner Styrofoam padding. The restroom toilet tissue dispenser was additionally observed loose-to-mount and missing 1 of 2 support arms. The laminate flooring transition strip between the resident room and hallway corridor was further observed missing. 519: 1 of 2 windowpanes were observed severely fogged and clouded from a damaged seal. The damaged windowpane measured approximately 3-feet-wide by 5-feet-long. The return-air-exhaust ventilation baffles and plenum were also observed heavily soiled with accumulated and encrusted dust and dirt deposits. 524: The drywall surface was observed severely (etched, scored, particulate), directly behind the Bed A headboard. The damaged drywall surface measured approximately 2-feet-wide by 5-feet-long. 526: The restroom hand sink faucet assembly was observed loose-to-mount. Director of Maintenance A indicated he would have staff perform necessary repairs as soon as possible. 528: The Bed A privacy curtain was observed missing 6 mounting hooks. The Packaged Terminal Air Conditioner (PTAC) Unit filters were also observed heavily soiled with accumulated and encrusted dust and dirt deposits. On 04/04/24 at 11:00 A.M., Record review of the Policy/Procedure entitled: Cleaning and Disinfection of Environmental Surfaces dated 08-2019 revealed under Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Record review of the Policy/Procedure entitled: Cleaning and Disinfection of Environmental Surfaces dated 08-2019 further revealed under Policy Interpretation and Implementation: (9) Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. (10) Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. (11) Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. On 04/04/24 at 11:15 A.M., Record review of the Policy/Procedure entitled: Exhaust Fans: Inspect Exhaust Fans dated 02/2022 revealed under Instructions: Exhaust Fans: Inspect exhaust fans for proper operation and clean if necessary.

Based on observation, interview and record review, the facility failed to ensure the Pharmacy Consultant Medication Regimen reviews were completed monthly for five residents (R12, R10, R13, R17, and R19) of five residents reviewed for pharmaceutical services. Findings include: R12 On 04/02/24 at 4:03 PM, R12 was observed to be seated in their wheelchair on the right side of their bed. R12 reported itching to their arms back and legs. R12 had visible scabs to the arms with loose gauze dressings hanging from the arms. The record indicated R12 had complained of itching since 02/29/24 and had been seen by the nurse practitioner (NP). The medical team had prescribed Bactrim (antibiotic), Ivermectin (anti-parasite), Tramcinolone Cream (anti-inflammatory) and Prednisone (anti-inflammatory) since that time. R12 had 20 or more active medication orders. A review of the medical record documented the last Pharmacy Consultant Review was on 06/27/23. This report indicated to see the report for noted irregularities. A review of the record for R12 documented R12 was admitted into the facility on [DATE] and had a readmission on 06/09/20. Diagnoses included Chronic Kidney Disease, Dementia, Diabetes and Mood Disorder. R10 A review of the record for R10 documented R10 was admitted into the facility 11/10/21 and readmitted [DATE]. Diagnoses included Dementia, Stroke and Heart Disease. R10 had 18 active medication orders one of which was the psychotropic/anti anxiety medication Ativan. A review of the medical record documented the last Pharmacy Consultant Review was on 06/27/23. This report indicated to see the report for noted irregularities. 34851 R13 On 4/02/24 at 8:40 AM, R13 was observed sitting in their wheelchair, sleeping with stuffed animals in their arms. R13's bed was observed to be low with floor mats folded up along the wall. An interview was attempted but unable to be completed due to cognitive impairment. On 4/03/24 at 8:55 AM, R13 was observed sitting in their wheelchair with an empty plate on their lap and an empty cup in their hand. R13 was observed to lick the plate and the outside of the cup. A review of R13's medical record noted, R13 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, without behavioral disturbance, mood disturbance, and anxiety. A review of R13's annual Minimum Data Set (MDS) assessment noted, R13 with a severely impaired cognition and that R13 required assistance with activities of daily living. A review of R13's physician orders noted, Memantine HCl Tablet 10 MG (milligram) Give 10 mg by mouth one time a day for dementia. A review of R13's Pharmacy Consultant Medication Reviews revealed no medication reviews were completed by the Pharmacist since 6/27/23. R17 On 4/02/24 at 8:33 AM, R17 was observed in a low bed asleep. On 4/04/24 at 8:43 AM, R17 was observed in bed eating breakfast. R17 was asked if they were being treated for depression. R17 explained that they thought they were but offered no other details regarding the type of treatment. A review of R17's annual (MDS) dated [DATE], noted, diagnoses of Alzheimer's disease, Non-Alzheimer's Dementia and Depression and was prescribed an antidepressant and anticoagulant (blood thinner). A review of R17's physician orders noted, Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for anticoagulant. Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for antidepressant. A review of the medical record for R17 noted, Pharmacy Consultant Medication Reviews on 1/24/2023, 4/26/2023, and 5/28/2023 which indicated to see the report for noted irregularities. A review of R17's Pharmacy Consultant Medication Reviews revealed no medication reviews were completed by the Pharmacist since 6/27/23. A review of R17's care plan noted, Focus: I have alteration in cognitive function R/T (related to); Dx (diagnosis) Alzheimer's disease, alert and oriented X 2-3, impaired thought process, impaired/poor decision-making skills, long term memory loss, poor insight, judgement, and reasoning, require assist with daily routine, schedule, and ADL (activites of daily living) care, short term memory loss. Date Initiated: 01/27/2022. Goal: Dx Alzheimer's disease, alert and oriented X 2-3, impaired thought process, impaired/poor decision-making skills, long term memory loss, poor insight, judgement, and reasoning, require assist with daily routine, schedule, and ADL care, short term memory loss Date Initiated: 01/27/2022. I will maintain current/optimal level of cognitive function through next review date. Date Initiated: 01/27/2022. My physical and psycho-social needs will be met as much as possible through next review date. Date Initiated: 01/27/2022. Interventions: Monitor effectiveness of antidepressant medication. Date Initiated: 01/27/2022. ate Initiated: 01/27/2022. Monitor for, document, and report any mood/behavior issues/problems. Date Initiated: 01/27/2022. Monitor for, document, and report to physician any s/s of side effects of antidepressant medication. Date Initiated: 01/27/2022. R19 On 4/02/24 at 8:38 AM, R19 was observed in bed with their shoes on top of the sheets. R19 reported no concerns. On 4/03/24 at 9:12 AM, R19 was observed in bed and under covers. A review of R19's medical record revealed, R19 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, unspecified severity, with other behavioral disturbance and Depression. A review of R19's admission MDS dated [DATE] noted, R19 with an impaired cognition and medications received an antipsychotic medication. A review of R19's physician order noted Quetiapine Fumarate Oral Tablet 25 MG (Quetiapine Fumarate) Give 0.5 tablet by mouth one time a day for agitation, aggression; 12.5 mg. Further review of R19's Pharmacy Consultant Medication Reviews revealed no medication reviews were completed by the Pharmacist since admission into the facility. A review of R19's care plan noted, Focus: I have alteration in cognitive function R/T; dx of dementia with behaviors, CVA with cognitive impairments and behavioral disturbance alert and oriented 2, impaired/poor decision-making skill, antipsychotic medication for agitation/aggression Date Initiated: 06/30/2023. Goal: I will maintain current/optimal level of cognitive function through next review date. Date Initiated: 06/30/2023. My physical and psycho-social needs will be met as much as possible through next review date. Date Initiated: 06/30/2023. Interventions: Monitor for, document, and report to physician and s/s of side effects of medications. Date Initiated: 07/13/2023. Offer cues and reminders as needed. Date Initiated: 07/13/2023. Provide antipsychotic mediation as ordered and monitor for unwanted side effects if noted notify md (medical doctor) and Behavioral Care. Date Initiated: 10/20/2023. On 4/04/24 at 9:18 AM, the Nursing Home Administrator (NHA) was asked about the Pharmacy Consultant Medication Reviews. The NHA explained that they have not had a consultant pharmacist since June of 2023 and that they were unable to locate any of the reports that indicated irregularities. A review of the policy titled, Medication Regimen Reviews dated May 2019, revealed, 1. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. 2. Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently in indicated . 8. Within 24hrs of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each residents identified as having a non-life threatening medication irregularity. The report contains: a The resident's name; b. The name of the medication; c. The identified irregularity; and d. The pharmacist's recommendation . 10. If the identified irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences .

Based on observation, interview, and record review, the facility failed to provide a safe environment for one resident (R1) of two residents reviewed for homelike environment. Findings include: On 04/02/24 at 10:54 AM, R1 was observed lying in bed in their room watching television. A large hole was noted in the wall behind the residents bed. The hole was approximately 12 inches long and was deep enough to see the wire in the wall from a plug nearby. Streaks of plaster was coming out of wall. R1 was asked about the hole and stated I didn't do it. It was there before I got here. It needs to be fixed. On 04/03/24 at 1:15 PM, R1 was observed sitting in wheelchair in the room watching television. The large hole with visible wiring remained the same. 04/04/24 01:40 PM, R1 was observed sitting in wheelchair in the room watching television. The large hole with visible wiring remained the same. Record review revealed that R1 was admitted on [DATE] with the following medical diagnoses of Schizophrenia, Hypertension, Open Wound in Abdominal Wall, and Congestive Heart Failure. A review of the Minimum Data Set, dated dated dated [DATE] noted Brief Interview in Mental Status of 10 which indicates mild cognitive impairment. On 04/04/24 at 02:13 PM, during an observation of R1's room with the Maintenance Director (MD) he stated, That's a bad hole. I was not aware of this but I will take care of it as soon as possible. It happens when the bed is pushed against the wall so much and pieces of the wall give in. It is my expectation that residents room are in good shape to provide a home like environment. A review of the policy titled Quality of Life - Homelike Environment revealed that residents are provided with a safe, clean, comfortable and home-like environment and encouraged to use their own personal belongings to the extent possible.

This citation has three deficient practices. Deficient Practice Statement #1. Based on interview and record review, the facility failed to implement an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the 48 residents in the facility. Findings include: On 1/9/23 at 10:00 AM, the building water management plan was requested from the Administrator. On 1/9/23 at 1:00 PM, the plan had not yet been provided, and the Administrator was again queried regarding the building water management plan. The Administrator stated she thought the information had been provided, and stated she would get that information right away. On 1/9/23 at 1:30 PM, the Administrator provide a binder with documentation of water testing for legionella, which had last been completed 10/4/22. A policy was provided entitled Water Management Program Plan. Review of the plan noted 25 pages of blank water management program documentation logs. On 1/9/23 at 2:15 PM, this surveyor requested an interview with the Maintenance Supervisor to discuss the building water management plan. The Administrator stated that the Maintenance Supervisor had resigned, and that they were looking for any documentation that he had regarding the water management program. On 1/9/23 at 4:33 PM, the Administrator provided the following documentation via email: Control Measure Log: Unoccupied Fixture Flushing Log, which noted Flush fixtures in unused areas three times per week dated as last completed 8/29/22 Control Measure Log: Hot Water System Temperature Log, which noted Measure hot water tank, mixing valve and loop return water temperature weekly dated as last completed 9/15/22. On 1/10/23 at 11:02 AM, when queried if the facility had done any more recent water management program documentation logs, the Administrator stated, It appears that the program was not continued as it was supposed to. 38207 Deficient Practice Statement #2. Based on observation, interview, and record review the facility failed to ensure the appropriate disinfectant was readily accessible to disinfect a room occupied by a resident with Clostridium Difficile ([C-DIFF] a spore bound toxin which may cause diarrhea) for one resident (R148) of one resident reviewed for transmission based precautions, resulting in the potential for the spread of infectious disease. Findings include: On 1/9/23 at 1:10 PM, a record review of R148's electronic medical record (EMR) revealed that R148 was admitted to the facility on [DATE] with a diagnosis which included C. diff. On 1/9/23 at 4:44 PM, an observation was made of the infection control cart next to R148's room containing a canister of alcohol-based sanitizing wipes. An examination of the canister revealed that the wipes did not contain bleach and were not indicated for use against C. diff. On 1/9/23 at 5:00 PM, Nurse F was interviewed about the canister of sanitizing wipes on R148's infection control cart and if they were appropriate for use against C. diff. Nurse F stated, Those are the wipes we use. Nurse F confirmed that disinfectant products containing bleach should be used against C. diff. On 1/10/23 at 9:13 AM, the Environmental Protection Agency (EPA) website was reviewed and revealed that products containing bleach should be used against C. diff. The website stated, .make sure to check that the product's label includes directions for use against C. diff. On 1/10/23 at 10:00 AM, the Centers for Disease Control and Prevention (CDC) website was reviewed regarding disinfection of C. diff and indicated that only products that contain chlorine bleach should be used for disinfection of C. diff .Ordinary alcohol-based cleaners or sanitizers do not kill C. difficile. On 1/10/23 at 1:15 PM, the Director of Nursing (DON) was interviewed regarding their expectations for the type of wipes that should be used in a room occupied by a resident who has C. diff. The DON stated, They are supposed to use bleach wipes for a C. diff patient. A facility policy titled Transmission Based Precautions Effective Date: 8/6/2020 documented, Policy Statement: Purpose: The purpose of this document is to provide guidance for Standard Infection Control Practices for Transmission Based Precautions. Standard precautions include .environmental cleaning and disinfection. A facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment Revised: October 2018 documented, Policy Statement: Resident-Care equipment .will be cleaned and disinfected according to current CDC recommendations. 32220 Deficient Practice Statement #3. Based on observation, interview and record review the facility failed to ensure proper donning and doffing of Personal Protective Equipment (PPE) or proper hand hygiene was performed for three sampled residents (R148, R248, R249) of seven residents reviewed for infection control practices, resulting the potential for the spread of infection. Findings include: On 01/10/23 at 10:15 AM, Licensed Practical Nurse (LPN) Hwas observed to administer medications for R148. The room of R148 had a sign on the door and a plastic three drawer cabinet outside the door to the right. A review of the record noted R148 was on contact precautions for Clostridium Difficile ([C-DIFF] a spore bound toxin which may cause diarrhea.) LPN H entered the room and set the plastic medication cup on the lid of the receptacle for the used PPE and trash. LPN H entered the bathroom and washed their hands for less than 20 seconds, then walked over to a yellow disposable type gown hanging on the wall next to the disposal can. Touching the front of the gown and sleeves LPN H donned the gown and tied the gown behind their back. LPN H then dropped the gloves they had removed from the box onto the floor at the threshold of the bathroom, picked them, disposed of them in the can for used PPE and put on a pair of gloves without first doing hand hygiene. LPN H then moved to the beside of R148 and assisted them to take their medications. LPN H touched the bed and items on the over bed table, removed their gloves, reached around the back and untied their gown, pulled the gown off using the sleeves and subsequently the gown was returned to the hook on the wall all without performing hand hygiene. LPN H then washed their hands to a count of 15 seconds and exited the room. LPN H reported that R148 preferred their medications to be administered over different sessions and reported additional medications were to be given. LPN H was then observed a second time for administration of medications for R148. During the second observation, LPN H placed a plastic cup of medications on a disposable foam tray which was then set on top of the disposal can for the used PPE. LPN H washed their hands for a count of 15 seconds, put on a pair of gloves and obtained the gown used during the prior medication pass. LPN H put on the gown over their head as it had been tied previously at the neck, then reached behind and tied the gown behind their back. LPN H then administered the medications to R148. When completed, LPN H removed the gown by pulling on the front of the gown, untied the back and lifted it over their head and hung it back on the wall. LPN H was their hand for a count of twenty seconds and exited the room. On 01/11/23 at 9:10 AM, LPN G was observed to enter the room of R249 and R248. Nurse G was observed to obtain a blood pressure from R248 using a wrist style blood pressure cuff and then from R249 and not complete hand hygiene between the care of the residents. LPN G was also observed to administer medications to R249, move items around the tray table of R249, assist R249 to drink and not complete hand hygiene upon exit from the room and returned to use the computer on the medication cart. On 01/11/23 at 12:38 PM, the identified concerns were reviewed with the Director of Nursing (DON). The DON reported hands should be washed for twenty seconds, a new gown should be donned and gloves may be left on and the gown rolled down from the outside and over the gloves to remove the gloves and gown. The DON also noted the ties should be broken by pulling on the gown and not untied when this method was used. The DON reported staff had been trained on proper removal of PPE and hand hygiene. A review of the facility policy titled, Administering Oral Medications dated October 2010, revealed, .21. Remain with resident until all medications have been taken. 22. Discard all disposable items into designated containers. 23. Perform hand antisepsis . A review of the facility policy titled, Department: Infection Control. Subject: Hand Hygiene dated 08/06/2020 revealed, Hand washing: Use an Alcohol based hand sanitizer. Immediately before touching a patient .After touching a patient or the patient's immediate environment. After contact with blood, body fluids or contaminated surfaces. Immediately after glove removal. When using alcohol based hand sanitizer. Put product on hands. Cover all surfaces until hands feel dry. This should take around twenty seconds. Wash with soap and water: When hands are visibly soiled. After caring for a person with know or suspected infectious diarrhea. After known or suspected exposure to spores e.g B. Anthracis and C. Difficile outbreaks. The (Center for Disease Control) CDC recommends: When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands and rub you hands together vigorously for at least twenty seconds, covering all surfaces of the hands and fingers . A review of the facility policy titled, Department: Infection Control. Subject: Appropriate use of PPE dated 08/06/2020 revealed, Donning PPE: The gown should be donned first. The mask or respirator should be put on next and properly adjusted to fit. Remember to fit check the respirator. The goggles or face shield should be donned next and the gloves are donned last. Keep in mind the combination of PPE used and therefore the sequence for donning, will be determined by the precautions that need to be taken . Doffing PPE: In general the outside, front and sleeves of the isolation gown .are considered contaminated regardless of whether there is visible soil. Also the outside of the gloves are considered contaminated . The gloves are considered to be the most contaminated pieces of PPE and are therefore removed first. The face shield or goggles are next .The gown is third in the sequence . Unfasten the gown ties with ungloved hands. Slip hands hands underneath the the gown at the neck and shoulder. Peel away from the shoulders. Slip the fingers of one hand under the cuff of the opposite arm. Pull the hand into the sleeve grasping the gown from the inside. Reach across and push the sleeve off the opposite arm. Fold or roll the gown towards the inside and fold or roll into a bundle. Only the clean part of the gown should be visible .

Based on interview and record review, the facility failed to ensure the Medical Director or their designee attended the Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly, resulting in the and or the potential for decreased over sight of facility infection control practices, medical coordination and resident care. Findings include: On 01/11/23 at 11:08 AM, The QAPI program was reviewed with the facility Administrator. Aong with the Administrator, a review of the QAPI meetings since the last recertfication survey revealed: A March 2022 meeting; A June 2022 meeting; A July 2022 meeting; A September 2022 meeting; An October 2022 meeting; A November 2022 meeting and a December 2022 meeting. The Medical Director nor a designee was documented as having attended a QAPI meeting in the last four months of 2022. The Administrator acknowledged that the Medical Director does have assigned residents at the facility and would reach out to the physician to attend the meetings. The Administrator also confirmed recent positive COVID cases for staff and residents. The expected minimal participants in QAPI meetings at least quarterly were reviewed with the Administrator and the Administrator acknowledged the need for the Medical Director to attend and stated, I get it. A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program dated February 2020 revealed, The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Establish systems through which to monitor and evaluate corrective actions . Implementation: 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. 3. The committee meets monthly to review reports, evaluate data and monitor QAPI related activities and make adjustments to the plan . A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action dated March 2020 revealed, 2. The methodology for analysis and action is guided by a written QAPI plan that includes: a. Definition of the problem, based on information obtained through data, self assessment and feedback systems. b. An analysis of the root cause of the problem from a systems perspective. c. Establishing measurable goals or benchmarks for improvement. d. Specific interventions aimed at correcting the problem and achieving the stated goals or benchmarks. e. Methods and frequency of monitoring performance improvement objectives .

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) meetings were effective and identified ongoing deficiencies, resulting in the decreased over sight of facility staffing practices and ongoing use of disposable services items for resident's meals. Findings include: On 01/11/23 at 11:08 AM, The QAPI program was reviewed with the Administrator. It was reported that that Administrator had been in their role about two years. Some items identified as concerns during the survey were reported and included cold food, kitchen staffing and the use of disposable dishes and utensils. The Administrator reported QAPI was to promote positive change, growth and development of the facility, staff and residents. The Administrator further noted the difficulty to maintain staff in the management roles such as the Director of Nursing and Minimum Data Set (MDS) Assessment and a genrally high staff turnover rate. An ongoing issue during the Administrators tenure has been the use of disposable plastic utensils and foam service items to serve the resident's food on. A main reason for this, the Adminstrator reported, was a lack of adequate numbers of kitchen and dietary staff needed to run the dishwasher. The Administrator was asked if this issue had come to to QAPI for review and corrective action and reported it had not and a set action plan had not been developed. A review of the QAPI meetings and agendas since the last survey revealed: A March 2022 meeting; A June 2022 meeting; A July 2022 meeting; A September 2022 meeting; An October 2022 meeting; A November 2022 meeting and a December 2022 meeting. The Adminstrator confirmed none of the agendas included the food service concerns. The Administrator acknowledged the need for the issue of disposable food service items to be formally identified in QAPI and stated, I get it. The Administrator further reported surveys concerns such as evening snacks, call light with in reach. A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program dated February 2020 revealed, The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Establish systems through which to monitor and evaluate corrective actions . Implementation: 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. 3. The committee meets monthly to review reports, evaluate data and monitor QAPI related activities and make adjustments to the plan . A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action dated March 2020 revealed, 2. The methodology for analysis and action is guided by a written QAPI plan that includes: a. Definition of the problem, based on information obtained through data, self assessment and feedback systems. b. An analysis of the root cause of the problem from a systems perspective. c. Establishing measurable goals or benchmarks for improvement. d. Specific interventions aimed at correcting the problem and achieving the stated goals or benchmarks. e. Methods and frequency of monitoring performance improvement objectives . A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program - Design and Scope dated February 2020 revealed, 1. The QAPI program is designed to address all systems and practices in this facility that affect residents, including clinical care, quality of life and resident choice and safety . 4. The QAPI functions prioritize identified problem areas that are high risk, high volume and or problem prone . Problem prone refers to care or services that have historically had repeated problems e.g. call bell response times; staff turnover; lost laundry.

Based on observation, interview, and record review the facility failed to ensure a sufficient number of dietary staff, resulting in resident meals being served with plastic utensils, disposable dishware, and disposable foam drinking cups, affecting all residents that eat meals from the kitchen, resulting in the potential for dissatisfaction with the dining experience. Findings include: On 1/9/23 at 8:35 AM, during an initial tour of the of the facility it was observed that all of the residents were being served their breakfast in disposable containers, with plastic utensils and Styrofoam cups. On 1/10/23 at 8:20 AM, Dietary Manager (DM) A was interviewed about the use of disposable dishes, plastic utensils, and foam cups when serving meals to residents and stated, We don't have enough kitchen staff. On 1/10/22 at 10:15 AM, a review of resident council meeting minute documentation revealed that during the months of August 2022 and September 2022, group residents indicated that the plastic knifes did not cut the ham being served to them. On 1/11/23 at 3:07 PM, Kitchen staff/Cook B was interviewed about the use of disposable dishes, nd plastic utensils, and Styrofoam cups when serving meals to the residents. Kitchen staff/Cook B stated, We don't have time to wash dishes, we are understaffed. On 1/11/23 at 3:10 PM, Dietary Aide C was interviewed about the use of disposable dishes, plastic utensils, and Styrofoam cups when serving meals to the residents. Dietary Aide C stated, We don't have enough staff, I have to do two jobs in the kitchen. On 1/11/23 at 3:15 PM, Cook Supervisor D was interviewed about the use of disposable dishes, plastic utensils, and foam cups when serving meals to the residents. Cook Supervisor D stated, We don't have time to do dishes. On 1/11/23 at 3:27 PM, the Administrator (NHA) was interviewed regarding their expectations for providing a homelike environment to residents when serving meals and why resident meals were being served on disposable dishes, with plastic utensils and foam cups. The NHA stated, The residents should have regular dishes and silverware to eat with. The NHA indicated that disposable dishes, plastic utensils, and Styrofoam cups were being used to serve resident meals on due to a shortage of kitchen staff and a high staff turnover rate. The NHA was asked how long disposable dishes and plastic utensils had been used at the facility. The NHA stated, Since I started two years ago. On 1/10/23 at 4:45 PM, a facility policy regarding kitchen staffing was requested from the facility and was not received by survey exit. On 1/11/23 at 3:38 PM, a facility policy titled Food Palatability-Hot Food Temperatures dated 2018 was reviewed and stated the following, .Avoid the use of disposables .

Based on observation, interview and record review the facility failed to ensure insulin pens were dated or discarded when expired in one of three medications care reviewed, resulting in the potential for decreased efficacy of the medication. Findings include: On [DATE] at 10:15 AM, a review of the medications in cart one on the fourth floor was conducted with Nurse H. A Novolog pen was open and not dated. A second Novolog pen for the same resident was dated [DATE]. Nurse H reported the resident had moved to the fifth floor and the pen would be discarded as it was past 30 days. A Humalog insulin pen was also open and not dated. According to Medscape (professional medical website, www.medscape.com) insulin should be stored opened no longer than 28 days at room temperature for insulin aspart (Novolog, Humalog) .

Based on observation, interview and record review the facility failed to provide food at a palatable temperature for four (R20, R12, R30, and R8) of 16 sampled residents resulting in dissatisfaction with meals and the potential for decreased quality of life and inadequate nutritional intake. Findings include: Review of the facility record for R20 revealed an admitted [DATE] with diagnoses which included Pneumonia and Acute Respiratory Failure. Minimum Data Set (MDS) dated [DATE] indicated R20 required setup assistance for eating. R20 was observed to be consistently alert and oriented to person, place and time and Brief Interview of Mental Status score (BIMS) was15 which indicated intact cognition. On 1/09/23 at 8:50 AM, R20 was observed to have eaten very little of their breakfast. R20 reported that the food is always cold. The breakfast was observed to be served in a disposable foam container. On 1/09/23 at 1:23 PM, R20 was observed to have lunch in a diposable foam container. R20 reported that the lunch was cold and approximately 20% appeared eaten. R20 reported being finished with the meal and expressed the intention to supplement the meal with snacks. On 1/10/23 at 9:20 AM, R20 reported that the breakfast was too cold and stated, I did drink my juice. The breakfast was observed on the bedside table in a disposable foam container primarily uneaten. On 1/10/23 at 2:26 PM, R20's family member was visiting and reported no concerns with R20's care but did verify that R20 had reported that the food is consistently cold. R20 reported that the lunch provided today had not been warm enough. On 1/11/23 at 9:28 AM, R20 reported that the breakfast was cold this morning. The breakfast was observed on the bedside table in a disposable foam container. On 1/11/23 at 2:00 PM, R20 reported the lunch was barely warm. The lunch was observed on the bedside table in a disposable foam container. Record review of the facilities Resident Council meeting minutes revealed that cold food was recorded as a resident concern during the November 2022 and September 2022 meetings. On 1/11/23 at 2:30 PM, when queried regarding the length of time the facility has been using disposable food service containers the facility administrator indicated approximately two years. 38207 R12 On 1/9/23 at 9:43 AM, during an initial tour of the facility an observation was made of R12 eating their breakfast out of a disposable foam container with plastic utensils. R12 was interviewed about food palatability at the facility and stated, The food could be warmer. On 1/10/23 at 10:30 AM, a record review of R12's most recent minimum data set assessment (MDS) dated [DATE] revealed that R12 had a severely impaired cognition. R30 On 1/09/23 at 9:52 AM, during an initial tour of the facility R30 was interviewed about food palatability at the facility and stated, The food is cold. On 1/10/23 at 10:44 AM, a record review of R30's most recent MDS dated [DATE] revealed that R30 had a moderately impaired cognition. R8 On 1/9/23 at 10:09 AM, during an initial tour of the facility R8 was interviewed about food palatability at the facility and indicated that the food was cold. R8 stated, How are you supposed to eat waffles and sausages that are cold. A record review of R8's most recent MDS dated [DATE] revealed that R8 had an intact cognition. On 1/10/23 at 8:20 AM, Dietary Manager (DM) A was interviewed about food palatability and cold food at the facility. DM A stated, Sometimes the food sits on the unit and doesn't get passed and sometimes staff leave the food cart doors open. On 01/11/23 at 8:16 AM, the breakfast meal tray cart was delivered to the fourth floor. Packets of disposable plastic utensils were brought to the cart as it had been identified that some trays were missing utensils for the residents to eat with. At 8:44 AM, the door for the uninsulated meal tray cart on the fourth floor was observed to be cracked open slightly not latched. At 8:58 AM, the last meal tray had been passed and the food item temperatures were: sausage links 81.4 F (Fahrenheit), French toast 67.3 F, cream of wheat 103.4 F and juice 48.4 F. At 9:59 AM, the DM A reported the food temperatures at the tray line in the kitchen were: french toast 180 F, cream of wheat 201 F and sausage 183 F. On 1/11/22 at 3:30 PM, the Administrator was interviewed regarding their expectations for food palatability at the facility and stated, The hot food should be hot and cold food should be cold. On 1/11/23 at 3:38 PM, a facility policy titled Food Palatability-Hot Food Temperatures dated 2018 was reviewed and stated the following, Policy: The healthcare community prepares and serves food .that [is] palatable .[at] appetizing [temperatures]. Procedure: Hot food will be held at or above 135 [Degrees] F [Fahrenheit] .The healthcare community makes every effort .to ensure that hot food[s] .are hot [and] served at .appetizing temperatures. The facility food policy and procedure also states, Steps healthcare communities may take into consideration to assure hot food and beverages are both safe and appetizing include the following: .Avoid the use of disposables which don't hold heat well.

Based on observation, interview and record review, the facility failed to reposition/offload pressure per standard of care, and/or treat for pain prior to wound care for three residents (Resident #22, #27 and #33) of five reviewed for pressure ulcers (a wound caused by prolonged pressure on the skin over a bony prominence), resulting in the development of a facility acquired unstageable pressure ulcer and unnecessary pain. Findings include: Resident #22 (R22) On 09/13/2021 at 09:38 AM, during an initial tour, Resident #22 was observed laying in bed on their back. Resident #22 was awake and had clear speech. Resident #22 was interviewed about the care at the facility and expressed that they had no concerns regarding the care they were receiving. Resident #22 was asked if they had any wounds and did reveal they had a wound on their foot. Resident #22 was unable to elaborate on the details of their wound, whereby a bandage was observed on their right foot. Resident #22's heels were observed resting directly on their mattress. On 09/14/2021 at 02:28 PM, Resident #22 was observed lying in bed with their heels resting directly on the mattress of their bed. On 09/14/2021 at 03:50 PM, Wound Care Nurse B was asked to schedule a wound observation with Resident #22 with this Surveyor. Wound Care Nurse B was asked what type of wounds Resident #22 had and explained that (Resident #22) had a pressure ulcer wound to the right heel. Wound Care Nurse B was asked if Resident #22 had any interventions in place to protect their heels and explained that the Resident was to have a dry dressing in place every two days and should have their heels floated. On 09/15/2021 at 08:19 AM, 09:11 AM, 10:45 AM and 11:52 AM, Resident #22 was observed resting in bed on their back, with their heels resting directly on the mattress. On 09/15/2021 at 11:59 AM, a wound care observation was made with Wound Care Nurse B, and Family Member E, whom was at the bedside of Resident #22. When the sheet was removed to reveal Resident #22's legs and feet, their heels were resting directly on the mattress. At that time, Wound Care Nurse B was questioned about the offloading of pressure from the heels and stated, They (the heels) are supposed to be floated. Wound Care Nurse B was asked if the facility used boots or any other methods to offload pressure to the heels and stated, (Resident #22) used to have a boot. Maybe it is in the closet. Family Member E stated, They (facility staff) never put it (the boot) on. Upon opening Resident #22's closet, one soft green boot was observed on the floor of the closet. Wound Care Nurse B then removed the dressing from the right heel of Resident #22 to reveal a large, hard black cap (necrotic/dead tissue) across the whole heel, the surrounding skin was intact. Resident #22 was grimacing with the manipulation of the dressing. Resident #22 was asked if the area hurt and stated, Yes, a little. Resident #22 was unable to describe the pain or rate it on a numeric pain scale. Wound Care Nurse B was asked if the wound was acquired within the facility and confirmed that the wound was facility acquired. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #22 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the physician orders revealed the following order for Resident #22: Dry Bulky dressing to right heel every 2nd day and PRN (as needed). Ordered 08/11/2021. Wound consult. Ordered 08/11/2021. A record review of Resident #22's progress notes revealed the following: 8/11/2021 21:28 (09:28 PM) Skin/Wound Note .Resident presented today with redness and swelling to right foot. Dorsal foot is warm to the touch. Resident is afebrile 98.0 Right heel has dark purple and black area of discoloration measuring 2 cm (centimeters) length x 2.5 cm width, and small red area of discoloration to medial ankle measuring 0.5 cm length x 0.5 cm width. Wound care consult ordered Bukly (sic) dry dressing applied to right heel, xeroform applied to right medial ankle. Orders in place for both treatments. Heels are floated. 8/31/2021 18:51 (06:51 PM) Skin/Wound Note .Resident was seen on 8/30/21 by WCT (wound care team) for right heel deep tissue injury measuring 3 cm length x 5 cm width with an area of 15 sq (square) cm. No drainage noted. Wound bed has dark maroon base granulation. Periwound skin texture , color and moisture are normal. Treatment is: Dry dressing every other day and PRN (as needed). Resident tolerates dressing changes well. Heels are floated and resident is repositioned frequently during shift. He sends (sic) time in .Geri chair, tolerating a few hours well. 9/10/2021 20:44 (08:44 PM) Skin/Wound Note .Resident has been seen this week for treatments .to right heel DTI (deep tissue injury) measuring 3 cm length x 5 cm width. Treatment is DRY DRESSING EOD (every other day). Heels are floated on support pillows. Resident tolerates dressing changes well. A record review of the skin care plans for Resident #22 revealed the following: Focus: I have alteration in skin integrity R/T (related to); Possible DTI to Right heel. Created 08/19/2021. Goal: Current ulcer/wound will display improvement/healing with no s/s (signs and symptoms) of infection by next review date. Interventions: Follow Wound Care Services recommendations/orders. Treatment as ordered. Monitor effectiveness of treatment. Monitor for, document, and report to physician any s/s (signs and symptoms) of infection; warmth, drainage, odor, pain . Assess, document, and report to physician wound status weekly and PRN (as needed). Wound Care Services consult as ordered. Focus: I have potential for alteration in skin integrity R/T age related skin changes, dependent on staff for bed mobility, episodes of bowel incontinence, abnormal labs. Initiated 07/08/2021. Goal: I will have reduced risk factors for skin breakdown through next review date. Interventions: Notify me/my responsible party of any changes in skin condition. Pressure reduction mattress on bed. Pressure reduction cushion in chair. Turn/reposition me every two hours and PRN. Use cushions/pads/pillows to position for pressure relief as needed. Float heels when in bed. Provide prompt pericare after each incontinent episode. Apply barrier cream to skin with pericare and PRN. Apply lotion/moisturizer to skin daily and PRN. Provide diet/tube feeding as ordered. Encourage completion of meals/fluids. Follow nutrition care plan. Monitor labs as ordered. Document and report abnormal to physician. Skin assessment weekly and PRN. Document and report to physician any changes in skin condition. Follow facility skin protocol. Educate me/my caregivers on risk factors and prevention of skin breakdown. A record review of the Michigan Wound Care + Hyperbaric Institute notes for Resident #22 revealed the following: 08/18/2021 .Right Heel is a Deep tissue injury .Initial wound encounter measurements are 3 cm length x 5 cm width .Pressure Relief/Offloading-Frequently reposition, Float heels . 08/23/2021 and 08/30/2021 .Right Heel is a Deep tissue injury .Subsequent wound encounter measurements are 3 cm length x 5 cm width .treatment recommendations-Dry dressing Q2d (every second day) and prn pressure relief/offloading-FREQUENTLY REPOSITION FLOAT HEELS . On 09/15/2021 at 03:30 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed in regards to pressure ulcer management. The DON was asked what the facility does when they discover a new heel wound on a resident. The NHA stated, We assess it. We look at the medications. We meet with the Registered Dietician and notify Doctor and family. We care plan it. (We) Float the heels, consult wound care. The DON was asked if Resident #22 gets out of bed and stated, (Resident #22) used to get up a lot. But, I have not seen (Resident #22) up since you are here. (Resident #22) even has a special boot in their wheelchair for that heel. The DON was asked about how the facility ensures that care planned interventions are being carried out. The DON stated, The interventions (from the care plan) go to the Kardex (the nurse aide care plan). The DON was made aware of the observations of Resident #22 having a facility acquired right heel wound and being in bed with the heels resting directly on the mattress and stated, They are supposed to be floated. I have even stopped and floated (Resident #22)'s heels before. The NHA did not comment during interview. A review of the facility policy titled Facility Acquired Pressure Ulcers dated 10/08/2020 revealed the following: Anticipated outcome: Residents will be identified for their risk of skin breakdown. Residents admitted without pressure ulcers will have measures implemented to reduce the prevalence of acquired pressure ulcers. A review of the facility policy titled Pressure Ulcer Prevention Measures dated 12/17 revealed the following: .18. For residents in bed, who are completely immobile, use devices that relieve pressure on the heels, most commonly by raising the heels off the bed .24 .Reposition the resident shifting the points under pressure every one to two hours depending on the residents needs. Resident #33 (R33) On 9/13/2021 at 11:20 AM, 2:00 PM, and 3:30 PM R33 was observed in their room laying on back in bed. R33 was queried as to whether they had any wounds to which they replied, On my heel that's why I'm on antibiotics and I think I have something on my butt. On 9/14/2021 at 12:15 PM R33 was observed in bed, laying on their back with their heel directly resting on the mattress. R33 revealed that they needed to be repositioned in bed because they were, uncomfortable and about to eat their lunch. Also, R33 revealed that they informed the nurse who was going to get help, to pull them up. On 9/14/2021 at 2:30 PM, R33 was observed in laying in bed with a heel protector on and positioned on their back. On 9/15/2021 at 10:15 AM, a wound care observation was made with Wound Care Nurse (WCN) B. When the sheet was removed to reveal R33's legs and foot, their heel was resting directly on the mattress. At that time, WCN B was questioned about the offloading of pressure from the heel and stated, [R33] heel is supposed to be floated, however [R33] often refuses to wear the protective boot. The protective boot was observed placed in the chair in R33's room. R33's heel wound was observed to have slough (thick, yellow coating) and drainage. WCN B stated that it, looked much better, and will probably be going through a debridement (surgical removal of slough). During wound care R33 stated that they were uncomfortable and wanted something for pain. At 10:26 AM, WCN B informed R33 nurse that they wanted something for pain. R33 coccyx wound was observed with WCN B and was observed to have minimal drainage and red in color. WCN B was questioned about R33 wounds. WCN B stated that R33 coccyx wound, started off red, then it opened up. WCN B went on to state that R33, is non-compliant with turning and repositioning. WCN B revealed that R33's right heel wound is a vascular wound. WCN B was questioned about interventions for R33 being that they were non-compliant with current interventions. WCN B stated that they continue to encourage R33 to wear the boot and to give them time, that they continue to educate R33 about the importance of floating their heel and repositioning and would be speaking to the physician about other interventions they can try. WCN B was questioned about how staff, including agency staff, deal with refusals when WCN B was not present. WCN B revealed that they educated the staff and often have them help with wound care so they can see how to handle R33 refusals. WCN B was questioned regarding pain administration prior to wound care. WCN B stated that they go around and ask patients if they need a pain pill, and if they feel like they do then they will administer one and they will go back in thirty minutes to complete wound care. On 9/15/2021 at 3:12 PM, R33 was observed laying on their back with their heel resting on the bed. R33 heel was not floated, and their heel protector was not in place. On 9/13/2021 a review of medical records revealed that R33 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent minimum data set (MDS) assessment dated [DATE] revealed a 12/15 indicating mild memory impairment and extensive assistance with activities of daily living (ADL's). A record review of R33 progress notes revealed the following: Admission Skin/Wound Note dated 4/20/2021 at 20:17 (8:17 PM), : Resident was seen today for admission 2nd skin assessment. Resident presented with the following skin issues : BKA to Left leg. Incisional scar dry, intact, no drainage, redness or swelling noted.Callous to heel of right foot Callous to ball of right foot with opening in center, measuring 0.2 cm (centimeters) length x 1.6 cm width . 7/20/2021 at 13:25 (1:25 PM) Skin/Wound Note: Resident seen by WCT on 7/19/21 for Redness to buttocks. Resident has Dermatological rash to Coccyx and Bilateral buttocks. Scant amount of drainage noted with no odor .Resident repositioned on [R33] right side upon completion of evaluation. Resident educated on importance of repositioning frequently during the day. Resident tolerated well. 8/11/2021 at 14:19 (2:19 PM) Skin/Wound Note: Resident seen today for report of open wound to right heel. Area measures 3 cm length x 3.5 cm width with bloody drainage. Wound base has yellow slough. NP (Nurse Practitioner H's name) from WCT notified and ordered the following treatment: Area to be cleansed with NS, [MEDICATION(S)] 500 mg crushed applied with Santyl ointment, covered with dry dressing daily. Treatment completed.Heel floated and boot protector with heel opening placed on foot. Resident tolerated dressing change without difficulty or pain. 8/24/2021 at 16:32 (4:32 PM) Skin/Wound Note: Resident was seen on 8/23/21 by WCT for the following skin issues : #1. Coccyx/bilateral buttocks stage 2 pressure ulcer measuring 2.5 cm length x 5 cm width x 0.1 cm depth with an area of 12.5 sq cm and volume of 1.25 cubic cm. Small amount of serous drainage noted with no odor. Wound bed has pink base epithelialization #2. Right posterior heel Diabetic ulcer measuring 3 cm length x 3 cm width x 0.2 cm depth with an area of 9 sq cm and volume of 1.8 cubic cm. Moderate amount of serous drainage noted with no odor. Wound bed has yellow necrotic base granulation. Resident did not resist turning on his side today to take pressure off his back side. Resident educated again on importance of allowing staff to reposition frequently during shifts. Care staff and floor nurse aware of open area. care staff educated on frequent repositioning and to alert floor nurse if resident refuses. 9/10/2021 at 19:58 (7:58 PM) Skin/Wound Note: Resident was seen this week for daily treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Area has small amount of drainage with no odor. Resident often kicks off support pillows requests support boot be removed. Treatment continues of Dermaginate and Santyl ointment daily and PRN. Resident tolerates tx well. 9/14/2021 at 13:47 (1:47 PM) Skin/Wound Note: Resident is also receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident educated for repositioning to relieve pressure off backside and keeping right heel afloat [R33] is reluctant often but allows staff to assist in repositioning . [R33] does not like to wear boot for heel protection . Pillows for heel floatation are kicked off the bed frequently. Treatments are tolerated well Bed in lowest position. Call light on residents abdomen per his request. Both wounds are improving. WCT to see resident this week. A record review of the skin care plans for R33 revealed the following: Focus: I have alteration in skin integrity R/T; Stage 2 pressure ulcer to Coccyx/ Buttocks and Diabetic ulcer to right heel. Goal: Current ulcer/wound will display improvement/healing with no s/s of infection by next review date. Interventions: Follow Wound Care Services recommendations/orders. -Low Air Loss Mattress. Settings: float, level 5 - Treatment as ordered. - Monitor effectiveness of treatment. - Monitor for, document, and report to physician any s/s of infection; warmth, drainage, odor, pain, etc. - Assess, document, and report to physician wound status weekly and PRN. - Wound Care Services consult as ordered. Focus: I have potential for alteration in skin integrity R/T: abnormal labs, age related skin changes, [CONDITION(S)], DM, [CONDITION(S)], episodes of bowel incontinence, PVD, requiring assist with bed mobility. Goal: I will have reduced risk factors for skin breakdown through next review date. Interventions: Resident will be turn and reposition with pillows. - Low Air Loss Mattress. Settings: Float, level 5 - Notify me/my responsible party of any changes in skin condition. - Administer medications as ordered. - Monitor effectiveness of medications. - Pressure reduction mattress on bed. - Pressure reduction cushion in chair. - Assist with turning/repositioning every two hours and PRN. - Use cushions/pads/pillows to position for pressure relief as needed. - Float heels when in bed The care plan did not reveal patient refusals or interventions to implement when R33 refuses. A record review of the Michigan Wound Care + Hyperbaric Institute most recent note for R33 revealed the following: 08/30/2021 .Coccyx/bilateral buttocks is a stage 2 pressure injury/ulcer .measurements 1.5 cm x 1.5 cm x 0.1 cm depth. Right Posterior Heel is a vasculitis ulcer Initial wound encounter measurements are 3 cm x 2 cm x 0.3 cm . Frequently reposition, Float heels . Resident #27 (R27) On 9/15/2021 at 9:49 AM, a wound care observation was made with Wound Care Nurse (WCN) B. WCN B was questioned regarding R27 wound to which they replied that, [R27] coccyx was red and then it opened, then it resolved, then [R27] went to the hospital and returned to the facility with a stage four coccyx wound. Upon turning R27 to view their coccyx, R27 began to grimace and [NAME] their teeth. WCN B stated that R27 has pain in their leg sometimes. WCN B was questioned as to whether they had received a pain pill prior to wound care to which they replied, No, I asked [R27] if they wanted one and they said no. R27 was observed to have a large open wound to their coccyx that was packed with gauze. As WCN B continued with wound care R27 was grimacing and making wincing noises. WCN B asked R27 how they were feeing to which they replied, terrible. WCN B stated that they would come back to complete R27's other treatment after they received a pain pill. R27 was left positioned on their right side, with no heel protectors in place. On 9/15/2021 at 12:06 PM, R27 was observed laying on right side with no heel boots applied and gritting teeth. When asked how they were feeling they did not respond. At 1:14 PM and 3:13 PM, R27 was observed laying on their back with no heel protectors applied. On 9/15/2021 a review of medical records revealed that R27 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent minimum data set (MDS) assessment dated [DATE], reflected R27 required extensive assistance with activities of daily living (ADL's), and had a Brief Interview for Mental Status (BIMS) score of 0/15 (indicating severe memory impairment). A record review of the skin care plans for R27 revealed the following: Focus: I have alteration in skin integrity R/T; Stage 2 pressure ulcer to Coccyx/ Buttocks and Diabetic ulcer to right heel. Goal: Current ulcer/wound will display improvement/healing with no s/s of infection by next review date. Interventions: Follow Wound Care Services recommendations/orders. - Low Air Loss Mattress. Settings: float, level 5 - Treatment as ordered. - Monitor effectiveness of treatment. - Monitor for, document, and report to physician any s/s of infection; warmth, drainage, odor, pain, etc. - Assess, document, and report to physician wound status weekly and PRN. - Wound Care Services consult as ordered. A record review of the Michigan Wound Care + Hyperbaric Institute most recent notes for R27 reflected the following: 08/30/2021: .Coccyx/bilateral buttocks is a stage 4 pressure injury/ulcer .measurements 5 cm x 5.5 cm x 2.5 cm depth. Bone is exposed .Undermining has been noted at 12:00 and ends at 12:00 with a maximum distance of 2 cm .Frequently reposition, Float heels . On 09/15/2021 at 03:30 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed regarding pressure ulcer management. The DON was asked what the facility does when they discover a new wound on a resident. The NHA stated, We assess it. We look at the medications. We meet with the Registered Dietician and notify Doctor and family. We care plan it. (We) Float the heels, consult wound care. The DON was questioned as to who is responsible for wound care plans and how do they ensure interventions are being followed to which they replied, WCN B is responsible, ideally at this point and the interventions are on the Kardex and they do rounds to ensure interventions are being followed. A review of the facility policy titled Facility Acquired Pressure Ulcers dated 10/08/2020 revealed the following: Anticipated outcome: Residents will be identified for their risk of skin breakdown. Residents admitted without pressure ulcers will have measures implemented to reduce the prevalence of acquired pressure ulcers. A review of the facility policy titled Pressure Ulcer Prevention Measures dated 12/17 revealed the following: .18. For residents in bed, who are completely immobile, use devices that relieve pressure on the heels, most commonly by raising the heels off the bed .24 .Reposition the resident shifting the points

Based on observation, interview, and record review, the facility failed to place residents under observation for COVID-19 (Coronavirus 2019, an easily transmitted respiratory illness) on isolation precautions, place signage for isolation, have personal protective equipment (PPE) available, and apply recommended PPE (eye protection, gowns) per Centers for Disease Control and Prevention (CDC) guidance. The facility had new admissions on the 4th floor (Residents #804, #805, #806, #807, #808, and #809) who were observed to not be under any isolation precautions after moving to the designated observation unit (long 400 hall) on 10/5/20. Staff was observed not wearing all CDC recommended PPE while caring for these residents. This increases the risk of the spread of COVID-19 throughout the facility, potentially affecting all residents and staff, and resulted in an Immediate Jeopardy (IJ). The IJ started on 10/5/20 and was identified on 10/9/20. The Administrator was notified of the Immediate Jeopardy on 10/9/20 at 11:00 AM and was asked for a plan to remove the immediacy. The IJ was removed on 10/9/20, based on the facility's implementation of the removal plan as verified onsite on 10/9/20. Although the IJ was removed, the facility's deficient practice remained widespread. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 10/9/20 at 9:09 AM, during the entrance conference, the Nursing Home Administrator (NHA) indicated a section of the 4th floor (back, long hall of high 400 rooms) held the COVID-19 observation unit for new admissions. On 10/9/20 at 10:00 AM, during a tour throughout the 4th floor, the long back 400 hall was noted to only have one person on isolation precautions. Licensed Practical Nurse (LPN) A indicated the room under isolation (room [ROOM NUMBER]) was for contact precautions and unrelated to COVID-19. LPN A was observed with a KN95 (filtering mask used typically in place of fitted N95 respirator masks if they are unavailable) and preparing to pass medications to a resident in room [ROOM NUMBER]. LPN A indicated that the resident in room [ROOM NUMBER] was under observation for signs/symptoms of COVID-19 as a new admission (record review revealed the resident was admitted on [DATE]). When queried regarding what PPE is worn in the rooms of newly admitted residents under observation for sign/symptoms of COVID-19 and how long residents were kept under observation, LPN A stated, Under observation from the hospital for 14 days. Just wearing the KN95 mask. When queried which rooms were newly admitted residents under observation for COVID-19, LPN A stated, Rooms 415 through 431 (long 400 hall) with the exception of room [ROOM NUMBER]. That resident refused to move. When queried regarding the lack of isolation precaution signage and PPE caddies/availability for the observation rooms, LPN A indicated they did not know and stated, You would have to ask the higher-ups. At this time, Registered Nurse (RN)/Minimum Data Set (MDS) Coordinator entered the hallway and was queried as to why the residents on the observation unit were not under isolation precautions with PPE available near the rooms. The MDS Coordinator stated, I'm not sure, I'll have to go get the infection control nurse. The following observations were made on the observation unit at this time: Rooms 418, 421, 424, 426, and 428 were observed to have one resident in each room with the doors open. No signs or PPE were near the rooms. Resident #'s 804, #805, #806, and #807 were observed to be in their respective rooms with the doors open, with no signage on or near the door for isolation precautions, and no readily available PPE outside of the rooms. An unidentified female resident was sitting in the hallway directly outside of R#807's room across from the nurses' station. Residents #808 and #809 were observed to be in their respective rooms. The doors had been shut but had no signage on or near the door for isolation precautions, and no readily available PPE outside of the rooms. On 10/9/20 at 10:11 AM, Certified Nursing Assistant (CNA) C was queried regarding what PPE was to be worn in the rooms on the observation portion of the 400 hall. CNA C stated, Mask, gloves. A gown if they are on isolation like [room [ROOM NUMBER]]. On 10/9/20 at 10:12 AM, LPN A was observed going into R#807's room to pass medications. LPN A was observed wearing only a mask. A review of R#804's record revealed the resident was admitted into the facility on [DATE]. Further review revealed the resident was moved from a room at the front of the long 400 hallway to a room towards the back of the long 400 observation hall on 10/5/20. R#804's care plan revealed no focus areas related to COVID-19 monitoring and/or isolation. A review of R#804's progress notes revealed: 10/5/2020 16:26 (4:26 PM) Social Service Note .SW (Social Worker) notified resident and [family] about room change .today .d/t (due to) medical necessity. SW also notified both about the COVID test for today and for next Monday d/t of a positive case in building . A review of R#805's record revealed the resident was admitted into the facility on [DATE]. Further review revealed the resident was moved from a room towards the front of the long 400 hallway to a room in the 400 observation hall on 10/5/20. R#805's care plan revealed no focus areas related to COVID-19 monitoring and/or isolation. A review of R#805's progress notes revealed: 10/5/2020 16:22 (4:22 PM) Social Service Note .SW notified resident and [family] about room change .today .d/t medical necessity. SW also notified both about the COVID test for today and for next Monday d/t of a positive case in building . A review of R#806's record revealed the resident was admitted into the facility on [DATE] into a room in the 400 observation hall. R#806's progress notes did not reveal mention of COVID-19 monitoring and/or isolation. A review of R#807's record revealed the resident was admitted into the facility on [DATE] into a room in the 400 observation hall. R#807's progress notes did not reveal mention of COVID-19 monitoring and/or isolation. A review of R#808's record revealed the resident was admitted into the facility on [DATE]. Further review revealed the resident was moved from a room on the short 400 hallway to a room in the long 400 observation hall on 10/5/20. A review of R#808's progress notes revealed: 10/5/2020 15:58 (3:58 PM) Social Service Note .SW notified resident and [family] about room change .d/t medical necessity. SW also notified resident and [family] about the COVID test for today and for next Monday d/t of a positive case occurred in the building. No further mention of COVID-19 monitoring and/or isolation was noted in the resident's record. A review of R#809's record revealed the resident was admitted into the facility on [DATE]. Further review revealed the resident was moved from a room on the short 400 hallway to a room in the long 400 observation hall on 10/5/20. A review of R#809's progress notes revealed: 10/5/2020 16:31 (4:31 PM) Social Service Note .SW notified resident and [family] about room change .d/t medical necessity. SW also notified both of them about the COVID test for today and next Monday d/t of a positive case occurred in building . No further mention of COVID-19 monitoring and/or isolation was noted in the resident's record. On 10/9/20 at 10:50 AM, the Director of Nursing (DON) was interviewed. The DON indicated that she was currently training the infection control nurse so any infection control related questions could be directed to her. When queried which rooms in the facility were considered to be COVID-19 observation rooms for newly admitted residents, the DON stated, 415 through 431. The DON was then queried what the observation unit entailed and stated, Our policy states it's effective today. By today we will have it in place. The isolation carts are up there now. Residents newly admitted or who return from appointments will be in a room on that unit for a minimum of 10 days and tested before they move off that unit. When queried what PPE is to be used when in the rooms on the observation unit, the DON stated, It's in the isolation carts. [The residents] will be considered in quarantine. The nurses will put on goggles/face shields, gowns, gloves, and KN95 masks. When queried if the procedure for the unit and PPE started today, the DON stated, It's effective today. We started in-servicing people this week. We had a 400 'short' (low 400 rooms) then we moved it because we realized we needed more rooms. Did room changes and deep cleaning. We just finished purchasing PPE carts this morning. When queried if the residents observed this morning on the long 400 hall should have been under isolation precautions, the DON stated, Well, it's quarantine. But as of today, yes. When asked if the reason why the residents were not under isolation was because the unit was moved, the DON stated, Yes. Well, they're still on precautions, Nurses are wearing gloves and washing their hands. When asked if the facility follows CDC COVID-19 guidance for new admission and re-admissions into the facility, the DON stated, Yes. The DON indicated the facility did not have any [CONDITION(S)] residents at this time. When asked if she could confirm that the residents (R#804, #805, #806, #807, #808, #809) on the long 400 hall were not on isolation this morning but should have been, the DON stated, We don't have them on isolation we have them on quarantine. When asked if quarantine includes marking the rooms with signs and having PPE readily available, the DON stated, Ideally, yes. That's starting today. On 10/9/20 at 11:49 AM, observation of the 4th floor now included PPE caddies outside of each room from 415 to 431. Unit Clerk D was observed putting up signs for isolation on each of the rooms' doors. On 10/9/20 at 11:52 AM, LPN B was interviewed regarding the observation unit on the 4th floor. LPN B stated, I don't know why the (PPE) carts weren't out because this is the observation floor. On 10/9/20 at 11:55 AM, LPN A was queried regarding the observation unit changes currently being implemented. LPN A stated, They're working on a plan for the observation unit. Putting signs up, and we will be wearing face shields in all rooms and gowns. LPN A was queried as to when the observation unit was moved from the short (low) 400 hallway to the current section of the 400 unit. LPN A replied, I was gone 4-5 days. When I came back it was swapped, within the last week. LPN A was then asked if PPE caddies were present outside of the rooms on the previous (short 400) observation unit and if staff was wearing full PPE (gowns, gloves, face shields/goggles, mask) in the rooms, LPN A shook their head no and stated, I can't lie, and indicated staff were only wearing masks in the rooms even though they were newly admitted residents under observation for COVID-19. On 10/9/20 at 12:10 PM, the NHA was queried regarding the facility changing the COVID-19 observation unit from the short 400 hall to the long 400 hall. The NHA indicated the dates the rooms changed should be in the electronic medical record (EMR). When queried regarding room changes on 10/5/20 noted in the EMR for Resident #'s 804, #805, #808, and #809 but the observations of those residents with no indication of isolation precautions today, the NHA indicated she was not sure when the physical moves took place and stated, We needed to order more PPE carts and just got them in. The NHA was then asked if the facility follows CDC COVID-19 guidance for new admission and re-admissions into the facility and stated, We follow CDC guidance for new admits. On 10/9/20 at 2:00 PM, the 400 hall rooms from 415 through 431 were now marked with signage indicating it was an observation area as well as each room under isolation. The Housekeeping Supervisor was queried regarding moving the observation unit from the short 400 hall to the long 400 hall. The Housekeeping Supervisor stated, We sanitized everything on the other hall when it was moved. It only took an hour to set up today. We were in the middle of moving everyone. When asked if they would expect to see the PPE and signs moved immediately over to the new room (on the long hall) as the resident under observation was moved, in order to help staff recognize their isolation status, the Housekeeping Supervisor provided no further information. On 10/9/20 at 2:06 PM, LPN A was queried regarding education received today and indicated that they had received education on the observation unit and PPE use. LPN A was then asked to observe the newly placed PPE caddies and signs on/outside of rooms 415 through 431, which was determined to be the observation unit for new admissions. When queried if that is how the previous observation unit (low 400 hall) was set up, LPN A stated, What I told you before is how it was. I can't lie. We did good hand hygiene, gloves, and wore the KN95 masks. On 10/9/20 at 2:25 PM, the NHA provided COVID-19 test results that had recently been conducted in the facility. When queried regarding the CDC's guidelines for new admissions/re-admissions into the facility regardless of COVID-19 testing being done, the NHA indicated that she understood the reasoning for full PPE use for the residents who are under observation for COVID-19 and provided no further information. On 10/9/20 at 2:51 PM, the DON and NHA were interviewed. The DON and NHA were asked if it is the policy/procedure of the facility to have a care plan area related to a resident being under observation for COVID-19 and the DON replied, It's not part of the policy yet, but we are observing them for symptoms. The NHA stated, Vitals are being taken every shift. When queried if they would expect that information to be part of the plan of care, the DON stated, Yes. The DON and NHA were asked if it is the policy/procedure to have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . We did not have isolation orders for them. We have isolation orders for people with things such C. Diff (gastrointestinal infection). The DON and NHA were then asked what their expectation is for isolation precautions and PPE worn in rooms for residents who are newly admitted /readmitted and under observation for COVID-19. The DON stated, I expect they (staff) will be wearing PPE when going in each room on the observation unit .[which includes] KN95 [mask], gown, face shield/goggles, and gloves. The DON and NHA were then queried if they had any further comments regarding the observed infection control concerns in the facility. The DON stated she had no further comments. The NHA stated, You caught us in the middle of making changes. We had just moved the rooms to the long hall. When queried if she would have expected the PPE to be available and in place for the new rooms despite the room changes, the NHA stated, It was accessible .but the plan (now) is to have it visually there and more convenient. We have the extra bins now so everyone has their own bins (for PPE). When asked if staff should have been wearing that PPE (goggles, face shield, gown, gloves, mask) in the observation unit today, the NHA stated, We just updated our observation unit policy/procedure .one of our staff was inservicing. That was planned for before you arrived. When queried if the use of full PPE was planned but not yet implemented, the NHA stated, It was in the process of being implemented .[the PPE] wasn't conveniently accessible. Review of, Responding to Coronavirus (COVID-19) in Nursing Homes, via https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, revealed, Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [CONDITION(S)]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. New residents could be transferred out of the observation area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). Testing at the end of this period could be considered to increase certainty. A review of the facility-provided policy/procedure titled, Isolation/Quarantine, undated, revealed, Isolation: Our designated isolation unit is [(401-414)]. It is MANDATORY to wear an N95 or KN95 mask, gown, and gloves in isolation resident rooms. If on droplet precautions a shield or goggles shall be donned and a surgical mask placed over the N95/KN95 mask. Covering the nose and mouth is required in all areas of the unit except in designated break areas. Masks will be located on the isolation unit .Quarantine: Standard precautions are to be utilized on the fourth and fifth floors . The facility's Transmission-Based Precautions, policy/procedure did not address COVID-19. Review of Preparing for COVID-19 in Nursing Homes, via https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed, Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Immediate Jeopardy abatement Measures for F-880: All residents admitted within the last 14 days were placed on the observation unit and were monitored for signs and symptoms of COVID-19. Proper PPE (gowns, gloves, N95 masks, face shields or goggles) was placed in a cart outside of each residents door with signage. Appropriate masking gear (N95 mask) was issued. Staff was reeducated PPE policy which includes don and doffing and was instructed to don and doff when entering any isolation rooms. All new admits, readmits, residents that go out on LOA, will be housed together in the same unit for 14 days per CDC recommendation. All residents have been assessed for signs and symptoms consistent with COVID-19. Active screening of Residents will continue. COVID-19 testing will be done prior to moving resident off the observation unit. All residents were assessed for signs and symptoms of COVID-19. Designated observation unit consists of rooms 415-431, this unit is housed with designated staff assigned.

This citation pertains to intake number: 5. Based on interview and record review, the facility failed to implement and document effective interventions for one resident (#702) with a known history of verbal and physically aggressive behavior, of three residents reviewed for abuse, resulting in the punching of Resident #703 in the arm/shoulder, continued aggressive behavior, and the likelihood of pain, fear, and mental anguish for Resident #703 using the reasonable person concept. Findings include: A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #702 was severely cognitively impaired and was most recently admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS also revealed that Resident #702 had periods of disorganized thinking and inattention. A record review of the care plan for Resident #702 revealed the following: Focus- .Potential for alteration in Mood/Behavior R/T; Dx (diagnosis) Dementia with behaviors such as hitting and kicking at staff, restless behavior .resident will often yell out with care at times .today 8/9/2019 resident was reported to have an altercation with another resident .resident was reported to being the aggressor. Goals- .mood/behavior will not interfere with daily routine/quality of life for self or others . .will refrain from aggressive behaviors towards others . A record review of the Progress Notes for Resident #702 revealed the following: 8/20/2019 18:43 (6:43 PM) .continues to have increased behaviors, while staff was changing resident after having a bowel movement resident proceeded to curse and hit staff members while trying to change them, (Resident #702) punched the staff members in the arms, management and MD (Medical Doctor) discussed and decided to have resident petitioned out of facility . 8/19/2019 20:54 (10:54 PM) .Pharmacy was spoken to and stated that the resident's new medication Vraylar (an antipyschotic medication) was approved and the medication is not in stock and has been ordered. Awaiting shipment of medication to began medicinal treatment 8/19/2019 16:42 (6:42 PM) .returned back from urologist, hit doctor in face while performing procedure . 8/17/2019 1844 (8:44 PM) .yelling and cussing at staff 8/16/2019 12:43 (PM) .Psych assistant (Physician Assistant/PA) was here at facility in regards to residents increased behaviors, resident has new order to start Vraylar 1.5 mg (milligrams) one time a day, and to DC (discontinue) [MEDICATION NAME] 50 mg BID and give [MEDICATION NAME] 50 mg just at bedtime This medication was not started until 8/20/19, the day of discharge for Resident #702. 8/16/2019 08:24 (AM) .Yelled/cussed at staff to leave them alone during ADL (Activities of Daily Living) care . Refused meds (medication) yelling . 8/15/19 18:19 (6:19 PM) . Resident had some behaviors this shift was calling out very loud, and swearing is combative with adl care . 8/13/19 1442 (2:42 PM) .Has been yelling on and off all day 8/12/2019 15:23 (3:23 PM) .during wound rounds with resident and wound care nurse practitioner. before assessment, resident during assessment, resident was combative and verbally abusive towards staff. Resident grabbed NP (Nurse Practitioner) hand and attempted to bite her hand, when NP pulled away, resident grabbed her pinky finger and bent it backwards. Staff talked resident into eventually letting NP finger go . 8/12/19 19:45 (7:45 PM) .resident had a behavior incident with wound care nurse (bending finger) 8/12/2019 15:08 (3:08 PM) .Social worker was informed that resident bite the finger of the wound care nurse. Resident has a Hx (history) of physically and verbally aggressive towards (staff) and peers (other residents). Social worker competed (sic) Petition for resident to be sent to the crisis center . 8/11/2019 23:20 (11:23 PM) .yelling and cussing at writer, calling me out of my name . 8/11/2019 14:03 (1:03 PM) .Patient was yelling racial slurs and physically trying to hit at nursing staff while attempting to complete wound care .would calm down but later began yelling . 8/11/2019 11:04 (AM) .Resident combative and verbally expressive during assessment. 8/9/2019 .Resident was in the hallway, hit another resident passing in a wheelchair. writer removed resident from the other resident . 8/6/2019 12:18 (PM) .Np was here and continued residents [MEDICATION NAME] (an antianxiety medication) for 14 days, and then will review again, due to increased agitation and anxiety, family is aware. 8/3/2019 .resident is awake and in wheel chair .calm displaying random screaming . 7/31/2019 06:30 (AM) .Resident became very combative and verbally abusive during care . 7/27/19 06:41 (AM) .Resident started fighting me and yelling .unable to clean and change dressing. 7/26/2019 19:27 (7:27 PM) .Resident being monitored for behaviors, they had some episodes of yelling. Resident was combative with care . 7/22/2019 18:45 (6:45 PM) .Spoke with attending physician today and received order to continue [MEDICATION NAME] 0.5 mg PRN (as needed) every 6 hrs for anxiety and aggression 7/22/2019 08:04 (AM) .continues exhibiting negative behaviors such as yelling and attempting to hit staff when care is given. Patient can be a harm to others and themselves. Not being compliant with medications and attempting to stand out of their wheelchair. Patient is not able to ambulate. Prn of [MEDICATION NAME] will be initiated for 14 days to help decrease negative behaviors. 7/20/2019 10:47 (AM) .Resident was very combative and verbally abusive. 7/19/2019 18:47 (6:47 PM) .Patient was encouraged 3 times to have their weight completed for today but patient refused. They began yelling stating, No, and get the hell away from me! Resident began swinging their arms and attempting to hit staff . 7/12/2019 12:22 (PM) .R/T (related to) recent safety occurrence (sic). Resident has impulsive behaviors, mood disorder, Poor safety awareness. Multiple intervention in place . 7/8/2019 12:10 (PM) .(Doctor Note) advanced dementia with behavior disturbance, anxiety with [MEDICAL CONDITION]-Periods of aggression combative behavior agitation restlessness, will reorder [MEDICATION NAME] ([MEDICATION NAME]), monitor treatment response, continue psych consult, continue other [MEDICAL CONDITION] medications . 7/7/2019 13:54 (1:54 PM) had multiple outburst of yelling .had to be redirect (sic) multiple times. Resident was resistance (sic) to care, kicking and hitting . 7/5/2019 08:00 (AM) .(Doctor Note) .Following on this patient for monthly visit .(Resident #702) is noted screaming yelling banging on the .table .This is their normal behavior. Staff states .For most part, patient is verbally and physically aggressive especially with doing ADLs .advanced dementia with behavior disturbance, anxiety with [MEDICAL CONDITION]-Periods of aggression combative behavior agitation restlessness, will reorder [MEDICATION NAME], monitor treatment response, continue psych consult, continue other [MEDICAL CONDITION] medications. Redirection reorientation . 7/4/2019 19:49 (7:49 PM) .Unreliable source stated to writer that resident A (#702) struck resident B twice. Writer and off going nurse heard resident A yelling we immediately ran to situation did not observe resident A strike resident B. Writer immediately removed resident A from situation . 7/3/2019 22:39 (10:39 PM) .yelling while sitting in wheel chair in hallway . 6/28/2019 12:50 (PM) .before leaving the facility resident was yelling in the hall way, and trying to get out of their chair 6/10/19 14:40 (2:40 PM) .(Doctor Note) (Resident #702) Is being evaluated to follow-up on their open wound in the abdominal area secondary to peritoneal abscess. They are seen and examined laying in bed initially they are cooperative however when attempted to evaluate abdominal area patient becomes combative and verbally aggressive. Patient's mentation remained stable patient does have chronic verbal aggression and combative behavior. 5/30/19 1132 (AM) .continues to pull off wound vac .Resident extremely combative with staff . 5/20/19 14:40 (2:40 PM) .resident continues to scream out and curse . 3/14/2019 19:42 (7:42 PM) .resident rolling on the floor, from mat to bed to mat constant, yelling out wife's name . 2/23/19 2032 (8:32 PM) .Resident had 1 episode of yelling and talking negative about another resident Additional documentation was noted of Resident #702 yelling noted on 7/3/19, 7/2/19, 7/1/19, 6/19/19, 6/16/19, 3/9/19 and 3/10/19 and on 5/20/19 Resident #702 was aggressive with the Doctor. A record review of the Incident Report dated 8/9/19 revealed that Resident #702 was observed hitting Resident #703's arm in the common area. On 9/4/19 at 9:49 AM, Resident #703 was observed lying in bed. The Resident had unclear speech and was able to answer yes to their name but unable to answer any other questions. Resident #703 was asked if they remembered being hit in the arm by Resident #702 on 8/9/19 and answered yes but could not describe the incident. A record review of the Progress Notes revealed that Resident #703 was pounded in the arm by Resident #702 on 8/9/19. A record review of the MDS dated [DATE] revealed that Resident #703 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 9/4/19 at 12:30 PM, an interview via telephone was completed with Licensed Practical Nurse (LPN) A, who witnessed the altercation between Resident #702 and #703 on 8/9/19. LPN A stated, I was walking down the hall and (Resident #702) stood up (out of their wheelchair) and hit (Resident #703). (Resident #702) had a closed fist when they did it. LPN A was queried on the behaviors of Resident #702 and stated, (Resident #702) has been like this (aggressive) before to other residents. We were told to keep (Resident #702) at arms lengths from other residents so they couldn't hit anyone else but we didn't get to (Resident #702) in time. On 9/4/19 at 12:55 PM, an interview was completed with Social Worker (SW) B in regards to the behavior management of Resident #702 and stated, (Resident #702) was very impulsive. We had sitters (activity aides or students) in the common areas. They were engaged in activities. They would just scream out, I would go in and sit with them and talk to (Resident #702). Verbally they were aggressive with other residents and staff and physically with staff. When (Resident #702) screamed out, we would ask them if they were in pain, they never said they were The staff were supposed to keep (Resident #702) an arms length away from other residents but because (Resident #702) was so impulsive they didn't get to them before they hit the resident (Resident #703). SW B was further queried on the length of time that Resident #702 was displaying aggressive behaviors and when they were petitioned out to a different setting and stated, After the last incident (hitting staff on 8/20/19) we called the Doctor and petitioned them out. The Doctor would not accept the Resident back to the facility. On 9/4/19 at 1:33 PM, an interview was completed with the Director of Nursing (DON) in regards to the aggressive behaviors displayed by Resident #702 and stated, (Resident #702) has a history of behaviors, and was being seen by psych, we told the staff to keep them at arms length (from other residents). They (Resident #702) would get upset if residents would just roll by, we would have to talk to them to calm them down. That was just their behavior. We petitioned them out because they hit a staff member and we didn't want anything else to happen to another resident. A review of the facility policy titled, Abuse Policy revised 3/19/2018 revealed the following: It is the policy of our facility to assure the well-being of all residents entrusted to our care and prevent the occurrence of abuse through effective development and implementation of written policies and procedures that prohibit .abuse of residents .Implementation: Our facility maintains a zero-tolerance stance on abuse of any kind from .other residents .

Based on observation, interview, and record review the facility failed to ensure timely X-ray services after a fall with injury for one sampled resident (Resident #34) of three reviewed for falls, resulting in a delay in treatment and extended time left in pain. Findings include: On 12/11/18 at 1:38 PM, Resident #34 was observed laying in a bed that was at the lowest position to the floor. A interview was unable to be conducted due to Resident #34's cognition. On 12/11/18 at 3:29 PM, Resident #34 was not in their room. Incident Report: Fall 12/11/18. Incident Description: writer observed patient on floor between foot of bed and sink. no (complaint of) c/o of pain or distress. (Active range of motion) arom performed to all extremities without difficulty (patient) pt stated that (they) was coming from the kitchen then lost (their) balance while walking back to bed. On 12/13/18 at 12:29 PM, during an interview, the Director of Nursing (DON) was asked about the fall that occurred on 12/11/18. The DON stated, The resident was found on the floor. (They) walk without assistance, but should not. (R34) was coming from the bathroom by (their) self. After interviewing the aide they reported leaving the room about 20 minutes prior to this happening. On 12/13/18 at 12:30 PM, a review of Resident #34's Minimum Data Set (MDS) assessment dated [DATE] revealed the following: Resident #34 was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident's cognitive skills for daily decision making were severely impaired, and required limited assistance from staff for activities of daily living (ADLs). A review of Resident #34's clinical record revealed the following: Care Plan. F[NAME]US: Resident is at risk for falls R/T; cognitive deficits, decreased muscle coordination/strength, episodes of incontinence, (History) Hx falls, receives [MEDICAL CONDITION] medication, unsteady balance/gait. Dementia, poor safety awareness, requires assist with transfers/ambulation, Resident likes to rearrange room several times a week. Recent fall, requested (their) bed be next to wall. Revision date 11/8/2018. GOAL: Resident will have reduced risk factors for falls through next review date. INTERVENTION: Encourage resident to asks for assistance when deciding to rearranging room. Re-educated resident on the use of call light for assistant from staff. Call light in reach. Encourage/remind resident to use call light to seek staff assist when needed. Anticipate and meet needs as much as possible. Educate resident/caregivers on safety awareness and fall prevention. Bed in lowest position when occupied. Follow facility fall protocol. Provide frequent visual checks/supervision. Progress Notes. 12/10/2018 22:01 (10:01 PM) Health Status Note: writer observed patient on floor between foot of bed and sink. no (complaint of) c/o pain or distress. arom performed to all extremities without difficulty . (Medical Director) md made aware will continue to monitor. (Nurse M). 12/11/2018 01:00 (1:00 AM) patient c/o left leg pain. md made aware and ordered X-ray for left hip,femur,tibia. writer attempted to call (radiology company) for X-ray. will continue to monitor. (Nurse M). 12/11/2018 01:03 (1:03AM) Orders - Administration Note Text: [MEDICATION NAME] (Concentrate) Solution 20 (Milligrams per Milliliter) MG/ML Give 5 mg by mouth every 1 hours as needed for Pain. (Nurse M). 12/11/2018 02:15 (2:15 PM) Orders - Administration Note Text: [MEDICATION NAME] (Concentrate) Solution 20 MG/ML. Give 5 mg by mouth every 1 hours as needed for Pain (as needed) PRN Administration was: Effective Follow-up Pain Scale was: 1. (Nurse M). 12/11/2018 02:40 (2:40 AM) Health Status Note Text: patient in bed resting with no c/o pain or distress. she has slight swelling and discoloration noted to left eye. will continue to monitor. (Nurse M). 12/11/2018 07:03 (7:03 AM) Health Status Note Text: I called responsible party to notify . of patient's condition but I was unable to get in touch with (them) and I couldn't leave a voicemail because it wasn't set up. (Nurse M). 12/11/2018 10:58 (10:58 AM) Health Status Note Text: (radiology company) was here to do X-ray at 10:00 am, awaiting results. (Nurse E). 12/11/2018 11:21 (11:21 AM) Orders - Administration Note Text: [MEDICATION NAME] (Concentrate) Solution 20 MG/ML. Give 5 mg by mouth every 1 hours as needed for Pain c/o (left) L hip and leg pain, tries to reposition and massage therapy was unsuccessful. (Nurse E). 12/11/2018 11:23 (11:23 AM) Health Status Note Text: Skin assessment of L hip and leg, pt is c/o pain with assessment no dislocation is noted, (range of motion) ROM is limited to L leg, awaiting x ray results. (Nurse E). 12/11/2018 12:29 (12:29 PM) Orders - Administration Note Text: [MEDICATION NAME] (Concentrate) Solution 20 MG/ML. Give 5 mg by mouth every 1 hours as needed for Pain PRN Administration was: Ineffective Follow-up Pain Scale was: 6. (Nurse E). 12/11/2018 12:32 (12:32 PM) Orders - Administration Note Text: [MEDICATION NAME] (Concentrate) Solution 20 MG/ML. Give 5 mg by mouth every 1 hours as needed for Pain c/o L leg and hip pain tried to reposition and resident stated it still hurts. (Nurse E). 12/11/2018 12:39 (12:39 PM) Health Status Note Note Text: Notified Granddaughter . of resident being observed on the floor and that MD ordered X-ray of L hip/leg, notified granddaughter that resident has bruise to L eye. (Nurse E). 12/11/2018 14:03 (2:03 PM) Health Status Note Text: Received lab results from (X-ray company), resident has a [MEDICAL CONDITION] femoral head, notified MD at 1:15 pm, granddaughter . at 1:20 pm and Hospice at 1:25 pm ., Md said to send resident to the hospital for evaluation, (Power Of Attorney) (Nurse E). 12/11/2018 14:14 (2:14 PM) Health Status Note Text: Resident left facility at 2:10 pm via stretcher with (Emergency Medical Technician) EMT's, for transport to (local hospital), report was called into ER (Emergency) ER at 1:55pm and report was given to (staff member). vital signs were . resident was c/o L hip pain upon leaving facility. (Nurse E). 12/11/2018 14:48 (2:48 PM) Orders - Administration Note Text: [MEDICATION NAME] (Concentrate) Solution 20 MG/ML Give 5 mg by mouth every 1 hours as needed for Pain PRN Administration was: Ineffective Follow-up Pain Scale was: 6 resident was sent to ER for fracture of L femoral head. (Nurse E). 12/11/2018 15:31 (3:31 PM) Health Status Note Note Text: All paperwork was sent with EMT's copy of xrays was in with paperwork. (Nurse E). Radiology Report. Date 12/11/18. Results: There is a fracture involving the left femoral head with no displacement. The joint shows no discoloration . Conclusion: Acute left [MEDICAL CONDITION] as described above. Old right pubic ring fracture noted. On 12/13/18 at 1:09 PM, during an interview, Nurse E was asked about Resident #34's fall incident and what time the X-ray company arrived. Nurse E stated, The fall happened before I got here. I didn't call the x-ray company. I can call them now to ask. A call was made to the radiology company which reported, the call came in at 3:00 AM on 12/11/18 for a stat X-ray for Resident #34. Nurse E was asked what is the window of time for a stat x-ray. Nurse E stated, I think four hours. The Radiology log book was reviewed at that time and revealed, Arrived 9:30 AM. On 12/13/18 at 1:23 PM, during a phone interview, Nurse M was asked what time was the radiology company called. Nurse M stated, I started calling when (R34) complained of pain at 1:00 AM. The line was busy, I kept calling it would ring and then go busy. I didn't get through until 3:00 AM. Nurse M was asked if the order was for a stat X-ray and how long does it take for a stat x-ray. Nurse M reported, Yes, it was a stat x-ray. Four hours. On 12/13/18 at 1:44 PM, during an interview, the DON was asked should it take six and a half hours for a stat x-ray for a resident in pain. The DON stated, I think a stat x-ray is four hours. The DON continued and explained, I think there was something going on with the (radiology company) that night. On 12/13/18 at 2:15 PM, a review of the (Portable Radiology) Services Agreement did not reveal a time range for completion of an x-ray or a stat x-ray. A call was made to the company. The (Radiology Company) was asked how long does it take for a stat x-ray to be completed. The Radiology company stated, We don't have a time frame. A review of of the facility's policy titled, Fall Management Guidelines dated (MONTH) (YEAR), noted, Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls .