Accolade Healthcare Of Pontiac

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure an incident resulting in a fracture was reported to the State Agency within the required timeframe for one (R1) of three residents reviewed for Accidents. Findings IncludeThe Facilities Accidents and Incidents policy revised on 1/26 documents that reporting accidents and incidents, including injuries of an unknown origin, must be reported to the department supervisor and an Accident/Incident Report form must be completed on the shift that the accident or incident occurred. This document also states that the Director of Nursing (DON)/Designee will report any accident/incident of major injury to the State Agency within 24 hours.On 11/29/26 at 3:04AM, R1's Nursing Progress note documents R1 was sent to the hospital after complaining of pain in the area above R1's left knee. R1 received Norco for pain management just before leaving for the hospital. The Hospital gave R1 Tylenol, Fentanyl and Ketorolac for pain management. R1 returned from the hospital at 6:00AM. The hospital diagnosis after review of the left knee Xray shows Sprain of medial collateral ligament of left knee.On 12/11/26 at 1:30PM, R1 went and saw the orthopedic doctor and completed a computed tomography scan (CT scan) of the left knee. The CT scan showed a Left Knee Fracture.R1's Minimum Data Set, dated [DATE] documents that R1 is Dependent with all transfers and is cognitively intact.On 2/9/26 at 11:05AM, V2 Director of Nursing confirmed that a reportable incident was not sent to the State Agency.On 2/9/26 at 1:15PM, V1 Administrator confirmed that R3's fracture that was received on 12/11/25 was not reported to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure documentation of the required transfer/discharge process for one (R3) of three residents reviewed for transfer/discharge. The facility discharged R3 without documentation of the required discharge notice and required elements in the medical record.The Facility Discharge/Transfer Policy revised 1/25 documents the facility is to provide guidelines for appropriate discharge and transfer procedures. The facility also documents that the facility will have a written or telephone order from the attending physician for the transfer or discharge of a resident. R3 was admitted to the facility on [DATE] per R3's nursing progress notes.Per R3's Hospital notes dated 2/23/26, R3 was dropped off at the Emergency Department (ED) from the facility with complaints of social concern. Per the facility, it was discovered during R3's background check that R3 had a sexual offense and could not be admitted to the facility. The Facility attempted to find different placement but could not. The Facility brought R3 back to the Emergency Department for nursing home placement. On 3/10/26 at 10:36AM, V7 (R3's) Power of Attorney stated the facility told V7 that R3 was being sent back to the hospital due to R3's background check results. On 3/10/26 at 11:00AM, V8 Social Service Director (SSD) stated R3's CHIRP (Criminal History Information Response Process) dated 2/23/26 was received and V8 SSD tried to find placement for R3. R3 was sent back to the hospital due to the CHIRP results showing R3 is listed as a Sexual Offender. On 3/10/26 at 9:35AM, V1 Administrator confirmed no discharge documentation or discharge orders were found in the chart for R3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure safe transfer techniques were implemented for one (R1) of three residents reviewed for accidents. The resident sustained a fracture of the left knee when a mechanical lift transfer requiring two staff members was performed by only one staff member.Findings Include The Facilities Hydraulic Lift (Hoyer) Policy revised on 1/26 documents all nursing staff will be trained on the proper use of the hydraulic (hoyer) lifts that are used within the facility, to ensure safe transfer for residents. This Policy also documents that the staff is to obtain assistance from a second staff member.On 11/29/26 at 3:04AM, the Nursing Progress notes documents: R1was sent to the hospital after complaining of pain in the area above her left knee. R1 received Norco (pain medication) just before leaving for the hospital. The hospital gave R1 Tylenol, Fentanyl and Ketorolac for pain management. R1 returned from hospital at 6:00AM. The Hospital diagnosis after the left knee Xray showed a Sprain of Medial Collateral Ligament of Left Knee.On 11/29/26 at 5:28AM, R1's Nursing Progress note documents: call received from the Emergency Department (ED) nurse. R1 was being discharged . Left knee x-ray was negative. R1 said R1 heard a pop when being transferred with a total body mechanical lift. R1 was given fentanyl 50mcg (microgram) given IM (Intramuscular) for pain management. No other concerns currently.On 11/29/25 through 12/3/25, R1 complained of pain in R1's left knee. R1 was given HYDROcodone-Acetaminophen Oral Tablet 7.5/325mg (Milligrams) for pain management.On 12/3/2025 the Nurse Practitioner's (NP) note documents R1 was assessed in R1's room lying in bed. NP reviewed R1's urine culture which showed mixed growth with possible contamination. R1 stated R1 still doesn't feel well. R1 was sent to the ED in the past week and stated that the Certified Nursing Assistant (CNA) hurt R1. The x-ray was performed of R1's left knee which was negative for a fracture. R1 stated R1 knows something is wrong and wants an MRI (Magnetic Resonance Imaging). The NP explained that R1 can be referred to ortho for further diagnostic testing and patient began yelling that she wants something done now and that she's tired of this place. The NP will refer R1 to ortho and instructed the nursing staff to get another UA (urinalysis).On 12/11/25 at 1:30PM, R1 had an appointment with the orthopedic doctor and completed a CT (computed tomography) scan of the left knee. The CT scan showed a Left Knee Fracture.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is Dependent with all transfers and is cognitively intact.On 2/9/26 at 10:40AM, R1 was lying in bed and stated that V9 CNA (Certified Nursing Assistant) was transferring R1 via a total body mechanical lift without the assistance of a second CNA. V9 was pushing on me, then suddenly R1 heard a pop and a crack. R1 stated that V9 told R1 look your standing up. R1 stated I haven't stood up in years. R1 stated that R1's feet were touching the floor and R1's left knee hit the side of the bed. On 2/9/26 at 11:05AM, V9 CNA confirmed that V9 did complete a total body mechanical lift transfer for R1 without the assistance of a second staff member.On 2/9/26 at 11:05AM, V2 DON (Director of Nursing) stated that R1 was sent to the hospital, and the x-ray from the Emergency Department stated it was only a sprain. V2 confirmed two nursing staff should have been performing the transfer and not just one. V2 stated V9 CNA had disciplinary action taken against him as a result of this incident.On 2/9/26 at 11:15AM, V3 ADON (Assist Director of Nursing) stated a two-person transfer is required for all staff when using a total body mechanical lift.

Based on Interview, Observation and Record Review the facility failed to follow admission orders for c-collar care for one (R1) out three residents reviewed on a sample list of three. Findings Include:On 7/18/2025, R1 had a fall that resulted in a C2 fracture of the neck. R1 was sent to the emergency room for evaluation due to pain in the left shoulder and returned on 7/19/25 with an Aspen C-Collar (Cervical Collar) and orders for care of the C-Collar. On 8/2/25 at 8:05AM, V8 (Certified Nursing Assistant) stated V8 put resident (R1) to bed on 7/18/25, there was no recliner in the room, which V8 stated that R1 usually sleeps in recliner. On 7/18/25, V8 found resident (R1) had rolled out of bed and was complaining of shoulder pain and with the assistance of V9 (Certified Nursing Aide) and V10 (Registered Nurse) resident (R1) was put back to bed via Hoyer lift.On 8/2/25 at 1:18 PM, V10 stated that after resident (R1) returned, the facility received orders to complete skin checks weekly. V10 stated since the bed had been taken out, there was only a recliner in the room and R1's c collar wasn't fitting right. The staff tried to adjust the C-Collar in the recliner, but the recliner wouldn't lay flat and R1 was in pain and yelling it hurts and is burning. V10 called the Medical Director and R1 was sent to the ER. V10 stated no daily skin checks were completed on R1 and 7/24/25 was the first time the C-Collar had been adjusted.On 8/5/25 at 8:30AM, V11 (Medical Director) stated that R1 needed to be lying flat when C-Collar was adjusted and not in a recliner and skin checks needed to be completed every day.On 8/5/2024 at 11:10AM, V1(Administrator) and V2(DON) agreed that admission orders were not followed when R1 returned to the facility on 7/19/25 that R1 readmission orders confirmed skin checks daily and R1 needed to be laid flat in a bed instead of a recliner that doesn't lay flat. Policy: admission Orders and Process dated 7/25 documents that upon admission/readmission, orders for care of the resident are received from attending physician, placed on physician's order sheet. This policy also documents that the facility will review all available transfer information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two (R1, R2) of three residents reviewed for infection control in the sample list of three.
Findings include:
The facility's Enhanced Barrier Precautions policy dated 1/20/24 documents EBP is an intervention designed to reduce the transmission of multidrug-resistant organisms by using gowns and gloves during high contact resident care activities for residents with indwelling medical devices or chronic wounds.
The Centers for Disease Control and Prevention Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated June 2021 documents Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE (Personal Protective Equipment) required and defining high risk resident care activities. Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room).
On 6/23/25 at 8:15AM there was an EBP sign posted on R1's room door that indicated to wear gown and gloves for high contact resident care activities that included toileting, dressing, and transfers.
On 6/23/25 at 8:30AM there was no EBP sign posted on R2's room door that indicated the facility is to wear gown and gloves for high contact resident care activities that included toileting, dressing and transfers due to R2's indwelling catheter.
On 6/23/25 at 10:00AM V5 Certified Nursing Assistant (CNA) entered 's room and emptied R1's catheter. R1 was on Contact Isolation for E-Coli Infection and V5 drained the urine out of the catheter bag and emptied the urine into the shared toilet with R1's roommate.
On 6/23/25 at 10:30AM, V5 was asked about EBP and V5 stated nobody ever wears them and when asked if V5 cleaned the toilet after pouring the urine into the toilet, V5 stated no, but I should have.
On 6/23/25 at 12:30PM, V7 Registered Nurse and V6 CNA provided R2's urinary catheter cleaning/care.
R1 and R2's Physician Orders documents EBP due to urinary catheter, UTI and R2's wounds.
R1's Electronic Medical Record (EMR) section titled Diagnosis documents R1 on 6/18/25 has the diagnosis of Urinary Tract Infection (UTI) with E-Coli and has a catheter which is why she is on EBP precautions.
R2's EMR documents R2 receives hospice services and was readmitted on [DATE] from the hospital and has an indwelling catheter with also skin breakdown, reason for his EBP status.
On 6/23/25 at 11:13 AM, V7 stated The reason we did not have the equipment carts outside the rooms is because she was admitted over the weekend and no EBP was put out.
On 6/23/25 at 2:30PM, V1 stated the admitting nurse should have known the resident needed to be on EBP when admitted due to her chronic wounds and catheter.

Based on interview and record review, the facility failed to notify a resident and their representative in writing about a hospital transfer and failed to provide a bed hold notice for five of five residents (R9, R26, R50, R63 and R74) reviewed for hospitalizations on the sample list of 35.
The facility's Bed Reserve Policy Notification no date, documents this bed reserve policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility.
1. R9's Nursing Notes document R9 was transferred to the emergency room on 3/29 and 5/25/25.
R9's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R9's representative for R9's hospitalizations on 3/29 and 5/25/25.
The facility could not provide documentation that R9's representative was provided a written copy of the Bed Hold Policy when R9 was transferred to the emergency room on 3/29 and 5/25/25.
2. R26's Nursing Notes document R26 was transferred to the emergency room on 5/14 and 5/25/25.
R26's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R26's representative for R26's hospitalizations on 5/14 and 5/25/25.
The facility could not provide documentation that R26's representative was provided a written copy of the Bed Hold Policy when R26 was transferred to the emergency room on 5/14 and 5/25/25.
3. R50's Nursing Notes document R50 was transferred to the emergency room on 4/25/25.
R50's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R50's representative for R50's hospitalizations on 4/25/25.
The facility could not provide documentation that R50's representative was provided a written copy of the Bed Hold Policy when R50 was transferred to the emergency room on 4/25/25.
4. R63's Nursing Notes document R63 was transferred to the emergency room on 3/29/25, 4/11/25, 4/16/25 and 5/26/25.
R63's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R63's representative for R63's hospitalizations on 3/29, 4/11, 4/16 and 5/26/25.
The facility could not provide documentation that R63's representative was provided a written copy of the Bed Hold Policy when R63 was transferred to the emergency room on 3/29, 4/11, 4/16 and 5/26/25.
On 6/3/25 at 10:58am V4 Social Service director stated that the resident or resident representative signs the bed reserve-policy notification form upon admission. V4 stated that nursing staff do not provide a bed hold policy form when residents are transferred out of the facility. V4 stated that V7 Admissions will follow up with the resident in the hospital.
On 6/3/24 at 11:08am V13 Licensed Practical Nurse stated that when V13 transfers a resident out of the facility to the emergency room, V13 does not provide the resident with a bed hold policy. V13 stated V7 admission or V4 Social Service follows up with that paperwork.
On 6/3/25 at 11:30am R63 stated that the nurse did not give R63 any bed hold policy or paperwork when R63 was transferred to the hospital. R63 stated that R63 has been to the hospital several times in the last couple months and was never given a bed hold notice. 5. R74's Nursing Notes document R74 left the facility for a procedure on 4/21/25.
Progress Notes dated 4/21/25 - 4/25/25 document R74 was hospitalized .
R74's medical record does not contain documentation that a bed hold notice, or a written notice of transfer was provided to R74's representative for R74's leave.
The facility could not provide documentation that R74's representative was provided a written copy of the Bed Hold Policy when R74 left the faciity on 4/21/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan. This failure affects one (R50) of 19 residents reviewed for care plans in the sample list of 35.
Findings include:
The facility's Care Planning Policy (revised June 2024) documents the following: To utilize the results of the comprehensive assessment to develop, revise and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consonant with the physician's plan of care. The resident care plan must be kept current at all times.
On 6/1/25, 6/2/25, 6/3/25, and 6/4/25 during intermittent observations throughout the survey period, R50 was observed with a nasal cannula in place in R50's nares.
R50's Face Sheet dated 6/4/25 documents R50 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Atrial Fibrillation.
R50's Physician Order Sheet (current) documents the following orders: O2 (Oxygen) 2 liters via nasal cannula as needed to keep O2 saturation above 90% and Apixaban (Anticoagulant) oral tablet 2.5 milligrams, give 1 tablet by mouth two times a day for blood thinner.
R50's Minimum Data Set, dated [DATE] documents R50 is receiving oxygen therapy and taking an anticoagulant.
R50's Care Plan (current) does not include R50's oxygen use and/or monitoring. This same record does not include anticoagulant medication use and/or monitoring.
On 6/4/24 at 11:10am, V1 Administrator stated care plans are to be updated with any change in condition and should include R50's anticoagulant and oxygen use. V1 confirmed R50's care plan does not include oxygen therapy and anticoagulant use and interventions for monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide numerous showers as scheduled for dependent residents. These failures affect two residents (R34 and R63) of six reviewed for activities of daily living in the sample list of 35.
Findings include:
The facility's Bath/Shower Policy dated 8/2023 documents: Purpose: To provide a procedure for bathing/showering the resident. Policy: A bath/shower for cleanliness and comfort will be scheduled at least weekly for all residents. Responsibility: It's the responsibility of the nursing assistants to provide the bath/shower to each resident per schedule. It is the responsibility of the Charge Nurse to ensure that bath/shower schedule is followed, and residents receive bath/shower per facility schedule.
1. R34's Facility Census documents R34 was admitted to the facility on [DATE] and has the following medical diagnosis; Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Aphasia, Lack of Coordination, Convulsions, Major Depressive Disorder, Delusional Disorders, Need for Assistance with Personal Care, Unsteadiness on Feet and Abnormalities of Gait and Mobility.
R34's Minimum Data Set (MDS) dated [DATE] documents R34's Brief Interview for mental Status (BIMS) score 0, severe cognitive impairment and needs substantial/maximum assistance from staff with Activities of Daily Living (ADLs).
R34's Shower Schedule dated April 3, 2025 - June 6, 2025, documents R34 is scheduled for showers on Tuesday, Thursday and Saturdays. R34 did not receive showers on 4/29, 5/1, 5/6, 5/13, 5/17, 5/20, 5/27, 5/29 and 6/3/25.
2. R63's Facility Census documents R63 was admitted to the facility on [DATE] and has the following medical diagnosis; Muscle Wasting and Atrophy, Cognitive Communication Deficit, Lack of Coordination, Multiple Fractures, Acute and Chronic Respiratory Failure and Unsteadiness on Feet.
R63's Minimum Data Set (MDS) dated [DATE] documents R63's Brief Interview for mental Status (BIMS) score 15, cognitively intact and is dependent on staff with Activities of Daily Living (ADLs).
R63's Shower Schedule dated April 3, 2025 - June 6, 2025, documents R63 is scheduled for showers on Thursday and Sundays. R34 did not receive showers on 4/17, 4/20, 4/24, 4/27, 5/1, 5/4, 5/8, 5/11, 5/15, 5/18 and 5/25/25.
On 6/3/25 at 11:30am R63 stated that R63 does not get two showers a week. R63 stated R63 is lucky to get any. R63 stated that staff always have an excuse to why they can't give R63 a shower. R63 stated R63 needs assistance from staff to get a shower.
On 6/3/25 at 11:08am V13 Licensed Practical Nurse stated Certified Nursing Assistant's should be providing the residents their showers per the residents scheduled shower, which are two showers a week. V13 stated after giving the resident a shower, the CNA should be documenting it in the resident's chart. V13 stated that if a resident refuses a shower, the CNA should be notifying the nurse so they can speak with the resident in an attempt to provide the scheduled shower. V13 stated that if the resident still refuses, the refusal should be documented by the CNA in the resident's chart.
On 6/3/25 at 1:20pm V17 Certified Nursing Supervisor stated that all residents are scheduled to receive two showers a week. V17 stated that all showers are documented under the tasks in the resident's chart. V17 stated that if it's not documented in the resident's chart, then the resident did not receive a shower. V17 stated staff can also document if the resident received a bed bath or refused the shower. V17 confirmed that R34 and R63 did not receive all scheduled showers and did not have any documented refused showers or bed baths.

Based on observation, interview and record review the facility staff failed to provide complete incontinence care for R18. R18 is one of one resident sampled for incontinence care in a total sample of 35.
Findings include:
The Electronic Medical Record under the section Medical Diagnoses dated 6/3/25 documents the primary diagnosis for R18 is Unspecified Cord Compression.
Progress Notes dated 5/13/25 and 6/3/25 document R18 received antibiotics for urinary tract infections.
V18, CNA (Certified Nurse Assistant) performed incontinence care for R18 on 6/3/25 at 2:40 PM. V18, used wash clothes to cleanse, rinse and dry R18's inner and outer labia. V18 then stated she was completed with perineal care for R18. V18 was asked about cleaning the groin area and the buttocks. V18 said Yes I should of cleaned R18's buttock's area.
R18 stated on 6/3/25 at 2:35 PM she was feeling strange and she had started a new antibiotic today (6/3/25) for another urinary tract infection.
V1, Administrator stated on 6/3/25 at 3:15 PM Yes, they are supposed to clean the entire area front and back when staff complete peri (perineal) care.
The Facility policy dated Toileting and Incontinent Care revision date 8/2023 documents #8 Wash all soiled skin areas and dry very well, especially between skin folds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R13's Medical Diagnosis sheet which is current has the following two diagnoses for R13, Dependence on Renal Dialysis and End stage Renal Disease.
R13's Physician's Order Sheet (POS) dated June 2026 does not document dialysis treatment orders for R13.
V24, LPN (Licensed Practical Nurse) stated on 6/1/25 at 10:30 AM R13 has dialysis five times a week and R13 goes to Dialysis every morning Monday thru Friday.
V16, Regional QA (Quality Assurance) stated on 6/4/25 at 10:30 AM that R13's dialysis order must of fallen off the physician's orders sheet. V16 stated (R13) goes to dialysis every morning Monday thru Friday.
Based on interview and record review, the facility failed to have an order for the provision of dialysis treatments for two (R13 and R46) of two residents reviewed for dialysis in the sample list of 35.
Findings include:
The facility's Long-Term Care Facility Renal Dialysis Affiliation Agreement dated 11/8/2019 documents the Dialysis Facility shall accept medically stable residents into its home Renal Dialysis program, within the limits of its programs and facilities, Each such resident accepted into the Dialysis Facility's home hemodialysis program is referred to herein as a Dialysis Resident. The medical management of the Dialysis Residents will be under the direction of each Dialysis Resident's attending physician. The LTC Facility retains primary responsibility for the development and implementation of each Dialysis Resident's overall plan of care. Coordination of care may include coordination of the following: Day(s), date(s), and time(s) of appointments with the Dialysis Facility and dialysis access orders.
The facility's Dialysis Residents list documents R13 and R46 as Dialysis Residents.
1. R46's Face Sheet (current) documents R46 was readmitted to the facility on [DATE] with diagnoses: End Stage Renal Disease, Stage 4 Chronic Kidney Disease, and Dependence on Renal Dialysis.
R46's Physician Orders (current) do not document any dialysis treatment orders for R46.
R46 did not have dialysis treatment orders from 3/22/25 until 6/3/25.
On 6/3/25 at 1:37pm, R46 stated R46 receives dialysis treatments in the facility Monday through Friday.
On 6/3/25 at 2:21pm, V15 Licensed Practical Nurse confirmed R46 does not have any dialysis treatment orders.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for two (R2 and R275) of seven residents reviewed for EBP on the sample list of 35.
Findings include:
The facility's Enhanced Barrier Precautions policy dated 10/21/22 documents EBP expands the use of gloves and gowns to be worn during high-contact care activities that provides opportunities for Multidrug Resistant Organisms (MDROs) to be transferred between staff hands or clothing and between residents during these high-contact cares. This policy documents residents with wounds and indwelling medical devices are at high risk of acquisition and colonization of MDROs. This policy documents to wear gown and gloves when assisting residents on EBP with high-contact care activities, including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, providing device care or wound care.
R2's care plan dated 4/8/24 documents that staff will always maintain EBP during high-contact resident care areas.
R2's physician's orders dated 9/17/2024 documents an order for EBP when providing cares involving R2's indwelling medical device.
On 6/2/25 at 12:08 PM, there was a sign posted on R2's room door that documented EBP and to wear a gown and gloves for the high-contact care activities listed.
On 6/2/25 at 12:10 PM, V10 Certified Nurse Assistant (CNA) emptied R2's urine collection bag but did not put on a gown.
On 6/2/25 at 12:25 PM, V10 stated that staff are supposed to wear gowns when emptying R2's urine collection bag. V10 stated that she should have put on a gown.
R275's care plan dated 6/2/25 documents that staff will always maintain EBP during high-contact resident care activities.
R275's physician's orders dated 6/2/25 documents an order for EBP when providing cares involving R275's indwelling medical device.
On 6/1/25 at 12:08 PM, V11 Registered Nurse emptied R275's urine collection bag. V11 was not wearing a gown.
On 6/3/25 at 10:00 AM, V2 Director of Nursing stated that all staff should wear a gown and gloves during high-contact resident care activities.

Based on observation, interview and record review the facility failed to maintain the facility kitchen food service areas, and equipment in a clean, sanitary condition to prevent potential cross-contamination and food-borne illness to residents. This failure has the potential to affect all 76 residents residing in the facility.
Findings include:
On 08/20/24 at 9:50 am, during the initial tour of the facility kitchen, accompanied by V7, Dietary Manager (DM), the commercial table mounted can opener had a build-up of a grease-like substance in the gears. Adhering to the grease-like substance were metal fragments, and rust. The commercial can opener also had the silver laminate missing from the bottom inch of the blade. The commercial can opener blade had exposed bare metal and rust at the tip of the blade. V7, DM confirmed the observation and stated he would have to get the build-up debris and blade tip cleaned properly before using the can opener.
During the same initial tour, the facility flat-top grill and stove burners had a range hood that spanned over all cook surfaces. The range hood had six separated metal framed filters. Each of the six metal enclosed filters had a build-up of dark and light brown, grease-like substance adhering to the surface. The grease-like substance had scattered strands of a dust-like substance, that dangled down one to two inches, and directly over the cooking areas. V7, DM stated the facility has a cleaning service that cleans the range hood filters every three months. V7 confirmed the soiled condition of the range hood screen like filters. V7 said he will have to clean the filter, and the contracted cleaning service will need to clean the filter more often.
On 8/22/24 at 10:45 am during subsequent tour of the kitchen, V7, Dietary Manager confirmed the following: The 15 foot long, metal food preparation table had caulking at the wall junction. The caulking had embedded brown and black sticky, food-like substance that adhered to the top and bottom of the caulking. The caulking had food-like particles that were crusted in patches. V7, DM confirmed the caulking debris build-up was a potential contaminate to the food preparation areas as V7 easily scraped off the crusted food debris with V7's finger. The facility three well, wash, rinse and sanitizer water had a windowsill that set directly above it. V7 confirmed that above the three well sink window had screens on the lower half of the window. The screens had copious amount of dust-like buildup and a build- up of grease and dust across the windowsill. Above the window there was a three-inch deep window frame, that junctions with the ceiling. The ceiling and wall junction of the window frame had rust and chipped paint across the full six foot width of the frame. The frame hung over the three well sink. The clean area of the dishwasher station, next to the three well sink was also exposed to chipped paint and thick clusters of dust-like strands and cobwebs on the ceiling above the clean racks of dishes. V7 confirmed these areas were heavily soiled and need to be cleaned to prevent cross contamination.
The facility policy Cleaning Instructions: Hoods and Filters dated 5/2021 documents the following: Policy: Stove hoods and filters will be cleaned according to a cleaning schedule, or at least monthly.
Procedure:
1. Remove the screens from the hoods.
2. Place the screens in soapy water in the sink. Scrub thoroughly. Rinse. (Or run through the dish machine if appropriate.)
3. Air dry screens after cleaning.
4. Replace the screens into the hoods.
5. To clean the interior and exterior of the hood, use a clean cloth soaked in soapy detergent water. Rinse thoroughly and air dry. A more abrasive cleaning agent may be needed in some cases. A cleaning agent that can handle grease may be needed.
6. Hoods and filters should be cleaned professionally at least yearly
The facility Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 08/20/24 documents 76 residents reside in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. R24 Minimum Data Set, dated [DATE] documents R24's Brief Interview of Mental status score as 8 out of a possible 15, indicating moderate cognitive impairment.
R24's Diagnoses list updated 6/10/24 included the following: Hemiplegia and Hemiparesis Following Non-Traumatic Intracerebral Hemorrhage Affecting Left Dominant Side, Morbid (severe) Obesity Due to Excess Calories, and Body Mass Index (BMI) 40-0-44.9.
R24's Care Plan dated 5/28/24 documents the following: (R24) has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) Stroke, history of radius fracture. The same care plan documents the following intervention: Dressing: The resident requires extensive assist of 1 (one) staff to dress. Is weak on the left side.
On 08/21/24 at 12:20 PM, R24 was seated in a bariatric wheelchair in a double wide dining room doorway. R24's abdomen was bare, and fully exposed to residents in the dining room. R24 asked loudly, Can someone help me, move my wheelchair. V12, Licensed Practical Nurse (LPN) did not pull down R24's shirt to cover R24's fully exposed abdomen. V12, LPN pushed R24's wheelchair from one end of the dining room to the other. V12 continued to push R24's wheelchair down the hall. R24's bare abdomen was in full view of other (unidentified) residents and visitors.
On 8/21/24 at 12:25 pm V12, LPN stated I saw his (R24) shirt was up. I should have pulled it down to cover his stomach. I do know, that is a dignity issue.
Failures at this level require more than one deficient practice statement.
A. Based on observation, interview, and record review the facility failed to respect a resident's right to have a visitor with a service support animal present during meal service for one of 18 residents (R377) reviewed for resident rights in the sample list of 26.
B. Based on observation, interview, and record review the facility failed to ensure a resident's right of dignity by failing to cover a resident's exposed abdomen in the dining room where other residents were present. This failure affected one of eighteen residents (R24) reviewed for dignity on the sample list of 26.
Findings include:
The facility policy Resident Privacy and Dignity dated as revised October 2023, documents the following: PURPOSE: To provide all residents with a home like environment that promotes dignity and respect to the residents of the facility.
POLICY: To ensure that all residents are provided with dignity and privacy. RESPONSIBILITY: It is the responsibility of all staff to ensure that all residents have privacy and dignity. the same policy documents: PROCEDURE: 4.
Privacy will be maintained for resident's receiving ADL care such as bathing, dressing and pericare, with the resident room/shower room door closed and curtain drawn., 5. Medically necessary procedures will be conducted in the resident's room/private setting., 7. All resident's rights will be honored throughout the resident's daily routine as listed on the Resident Rights for People in Long term Care Facilities.
A. On 8/20/24 at 1200 PM, V5 (R377's family) was sitting at the dining room table next to R377 and had a small service dog, wearing a red service dog vest, on V5's lap. At this time V3 LPN (Licensed Practical Nurse) asked V5 to remove the service dog from the dining room. V5 stated the dog is a certified service dog and has papers certifying it as a service dog while lifting a lanyard towards V3 that contained the certification. V3 walked away from V5 and entered V1's (Administrator) office. R377 then stated I (R377) don't understand why the dog can't be here with me (R377), he {dog} is a service dog, and this is my home. At 12:08 PM, V3 exited V1's office and approached R377 and V5 and said something that could not be heard, then an unidentified staff member gathered R377's remaining lunch and escorted R377 and V5 along with the service dog to R377's room to finish their lunch.
On 8/21/24 at 12:58 PM, V1 with V2 (Director of Nursing) present stated the facilities dietary consulting company recommended not have the service dog in the dining room during meals. V1 acknowledges that on 8/20/2024 when V5 was asked to leave the dining room the only people at that table, where the service dog was located, was R377 and V5. V1 stated that the facility does not currently have a policy for service dogs. V1 stated that all residents are given a Resident Rights pamphlet at the time of admission for their rights while in the facility.
On 08/21/24 at 2:30 PM, V1 provided Understanding How to Accommodate Service Animals in Healthcare Facilities guide dated 08/16/2024 from HHS (Health and Human Services) website. This guide documents health care facilities must permit the use of a service animal by a person with a disability.
On 8/21/24 at 3:30 PM, V1 provided an undated Resident Rights for People in Long-Term Care Facilities, which is what the residents are given at the time of admission, that documents residents have the rights to make their own choices, be treated with dignity and respect in a home like environment.
On 8/22/24 at 3:30 pm V1 and V2 provided, V5,'s Identification Dog Handler Registration card that documents Access is required by Federal law.

Based on observation, interview, and record review the facility failed to obtain an order for a therapy recommended arm sling and failed to assist in applying the arm sling for one of one resident (R377) reviewed for Limited Range of Motion in the sample list of 26.
Findings include:
On 8/20/2024 at 10:36 AM, R377 was sitting in wheelchair with V5 (family) present. V5 stated R377 had a fall while at home and sustained a fractured right shoulder and should have an immobilizer on. At this time R377 states R377 was sitting on the arm sling.
R377's Occupational Therapy Evaluation and Plan of Treatment dated 8/14/2024 documents R377 was admitted to the facility following a mechanical fall and sustaining a comminuted transverse fracture of the right humeral neck. This evaluation also documents R377 has a brace and/or splint with instructions for the right shoulder sling to be worn to prevent subluxation (separation of the joint).
R377's August 2024 Physician Orders do not document an order for an arm sling.
On 08/20/2024 at 12:00 PM and 2:16 PM, R377 was not wearing the sling. At 2:16 PM when asked why R377 was not wearing the arm sling, R377 states, I haven't gotten someone to put it back on.
On 8/21/2024 at 8:00 AM, R377 was propelling self in wheelchair into the therapy room without the right arm sling in place.
On 8/21/2024 at 8:10 AM, R377 was in therapy working with V13 PTA (Physical Therapy Assistant) with no sling in place.
On 8/21/24 at 1:14 PM, V14 OTR (Occupational Therapist-Registered) with V1 (Administrator) present confirmed there is no order written for an immobilizer or sling, but V14's recommendation has been that R377 is to wear an arm sling on the right arm to prevent subluxation and would expect nursing services to obtain the order.
On 8/22/24 at 12:46 PM, V23 (Nurse for V24 (Orthopedic Physician Assistant)) stated the orders that V24 received from the hospital emergency room were for sling to be worn for 24 hours per day with gentle hand/wrist range of motion and non-weight bearing. V23 explained noncompliance with the sling could cause the fracture to shift and to not heal correctly however R377 has not been seen in the office yet so V23 is unsure how it is healing.

Based on observation, interview, and record review the facility failed to implement an ordered nutritional supplement and failed to notify a resident representative of the significant weight loss for one of two residents (R379) reviewed for nutrition in the sample list of 26. These failures resulted in R1's severe weight loss of 10.8% in 12 days.
Finding include:
On 8/20/2024 at 11:55 AM, R379 was sitting in a wheelchair in the dining room eating lunch with V17 (family) present. No nutritional supplements were present on the tray. At this time, V17 states R379 has lost a lot of weight since his surgery, which was prior to being admitted to the facility. V17 is not aware of any ordered nutritional supplements and has not been notified by the facility of any weight loss since R379 being admitted . V17 stated V17 is at the facility for most of R379's meals and acknowledges that R379 has a decreased appetite and intake.
R379's ongoing Census documents R379 was admitted to the facility of 8/07/2024.
R379's ongoing Weight Log documents a weight of 149.8 pounds on 8/07/2024 and 133.6 pounds on 8/19/2024. This weight loss calculates as a 10.8% weight loss in 12 days.
R379's Dining RD Request for Diet Change report dated 8/08/2024 documents (R379) is at risk for altered nutrition status r/t (related to) reduced meal intake, recent surgery, and dx (diagnosis) of Dementia. Recommend {to} add house supplement 1 dly (daily) and liq (liquid) pro (protein) 30ml (milliliters) dly (daily). Monitor wt (weight). This report recommendation was signed and accepted by V11 (Nurse Practitioner) on 8/09/2024. R379's ongoing August 2024 Physician Order Sheet does not contain the accepted dietary recommendations for nutritional supplements.
On 8/21/2024 at 8:35 AM, R379 was sitting at the dining room table eating breakfast which consisted of: scrambled eggs with cheese, cornflakes, toast, milk, and coffee. R379 consumed: 100% of coffee, 10% of eggs, 0% toast, 0% cornflakes, 0% milk. No nutritional supplement was present at breakfast.
On 8/21/2024 at 8:40 AM, V6 CNA (Certified Nursing Assistant) states I am not aware of any nutritional supplement (R379) is supposed to get but I (V6) usually work in the evenings. V6 acknowledged that if R379 was getting a supplement it would be on the tray.
On 8/21/2024 at 08:45 AM, V4 RN (Registered Nurse) confirms that R379 has not received any nutritional supplements. V4 looked in the EMR (Electronic Medical Record) and confirmed there was no order transcribed for a nutritional supplement.
On 8/21/24 at 10:55 AM, V8 RD (Registered Dietitian) confirmed that V8 recommended the above nutritional supplements on 8/09/2024 for R379, and states V8 would have expected the supplement to be given by now. V8 also stated if R379 was receiving the nutritional supplements as recommended and ordered, it could have possibly prevented R379's additional weight loss.
On 8/21/24 at 12:38 PM, R379 was in the dining room with V17 eating lunch with no nutritional supplement present.
On 8/21/24 at 12:52 PM, V1 (Administrator) with V2 (Director of Nursing) present stated that V8 had notified V1 that the ordered supplement was not implemented because V8 sent the signed recommendations to an invalid email address.
R379's computerized Medical Record does document a history of CHF (Congestive Heart Failure), however R379's Progress Notes do not document any signs and symptoms of CHF. V10's (Nurse Practitioner) Progress Notes on 8/12/2024 and 8/19/2024 do not document any CHF signs or symptoms, nor does V11's (Nurse Practitioner) Progress Note on 8/08/2024, 8/12/2024, and 8/16/2024.
On 8/22/24 at 8:10 AM, V8 confirmed that the order for the nutritional supplement was not implemented and that it was an error on V8's part due to sending the signed recommendation to an invalid email address.
The facilities policy Fortified Foods, Supplements, and Snacks dated 2020 documents residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for Fortified Foods, snacks, or supplements in order to increase nutritional intake. Residents will be evaluated by the Registered Dietitian when additional nutritional intervention is warranted. Commercially prepared supplements, including liquid high calorie and high protein supplements, will be ordered by the physician. Fortified foods, house supplements, or snacks will be provided within the specifications of the diet order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate pain management was provided for one of two residents (R29) reviewed for pain on the sample list of 26.
Findings Include:
The facility's Pain Management Policy dated August 2017 documents the facility's mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of the policy is to accomplish that mission through an effective pain management program, providing residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. The same policy documents pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan.
R29's Minimum Data Set (MDS) dated [DATE] documents R29 is cognitively intact.
R29's Physician Order Set (POS) dated August 2024 documents R29 is prescribed Acetaminophen 500 milligrams three times a day for chronic pain (started on 5/30/2024) and Ibuprofen 200 milligrams every 8 hours as needed for mild or more severe pain (started on 8/21/2024).
R29's Psychiatry Note dated 7/9/24 documents R29 reports she has not been sleeping well due to pain and continues to show impulsive behaviors. Staff reported R29 hasn't been sleeping and often requests pain medications to get out of bed.
R29's Care Plan dated November 2022 documents R29 has potential for pain related to Lumbar Degenerative Disc Disease and Fibromyalgia. Staff are to administer pain medications as ordered by physician and notify the physician if interventions are unsuccessful.
R29's Medication Administration Record (MAR) dated August 2024 documents R29 reported a pain rating of 10/10 twice on 8/16/24, and once on 8/19/24 and 8/21/24.
On 8/20/24 at 1:20 PM R29 was lying in bed with a blanket over her head and when asked how she was feeling, R29 stated she was in pain and her back hurt, and the staff aren't getting her the medication that would actually relieve her pain. R29 stated she gets Acetaminophen, and she needs something stronger. R29 has told the nurses but they say they will talk to the doctor and she never hears anything else about it. R29 stated she asks for pain medicine but what they give her doesn't help. R29 stated she needs something stronger, but they won't give it to her because they are afraid, she will become addicted. R29 stated she hurts at about an 8/10 most of the time.
On 8/23/24 at 10:45 AM V1 Administrator and V2 Director of Nurses (DON) confirmed R29's repeated complaints of uncontrolled pain need to be addressed. V2 DON confirmed if R29 is in significant pain something more needs to be done to assist in making R29 more comfortable.
On 8/23/24 at 12:25 PM V11 Nurse Practitioner stated R29 has multiple medical diagnoses contributing to her chronic pain. These include Intervertebral Disc Degeneration in the Lumbar Region, Fibromyalgia, and Weakness. V11 stated R29 also has Dementia. V11 stated R29 is prescribed scheduled Acetaminophen 1000 milligrams three times per day and V11 just started Ibuprofen 400 milligrams every eight hours as needed for pain on 8/21/24. V11 stated she was not made aware by facility staff that R29 was complaining of significant pain of 10/10 until 8/21/24. V11 stated she does not want to prescribe a narcotic pain medication for R29's chronic pain and does not know what else the facility has tried to help relive R29's constant pain.

Based on observation, interview, and record review the facility failed to dispose of discontinued medications for one (R9) of 22 residents reviewed for physician orders in the sample list of 26.
Findings include:
On 8/21/24 at 4:30 PM,
the bottom drawer of the [NAME] Wing Medication Cart contained a medication bottle without a label. Inside of this bottle, there were three new Haldol {Antipsychotic} 5mg (milligrams)/ml (milliliters) vials that had a sticker on the bottles with R9's name. At this time, V2 (Director of Nursing) stated the Haldol was a one-time order and should have been destroyed or sent back to the pharmacy.
R9's July 2024 Physician Order Sheet documents an order received on 7/15/2024 for Haloperidol {Haldol} Lactate Injection Solution 5mg/5ml (Haloperidol Lactate)-
Inject one ml intramuscularly, every 8 hours as needed for agitation and aggression, for 14 Days with instructions of may give IM (Intramuscularly) when not given PO (by mouth).
The facilities Destroying Medication policy date 9/2023 documents, all discontinued medications or medications of discharged residents will be destroyed as soon as possible.

Based on observation, interview and record review the facility failed to ensure residents medications, including Schedule II controlled substances, were stored appropriately within visual control of the nurse. This failure affects four of 22 residents (R2, R31, R35, R25) reviewed for medication storage for the sample list of 26.
Findings include:
On 8/21/2024 at 4:09 PM, the [NAME] Wing Medication Cart was unlocked and not secured to the wall. There were no staff present. There was an opened stock bottle of Melatonin 5 mg (milligrams) sitting on top of medication cart.
On 8/21/2024 at 4:10 pm, V16 LPN (Licensed Practical Nurse) exited the [NAME] Wing Medication Room and walked down the hall and into a resident room, leaving the unsecured medication cart in the hallway, unlocked and out of V16's sight. V16 returned to the medication cart at 4:12 PM, gathered supplies and walked away from the cart again at 4:17 PM and entered another resident room, leaving the cart unlocked, unattended and out of V16's sight until 4:20 PM. V16 returned to the cart at 4:21 PM to gather supplies, then left the cart again, leaving it unlocked, unsecured and out of V16's sight while in a resident room. At 4:22 PM, V2 (Director of Nursing) approached the medication cart and confirmed the Melatonin should not be on top of the medication cart and states the medication cart should be locked when staff are not within sight. At 4:25 PM, upon V16's return to the medication cart, V2 stated, do you see we are in your cart; it should have been locked. Included in the unlocked medication cart were the following controlled substances: Norco (Narcotic) 10/325 mg for R31, Norco (Narcotic) 7.5/325 mg for R2, Methylphenid (Central Nervous System Stimulant) 20 mg for R35, Reprexain (Narcotic) 10mg/200mg for R25; all which are classified as Schedule II narcotics.
The facilities Storage of Medications policy dated 10/2023 documents all medications will be safe and properly stored at all times. All medications for all residents shall be stored in or near the nurse's station, in a locked cabinet, a locked medication room, or in locked, secured medication cart. Mobile medication carts, when not in the visual control of the nurse, shall be stored in a locked room affixed in such a way to render them immobile. All scheduled II controlled substances shall be stored in the drawer of the medication cart which is separately keyed and locked.

Based on observation, interview and record review, the facility failed to ensure a call light was within reach for one of five residents (R1) reviewed for call lights on the sample list of seven.
Findings Include:
R1's ongoing and undated Medical Diagnosis Listing documents the following diagnoses: Quadriplegia, Multiple Sclerosis, Anxiety Disorder, and Neuromuscular Dysfunction of the Bladder.
On 4/15/24 at 9:15 am, R1 was sitting up in a motorized wheelchair in R1's room and stated, R1 was needing R1's incontinence brief changed but that R1 can't even call them to tell them because R1's call light is hanging on the wall {behind the bed} and R1 can't reach it. At this time, R1's call light was secured to the wall, behind the head of R1's bed, out of reach and next to R1's bed was an end table, which prevented R1 from getting close enough to the wall to reach the call light.
On 4/15/24 at 9:35 am, V4 CNA (Certified Nursing Assistant) and V7 RN (Registered Nurse) were in R1's room, changing R1. At this time, V4 and V7 confirmed R1's call light was secured on the wall, out of R1's reach. V4 explained that V5 CNA had made R1's bed earlier that morning and must have forgot to place the call light back on the bed, where it should be.
The facility's Call Lights: Answering Policy dated July 2023 documents when a resident is in bed or confined to a chair, ensure that the call light is within easy reach of the resident.

Based on observation and record review, the facility failed to prevent possible cross contamination during incontinence care for one of four residents (R1) reviewed for toileting on the sample list of seven.
Findings Include:
On 4/15/24 at 9:35 am, V4 CNA (Certified Nursing Assistant) and V7 RN (Registered Nurse) were changing R1's incontinence brief. R1 had been incontinent of urine and stool and R1's brief was saturated. V4 donned gloves and provided incontinence cares using disposable wipes, then proceeded to grab a clean incontinence brief and placed it under R1 without removing the potentially contaminated gloves or performing hand hygiene. R1 then urinated again, onto the new incontinence brief. V4 changed gloves at this time but did not perform hand hygiene. V4 provided incontinence care again and upon rolling R1 to R1's side, it was noted that R1 had also had another small bowel movement. V4 continued to provide incontinence care, cleaning the bowel movement, then obtained another clean brief from the bed side table and placed it under R1 without changing gloves or performing hand hygiene.
The facility's Hand Washing Policy dated March 2024 documents hand hygiene is the primary means to prevent the spread of infections. All staff will properly wash hands after direct contact with any contaminated substances, after direct resident care, and as instructed. Employees must wash their hands for 15 to 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin, after removing gloves and after handling items potentially contaminated with blood, body fluids, or secretions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide personal hygiene or grooming services to remove facial hair from a female resident. This failure affects one resident (R37) out of three reviewed for activities of daily living on the sample list of 28.
Findings include:
On 6/6/23 at 3:33 pm, R37 was seated in a wheelchair in R37's own room. R37 had dark colored black and gray hair below the chin in an area covering the same distance as from one corner of the mouth to the other corner of the mouth. R37 reached a hand up to stroke this under chin hair and the hair was as long as the length of R37's fingernail beds. R37 also had dark colored brown and black facial hair approximately one quarter inch long across the width of the upper lip. All this facial hair was prominently visible.
On 6/6/23 at 3:33 pm, R37 stated, The staff have to do the shaving for me but sometimes it goes a while between shavings.
R37's Minimum Data Set, dated [DATE] documents R37 requires extensive assistance from one staff person to accomplish personal hygiene functions such as shaving. This same Minimum Data Set documents R37 did not exhibit any behavior of rejecting care.
R37's Electronic Medical Diagnoses List (undated) documents R37 experiences Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side.
On 6/8/23 at 9:30 am, V18, Registered Nurse, stated, (R37) cannot shave herself. (R37) usually gets showers on third shift. I don't think (R37) would want to shave herself because (R37) has a right hand affected by a stroke and some pain which makes her handshake. V18 continued, (R37) does not typically refuse care or showers, (R37) actually sets her alarm for 2 or 3 in the morning in order to get showers at that time.
R37's Nurses Notes dated 12/1/22 through 6/5/23 did not document any refusals of hygiene care nor showers. R37's task charting (point of care charting) for bathing, and personal hygiene, dated 5/9/23 through 6/8/23 did not document any refusals of showers nor hygiene care.

Based on observation, interview, and record review, the facility failed to utilize basic infection control procedures by failing to wear gloves during the administration of a finger puncture blood glucose check and administration of an insulin injection. This failure affects one resident (R39) out of one observed for glucose checks and insulin administration on the sample list of 28.
Findings include:
On 6/8/23 at 12:45 pm, R39 was sitting outside the facility's entry door next to the therapy department. V20, Licensed Practical Nurse, exited the facility from this therapy door and administered a finger puncture blood glucose check without the benefit of wearing gloves. V20 returned inside the facility, then returned outside after several minutes to approach R39 and administered an insulin injection to R39 utilizing a re-useable insulin pen injection set, again without benefit of wearing gloves. V20 then placed R39's insulin pen inside V20's front lower left shirt pocket and returned inside the building.
On 6/8/23 at 2:14 pm, V20, Licensed Practical Nurse, confirmed V20 had administered the blood glucose check and insulin injection without wearing gloves by stating, Yeah. V20 further stated an understanding of facility policy about glove use while conducting such procedures, and stated, The policy says to wear gloves.
The facility policy Blood Glucose Monitoring dated (most recently revised) 1/2023, documents, Wash hands, put on gloves. Wipe site to be used with an alcohol pad, obtain a sample of blood from the resident's finger with a lancet, discard the lancet in a sharp's container. If insulin is ordered based on a sliding scale order, document type and amount of insulin administered and site of injection. Remove gloves and wash hands.
R39's current Electronic Physician Order Sheet (undated) documents a physician order for R39, Insulin Lispro, 1 unit dial, 100 unit/ ml (milliliter) solution pen injector, inject per sliding scale, if 0 - 160 (blood glucose check result) = 0 (equals no insulin), if 160 - 400 = 6 (administer 6 units) subcutaneously before meals.
R39's Medication Administration Record dated for June 2023, documents, and confirms V20 administered R39's blood glucose check and insulin injection for the noon medication administration time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and submit a comprehensive Minimum Data Set within the 14-day requirement after determining a significant change in a resident's health status. This failure affects one resident (R28) out of three reviewed for pressure ulcers on the sample list of 28.
Findings include:
R28's Minimum Data Set (MDS, resident assessment instrument) dated 1/31/23 documents R28 required supervision and set up assistance to accomplish bed mobility, surface to surface transfers, ambulation in the room and corridor, eating, and toileting. This same MDS documents R28 required supervision and physical assistance from one staff member to accomplish locomotion on and off the nursing unit with a walker, and dressing. This MDS documents R28 required extensive assistance of one staff member to accomplish bathing. This MDS documents R28 is not steady in transitions such as rising from sitting to standing, walking, turning around, and during surface-to-surface transfers but is able to stabilize self without staff assistance. This MDS documents R28 is occasionally incontinent of bladder, and always continent of bowel. This MDS documents R28 experienced no skin conditions such as unhealed pressure ulcers, infections, nor other lesions of the feet. This MDS documents R28 utilized pressure relieving devices on the chair and bed. This MDS documents R28 had not received any special treatments, programs, or procedures, such as intravenous therapy or quarantine. This MDS documents R28 received no skilled therapy services such as Speech Therapy, Physical Therapy, nor Occupational Therapy. This MDS documents R28's physician had not visited nor changed R28's orders.
R28's MDS dated [DATE] (modified) documents R28 required extensive assistance of one staff member to accomplish bed mobility, dressing, toileting, and personal hygiene (all significant declines requiring revision to the plan of care). This same MDS documents R28 required extensive assistance of two staff members to accomplish surface to surface transfers, locomotion on and off the nursing unit, and accomplished no ambulation (all significant declines requiring revision to the plan of care). This MDS documents R28 was dependent on one staff member for bathing (decline). This MDS documents R28 is unsteady rising from sitting to standing, during surface-to-surface transfers, is unable to stabilize without staff assistance, and now accomplishes locomotion with a walker or wheelchair (decline). This MDS documents R28 is frequently incontinent of bladder and always incontinent of bowel (significant decline). This MDS documents R28 experienced an unstageable pressure ulcer, infections, and other open lesions of the feet (significant decline requiring revision to the plan of care). This MDS documents R28 utilizes pressure relieving devices on the chair and bed, nutrition, and hydration interventions to manage skin problems, pressure ulcer care, applications of ointments or medications other than to the feet, and application of dressings to the feet (significant decline requiring revision to the plan of care). This MDS documents R28 received intravenous medications, and isolation or quarantine for active infectious disease (significant decline requiring revision to the plan of care). This MDS documents R28 received 95 minutes of Speech Therapy, 105 minutes of Occupational Therapy, and 136 minutes of Physical Therapy (significant revision to plan of care). This MDS documents R28's physician had visited and changed R28's orders on 3 occasions (significant revision to plan of care).
On 6/8/23 at 10:59 am, V21, Minimum Data Set Coordinator, stated, (R28) did have a significant decline in physical functional abilities. (R28) had covid in March and had to go to the hospital. When (R28) returned from the hospital, (R28) had ulcers on the heels. V21 continued, I considered a significant change MDS in March, but I was hoping the heel ulcers would improve and (R28) would get back to normal, so I made the decision to complete a normal quarterly MDS while we were waiting to see the outcome of (R28's) heel ulcers. Now we are 3 months into that process I should speak with the wound nurse to see what the prognosis is as far as the ulcers. V21 concluded by stating, A significant change MDS cannot be a regular quarterly, it has to be a comprehensive MDS like the annual.
On 6/8/23 at 10:59 am, V22, Certified Occupational Therapist Assistant/ Director of Therapy, stated, (R28) was receiving therapy from March 28 (2023) through May 6 (2023). (R28) was not participating, was even combative at times, and I would go by (R28's) room and see (R28) attempting actions that (R28) should not have been attempting independently, like trying to get into bed, because (R28's) safety awareness had become so poor. V22 further stated, I am sure (R28's) inability to participate in therapy was mainly due to (R28's) poor circulation to the feet and the ulcers on the heels, making it difficult to walk and participate in therapy.

Based on observation, interview, and record review, the facility failed to store a frozen food item to protect from freezer damage, failed to maintain the range hood in a manner to protect foods being prepared, and failed to protect serving wares from cross contamination during meal services. These failures have the potential to affect all 79 residents residing in the facility.
Findings include:
On 6/6/23 at 9:35 am, the facility walk-in freezer contained an open cardboard box of frozen chicken breast fillets. Inside the cardboard box, the chicken was in a plastic bag that was wide open, exposing the chicken to the freezer air. V12, Dietary Manager, stated, We will have to get that closed up.
On 6/6/23 at 9:40 am, the range exhaust hood had greasy particles and clumps of material with the appearance of lint or cobwebs. These particles and clumps were too numerous to count but several dozen were present on each of the internal slat structures of the range hood. Many, again too numerous to count, of the clumps were loosely hanging directly over the range where there was green beans and mashed potatoes being prepared in large in open top pans. V13, Cook, confirmed the items in preparation on the range were green beans and mashed potatoes. V12, Dietary Manager, stated to V13, Cook, Cover those pans.
On 6/6/23 at 11:42 am, V13, Cook, was in process of the lunch meal service. On the range-front shelf were drippings of chicken gravy and/ or cream of chicken soup, and some stuck on browned food debris. V13 had 4 serving bowls turned upside down on this shelf with the lip rim of the bowls sitting directly on the food debris and drippings. V13 picked up one of the serving bowls and filled it with the cream of chicken soup, then placed the bowl on a serving tray intended for R15. V13 confirmed the food items in the pans on the range were, Chicken gravy and cream of chicken soup. V13 confirmed the serving tray was intended for (R15). A Dietary Aid (unidentified) placed the serving tray intended for R15 into an insulated transport cart. At this point, (surveyor) pointed out to V12, Dietary Manager, the drippings and stuck-on browned matter on the range shelf where the serving bowls were sitting. V12 picked up the remaining 3 serving bowls and placed them into the line for dishwashing. (Surveyor) then also informed V12 that one bowl which was sitting on the range shelf had already been filled and was now on the transport cart and intended for R15. V12 went and removed the serving bowl from R15's tray and instructed V13 to Make another bowl of soup for (R15).
On 6/7/23 at 11:28 am, V12, Dietary Manager, stated, I don't see the potential for harm from the open chicken breasts in the freezer from yesterday, it stayed in the original bag and didn't touch anything else. V12 did acknowledge the potential for freezer burn and stated, But we go through it quickly. V12 further stated, (V13) should not have had those bowls upside down on the dirty range shelf yesterday. V12 did confirm that the soup for R15, Would have been delivered to (R15) if (surveyor) had not said something. V12 examined the range hood again at this time and stated, We are due for a cleaning I believe this month. The maintenance label on the front of the range hood was unclear as to the cleaning schedule. The maintenance label documented a cleaning performed June 2023, and a next cleaning due June but the indicating hole was directly between the 2022 and 2023 years. V12 confirmed the hood had not been cleaned in June 2023 but was Due for a cleaning this month. V12 further stated, I don't see how lint could get in there, but I don't want to touch any of that (greasy lint/ cobweb material) to see what that actually is during the food service, so it doesn't knock loose and fall into the food cooking on the range. At this time, there was brown gravy and minestrone soup in large open top pans cooking on the range.
The facility's Resident Census and Conditions of Residents dated 6/6/23 documents 79 residents reside in the facility, all of whom consume food prepared in the facility's kitchen with one exception, R38 received nutrition by a gastrostomy tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a resident's care plan to reflect the actual level of assistance required to accomplish activities of daily living. This failure affects one resident (R37) out of three reviewed for activities of daily living on the sample list of 28.
Findings include:
On 6/6/23 at 3:56 pm, R37 stated, The staff have to do the shaving for me. I can transfer but I need help doing it, and I need help for showers.
R37's Minimum Data Assessment (MDS, resident assessment instrument) dated 12/3/22 documents R37 required limited assistance of one staff member to accomplish bed mobility and surface to surface transfers. This same MDS documents R37 required supervision and set up assistance to accomplish locomotion in a wheelchair on the nursing unit. This same MDS documents R37 required extensive assistance of one staff member to accomplish bathing and personal hygiene.
R37's MDS dated [DATE] documents R37 required extensive assistance of one staff member to accomplish bed mobility (decline). This same MDS documents R37 required extensive assistance of two staff members to accomplish surface to surface transfers (significant decline). This same MDS documents R37 required supervision and physical assistance of one staff member to accomplish locomotion in a wheelchair on the nursing unit (decline). This same MDS documents R37 was totally dependent on one staff member to accomplish bathing (decline).
R37's current Care Plan focus area for ADL (activities of daily living) self-care deficit, dated as revised 11/20/22. The nursing interventions for this care area document R37 requires set up assistance of one staff member for bathing/ showering, dated revised 2/21/20, failing to address R37's decline to dependency for bathing. These same nursing interventions document R37 requires set up and supervision with bed mobility, dated revised 1/28/20, failing to address R37's decline to extensive assistance. These nursing interventions document R37 requires set up by staff with personal hygiene (includes shaving) and oral care, dated 6/29/16, failing to address R37's need for extensive assistance for personal hygiene. The nursing interventions document R37 requires set up for transfers, dated revised 4/20/23, failing to address R37's decline to extensive assistance of two staff members to accomplish transfers. The nursing interventions include to monitor/ document/ report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, or declines in function, dated initiated 6/29/16.