Schoolcraft Medical Care Facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Facility Reported Incident (FRI) 2631248Based on observation, interview, and record review, the facility failed to implement interventions and physician recommendations/orders to prevent one Resident (#1) with a known history of elopement of three residents reviewed for elopement from eloping from the facility. This deficient practice resulted in an immediate jeopardy when Resident #1 eloped from the facility and was found 1.2 miles away and was missing for approximately 2 hours, resulting in the likelihood of series injury, harm or death.Findings include:The Immediate Jeopardy began at 12:16 p.m. on 9/28/25 when R1 eloped from the facility undetected and was reported by a facility staff member to be located at a fast-food restaurant, 1.2 miles away at 2:10 pm. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on 10/8/25 at 2:10 PM. At that time, an immediacy removal plan was requested from the facility. This surveyor confirmed by observation, interview, and record review that the immediacy was removed on 10/8/25 at 4:06 p.m., however, noncompliance remained at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA).Resident #1 (R1)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 4/7/25, with active diagnoses that included: Alzheimer's disease and macular degeneration (an eye disease that damages the macula [part of the eye for sharp, central vision], causing blurry or distorted central vision). Further review of MDS Section B1000 Vision revealed R1 vision is severely impaired with no vision or sees only light, colors or shapes; eyes to not appear to follow objects. R1 scored a 4 of 15 on the Brief Interview for Mental Status reflective of severe cognitive impairment.Review of the Facility Reported Incident (FRI) submitted to the SA included an Incident Summary read in part, .R1 was found not to be in the facility.he went out when a family member came into the facility. Investigation Summary/Actions Taken.At approximately 1:13 p.m. on 9/28/25, Administrator was called by charge nurse.who stated that R1 could not be found in the facility.the facility has been checked and R1 was not in the building.at 2:10 p.m. the resident has been found at [fast food restaurant] 1.2 miles away from the facility.the Director of Nursing (DON) and Administrator reviewed the cameras after the event and noticed that the resident was playing with the door code earlier in the day.Views of the camera showed that he waited for a family member to come in the door to sneak out of the facility.he did walk around.before leaving the facility premises.Review of google maps revealed R1 would have crossed multiple streets and likely walked along a busy highway to gain entrance into the fast-food restaurant located next to the highway. The fast-food restaurant is also located near a very large lake with an average surface temperature in late September of approximately 50 degrees Fahrenheit.Review of the Elopement [R1] Incident Timeline dated 9/28/25, read in part .12:16 p.m. a residents family entered the facility in the Northeast entrance. R1 seen them come in and he immediately went to the door and got outside. nobody seen him go out.12:59 p.m. Certified Nurse's Assistant (CNA) went to check on resident and realized he was not there.at 2:10 PM Staff Member D found resident at [fast food restaurant].Review of Incident Report titled Elopement dated 9/28/25, read in part . Nursing Description: Resident waited for a family member enter the building so that he could exit the building.He was seen on [video] camera playing with the door code at 11:35 a.m.No witnesses to that.During an interview on 10/7/25 at 12:28 p.m., the NHA reported I don't know how he made it to the [fast food restaurant], he can't see. I had 40 people looking all over the [city name] looking for him.he wants to get out of here and go to another facility.he does not want to be here, especially since his wife died.she died just before he eloped from here.During a phone interview on 10/7/25 at 1:04 p.m., family member [daughter] A reported He has talked about leaving the facility prior to the elopement.he left that day and he just didn't want to be there since mom died.During an interview on 10/7/25 at 1:15 p.m., CNA B reported He was grieving since his wife passed.he always talked about leaving and going to the city where he used to live [50 miles away].he has gone to the doors before.I worked that day and went to his room to check on him and he was gone.he left the facility and was found a mile or so away.During an observation on 10/7/25 at 1:27 p.m., the Northeast exit door was noted to be across from the dining room.During an observation on 10/7/25 at 1:33 p.m., the NHA replayed the video camera footage which revealed R1 walked out of the dining room and exited the northeast exit door after other visitors entered. R1 walked outside of the fence and then walked across the parking lot towards the street.During an interview on 10/7/25 at 2:40 p.m., R1 stated I wanted to get out of here and I did. I will try again, and they will not find me.I don't want to be here.Review of R1's physician progress notes revealed the following entries:5/21/25, read in part .[R1] Resides in the memory care unit. He greatly benefits from this environment due to poor safety awareness and wandering.6/29/25, read in part .He was admitted to the memory care unit on 4/7/25. He was diagnosed with Alzheimer's disease in March of 2025.Review of R1's progress notes revealed the following entries:7/1/25, read in part .Room change.Reason: resident to move on main nursing floor. The progress note did not indicate R1 did not meet the criteria for being in the memory care unit or the reason why he was taken out of the memory care unit.7/5/25, read in part R1.said he wanted to get out of here.he was very upset and said he wanted to go home. 7/6/25, read in part .Resident went out the south exit door. CNA went out to get him.he came back in the Northeast exit door.Review of document titled Elopement Risk Assessment dated 7/7/25, read in part .total score elopement risk.total score of 21 [out of 24] .if total score is above 10 indicates need for care planning .Review of R1's care plan revealed no care planning was completed regarding elopement risk.During an interview on 10/8/25 at 10:49 a.m., the NHA reported There was no investigation or incident/accident report when R1 exited the facility on 7/6/25.there was no care plan or interventions put in place after he exited facility on 7/6/25. During a follow-up interview at 11:08 a.m., the NHA reported There was no care plan in place after the elopement assessment was completed on 7/7/25.we missed it, and I don't know why.Review of physician progress revealed the following entries: 7/11/25, read in part .Noted to be pacing up and down hall, approaching nurses' station to inquire about.getting back home.He is repetitive with his thoughts and is noted to be wandering/pacing in the halls.7/21/25, read in part .R1 requested to be moved back into the secure memory unit.Review of R1's progress notes revealed the following:7/25/25, read in part ID (interdisciplinary) team met for weekly meeting Admin (NHA), wound care nurse, AD (Activity Director), SWD (Social Worker Designee), RD (Registered Dietician), NP (Nurse Practitioner), and DON (Director of Nursing) in attendance. Resident has been having increased behaviors and exit seeking.8/5/25, read in part .Resident walked out Northeast exit door.During an interview on 10/8/25 at 10:49 a.m., the NHA reported There was no investigation or incident/accident report when R1 exited the facility on 8/5/25.there was no care plan or interventions put in place after he exited the facility on 8/5/26. We did not have a care plan for him regarding elopement or elopement risk until after the elopement on 9/28/25.Review of policy titled Comprehensive Care Plans date reviewed/revised 3/25/25, read in part .It is the policy of this facility to develop and implement a comprehensive person centered care plan for each resident.that includes measurable objectives and timeframes to meet a residents medical, nursing, mental and psychosocial needs and all services that are identified.and meet professional standards of quality.the comprehensive care plan will be reviewed and revised by the interdisciplinary team.alternative interventions will be documented as needed.Review of policy titled Resident Elopement read in part .It is the policy of this facility that all residents will be assessed for behaviors or conditions that put them at risk for elopement. All resident so identified will have these issues addressed in their individual care plan.Residents at risk for elopement shall be identified and documented in the individual plan of care.Review of R1's social worker notes revealed the following entries: 8/12/25, read in part .left message with residents Durable Power of Attorney (DPOA) related to possibly moving resident to the secured unit. 8/18/25, read in part .spoke with residents DPOA and she gave consent for resident to reside in the memory care unit.related to safety issues, she will sign a new consent if necessary.During an interview on 10/8/25 at 1:43 p.m., the NHA reported The facility did not formally move R1 to the memory care unit after his previous attempts of eloping from the facility.he went back there [to the memory care unit] a couple times to take a break from being with his wife who was declining in health, however he did not meet the criteria to be in the memory care unit.Review of facility document titled [Facility name] Memory Care Unit-Consent Form revealed the DPOA signed the consent form on 4/7/25.Review of policy titled Memory Care Unit read in part .It is the policy of this facility to provide holistic are to those residents affected with.Alzheimer's disease by providing a.safe environment.criteria is identified on the Memory Care Unit Consent Form that is signed on admission.admission Criteria 1. Individual must have diagnosis of .Alzheimer's Disease.2. Individual must be able to .b. be up in a chair.or ambulate.3. Individual must be assessed to have moderate to severe cognitive impairment.4. The individual requires no more support than 1 person assisting with transfers.Review of MDS revealed R1 did meet the criteria to stay in the Memory Care Unit based on the criteria above.Review of social work note dated 9/8/25, read in part .Spoke with the residents DPOA and she believes his dementia is progressing.Review of physician progress note dated 9/26/25, read in part .adjustment disorder with mixed anxiety and depressed mood: R1 wife passed away very recently .He is noted to have some increased sadness and agitation.Review of R1's progress notes revealed the following entries:9/27/25, read in part .He is upset because he is here and is just here to die.9//28/25, read in part .He was in the dining room for lunch and came up missing.staff searched the whole building and outside premises for him. DPOA/daughter was called.DPOA states she figured this would happen because of [wife's] passing.he had $100 dollars in his wallet and he is very [NAME] and is probably on his way to try to get to [hometown city approximately 50 miles away].the DPOA was going to call neighbors and friends.to be on the lookout for him.This nurse went out and walked close by streets to try and find resident. Then this nurse got in her truck and rode around.Review of policy titled Resident Elopement read in part .Definitions.for the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds.all residents shall be reviewed for safety concerns.The Immediate Jeopardy which began on 9/28/25 was removed on 10/8/25 at 4:06 p.m. when the facility took the following actions to remove the immediacy. The Facility Removal Plan read:R #1 is safe and residing in the Memory Care Neighborhood, a secured unit. No physical injury, mental anguish, harm or painR #1 Elopement Assessment has been updated, and a care plan has been developed, with appropriate interventions.All residents have an Elopement Assessment. All were audited to ensure that if they have a score higher than 10, that they will; have a care plan in place with appropriate interventions. All are completed. All staff have reviewed and signed a copy of the Facility Elopement Policy. The Director of Nursing, or designee will audit all new admissions for elopement risk and ensure appropriate interventions are in placeThe Director of Nursing, or designee will audit residents, based on MDS schedule, to ensure Elopement Assessment is completed and appropriate interventions are in place. The Director of Nursing was educated to review Elopement Assessments to ensure that proper care plan interventions are in ace, based on the MDS schedule and admissions. The Northeast door code has been changed and only staff are allowed to have this code. All visitors and staff must enter and exit the facility through the front lobby only. All DPOA's and Emergency contacts will be contacted today to let them now of the change. Signage will also be posted. Staff education has been sent regarding these changes and to ensure they do not give out the cede to the Northeast door and that they all use the front lobby to enter and exit. If they hear the alarm o off, they need to remind the visitor to use the front lobby door, or if they cannot identify who set the alarm off, they need to call a code missing person and start a headcount. All physician orders and physician progress notes have been reviewed for R #1 and have been placed. Resident is utilizing nonpharmacological interventions, residing in the memory care unit, and on antidepressant medications, per Behavioral Care Solutions recommendations. The Director of Nursing and Administrator consulted with [physician name], our Medical Director, who has no concerns at this time that we have not followed any of his recommendations on any other residents. He does not have any concerns at this time with any resident risk of elopement, safety, or wandering.

Based on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid Services). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 53 residents.
Findings include:
Review of CMS PBJ Staffing Data Report FY (fiscal year) Quarter 4 2024 (July 1 -September 30) revealed the metric No RN (Registered Nurse) Hours, Excessively Low Weekend Staffing, One Star Staffing Rating, and Failed to have Licensed Nursing Coverage 24 Hours/Day Triggered with the following infraction dates being: No RN hours every day beginning with 7/1/24 through 9/30/24. Failed to have Licensed Nursing Coverage 24/Hours/Day every day beginning with 7/1/24 through 9/30/24
During an interview on 1/9/25 at 9:59 a.m., Human Resource Manager F stated, I input the information for the PBJ report . we switched companies to take our data and convert it and send it to CMS .we did find out that it did not work.
During an interview on 1/9/25 at 10:27 a.m., Nursing Home Administrator (NHA) stated, the report was not created correctly., acknowledging the report was not submitted correctly.
Facility policy for PBJ reporting was requested from facility but was not given prior to exit.

3. Appropriate Performance of Hand Hygiene
On 1/9/25 at approximately 9:00 a.m., RN G administered Azelastine Hydrochloride nasal spray, two puffs, into each nostril of Resident #12 (R12) without the performance of hand hygiene or donning of gloves.
On 1/9/25 at approximately 9:05 a.m., RN G was observed as they examined R12's open, what appeared to be a scratched area on their posterior, upper hip. RN G explained the scratched area was new and RN G said she was going to apply barrier cream to the open, scratched skin area. RN G applied barrier cream to R12's open wound without performance of hand hygiene or donning of gloves.
On 1/9/25 at approximately 9:07 a.m., RN G was observed as they applied a 4% Lidocaine Transdermal Patch to R12's posterior, right hip. RN G did not don gloves prior to application of the patch to R12's skin. RN G's bare hands were observed to touch R12's bare posterior hip as the patch was smoothed out over the Resident's skin. No hand hygiene was performed after the patch application. RN G then assisted with repositioning R12 in bed, tied up the open garbage bag near the sink and rearranged the linens on R12's bed. No hand hygiene was performed.
On 1/9/25 at approximately 9:09 a.m., RN G was observed as they administered Fluticasone Propionate nasal spray, one puff in each nostril without the performance of hand hygiene before or after administration of the nasal spray. RN G held the nasal spray in her bare right hand while activating R12's nasal spray.
On 1/9/25 at approximately 9:12 a.m., RN G was observed to pick up a box of tissues R12 had dropped onto the floor, with bare hands, and placed the now dirty box of tissues on top of R12's over bed table. No hand hygiene was performed prior to exit from the room.
On 1/9/25 at 9:16 a.m., RN G was asked if they had used gloves during the administration of R12's nasal sprays. RN G stated, No, I did not use gloves at all. When asked about the application of barrier cream to R12's open, scratch wound, RN G acknowledged they had put the cream on the R12's open skin without donning gloves. RN G also confirmed they had not donned gloves prior to application of R12's transdermal patch, nor had they performed hand hygiene following application of R12's transdermal patch. RN G stated, I cannot do patches with gloves. RN G confirmed she had picked up R12's tissue box and placed it on top of R12's over bed table. When asked if the tissue box would be considered clean or dirty, RN G agreed the box from the floor would be dirty when placed on the over bed table. RN G did not perform hand hygiene following picking up the tissue box from the floor. RN G gathered the two nasal spray bottles in her dirty, bare hands as they exited the room. The nasal spray bottles were placed on top of the medication cart, without a barrier, and then placed back into the manufacturer's boxes in the medication cart.
During an interview on 1/9/25 at 10:05 a.m., the NHA was informed of observation of ungloved hands during contact with skin and/or body fluids, failure to perform hand hygiene, and potential contamination of environmental surfaces. The NHA stated, What was [RN G] thinking. That is Nursing 101 (to perform hand hygiene). The NHA expressed understanding of the concern with infection control practices, especially during an outbreak of Norovirus within the facility and said RN G would be educated immediately.
Review of the [Facility] Hand Hygiene policy, dated 4/2/2021 and reviewed 1/9/25 at 10:35 a.m., revealed the following, in part: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
Review of the Hand Hygiene Table, reviewed 1/9/25, revealed hand hygiene should be performed in the following situations, in part: .After caring for a person with known or suspected infectious diarrhea (such as Norovirus), when coming on duty, between resident contacts, after handling contaminated objects .before applying and after removing personal protective equipment (PPE), including gloves, before preparing or handling medications, before and after handling clean or soiled dressings, linens, etc., before performing resident care procedures . After handling items potentially contaminated with blood, body fluids, secretions, or excretions, when, during resident care, moving from a contaminated body site to a clean body site, after assistance with personal body functions, after sneezing, coughing, and/or blowing or wiping nose . When in doubt .
Based on observation, interview, and record review, the facility failed to implement a comprehensive infection control program to mitigate the spread of Norovirus during an outbreak by failure to:
1.
Implement effective disinfection of the facility.
2.
Perform outbreak surveillance to track and mitigate the spread of Norovirus.
3.
Adhere to Hand Hygiene Infection Control Principles.
This deficient practice resulted in a sustained outbreak affecting 18 Residents out of a total facility census of 63 residents who contracted Norovirus. Residents (R26 and R44) were hospitalized from the outbreak. The failure to mitigate the outbreak also resulted in identification of sustained transmission of Norovirus with two additional Residents confirmed by facility staff who tested positive on 1/8/25.
Findings include:
On 1/1/25, three Residents (#8, #44, & #250), developed symptoms of emesis (vomiting) and diarrhea. Resident #44 (R44) was sent to the hospital on 1/2/25 and was confirmed positive for Norovirus infection and was subsequently admitted to the hospital. The Infection Preventionist (IP)/Registered Nurse (RN) A provided a handwritten note which indicated Resident #26 (R26) developed symptoms of Norovirus on 1/6/25, including diarrhea and vital signs very unstable and was sent to the Emergency Department. R26 was also admitted to the hospital and was admitted with Pneumonia and was on contact precautions at the hospital due to the diarrhea. Testing had not been performed for Norovirus according to the hospital.
On 1/7/25 at approximately 1:30 p.m., an unidentified housekeeper was observed in the east hallway wiping down the handrails. This staff member stated to not to lean on the handrails because they were wiping them down with bleach. The unidentified housekeeper then gestured to the white cloth in her hand. This Surveyor observed the cloth and noted it was not completely saturated. The unidentified staff member continued down the hall wiping down the handrails with the same damp cloth.
On 1/7/25 at approximately 3:00 p.m., Housekeeping Aide/Staff E stated the facility used bleach water to clean and disinfect using one cup of bleach to every gallon of water. Staff E stated their supervisor told them to use the bleach water to clean high touch areas twice a day.
During an interview on 1/8/25 at 10:09 a.m., the Director of Nursing (DON) stated there were two additional cases of resident illnesses consistent with Norovirus today, and confirmed there were currently two residents hospitalized with Norovirus .
The facility was asked to provide their surveillance of the outbreak. RN A provided the survey team with a typed summary of events from the outbreak on 1/8/24. However, there was no additional information on education provided, auditing, or monitoring of the outbreak to mitigate the spread.
On 1/8/25 at approximately 10:12 a.m., during an interview, RN A stated, The Norovirus started with two Residents on the South wing and one Resident on the [NAME] wing . we were encouraging residents to stay in their rooms . the Norovirus then jumped to the Northeast wing . our team decided not to close down dining or activities . if residents are not symptomatic and their roommate is sick the resident without symptoms can come out for dining . we have 17 residents with the Norovirus currently .
RN A was asked to provide their surveillance of the outbreak and any efforts to mitigate the spread.
During an interview on 1/8/25 at 11:41 a.m., the NHA stated, We are still having communal dining .I feel that closing dining would not change anything (won't assist in stopping the spread of Norovirus) .
During an interview on 1/8/25 at 12:18 p.m., Licensed Practical Nurse (LPN) B stated, I didn't know we could not use hand sanitizer for the Norovirus .it is what I have been using .
Review of facility document titled GI Outbreak January 2025, read in part . Wash hands with soap and water as hand sanitizer does not kill the Norovirus .
During an interview on 1/8/25 at 12:31 p.m., Housekeeping Supervisor/Staff C stated, We are using bleach to clean due to the Norovirus .we are using a 1 to 10 ratio .bleach to water .we did get a special cleaner to use that would kill the Norovirus but .we decided not to use it .the bleach has a three minute contact time (how long the surface needs to remain visibly wet in order for the disinfectant to be fully effective) .I looked to the CDC website .I educated the housekeeping staff how to use the bleach on the 6th of January .
On 1/8/25 at 12:41 p.m., Housekeeping Aide D stated, We use a 1 to 10 ratio (bleach to water) to clean .1 cup of bleach to 10 cups of water and clean high touch areas three times a shift and wring out the cleaning rags so they aren't dripping wet .
On 1/8/24 at 11:22 a.m., Supervisor C stated, We went to a spray that kills in one minute . but when we are spraying it on, we felt it didn't cover everything we would like it to cover as it was a spray . that product worked in one-minute.
On 1/9/25 at 12:28 p.m., Supervisor C stated this was why they went to a bleach solution because the staff weren't sure of the effectiveness of the spray and didn't like to use it.
During a follow-up interview on 1/8/25 at 1:02 p.m., Supervisor C acknowledged the housekeeping staff were not waiting for three minutes to ensure proper contact time of the bleach solution to the surfaces. Supervisor C indicated staff felt pressure from too many other job duties. Indicating staff would only wipe down surfaces, then move on to other job duties and would not leave surface completely wet for the correct time frame.
On 1/8/25 at 3:00 p.m., Resident #64 (R64), who was identified as having Norovirus was observed sitting in her wheelchair in the East hallway. R64 attempted to grab this Surveyor's hand while self-propelling. There was no staff noted in the hallway at the time to redirect R64 back to her room.
During a follow-up interview on 1/8/24 at 4:06 p.m., RN A acknowledged the facility had 18 residents with Norovirus, two of which were identified during this annual survey, demonstrating the facility was experiencing a sustained outbreak of Norovirus.
Review of CDC website on 1/13/25 at 8:41 a.m., titled Norovirus: Explore Topics subtitled: How to Prevent Norovirus .Clean and Disinfect Surfaces, 11/1/24, read in part . Leave bleach disinfectant on the affected area for at least 5 minutes .
Review of the CDC website on 1/13/25 at 8:43 a.m., titled Norovirus: Explore Topics subtitled Norovirus Prevention Steps and Strategies, last updated 11/1/24, read in part . clean and disinfect surfaces after someone vomits or has diarrhea .disinfect the area as directed on the product label .
Review of facility housekeeping policies found no instructions on how to appropriately disinfect or clean nonporous surfaces using a bleach solution in response to an outbreak of an infectious disease. None of the policies specified surfaces had to remain wet for a minimum contact time as described in the guidance from the CDC in response to mitigating an outbreak of Norovirus.
On 1/8/24 at approximately 3:45 p.m., the NHA stated the facility did not stop communal dining or activities during the active outbreak. The NHA did acknowledge Norovirus spreads thru direct contact with the organism from an infected person.
Review of facility policy titled Infection Outbreak Response and Investigation last reviewed/revised 3/5/24, read in part . Implementation of infection control measures .staff will be educated on the mode of transmission of the organism, symptoms of infection and isolation or other special procedures this includes special environmental infection control measures that are warranted based on the organism and current CDC guidelines .
During a follow up interview on 1/8/25 at 4:06 p.m., RN A acknowledged the outbreak was not posted at the entrance of the facility. RN A stated they did not know how the facility was being disinfected and was not monitoring this activity for staff adherence to proper infection control practices and/or cleaning/disinfection.
Review of facility policy titled Infection Prevention and Control Program, last reviewed 1/2/25, read in part . An infection prevention and control program is designed .to help prevent the development and transmission of communicable diseases and infections .the infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases .a system of surveillance is utilized for prevention, identifying, reporting, investigation, and controlling infections and communicable diseases .
Review of facility document titled Infection Preventionist Job Description read in part . Major duties and responsibilities . develops and implements an ongoing infection prevention and control program to prevent, recognize and control the onset and spread of infections .establishes facility wide systems for the prevention, identification, reporting, investigation and control of infections an communicable diseases of residents .overseas resident care activities that increase risk of infection .provides education related to infection prevention and control principles, policies, and procedures to staff, residents and families .collaborates with other departments in fulfilling requirements in relation to occupational health and safety .develops, schedules and directs refresh training as necessary for all personnel .serves as a resource for staff regarding infection prevention and control, including the identification of when a resident needs to be place on transmission based precautions .works with environmental services to prevent cross contamination in the care environment .helps to prevent transmission of infection during care.
Review of facility policy titled Isolation Precautions last reviewed 4/2/21, read in part .It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents .transmission based precaution refers to the actions .that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections .contact precautions are measures that are intended to prevent the transmission of infectious agents .which are spread by direct or indirect contact with the resident or the residents environment .
Review of facility policy titled Infection Outbreak Response and Investigation last reviewed 1/2/25, read in part .The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission and prevent additional infections .outbreak refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time .recognition of outbreak . a sudden cluster of infections .during a short period of time i.e. three or more cases .
Review of Centers for Disease Control and Prevention (CDC) website on 1/13/25 at 8:40 a.m., titled, Norovirus: Explore Topics subtitled Norovirus Prevention Steps and Strategies, last updated 11/1/24, read in part . Wash your hands often with soap and water, hand sanitizer alone does not work well against Norovirus .
Review of facility policy titled Hand Hygiene, last reviewed 1/9/25, read in part . Staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .hand hygiene .soap and water .after caring for a person with known or suspected infectious diarrhea .
Review of CDC website on 1/13/25 at 8:48 a.m., titled Norovirus: Explore Topics subtitled How Norovirus Spreads last updated 4/24/24, read in part . Norovirus is very contagious .you can get Norovirus by accidentally getting tiny particles of feces or vomit in your mouth from a person infected with Norovirus .Norovirus spreads through sick people and contaminated surfaces when a person with Norovirus touches surfaces with their bare hands .tiny drops of vomit from a person with Norovirus spray through the air landing on surfaces or entering another person's mouth, or a person with Norovirus has diarrhea that splatters onto surfaces .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00146197.
Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the identification and reporting of potential abuse for five Residents (#10, #12, #14, #18 and #20) of six residents reviewed for abuse, resulting in the potential for unidentified abuse and further exposure to abusive situations. Findings include:
Resident #10 (R10)
R10 was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R10's Minimum Data Set (MDS) assessment, dated 8/15/2024, revealed R10 was independent with transfers and ambulation. Further review of the MDS assessment revealed R10 had severe cognitive impairment.
Review of R10's electronic medical record (EMR) revealed the following:
6/11/2024 23:02 [11:02 p.m.] Nurses Note. Resident [complained of] hand broken after being redirected from another resident's room . DON [Director of Nursing] notified .
6/12/2024 07:57 [7:57 a.m.] Nurses Note. Writer in the [morning] to assess reports of possible broken hand .
6/12/2024 11:16 [11:16 a.m.] Nurses Note. DPOA [Durable Power of Attorney] notified of incident that occurred last night and [x-ray] orders.
Review of R10's incident reports for April 1, 2024 through August 19, 2024, provided by the Nursing Home Administrator (NHA), revealed the following:
Injury of Unknown Source . Incident Description: Called into unit, CNA [Certified Nursing Assistant] upset, stated [R10] was in a female resident's bed and that she tried to get him out he punched her in the leg and called her a name. Sent CNA on break and in to assess resident. Resident unable to give description. Skin assessed on hand. ROM [range of motion] assessed and [positive] for pain when making a fist. Call placed to DON, notified of same. Instructions received to obtain x-ray of hand/wrist. CNA instructed to get nurse if residents need redirecting . The Injury of Unknown Origin, checklist attached to the incident report indicated both the DON and NHA were notified of the incident.
During a telephone interview on 8/20/2024 at 10:53 a.m., CNA D reported finding R10 in bed with a female resident on 6/11/2024. CNA D stated upon attempting to redirect R10 from the female resident's bed, R10 became combative. CNA D stated she did not remember who the female resident was or how R10 injured his hand.
Further review of R10's EMR revealed the following:
7/29/2024 14:02 [2:02 p.m.] Nurses Note. Follow up from CNA behavior charting on 7/26 [7/26/2024]. Resident was found in bed with another male resident. [R10] was naked from the waste [sic] down. Other resident unaffected by this action. CNA immediately intervened with no issues.
Review of R10's incident reports revealed no report to correspond with the incident documented in R10's EMR for 7/26/2024.
Review of R10's point of care Behavior charting the following, entered by CNA C on 7/26/2024 at 6:55 a.m. Resident took of dry pants and [brief] and layed [sic] in bed with another resident twice.
During a telephone interview on 8/20/2024 at 11:57 a.m., CNA C reported on 7/26/2024 she found R10 unclothed and lying in Resident #12's (R12's) bed with R12. CNA C stated she did not know what R10 was doing but she thought R12 was sleeping. When asked if she reported the incident, CNA C stated she alerted the nurse but was unsure if the nurse came in to assess either resident after the incidents were reported. CNA C could not identify the nurse she alerted to R10's behavior on 7/26/2024. CNA C reported R10 was not put on one-to-one supervision following the incident.
During a telephone interview on 8/20/2024 at 11:59 a.m., the DON reported she was alerted to the incident involving R10 being found unclothed in bed with R12 by reviewing R10's behavior notes. The DON stated staff did not alert her when the incidents occurred on 7/26/2024. The DON reported she did not initiate an incident report, investigation or report the incident to the NHA or the State Agency (SA) as an allegation of abuse.
Resident #14 (R14)
Resident 14 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety and anoxic brain injury (brain damage due to lack of oxygen). Review of R14's MDS assessment dated [DATE] revealed was independent with transfers and ambulation. Further review of the MDS assessment revealed R14 had severe cognitive impairment.
Review of R14's EMR revealed the following:
6/15/2024 2216 [10:16 p.m.] Nurses Note. Resident (1) was found in resident (2) room laying on top of resident (2) when aid went in to try to get resident (1) off of resident (2), resident (1) tried to hit the aid and kick at her. So, aid got resident (2) out of bed to try to remove resident (1) other resident (3) came in the room and resident (1) tried to hit him, so he turned and tried to hit the aid. The note was entered by Licensed Practical Nurse (LPN) B.
Review of R14's incident reports for April 1, 2024, through August 19, 2024, provided by the NHA, revealed no incident report to correspond with the incident documented in R10's EMR on 6/15/2024.
During a telephone interview on 8/20/2024 at 11:33 a.m., LPN B she was alerted by a CNA of the incident on 6/15/2024. LPN B stated she was alerted R14 was found lying on top of Resident #18 (R18) in R18's bed. LPN B reported she was unsure of what R14 was doing or if there was a conflict prior to the CNA's attempts to redirect and separate the residents but remembered R20 was involved. LPN B could not recall the CNA who alerted her of the incident.
A review of R14's EMR was conducted with the NHA on 8/20/2024 at 2:10 p.m. The NHA confirmed no incident report or investigation was initiated regarding the incident involving R14, R18 and R20 on 6/15/2024. The NHA stated she recognized the incident as an allegation of abuse and that it should have been reported to her and the SA. The NHA reported she was also unaware of the incident between R10 and R12 on 7/26/2024. The NHA stated a diagnoses of dementia and/or when residents state they do not remember an incident does not negate the facility's responsibility to identify allegations of abuse and report such allegations to the SA.
Review of the undated facility policy titled Abuse, Prevention and Prohibition Of, revealed the following, in part: The facility employee or agent who becomes aware of abuse or neglect, including injuries of unknown source . shall immediately report the matter to the facility Administrator and/or the Director of Nursing . The facility Administrator, employee, or agent who has reasonable cause to believe any resident with whom they have direct contact has been subjected to abuse or neglect, or any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria . Definitions: Abuse means the willful infliction of injury . intimidation . resulting in physical harm, pain or mental anguish . Willful means that individual intended the action . Special Note: A diagnosis of dementia (including Alzheimer's) does not rule out the ability of a person to form intent .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00146197.
Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse for five Residents (#10, #12, #14, #18 and #20) of six residents reviewed for abuse. Findings include:
Resident #10 (R10)
R10 was admitted to the facility on [DATE] with a primary diagnosis of dementia. Review of R10's Minimum Data Set (MDS) assessment, dated 8/15/2024, revealed R10 was independent with transfers and ambulation. Further review of the MDS assessment revealed R10 had severe cognitive impairment.
Review of R10's incident reports for April 1, 2024, through August 19, 2024, provided by the Nursing Home Administrator (NHA), revealed the following:
Injury of Unknown Source . Incident Description: Called into unit, CNA [Certified Nursing Assistant] upset, stated [R10] was in a female resident's bed and that she tried to get him out he punched her in the leg and called her a name. Sent CNA on break and in to assess resident. Resident unable to give description. Skin assessed on hand. ROM [range of motion] assessed and [positive] for pain when making a fist. Call placed to DON, notified of same. Instructions received to obtain x-ray of hand/wrist. CNA instructed to get nurse if residents need redirecting . The Injury of Unknown Origin, checklist attached to the incident report indicated both the DON and NHA were notified of the incident.
Review of the written statement signed by CNA D and dated 6/11/2024 at 10:15 p.m., revealed the following:
[R10] was in bed with another resident. When I went to get him out he swung at me and while I was getting him out of the female resident's bed he punched me in my leg and called me a [expletive]. Finally got him in his own room.
It was noted there was no documentation in R10's EMR or in the incident report and witness statement, dated 6/11/2024, as to how R10 injured his hand.
During a telephone interview on 8/20/2024 at 10:53 a.m., CNA D reported finding R10 in bed with a female resident on 6/11/2024. CNA D stated upon attempting to redirect R10 from the female resident's bed, R10 became combative. CNA D stated she did not remember who the female resident was or how R10 injured his hand.
Further review of R10's EMR revealed the following:
7/29/2024 14:02 [2:02 p.m.] Nurses Note. Follow up from CNA behavior charting on 7/26 [7/26/2024]. Resident was found in bed with another male resident. [R10] was naked from the waste [sic] down. Other resident unaffected by this action. CNA immediately intervened with no issues.
Review of R10's incident reports revealed no report to correspond with the incident documented in R10's EMR for 7/26/2024.
Review of R10's point of care Behavior charting the following, entered by CNA C on 7/26/2024 at 6:55 a.m. Resident took of dry pants and [brief] and layed [sic] in bed with another resident twice.
During a telephone interview on 8/20/2024 at 11:57 a.m., CNA C reported on 7/26/2024 she found R10 unclothed and lying in Resident #12's (R12's) bed with R12. CNA C stated she did not know what R10 was doing but she thought R12 was sleeping. When asked if she reported the incident, CNA C stated she alerted the nurse but was unsure if the nurse came in to assess either resident after the incidents were reported. CNA C could not identify the nurse she alerted to R10's behavior on 7/26/2024. CNA C reported R10 was not put on one-to-one supervision following the incident.
Further review of the EMRs for R10 and R12 revealed no documentation of physical or psychosocial assessments by licensed staff following the incidents on 7/26/2024. In addition, no documentation of physical or psychosocial assessments were conducted in relation to the incident involving R10 and R14 on 6/11/2024.
During a telephone interview on 8/20/2024 at 11:59 a.m., the DON reported she was alerted to the incident involving R10 being found unclothed in bed with R12 by reviewing R10's behavior notes. The DON stated she interviewed R10 and R12 and found neither Resident recalled the incidents, therefore an investigation was not conducted. The DON reported no physical or psychosocial assessments were completed on R10 and R12 in relation to the incident since they did not remember, and she did not feel any harm was done.
Resident #14 (R14)
Resident 14 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety and anoxic brain injury (brain damage due to lack of oxygen). Review of R14's MDS assessment dated [DATE] revealed was independent with transfers and ambulation. Further review of the MDS assessment revealed R14 had severe cognitive impairment.
Review of R14's EMR revealed the following:
6/15/2024 2216 [10:16 p.m.] Nurses Note. Resident (1) was found in resident (2) room laying on top of resident (2) when aid went in to try to get resident (1) off of resident (2), resident (1) tried to hit the aid and kick at her. So, aid got resident (2) out of bed to try to remove resident (1) other resident (3) came in the room and resident (1) tried to hit him, so he turned and tried to hit the aid. The note was entered by Licensed Practical Nurse (LPN) B.
Review of R14's incident reports for April 1, 2024, through August 19, 2024, provided by the NHA, revealed no incident report to correspond with the incident documented in R10's EMR on 6/15/2024.
During a telephone interview on 8/20/2024 at 11:33 a.m., LPN B she was alerted by a CNA of the incident on 6/15/2024. LPN B stated she was alerted R14 was found lying on top of Resident #18 (R18) in R18's bed. LPN B reported she was unsure of what R14 was doing or if there was a conflict prior to the CNA's attempts to redirect and separate the residents but remembered R20 was involved. LPN B could not recall the CNA who alerted her of the incident.
A review of R14's EMR was conducted with the NHA on 8/20/2024 at 2:10 p.m. The NHA confirmed no incident report or investigation was initiated regarding the incident involving R14, R18 and R20 on 6/15/2024. The NHA stated the incident should have been investigated as an allegation of abuse. The NHA reported she was also unaware of the incident between R10 and R12 on 7/26/2024. The NHA stated a diagnosis of dementia and/or when residents state they do not remember an incident does not negate the facility's responsibility to identify and investigate allegations of abuse.
Review of the undated facility policy titled Abuse, Prevention and Prohibition Of, revealed the following, in part: Resident abuse must be reported immediately to the Director of Nursing . and the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action . Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Employees will be interviewed who were working on the specific hall/wing . If the resident is not interviewable, question the roommate and any family or friends who visit frequently to assist with completion of a questionnaire. Follow-up counseling should be made available . Definitions: Abuse means the willful infliction of injury . intimidation . resulting in physical harm, pain or mental anguish . Willful means that individual intended the action . Special Note: A diagnosis of dementia (including Alzheimer's) does not rule out the ability of a person to form intent .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain adequate resident and employee infection surveillance based on current professional standards for Infection Control (IC). This deficient practice had the potential to contribute to a facility COVID-19 infection outbreak, and the potential for ongoing infection spread, with the potential to affect all 58 facility residents. Findings include:
Review of the November 2023, Infection Surveillance Monthly Report, showed 25 residents had respiratory infections, with 23 HAI's (Health Associated Infections - obtained in a health care facility after admission). The infection column showed 22 COVID-19 infections marked. When each column was followed to the right to the comments section, to show 21 residents tested positive for COVID, with infections resolved. There was no infection visual location mapping provided, which showed trends/clusters, locations of residents (rooms) with infections, or the potential for contact tracing. The monthly report yielded no narrative monthly summary, to show how the facility responded to contain the spread, i.e. education, audits, or other methods to contain and stop the COVID-19 infection spread. There was no separate Outbreak surveillance log for the COVID-19 outbreak, or outbreak investigation found.
Review of the October 2023, Infection Surveillance Monthly Report, showed 20 residents had respiratory infections, with 16 HAI's. The infection column showed 17 COVID-19 infections, with 16 residents testing positive in the facility. There was no visual mapping for distinguishing patterns of infection spread, consistent contact tracing, outbreak surveillance, outbreak investigation, or monthly summary of the outbreak and actions taken to prevent spread.
Review of the September 2023, Infection Surveillance Monthly Report, showed 59 respiratory infections, with 7 HAI's. The log showed 57 COVID infections in the infection column.
Review of the August 2023, Infection Surveillance Monthly Report, showed 56 respiratory infections, and 6 HAI's. The log showed 54 COVID infections in the infection column.
During an interview on 2/13/2023 at 3:13 p.m., the Infection Preventionist, Registered Nurse (RN) D, and the Director of Nursing (DON) were asked about the 57 COVID infections in September 2023, and the 56 COVID infection in August 2023, and what had been done to stop the outbreaks. Both reviewed the August 2023, and September 2023 resident infection facility surveillance logs (line listings). Neither could answer, as both reported they were not employed in the facility at that time. RN D reported they could not explain the data and high incidence of COVID-19 in the facility during these months. Surveyor asked if some of the infections could have been carried over from the month prior. Both reported they were unaware, as there had been another IP nurse in the facility at that time, and they could not tell this from the surveillance logs. Neither could confirm COVID-19 outbreak months with certainty, as they reported they were not employed during the entire outbreak time period.
Further review of the November 2023 line listing revealed 17 of these infections were carried over from October 2023, by showing an infection onset date during October (2023). Thus, there were 5 new onset COVID infections in November 2023, however this was unclear from the general surveillance line listing for all facility resident infections, which appeared to show 22 residents were COVID-19 positive during the month of November 2023.
Further review of the October 2023 line listing revealed the surveillance line listing was an accurate representation of COVID-19 positive residents in the facility, which showed 17 residents.
Further review of the September 2023 log showed there were 3 new COVID-19 infections for the month of September, and 4 COVID 19 infections on the log carried over from August 2023. The 52 other infections in the infection column were residents tested for COVID-19 due to facility outbreak, who were negative. This showed the log reflected inaccurate data.
Further review of the August 2023 log showed there were 4 new COVID-19 infections for the month of August, and 3 COVID 19 infections on the log which showed positive tests in September 2023. The 52 other infections in the infection column were residents tested for COVID-19 due to facility outbreak, who were negative. It was unclear why the August 2023 log had testing results in the comments section from September 2023, if the August infection log was completed in August.
Due to the three-month COVID-19 outbreak, other resident surveillance logs were reviewed to confirm the date of the outbreak inception, and month the outbreak ended, both prior and post these three months.
Review of these reports showed the resident COVID-19 facility outbreak started in August 2023.
Review of these reports showed the resident COVID-19 facility outbreak ended in November 2023.
Post review of facility surveillance logs, it was confirmed by RN D and Surveyor review the COVID-19 outbreak started in August 2023, with a resident positive. When asked what hall the outbreak started on, RN D reported they were unaware.
During further interview on 2/13/24 at 3:30 p.m., RN D and the DON were asked if they would have expected to see a separate COVID-19 outbreak line listing (separate surveillance logs), an outbreak investigation, and a narrative monthly summary describing what was done about the COVID-19 outbreak to prevent spread. Both affirmed this would be the expectation per Infection Control standards and could find no evidence in the facility surveillance records. Both understood the need to correlate data between months and an accurate representation of COVID-19 infections was imperative to prevent the spread, including the need for visual location mapping to trace and contain outbreaks. Both acknowledged there was no evidence of education or audits found during the outbreaks which also could help prevent infection spread and contain outbreaks. Regarding testing, both were asked what criteria or resident symptoms indicated a need to test for COVID-19, such as when residents had respiratory symptoms, i.e. given pneumonia and COVID-19 and other infections may have similar symptoms and were unable to reference a specific criterion the facility used to differentiate.
Record review of resident surveillance revealed the COVID outbreak occurred from August 2023, through November 2023. After the interview, the Nursing Home Administrator (NHA) was asked for a list of COVID + residents, since the monthly surveillance logs had carryover/crossover residents in each month, and it was unclear the total number of residents who were COVID-19 positive during the outbreak. Moreover, there was no COVID or outbreak surveillance log which would have had this data, which the NHA confirmed.
Surveyor requested clarification for the COVID-19 residents, due to no COVID-19 line listing. The NHA provided separate pages for each of 26 COVID-19 positive residents during the facility outbreak, with the first resident positive on 8/27/23. There was no separate line listing for these residents provided by survey exit.
Review of the employee infection tracking binder, provided by RN D, revealed separate pages which showed each staff call-off date, and reason, including symptoms, such as having a fever. There were no employee tracking surveillance sheets which would show staff infections on a log, common symptoms, COVID 19 tracking, and when testing was done. RN D confirmed they had not been tracking employee infections on a surveillance log or line list, including COVID-19, and had not found any history of any employee surveillance logs.
During an interview on 2/13/24 at 4:32 p.m., the Infection Surveillance, Infection tracking, and COVID-19 outbreak concerns were reviewed with the NHA, who reported they understood each concern. The NHA confirmed they understood some of the current infection surveillance logs contained inaccurate data, and an inaccurate reflection of facility resident and staff infections.
Review of the policy, Infection Surveillance, reviewed annually, received from the Nursing Home Administrator (NHA), revealed, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infection and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infection. Infection Surveillance refers to an ongoing systematic collection, analysis, interpretation, and dissemination of infection-related data .The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required .6. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. All resident infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment. Outbreaks will be investigated. Employee, volunteer, and contract employee infections will be tracked, as appropriate .Data to be used in surveillance activities may include, but are not limited to .e. Skills validations for hand hygiene, PPE, and/or high-risk procedures .
Review of the policy, Infection Outbreak Response and Investigation, reviewed annually, provided by the NHA, revealed, The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections. Definitions: Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. Some infections are so rare that a single case would constitute and outbreak .Policy Explanation and Compliance Guidelines: 1. Prompt recognition of outbreak: a. Changes in condition and/or signs and symptoms of infection will be reported according to procedures for infection reporting. b. The following triggers shall prompt an investigation as to whether an outbreak exists: i. An increase over a baseline infection rate (i.e. ten percent or more increase). ii. A sudden cluster of infections on a unit or during a short period of time. (i.e. three or more cases). iii. A single case of a rare or serious infection .c. An outbreak will be defined according to the characteristics of a given organism. Current definitions used by local and state health departments will help guide the determination. d. An outbreak will be reported to the local and/or state health department .2. Implementation of infection control measures. a. Symptomatic residents will be considered potentially infected, assessed for immediate needs, and placed on empiric precautions while awaiting physician orders. b. Symptomatic employees will be screened by the Infection Preventionist, or designee, and referred to the appropriate medical provider. c. Standard precautions will be emphasized. Transmission-based precautions will be implemented as indicated for the particular organism. d. Staff will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures. e. Surveillance activities will increase to daily for the duration of the outbreak. 3. Outbreak investigation: a. When the existence of an outbreak has been established, an investigation will begin. b. the Infection Preventionist will be responsible for coordinating all investigation activities .c. A case definition will be developed in order to identify other staff and residents who may be affected. Criteria for developing a case definition include i. Person - key characteristics the patients (or staff) share in common. ii. Place - the location associated with the outbreak. iii. Time - period of time associated with illness onset for the cases under investigation. iv. Clinical features - objective signs and symptoms, such as sudden onset of fever and cough. d. A line list about each person affected by the outbreak will be maintained. e. The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved. F. A summary of the investigation will be documented and reported to QAA committee and health department, if indicated.
Review of the policy, COVID-19 Prevention, Response, and Reporting, dated 9/25/2023, revealed, It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID-19 information will be reported through the proper channels as per federal, state, and/or local health authority guidance .Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection in the community and illnesses present in the facility. a. No current risk .b. Threat detected - the facility will respond promptly and implement emergency and/or outbreak procedures. 2. Staff will be alert to signs of COVID-19 and notify the resident's physician/practitioner if evident: a. fever and chills. b. cough. c. shortness of breath or difficulty breathing. d. fatigue. e. muscle or body aches. f. headache. g. new loss of taste of smell. h. sore throat. i. congestion or runny nose. j. nausea or vomiting. k. diarrhea .5. The facility will instruct HCP [health care personnel] to report any of the 3 above criteria to the Infection Preventionist or designee for proper management .21. Responding to a newly identified SARS-Co-V-2 infected HCP [health care practitioner] or resident: b. A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. c. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach (e.g. unit, floor, or other specific area(s) of the facility) is preferred if all potential contact cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. d. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. 22. The Infection Preventionist, or designee, will monitor and track COVID-19 related information to include, but not limited to: a. The number of residents and staff who exhibit signs and symptoms of COVID-19. b. The number of residents and staff who have suspected or confirmed COVID-19 and date of confirmation. c. Staff and resident vaccination status. d. Employee compliance with hand hygiene. e. Employee compliance with standard and transmission-based precautions. f. Employee compliance with cleaning and disinfection policies and procedures. g. Supply of personal protective equipment, cleaning/disinfection supplies, alcohol-based hand rub, and other relevant supplies. h. other information as per federal, state, and/or local guidance .
Centers for Disease Control (CDC), Mapping Public Health, https://www.cdc.gov/museum/pdf/cdcm-[NAME]-stem-mapping-public-health-lesson.pdf, accessed 2/22/2024, revealed, Maps are used in public health to plan health interventions, monitor outbreaks, identify vulnerable populations, and communicate health data. They are invaluable visualization and analysis tools that scientists and researchers use to address health problems .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation relates to Intake #MI00142455.
Based on interview and record review, the facility failed to prevent employee to resident abuse for two Residents (R3, R22) of three residents reviewed for abuse. This deficient practice resulted in the abuse of R22, and the potential for ongoing abuse of R3 and other facility residents. Findings include:
Review of R22's Minimum Data Set (MDS) assessment, dated 1/25/24, revealed R22 was admitted on [DATE], with diagnoses including stroke and depression. R22 required one-person assistance with transfers and bed mobility and was independent with toileting. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 11/15, which showed R22 had moderate cognitive impairment.
Review of R3's MDS assessment, dated 12/14/23, revealed R3 was admitted to the facility on [DATE], with diagnoses including diabetes, thyroid disorder, arthritis, depression, and anxiety. R3 was independent with bed mobility and transfers and required moderate assistance for toileting. The BIMS assessment revealed a score of 15/15, which showed R22 had no cognitive impairment.
Review of R3's profile revealed she had a guardian as her responsible party.
Review of R22's Investigation report, dated 1/31/24 at 2:21 p.m., revealed, It was discovered on 1/28/24 a CNA [Certified Nurse Aide B] was doing cares on [R22] and found bruising on resident's arm. The CNA [B] asked [R22] what happened, and she said it was from a CNA [H], that she feels doesn't like her and is rough with her. The CNA [B] immediately got the nurse [Licensed Practical Nurse - LPN A] who assessed the resident and it did look like fingerprints on the bruising . The report confirmed R22 was her own responsible party. The report further revealed the Nursing Home Administrator (NHA) and the Director of Nursing (DON) went to talk to R22 on 1/29/24 at 9:00 a.m . when [R22] immediately started crying .The DON assessed bruising on resident's arms and they did look like fingerprints. [The] DON asked what happened and R22 said a CNA [H] was rough with her and that she obviously wasn't moving fast enough for the CNA's liking, so she pulled her to turn her in bed. [R22] said the CNA is not nice, doesn't seem to like her job or care about her, and has been rough with her before. [R22] said she never reported it to anyone before until the CNA [B] asked her about it. [R22] then identified the aide as [CNA H] , who is a day shift CNA. [R22] was very tearful when talking to use about the CNA's behaviors .Writer asked [R22] if she feels safe here and she stated, When she's not here [CNA H]. The report confirmed R22 was her own responsible party.
The report further revealed, Other residents interviewed [for potential abuse]; one resident said she is crabby, and another resident [R3] did say she would rather [CNA H] not take care of her, as she hollers and points her finger at her. [R3] said she feels safe here but does not want [CNA H] to take care of her if she can help it .After reviewing the statements and the facts, [CNA H] was terminated. The police were called as a potential abuse .case was created. The officer came and talked with [R22] .
Review of R22's Accident and Incident report, dated 1/28/24 at 18:20 p.m. (6:20 p.m.), by Licensed Practical Nurse (LPN) A revealed, [LPN A] asked to go to resident's room [R22]. Upon getting to room, [R22] was on toilet with arms bare, getting evening cares done. I was shown by CNA [B] bruises on left and right upper arms. Discussed with [R22] how these were obtained. Resident is fearful; she does not want trouble. Encouraged to let us know what happened. [R22] proceeded to tell that CNA is rough .'She grabs my arm tight and puts me to bed roughly.' [R22] continues to say, 'CNA is gruff at times', when she brings my food trays, she throws them on the bedside table and does not help me. I do not think she likes me.'
Review of R22's police report, dated 1/29/24 at 12:04 p.m., revealed the incident [employee to resident abuse towards R22] occurred on 1/24/24 between 4:00 p.m. and 10:00 p.m., and was reported on 1/29/24 at 12:00 p.m .The report showed, [Local police] dispatched to [facility] for report of Elder Abuse, reported by staff. Upon arrival, contact made with [NHA] who stated [R22] told staff she was abused by caregiver, later identified as [CNA H] .[Police Officer] made contact with [R22] who shared the incident .[R22] said when staff was assisting her rolling over in bed that she was just too aggressive and that's how she bruised her INJURIES: Injuries noted on [R22] appeared as hand prints on both arms from over gripping . It was later clarified by the NHA the date of the incident was not 1/24/24, and occurred on 1/28/24.
Review of R22's, Report of Alleged Resident Abuse, dated 1/29/24, revealed, Evidence of Injury, marked Yes, described as bruising on both arms found by CNA during cares . The category, Types of Abuse was marked with an X as follows: Physical, Verbal/emotional/psychological, and Staff to Resident . The report concluded, Abuse is still substantiated d/t [due to] CNA's [H] verbal outbursts towards residents and the fact that residents say she is not nice to them [Two resident statements attached]. Staff have had to intervene and educate CNA [H] on how to talk to residents .[CNA H] terminated .
Review of R3's abuse interview witness statement revealed, .[CNA H] hollers, points fingers at me. I don't want her taking care of me if I can help it .
During an interview on 2/12/24 at 3:16 p.m., LPN C was asked about any abuse concerns on R22's hall. LPN C reported they had seen marks on R22's arms which looked like fingerprints, and R22 had reported being treated roughly. LPN C reported they believed it occurred, as they had seen the bruises, and found R22 to be a reliable reporter.
During an interview on 2/12/24 at 3:19 p.m., R22 was interviewed and stated her care is good now. R22 was fully oriented and was interviewable. When asked if she felt safe at the facility, R22 stated, [CNA H] just didn't like her job; she yelled at me one day in the bathroom, and I said, 'I can't wipe myself', and she said, 'Lose the attitude' .Her name was [CNA H]. [CNA H] was rough with me. When she came in here, I was incontinent, and she came to change my brief and told me to roll over and I grabbed my left rail and she grabbed me hard over the arm. R22 showed Surveyor how CNA H grabbed her hard by both arms in the bed to turn her, and how she still had a couple bruises. A faded yellow dime-sized bruise was observed on the front of her left arm, just below the shoulder, and the right arm appeared to have a small older bruise in the same location. R22 denied pain, and stated, [CNA H] didn't want to do anything for you. I just came in a couple weeks [after admission to the facility] when it happened. I knew she hurt me and my CNA [CNA B] saw it. When asked if she feared CNA H, R22 affirmed, stating, A little bit, as I didn't know what to expect of her after that, and a couple days before she yelled at me in the bathroom .[CNA H] was mad I wasn't moving fast enough .
During a phone interview on 2/14/24 at 9:32 a.m., LPN A was asked about the incident. LPN A stated, I was brought in by a CNA [B] when they were doing bedtime cares. When I got there, [R22] was on the toilet and she had bruises on both of her arms. I asked her what happened. and she said, 'Someone was rough with her and she didn't want to get in trouble'. [R22] said it was an employee, one of the CNAs, and described the employee to her. LPN A stated there were bruises on both of R22's arms, almost identical, and it looked like a handprint, as there was a thumb print in front and the back was fingers. Surveyor asked about any pain, and LPN A said R22 did not want them to touch the bruises and described the bruises as looking a couple days old. LPN A stated they presented as yellowing, with some very noticeable bluish purple bruises. LPN A confirmed the employee was CNA H, and reported R22 was fearful of her, and stated, I don't want her in my room anymore, as it had happened during cares more than once. LPN A reported there was no lasting psychosocial change for R22.
During further interview on 2/14/24 at approximately 9:40 a.m., LPN A was asked if she had any concerns with CNA H prior, as she worked on their hall. LPN A reported, A week or so before [the incident with R22] CNA H was observed hollering at a resident, and I said, 'You do not treat our residents like that.' And she grinned .It was [R3]. When asked if there was any psychosocial affect for R3, LPN B reported she had her head down, which was not typical for R3. LPN B reported she should have reported the incident and understood after education it was abuse.
During an interview on 2/14/24 at 9:59 a.m., CNA B was asked about their care of R22. CNA B reported they noticed bruises all over her and said, I asked [R22] where she got the bruises and she said, It was one of the CNAs, and I told her to be gentle with me. R22 clarified this CNA was rough with her. CNA B stated, [R22] had multiple bruises on her upper arms and on her left arm; it looked to be a handprint, and it didn't look like regular bruises, to me they looked like fingerprints, with a thumb in front and fingers on her left arm and random little bruises. I would suspect the resident [R22] was right and the aide was being rough with her, [CNA H]. I had noticed .[CNA H] was more aggressive than she needed to be on the floor, and they [the residents] seemed borderline nervous around her. I had mentioned it to a nurse [could not recall who] and I was trying to see if there was something more substantial [before substantiating it was abusive treatment.] I wasn't sure what was going on, as no residents had said anything, and clarified they did not regularly work on R22's hall or with CNA H very often.
LPN A's and CNA B's witness statements were reviewed and corroborated their interviews.
During a follow up phone interview on 2/14/24 at approximatley 2:00 p.m., LPN A was asked to clarify during the call if the incident between R3 and CNA H was verbal abuse, and stated, Yes. LPN A described CNA H arguing with R3, and stated, None of them [residents] should be treated that way in their home .It was gruff .
During an interview on 2/14/24 at 2:11 p.m, the DON was asked about their findings related to abuse or potential abuse of R22 and R3. The DON reported when they and the NHA walked into R22's room, R22 immediately started to cry and said the aide [CNA H] did not like her, and stated, She's rough with me when she's around, and she plops her food tray down and doesn't set it up. The DON reported they observed R22's bruises under her arms and one arm had a thumbprint which was green and yellow, and up to 4 days old. The DON added the other bruises appeared a couple days old, with a newer bruise which was purple, with the edges turning green and yellow. The DON reported they suspected it was physical abuse more than likely because of the location, and they could not explain how the bruises would be there. The DON brought pictures of the bruises, taken by LPN A, and showed how it appeared R22 was grabbed by their arms as if to pull them up, and pointed out an apparent thumb print and bruising under the arms. The DON clarified the bruises would not be bruises from a medication or diabetic care, and confirmed R22 was a credible resident and reporter. The DON concluded, We substantiated emotional abuse 100%, as it was emotional abuse .
During an interview on 2/14/24 at approximately 2:25 p.m., the DON was asked about R3 and their description of LPN H yelling at them, and confirmed this verbal abuse incident should also have been reported, as they and the NHA were unaware until the abuse audits were completed, after the abuse was discovered towards R22 on 1/28/24.
During a phone interview on 2/14/24 at approximately 4:15 p.m. with R3's responsible party, Guardian F, confirmed R3 reported to them a staff member had been mean to her, and R3 had asked they not work with her again. The staff member was later confirmed to be CNA H.
During an interview on 2/14/24 at 4:26 p.m., the NHA was asked about the abuse incidents towards R22 and R3, perpetrated by CNA H. The NHA confirmed they had substantiated abuse towards both residents, suspended CNA H pending investigation, and terminated their employment. The facility requested past noncompliance.
Review of the policy, Abuse, Prevention, and Prohibition of, dated 10/31/22, provided by the NHA, revealed, Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility will not use emotional, verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, employees, the medical director, consultants, and volunteers .Policy: This policy prohibits mistreatment, neglect, or abuse of residents .This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone .4. Identification: The facility will identify residents whose personal histories render them at risk for abusing other residents through the prescreening process. The nursing staff is responsible for reporting the appearance of bruises, lacerations, skin tears or other abnormalities as they occur .The Director of Nursing (DON) is responsible for their evaluation and assessment. If the source of the injuries is unknown, a UKO [Unknown Origin] injury investigation must be completed. An abuse investigation may also be conducted based on the investigation findings. Investigation: Resident abuse must be reported immediately to the Director of Nursing (or Nurse Manager on call) and the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress .Implement steps to prevent further potential abuse. Initiate investigation including initial notifications of all listed on the notification form, documenting on the form. This includes the state agency and law enforcement if there is reasonable suspicion of a crime or serious bodily harm .Complete a report of alleged resident abuse within required timelines .A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted .Complete a thorough investigation .Protection: The facility will immediately remove any alleged perpetrator from any further contact with any resident. b. Employee Allegations. When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending outcome of the facility investigation, prosecution, or disciplinary action against the employee .Reporting/Response: The facility employee or agent who becomes aware of abuse, neglect, exploitation, or mistreatment, including injuries of unknow source or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator and/or the Director of Nursing regardless of whether serious bodily injury occurred. The facility Administrator, and/or the Director of Nursing, who has reasonable cause to believe any resident with whom they have direct contact has been subjected to abuse, neglect, exploitation, or mistreatment or any allegation of such shall report or cause a report to be made to the mandated State Agency per reporting criteria immediately: but no later than 2 hours after an allegation is made if the allegations involve abuse or result in serious bodily injury .such reports may be made to the local law enforcement agency in the same manner .
Review of facility Past Non-Compliance (PNC) document, dated 2/01/24, revealed: This plan of correction is submitted as the facility's credible allegation of compliance. 1. Immediate action(s) taken for the resident(s) found to have been affected include: A thorough investigation was conducted by Director of Nursing Services and the facility Administrator regarding the allegations made by Resident #1 [R22]. Facility ensures residents safety, residents has been given 1:1 activity staff, the Social Services Designee has been checking on resident, she is working with therapy, and a BCS (Behavioral Care Solutions) referral has been made. Resident stated she felt safe the night the incident was identified. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: All staff, besides those on a LOA, have been in-serviced on the facility's abuse policy. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services, or designee, will be conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that they feel safety and have no concerns with any of the staff members. The Director of Nursing Services, or designee, will conduct a random audit of five (5) staff members weekly for four (4) consecutive weeks. These staff will be assessed and interviewed to ensure that they have not failed to report any suspected abuse to the facility's Abuse Coordinator. Findings of this audit will be discussed with the Resident Council. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Corrective action completion date: 2/1/2024. Attached education 1/29/24 included education in the types of abuse, abuse reporting, and staff abuse audits.
It was verified onsight the residents were protected from further abuse. The facility ensured their safety and psychosocial well-being. Resident abuse interviews were completed to ensure no ongoing abuse. Staff educations and audits verified substantial compliance following the incidents. The facilty determined CNA H was responsible for their behavior and was terminated from employment at the facility.
All elements of the PNC were met and accepted by the State Agency.

This citation relates to Intake #MI00142455.
Based on interview and record review, the facility failed to follow their abuse policy and report abuse to prevent employee to resident abuse for two Residents (R3, R22) of three residents reviewed for abuse. Findings include:
Review of R22's Investigation report, dated 1/31/24 at 2:21 p.m., revealed Certified Nurse Aide (CNA) B discovered bruising on R22's arms and notified Licensed Practical Nurse (LPN) A. R22 was tearful when interviewed and reported a CNA (identified as CNA H) was rough with her during cares and she did not feel safe when CNA H was working with her. LPN A observed the bruising appeared to be fingerprints on R22's upper arms.
The report showed other residents were interviewed for potential abuse. R3 reported CNA H hollered at her and pointed her finger at her and stated she did not want CNA H to work with her.
Review of R22's police report, dated 1/29/24 at 12:04 p.m., described how R22 said when a staff person was assisting her rolling over in bed, CNA H was too aggressive and bruised her. The Officer reported they observed handprints on both of R22's arms from over gripping.
Review of R22's, Report of Alleged Resident Abuse, dated 1/29/24, revealed, Evidence of Injury, marked Yes, described as bruising on both arms found by CNA during cares . The category, Types of Abuse was marked with an X as follows: Physical, Verbal/emotional/psychological, and Staff to Resident. Summary of interview with resident described the incident as [R22] was very upset. Didn't want to report at first. Stated CNA [H] is rough with her . The NHA conveyed, .Abuse is still substantiated d/t [due to] CNA's [H] verbal outbursts towards residents, and the fact that residents say she is not nice to them [Two resident statements .]. Staff have had to intervene and educate CNA [H] on how to talk to residents .[CNA H] terminated .
Review of R3's abuse interview revealed, .[CNA H] hollers, points fingers at me. I don't want her taking care of me if I can help it .
During an interview on 2/12/24 at 3:16 p.m., LPN C was asked about any abuse concerns on R22's hall. LPN C reported they had seen marks on R22's arms which looked like fingerprints on her arms, and R22 had reported being treated roughly. LPN C reported they believed it occurred, as they had seen the bruises, and found R22 to be a reliable reporter.
During an interview on 2/12/24 at 3:19 p.m., R22 was interviewed regarding their care at the facility, and confirmed CNA H was verbally and emotionally abusive to them and provided rough treatment.
During a phone interview on 2/14/24 at 9:32 a.m., LPN A was asked about the incident. LPN A confirmed R22 reported rough treatment by CNA H towards her, emotional abuse, and expressed feelings of fearfulness.
During further interview on 2/14/24 at approximately 9:40 a.m., LPN A was asked if she had any concerns with CNA H prior, as she worked on their hall. LPN A reported, A week or so before [the incident with R22], CNA H was observed hollering at a resident, and I said, 'You do not treat our residents like that.' And she grinned .It was [R3]. When asked if there was any psychosocial affect for R3, LPN B reported she had her head down, which was not typical for R3. LPN B reported she should have reported the incident and understood after education it was abuse.
During an interview on 2/14/24 at 2:11 p.m, the DON was asked about their observations of R22's bruises and affect, and their findings related to abuse or potential abuse of R22 and R3. The DON reported when they and the NHA walked into R22's room, R22 immediately started to cry and said the aide [CNA H] did not like her, and stated, She's rough with me when she's around, and she plops my food tray down and doesn't set it up. The DON reported they observed R22's bruises under her arms and one arm had a thumbprint which was green and yellow, and up to 4 days old. The DON clarified the other bruises appeared a couple days old, with a newer bruise which was purple, with the edges turning green and yellow. The DON reported they suspected it was physical abuse more than likely because of the location, and they could not explain how the bruises would be there. The DON brought pictures of the bruises, taken by LPN A, and showed how it appeared R22 was grabbed by their arms as if to pull them up, and pointed out an apparent thumb print and bruising under the arms. The DON clarified the bruises would not be bruises from a medication or diabetic care, and confirmed R22 was a credible resident and reporter, and they believed them.
During an interview on 2/14/24 at 2:20 p.m., the DON concluded, We substantiated emotional abuse 100%, as it was emotional abuse .[R22] described to them, [CNA H] is very rough with me when she turns me. The tray [setting it down hard] was verbal abuse .when R22 said, '[CNA H] is very short with me.'
During an interview on 2/14/24 at approximately 2:25 p.m., the DON was asked about R3 and their description of LPN H yelling at them. The DON confirmed this verbal abuse incident should also have been reported, as they and the NHA were unaware until the abuse audits were completed, after the abuse was discovered towards R22 on 1/28/24.
During an interview on 2/14/24 at 4:26 p.m., the NHA was asked about the abuse incidents towards R22 and R3, perpetrated by CNA H. The NHA confirmed they had substantiated abuse towards both residents, suspended CNA H pending investigation, and terminated their employment.
Review of the policy, Abuse, Prevention, and Prohibition of, dated 10/31/22, provided by the NHA, revealed, Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility will not use emotional, verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, employees, the medical director, consultants, and volunteers .Policy: This policy prohibits mistreatment, neglect, or abuse of residents .This presumes that all instances of abuse, even those residents in a coma, can cause physical harm, pain, or mental anguish. The facility also prohibits misappropriation of resident property. The residents must not be subjected to abuse by anyone .4. Identification: The facility will identify residents whose personal histories render them at risk for abusing other residents through the prescreening process. The nursing staff is responsible for reporting the appearance of bruises, lacerations, skin tears or other abnormalities as they occur .The Director of Nursing (DON) is responsible for their evaluation and assessment. If the source of the injuries is unknown, a UKO [Unknown Origin] injury investigation must be completed. An abuse investigation may also be conducted based on the investigation findings. Investigation: Resident abuse must be reported immediately to the Director of Nursing (or Nurse Manager on call) and the Administrator. The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress .Implement steps to prevent further potential abuse. Initiate investigation including initial notifications of all listed on the notification form, documenting on the form. This includes the state agency and law enforcement if there is reasonable suspicion of a crime or serious bodily harm .Complete a report of alleged resident abuse within required timelines .A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party of any injuries noted .Complete a thorough investigation .Protection: The facility will immediately remove any alleged perpetrator from any further contact with any resident. b. Employee Allegations. When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending outcome of the facility investigation, prosecution, or disciplinary action against the employee .Reporting/Response: The facility employee or agent who becomes aware of abuse, neglect, exploitation, or mistreatment, including injuries of unknow source or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator and/or the Director of Nursing regardless of whether serious bodily injury occurred. The facility Administrator, and/or the Director of Nursing, who has reasonable cause to believe any resident with whom they have direct contact has been subjected to abuse, neglect, exploitation, or mistreatment or any allegation of such shall report or cause a report to be made to the mandated State Agency per reporting criteria immediately: but no later than 2 hours after an allegation is made if the allegations involve abuse or result in serious bodily injury .such reports may be made to the local law enforcement agency in the same manner .
Review of facility Past Non-Compliance (PNC) document, dated 2/01/24, revealed: This plan of correction is submitted as the facility's credible allegation of compliance. 1. Immediate action(s) taken for the resident(s) found to have been affected include: A thorough investigation was conducted by Director of Nursing Services and the facility Administrator regarding the allegations made by Resident #1 [R22]. Facility ensures residents safety, residents has been given 1:1 activity staff, the Social Services Designee has been checking on resident, she is working with therapy, and a BCS (Behavioral Care Solutions) referral has been made. Resident stated she felt safe the night the incident was identified. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: All staff, besides those on a LOA, have been in-serviced on the facility's abuse policy. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services, or designee, will be conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that they feel safety and have no concerns with any of the staff members. The Director of Nursing Services, or designee, will conduct a random audit of five (5) staff members weekly for four (4) consecutive weeks. These staff will be assessed and interviewed to ensure that they have not failed to report any suspected abuse to the facility's Abuse Coordinator. Findings of this audit will be discussed with the Resident Council. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Corrective action completion date: 2/1/2024. Attached education 1/29/24 included education in the types of abuse, abuse reporting, and staff abuse audits.
It was verified onsight the residents were protected from further abuse. The facility ensured their safety and psychosocial well-being. Resident abuse interviews were completed to ensure staff followed their policy to report all types of abuse and allegations of abuse. Staff educations and audits verified substantial compliance following the incidents.
All elements of the PNC were met and accepted by the State Agency.
All elements of PNC were met and accepted by the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide comprehensive diabetic management for one Resident (R60) of one resident reviewed for diabetic care. This deficient practice resulted in harm when R60 was hospitalized in the intensive care unit (ICU). Finding include:
On 10/4/23, R60 was hospitalized with severe hyperglycemia (high blood glucose levels) and encephalopathy (brain dysfunction that can appear as confusion, memory loss personality changes and/or coma) due to hyperosmolar hyperglycemic state [HHS] (a metabolic complication of diabetes mellitus characterized by severe hyperglycemia, extreme dehydration, and altered consciousness.)
Review of R60's Minimum Data Set (MDS) admission assessment, dated 6/14/23, revealed R60 was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS) score of 15 of 15, reflective of intact cognition. R60 was responsible for her own medical decisions, and was documented with clear speech, the ability to understand others and be understood in making their needs known. No behaviors were documented on the MDS admission assessment.
Review of R60's MDS assessment, dated 9/14/23 (prior to hospitalization for HHS), revealed a BIMS score of 9 of 15, reflective of moderate cognitive impairment. R60 was again documented with clear speech, clear comprehension, and understood by others with no behaviors noted.
Review of R60's MDS assessment, dated 10/17/23, following hospitalization for HHS revealed a BIMS score of 6 of 15, reflective of severe cognitive impairment, with clear speech, sometimes understood, and sometimes able to understand. No behaviors were noted on the 10/17/23 MDS assessment for R60.
Review of R60's Progress Notes revealed the following, in part:
- 8/20/23 02:58 (2:58 a.m.), .Resident stated [they] had been feeling dizzy and weak . Blood sugar checked with result of 252 . No physician order was in place at this time for the blood glucose monitoring of R60.
- 9/6/23 14:13 (2:13 p.m.), .Resident alert to self this am, increasing confusion, increasing lethargic .
- 9/8/23 19:53 (7:53 p.m.), .[R60] does not have a UTI (urinary tract infection) per culture.
- 9/25/23 04:27 (4:27 a.m.), .Resident (R60) out of bed at HS (hour of sleep), acute confusion, calling out for [Name] . Calmer but confusion remains. Does not appear to recognize surroundings or staff .
- 10/4/23 04:01 (4:01 a.m.), .Resident has been awake most of the night . Resident continues to have difficulty finding words and is easily frustrated. Can say 2-3 words at times, other times unable to form any intelligible word. Balance very poor with walker tonight .
- 10/4/23 13:57 (1:57 p.m.), Resident alert and oriented to self. Needing assistance with meals . Resident not able to verbalize needs appropriately. Word salad verbally. Res (Resident) unable to focus on tasks, appearing distracted and unable to follow at times. Increasing confusion.
- 10/4/23 15:02 (3:02 p.m.), Res CBG (Capillary Blood Glucose), measured with a glucometer) 'HI' (over the number the glucometer is able to measure), tremors, shaking, warm to touch. Call placed to provider. Orders eval (evaluation) and treat [local acute care hospital] .
- 10/5/23 14:27 (2:27 p.m.), Resident (R60) currently in [Regional Hospital] ICU (Intensive Care Unit).
- 10/9/23 11:56 a.m., . Spoke with [Regional Hospital staff] resident (R60) was moved (out of ICU).
- 10/12/23 14:42 (2:42 p.m.), .Alert to person and place. She was well aware she was coming back from [Regional Hospital city] and wanting to go to her home . Very pleasant mood with staff. Big smiles and happy to be back . Diagnosis at discharge of acute metabolic encephalopathy due to hyperosmolar hyperglycemic state without coma .
- 10/17/23 10:23 a.m., [R60] is readmitted to facility after hospital stay for hyperglycemia with a BG (blood glucose via blood draw in the hospital) 966 and HgbA1C (Hemoglobin A1C, measures blood glucose levels over time) 11.6. [They were] fed thru a N/G (nasogastric) tube initially but later progress to a dysphagia diabetic diet with insulin and coverage . seems to forget to eat and needs cueing often .
- 11/14/23 12:42 p.m., Resident (R60) extremely jittery/shaking, vitals charted, high blood sugar. Unable to answer simple questions, slurred speech. Right sided weakness. Unable to follow commands . Called EMS .
Review of Physician Orders as documented in R60's Medication Administration Records (MARs) for June through November of 2023, revealed the absence of a physician order for any capillary blood glucose monitoring from the date of admission into the facility on 6/9/23 until 10/4/23 when R60 presented symptoms of acute encephalopathy due to HHS.
Review of R60's Physician Order Summary report for all physician orders between 6/9/23 and 11/22/23, revealed the following admission orders which were initiated by Physician J:
Diabetes S. O. (Standing Order): If blood sugar is < (less than) 60 and the resident is symptomatic and does not respond to oral Intervention Glucose Gel within 15 minutes, administered 1 mg (1 unit) of IM (intramuscular) glucagon from the emergency kit and call the physician for no response within 10-15 minutes, Blood sugars greater than 400 call the Nurse Practitioner/Physician as needed for diabetes, Order date: 6/9/23, Start Date: 6/9/23.
Januvia Oral Tablet, 50 mg (milligrams), Give 50 mg by mouth one time a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEPHROPATHY. Order Date: 6/9/23, Start Date: 6/10/23.
Review of the facility Standing Orders provided by the Director of Nursing (DON) on 2/14/24 at 10:52 a.m., revealed the only diabetic standing order was the was one previously identified on R60's Physician Order Summary. No standing orders were present for any CBG monitoring should resident symptoms be identified related to adverse diabetic outcomes.
During an interview on 2/14/24 at 7:52 a.m., when asked about R60's hospital blood glucose level of 966, the DON confirmed that CBG orders were put in place after she returned from the hospital and the diagnosis of HHS. The DON confirmed R60 was having some seizure-like activity, and she was transferred to [a Regional Medical Center] and ended up in the ICU. The DON stated, When [R60] came back from the hospital, she never came back (to baseline functional status).
During an interview on 2/14/24 at 8:05 a.m., Licensed Practical Nurse (LPN) H said she had frequently provided care for R60. LPN H stated, [R60] came in post-surgical for her shoulder and she wanted to rehab and go home. LPN H did recall that R60 did have a blood glucose level of 966 in the hospital, and stated, I don't think I got a reading (numerical value on the glucometer). It (glucometer) just read 'HI'.
During an interview on 2/14/24 at 10:26 a.m., the DON reviewed R60's Physician Order History report and the Telephone/Verbal Order Signature Detail report with this Surveyor and acknowledged there was no order for any blood glucose monitoring for R60 prior to their hospitalization on 10/4/23 with encephalopathy related to HHS. The DON said she talked to Physician K the previous week, and Physician K said that we (the facility) have to have a way to monitor CBGs for two weeks with diabetics who come into the facility. The DON was asked to provide a copy of any diabetic management policies related to resident care in the facility.
During an interview on 2/14/24 at 10:52 a.m., the DON returned with a copy of the facility Standing Orders and the Physician Orders signed by Physician J upon R60's admission and Physician K beginning 10/4/23. The DON said the facility did not have any diabetic management policies for resident care in the facility. No Physician Standing Order was present for blood glucose monitoring for residents with diabetes residing in the facility. The DON said there was no standardized monitoring for diabetic blood glucose levels upon their admission. The blood glucose monitoring would only be performed based upon physician orders. The DON agreed there were no physician orders for blood glucose monitoring for R60, and that the facility did need a physician order for any blood glucose monitoring because it was an invasive procedure. When asked if the DON would be surprised if the concern related to lack of diabetic management and blood glucose monitoring may rise to the level of harm the DON stated, Yes, I would be surprised. I don't believe the high blood sugar caused her death. She had many other co-morbidities. This Surveyor acknowledged R60's comorbidities and asked if the lack of diabetic blood glucose monitoring, and the lack of facility processes for management of diabetic residents resulted in the absence of blood glucose monitoring for R60 from the time of admission, resulted in her intensive care hospitalization for treatment of encephalopathy which resulted from a hyperosmolar hyperglycemia state with an extremely high blood glucose level of 966. The DON stated, Now that you say it like that, I would agree with you. The resident was transferred (to the hospital) because of the results of an unmonitored high blood sugar.
During a telephone interview on 2/14/24 at 1:24 p.m., Physician K was asked about R60's lack of blood glucose monitoring upon admission to the facility. Physician K said that they began working at the facility on September 1st, and they were not aware that all residents in the facility who were diabetic were not having their blood glucose measured upon admission. When asked about the lack of a diabetic management program within the facility, Physician K stated, I really like taking care of diabetic patients .The main issue is that residents weren't getting their blood sugars checked. Physician K said they were very surprised at how high R60's blood sugars were when [R60] was transferred to the ER on [DATE]. When asked what the expectation would be regarding monitoring new admission residents (diabetic) blood sugars, Physician K said they would want every diabetic newly admitted to the facility to have their blood glucose checked twice daily until seen by the physician. Physician K would then evaluate the blood glucose numbers and write orders to meet each resident's needs. When asked about the complete lack of physician orders to monitor a new resident's blood glucose, Physician K stated, It would be completely unacceptable to me.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review the facility failed to ensure Physician's orders were obtained and communication/documentation occurred for coordination of care for hospice services provided to two Residents (R6 and R13) of two Residents reviewed for hospice services. This deficient practice resulted in the potential for a lack of coordination of comprehensive services and unmet needs. Findings include:
Resident #6 (R6)
A review of the medical record for R6 revealed an admission date of 4/13/18. The Minimum Data Set (MDS) assessment dated [DATE] indicated R6 was receiving hospice services. The Resident Roster printed on 2/12/24 denoted R6 was on hospice.
During an interview on 2/12/24 at approximately 12:05 PM, Family Member L stated R6 started on hospice services in December 2023. The Electronic Medical Record (EMR) was reviewed and there was not a Physician order for Hospice Services.
On 02/14/24 at 12:17 PM, the hospice resident folder in R6's room did not include calendar entries for January or February indicating a schedule for planned visits. Both months were blank. No documentation by any hospice personnel was in this folder. The unit hospice folder found in the nurse's station had two names of other residents on hospice and did not include a section for R6 or any hospice documentation of visits or care plans for R6.
Resident #13 (R13)
A review of the medical record for R13 revealed an admission date of 9/04/23. The Minimum Data Set (MDS) assessments dated 11/09/23 and 2/1/24 indicated R13 was receiving hospice services. The Resident Roster printed on 2/12/24 denoted R13 was on hospice. The EMR was reviewed and there was not a Physician order for Hospice Services. The care plan for R13 included a focus of (R13) is receiving Hospice services. The goal included: Hospice Binder in (R13's) room, with Hospice information.
During an interview on 2/14/24 at 12:16 PM Registered Nurse (RN) M stated the hospice staff speaks to the facility staff and gives a progress report, but she was not sure where any documentation was. RN M said there should be a folder in the hospice resident's room with information. The room for R13 was accessed and a Hospice folder was observed. The folder contained:
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An October 2023 calendar with the name of the hospice and a line designating Patient Name:_____________ which was blank. One day - October 31 had a name written in and the word admit.
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A November 2023 calendar with the name of the hospice and a line designating Patient Name:_____________ which was blank.
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A December 2023 calendar which had the name of the hospice and a line designating Patient Name:_____________ which was blank. There were two dates on the calendar 12/5/23 and 12/7/23 which had a name written on each day. All other dates were blank.
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A January 2024 calendar with the name of the hospice and a line designating Patient Name:_____________ which was blank.
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A February 2024 calendar with the name of the hospice and a line designating Patient Name:_____________ which was blank.
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A Vital Signs Record with R13's name and one set of vitals recorded for 11/7 The remainder of the log was blank.
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There was one Volunteer Assignment sheet filled out and signed on 11/15/23.
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There was no other documentation indicating hospice personnel such as hospice nurses, hospice aides, hospice social workers or hospice chaplains had been in to serve R13.
During an interview on 2/14/24 at 12:19 PM, the Director of Nursing (DON) explained the process used for obtaining hospice services. The DON stated the physician would review the resident to determine if that resident was eligible and if the resident was accepted to hospice the facility would obtain a physician order. The DON reviewed the EMR and confirmed there had not been a physician order for R6 or R13 to receive hospice services. The EMR also did not contain documented communication from hospice personnel. The DON stated, the facility did not have documented communication from the hospice staff, but she was able to access it online. When asked if the information had been printed out or available to any of the floor staff the DON stated it was not.
During an interview on 2/14/24 at 1:10 PM, RN N stated there was not a calendar to indicate when the hospice personnel were scheduled to visit or what services they would be providing. RN N stated, It is very hard to plan.
The facility policy titled, Coordination of Hospice Services and dated as implemented on 9/1/23, read in part, The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility . The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities.
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was prescribed for 2 of 2 residents reviewed for therapeutic diets (Resident #2 and Resident #14). This deficient practice resulted in the potential for unmet nutritional needs and the potential for health complications. Findings include:
Resident #2
The Electronic Medical Record (EMR) revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including diverticulitis (infection or inflammation in the intestine), gastroesophageal reflux disease (GERD), hypertension, anxiety disorder and depression. The Physician orders listed a diet order of: Regular, Diver diet, Soft foods texture, Thin consistency for Bland diet as tolerated for diverticulitis. Active
10/17/2022
A Registered Dietitian (RD) progress note on 10/25/2022 read in part: (Resident #2) was readmitted to facility after hospitalization for diverticulitis . She is provided with a Regular diet- bland with diver (diverticulitis) features, small portions .
An RD progress note of 11/8/2022 read in part: Resident's weight is up 2 lbs (pounds) this week. She is on a bland diet. Intake is 50-75% .
The EMR for Resident #2 included a Care Plan with a focus of . at risk for alteration of nutritional status r/t (related to) multiple dx (diagnoses) . Interventions for this focus included, Provide and serve diet as ordered: Regular, bland, diver features, small portions.
Lunch was observed on 01/31/23 at 12:15 PM, Resident # 2 received her meal which included a tray card indicating the following diet was to be served: Regular, Sm (small) Portions, Finger Fd (food), Diver.
Breakfast was observed on 02/01/23 at 8:45 AM. The tray card listed Resident # 2 was to receive the following diet: Regular, Sm Portions, Finger Fd, Diver.
Resident #14
The EMR revealed Resident #14 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) dated [DATE] indicated active diagnoses included anxiety, depression, and pulmonary concerns. The Physician orders listed a diet order of: Dysphagia Mechanic diet Soft foods texture, Nectar consistency Start Date: 10/3/22.
An RD progress note of 10/4/2022 read in part: (Resident #14) is alert and able to make needs known. She is provided with a Dysphagia Mechanical diet with nectar thick liquids, no straws per speech, diver features, small portions .
An RD progress note of 11/11/2022 read in part: Per Speech, the elder will remain on a Mech Soft diet, nectar thick liquids. Straws are now ok and nosey cups will be used per the request of the elder.
On 02/02/23 the Care Plan for Resident #14 was reviewed and included a focus of: (Resident #14) is at risk for alteration of nutritional status r/t multiple dx including Schizophrenia, Depression, Anxiety, and GERD, h/o GI hemorrhage (history of bleeding stomach/intestines), Diverticulosis . This focus included interventions of: Provide and serve diet as ordered. Dysphagia mechanical, nectar thick liquids, straws ok (per speech. Diver features, Small portions.
Lunch was observed on 01/31/23 at 12:15 PM. Resident # 14 received a meal which included a tray card indicating the following diet was to be served: Mech Soft, Diver, Nectar/Mild Sm Portions.
Breakfast was observed on 2/01/23 at 9:20 AM. Resident # 14 received a meal which included a tray card indicating the following diet was to be served: Mech Soft, Diver, Nectar/Mild Sm Portions.
During an interview on 2/01/23 at 2:00 PM, Dietary Aide (Staff) K stated a diver diet was one without seeds, nuts, or skins.
During an interview on 2/01/23 at 2:02 PM, Dietary Manager (DM) A stated a diver diet was used With people with diverticulitis - no seeds nuts, skins . but if they want strawberries for instance they can have them. DM A said this therapeutic diet was served daily to four residents and she had a list of foods to avoid on a diver diet but this diet was not found in the facility diet manuals available in her office. DM A confirmed Resident #2 was served a Regular, Sm Portions, Finger Fd, Diver diet. The Physician's diet order for Resident #2 also included a bland and a soft restriction. DM A stated a bland diet excluded spicey foods but she did not know Resident #2 was on this restriction. The facility diet manuals did not define bland or soft foods restrictions and this portion of the order was not followed. DM A confirmed Resident #14 received a Mechanical Soft, Diver, Nectar/Mild Small Portions diet. The Physician's diet order for Resident #14 did not include a diver restriction but did include a soft food restriction. The facility diet manuals did not define soft foods restriction and this portion of the order was not followed.
During an interview on 2/02/23 at 10:12 AM, DM A stated there was a diet manual on line. This manual was reviewed and did not define a diver diet, a bland diet, or a soft diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #44
Review of the Minimum Data Set (MDS) assessment, dated 12/07/22, revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including kidney disease, septicemia (systemic infection), dementia, depression, anxiety disorder, muscle weakness, and palliative care (specialized care for people living with serious illness). Resident #44 needed one-person assistance for feeding. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 08/15, which showed Resident #15 had moderate cognitive impairment.
During an observation on 01/31/23 at 11:08 a.m., Resident #44 was observed in their bed with wearing a hospital gown. Resident #44 was attempting to hold his Styrofoam (lightweight, unstable) coffee cup with a removeable plastic lid, however, demonstrated bradykinesia (impaired and slow movements) as he attempted to pick up the coffee cup on the tray table in front of him. Resident #44 was hunched forward due to cervical spine curvature and was struggling to lift their arm up to the height of the tray table. It appeared Resident #44 was going to spill the coffee on himself, as he reached unsteadily and the cup was shaking when he attempted to pick it up. Resident #44 was covered with one white hand towel, which the hot coffee could have easily permeated. Surveyor intervened and called CNA Q to assist; they provided Resident #44 with a straw, and began to leave the room. Surveyor intervened a second time to clarify the safety concern regarding Resident #44 drinking hot coffee from a Styrofoam coffee cup, without supervision and assistance as needed, or a waterproof protective barrier. CNA Q then assisted Resident #44. CNA Q reported residents on their hall were all solely using Styrofoam dinnerware due to COVID (transmissible viral infection) outbreak on Resident #44's hall. CNA Q reported prior to COVID outbreak in the facility, Resident #44 used a large brown lidded plastic coffee cup for drinking his coffee, a sippy cup (a cup with a lid and a spout, for safe drinking to prevent any spillage). Resident #44 agreed they needed assistance to drink their coffee during this observation, and understood the concern.
During an interview on 01/31/23 at approximately 11:20 a.m., CNA R was asked if Resident #44 was typically able to feed himself. CNA R clarified Resident #44 could feed himself, mainly finger foods, and required set-up and assistance with feeding to begin the task, and some days needed additional assistance for self-feeding, due to weakness. When asked about Resident #44 drinking coffee from a Styrofoam cup, CNA R confirmed Resident #44 used a brown lidded spillproof plastic mug prior to the COVID outbreak on their hall.
During a second observation on 02/01/23 at 8:58 a.m., Resident #44 was observed dressed and sitting up in their wheelchair. Resident #44 did not have a coffee initially and asked for an aide (unnamed) to bring them a hot coffee. The aide delivered the hot coffee and left the room. Resident #44 began drinking their hot coffee from a Styrofoam cup with lightweight plastic lid, without spillage, however, they were not wearing a waterproof protective barrier. An unnamed CNA was called to supervise/assist, per Resident #44's Care Plan requiring supervision and assistance as needed with drinking hot liquids. Surveyor shared the additional safety concern with the lack of a waterproof protective barrier when Resident #44 was observed drinking hot coffee.
Review of Resident #44's Care Plan, accessed 02/02/23, revealed, [Resident #44] has deficit in performing ADL's (activities of daily living tasks) due to his physical condition [unspecified]. Date initiated: 09/10/2022 .Staff will set up and assist as needed for eating, oral care .Date initiated: 09/10/2022 .[Resident 44] has the potential/actual impairment to skin integrity related to burns from hot foods/hot liquids due to decreased safety awareness related to dx of dementia. Date initiated: 09/25/2022 .[Resident #44] is not able to have hot beverages or soups in his room with-out supervision. All hot beverages must have sip lid [spill proof lid with spout] .Revision on : 09/25/2022 .
Review of Resident #44's Electronic Medical Record (EMR) on 02/02/23 at 10:42 a.m., including assessments and miscellaneous documents showed Resident #44 had no hot liquid assessment.
During an interview on 02/01/23 at 11:14 a.m., the Director of Nursing (DON) was asked about Resident #44's safety during the observations of Resident #44 using Styrofoam (lightweight unstable) cups for drinking hot coffee without supervision or assistance. The DON reported they understood the concern and verified with the Nursing Home Administrator (NHA) (via phone during the interview) Resident #44 should have had a plastic lidded (spill prevention) cup for hot coffee. The DON called the dietary department during the interview, to address the concern for the next meal, to ensure Resident #44 received their coffee in the adaptive mug, and would update their Care Plan. Soon after, the DON showed Surveyor a laminated sign which showed Resident #44 should not drink hot coffee in a regular cup, and planned to update further with verbiage, and post as a visual reminder for Resident #44's nursing staff.
During an interview on 02/02/23 at approximately 11:35 a.m., the Rehabilitation Director, Occupational Therapist (OT) O, was asked about Resident #44's ability to self-feed, and the concern with drinking hot coffee from a Styrofoam cup, including in bed (during first observation).OT O understood the concerns, and reported Resident #44 would have the most success and optimal positioning and safety with self-feeding positioned upright in their wheelchair. OT O clarified this was due in part to marked range of motion impairment of their right shoulder and cervical spine. OT O reported they would address self-feeding with Resident #44 by picking them up on their caseload.
During an interview on 02/02/23 at 1:42 p.m., the NHA was asked about the concern regarding Resident #44 drinking hot coffee from Styrofoam cups. The NHA confirmed they understood the concern, and the facility had addressed during the survey.
During an interview on 02/02/23 at approximately 2:00 p.m., the Administrative Assistant, Staff L, reported there was no policy addressing the provision of adaptive feeding equipment or regarding activities of daily living including self-feeding.
Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for three Residents (#2, #43, and #44) of three residents reviewed for dining assisstive devices. This deficient practice resulted in increased difficulty with food consumption and independent eating, as well as the potential for decreased food/fluid intake and risk for weight loss. Findings include:
Resident #2
The Electronic Medical Record (EMR) revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including diverticulitis (infection or inflammation in the intestine), gastroesophageal reflux disease (GERD), hypertension, anxiety disorder and depression.
The facility Registered Dietitian (RD) progress note of 10/25/2022 read in part: (Resident #2) was readmitted to facility after hospitalization for diverticulitis . Finger foods are provided as able also to help with her independence with meals as vision is extremely limited and she does well with finger foods . She does need assist and cueing at meals due to vision- colored lip plate, suction bowls and colored utensils are provided .
A further facility RD progress note of 11/28/2022 read in part: Residents weight has slowly increased since admission . She is provided with a colored lip plate, suction bowls and colored utensils at meals to help promote self feeding as she has very limited vision .
The Care Plan for Resident #2 as reviewed on 2/1/23 read in part: (Resident #2) has very limited vision in left eye and is blind in right eye. She needs assistance with meal set up- placement cueing using clock method and assist with meals as needed. Please offer her more finger food options .Provide and serve diet as ordered: Regular, bland, diver features, small portions. Colored lip plate, suction bowl, and colored utensils at all meals.
Lunch was observed on 01/31/23 at 12:15 PM. Resident # 2 received her meal, but her tray did not include a colored lip plate, or colored utensils and had no suction bowl. (All of these adaptive pieces of equipment were listed as needed on Resident #2's tray card.) Resident #2 received disposable plates and utensils with regular mugs and was not on transmission-based precautions (quarantine) for infection.
Breakfast was observed on 02/01/23 at 8:45 AM. Resident # 2 had her chocolate supplement poured into her disposable Styrofoam bowl containing oatmeal. The supplement was also spilled into the to-go container under the bowl. Resident #2 stated, We have to have these dishes because we have COVID in the building, but I do not have it.
During an interview on 2/01/23 at 9:00 AM, Dietary Manager (DM) A stated, Everyone is on disposables. DM A investigated the spilled supplement and Styrofoam containers in Resident #2's room and she stated, You will not see that again.
Resident #43
The EMR revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), epilepsy, hypertension, anxiety disorder and dementia.
During breakfast observations on 02/01/23 at 8:40 AM, Resident # 43 was in his room in bed struggling to feed himself. He was not on transmission-based precautions (quarantine) for an infection. His meal tray card indicated he needed Built-Up Utensil 1 each, and Inner Lip Plate 1 each. These items were not present. When Resident #43 was asked if he did better with his built-up adaptive equipment, Resident #43 replied, yes, he did.
During an interview on 2/01/23 at 8:45 AM, Certified Nurse Aide (CNA) H confirmed Resident #43 should have received adaptive utensils.
The EMR for Resident #43 had a Care Plan with a focus of . at risk for alteration of nutritional status r/t (related to) multiple dx (diagnoses) including Epilepsy . Interventions for this focus included, Provide and serve diet as ordered . Built up utensils and lip plate at meals.
During an interview on 2/01/23 at 8:55 AM, Dietary Aide (Staff) I stated, We have been under construction and in COVID outbreak . we have not been putting special equipment on trays.
During an interview on 2/01/23 at 5:22 PM, DM A stated there was not a policy or guidelines for adaptive meal equipment.
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Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by:
1. Failing to ensure the mechanical dish machine was properly sanitizing food contact surfaces, including plates, glasses, flatware and cooking utensils.
2. Failing to ensure food service staff properly washed their hands following contamination and returning to food related tasks.
3. Failing to ensure all food staff properly had their hair restrained.
This deficient practice has the potential to result in food borne illness among any or all 46 residents in the facility.
Findings include:
1. On 1/31/23 at approximately 1:30 PM, observations of the mechanical dish machine were made and determined the machine was a high temperature sanitizing type with a conveyor mechanism. This type of machine requires a series of cycles of hot water to ensure that food contact surfaces are properly sanitized by the surface reaching a minimum temperature of 160°F. Dietary Aide (DA) I was conducting dish washing activities by placing soiled dishes, plates, cups, glasses and utensils on the cassettes and pushing them into the machine. Three cycles were observed during the wash rinse and sanitize cycle, which included the final rinse registering 197°F on the machine's temperature gauge.
Two DishTemp irreversible maximum registering thermometers (one facility and one surveyor's) were placed on the cassette and allowed to measure a complete cycle of washing, rinsing and sanitizing. Upon exit from the machine, the DishTemp thermometers read 154°F and 156°F respectively. At 1:45 PM an interview was conducted with Dietary Manager (DM) A at this time and asked if this reading on the maximum registering thermometer was acceptable, who then replied No. The interview continued related to the monitoring of the dish machine temperature. A log was located hanging on the wall in the dish room labeled Dish Machine Temperatures was for January 2023. A column on the log was labeled Thermo-Works temp and was used to document the readings from the DishTemp irreversible maximum registering thermometer used by the facility. On 13 occasions from 1/1/23 through 1/30/23 the documented temperatures were below 160°F, indicating improper sanitizing of food contact surfaces by the machine. DM A acknowledged she did not review the logs. DM A acknowledged the facility did not have a back up system (e.g.: heat sensitive strips) or quality assurance system to confirm the accuracy of the thermometer. The proper temperature for sanitizing was not present on the form, nor was any corrective action requirement when the machine failed to meet the proper parameters.
The FDA Food Code 2017 states: 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing:
(B) In hot water mechanical WAREWASHING operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL surface temperature
4-302.13 Temperature Measuring Devices, Manual Warewashing.
Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization.
Effective mechanical hot water sanitization occurs when the surface temperatures of
utensils passing through the warewashing machine meet or exceed the required
71°C(160°F). Parameters such as water temperature, rinse pressure, and time
determine whether the appropriate surface temperature is achieved. Although the Food
Code requires integral temperature measuring devices and a pressure gauge for hot
water mechanical warewashers, the measurements displayed by these devices may not
always be sufficient to determine that the surface temperatures of utensils are reaching
71°C(160°F). The regular use of irreversible registering temperature indicators provides
a simple method to verify that the hot water mechanical sanitizing operation is effective
in achieving a utensil surface temperature of 71ºC (160ºF).
2. On 1/31/23 at approximately 11:45 AM, observations were made during the noon meal preparation and service. Dietary [NAME] (DC) J was observed to wash her hands, dry her hands with a paper towel, lift the lid to a 45 gallon garbage can, dispose of the towel, replace the lid and return to the preparation work counter. At 12:10 PM DA I was observed to do the same, at a different garbage can in the kitchen, then again at 12:15 PM DC J did the same. An interview was conducted with DC J at 12:15 PM related to the use of the garbage can versus simply disposing of paper towels in the open trash can below the sink. DC J stated I don't know why I did that.
The FDA Food Code 2017 states: 2-301.14 When to Wash.
FOOD EMPLOYEES shall clean their hands and exposed portions of
their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and
SINGLE-USE ARTICLES and:
(E) After handling soiled EQUIPMENT or UTENSILS;
(F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;
(G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD;
(H) Before donning gloves to initiate a task that involves working with FOOD; and
(I) After engaging in other activities that contaminate the hands.
3. On 1/31/22 at 10:00 AM, during the initial tour of the kitchen, DM A was observed with a hair restraint on, but with large amounts of loose hair extending below the restraint. During subsequent observations during the noon meal and dish washing observations on 1/31/23, (11;15 AM to 3:00 PM) then again on 2/1/23 at approximately 7:30 AM during the morning meal preparation and service this same condition of unrestrained hair was observed. DA K was observed at this same time with an excessive amount of hair extending below her hair bouffant. On 2/1/23 at approximately 8:00 AM an interview was conducted with DM A related to the unrestrained hair. DM A stated she was not aware her hair was hanging below the hair restraint.
The FDA Food Code 2017 states: Hair Restraints 2-402.11 Effectiveness.
(A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and
worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff were properly donning and doffing Personal Protective Equipment (PPE) while entering and exiting COVID-19 isolation rooms. This deficient practice resulted in the potential for further spread of COVID-19 to the entire facility population. Findings include:
On 1/31/23 at 12:35 p.m., Certified Nurse Aide (CNA) T was observed entering and exiting rooms during meal tray delivery service on the COVID-19 and Influenza unit. CNA T was observed entering and exiting room [ROOM NUMBER] (Resident #39) on the SNU (resident unit designation) unit, who was positive for COVID-19, with only the upper strap of the N95 (Direct Supply-Brand Name) secured, the bottom strap was hanging loose in front of the mask.
On 1/31/23 at 12:40 p.m., CNA T then entered and exited room [ROOM NUMBER] (Resident #24) on the SNU unit with a different N95 (Makrite-Brand Name) and failed to ensure the metal nose stay (bendable metal strip) was formed to the face. A gap was visualized between the mask and the face of CNA T between the cheek bone and nose on both sides.
On 1/31/23 at 12:42 p.m., CNA T failed to perform hand hygiene between removal of an N95 used to enter and exit COVID-19 positive room [ROOM NUMBER] (Resident #28) and donning a new N95 mask. CNA T contaminated her face. CNA T again did not ensure the metal nose stay was form fitted to the face (Makrite).
On 1/31/23 at 12:45 p.m., CNA T was observed entering and exiting room [ROOM NUMBER] (Resident #47) on the SNU unit without ensuring the metal nose stay was form fitted to her face. (Makrite)
On 1/31/23 at 12:47 p.m., CNA T changed her N95 mask without performing hand hygiene between removing the old mask and donning a new mask and contaminated her face.
On 1/31/23 at 12:55 p.m., CNA T went from room [ROOM NUMBER] (Resident #10) to room [ROOM NUMBER] (Resident #47) on the SNU unit without changing the N95 mask and no face shield or outer mask was worn over the N95 mask.
On 1/31/23 at 12:58 p.m. CNA T doffed an N95 mask and donned a new N95 mask and failed to perform hand hygiene, contaminating her face.
On 1/31/23 at 1:01 p.m., CNA U doffed an N95 mask and failed to perform hand hygiene before donning a new N95 mask.
During an interview on 2/1/23 at 8:20 a.m., CNA V stated CNA T was responsible for the south and west halls (non-COVID-19 area) and CNA V stated she was assigned to the COVID-19 unit.
On 2/1/23 at 8:40 a.m., the breakfast tray cart for the SNU unit arrived and CNA V brought the cart onto the unit, leaving one of the doors open to the remainder of the facility.
On 2/1/23 at 8:50 a.m., an unknown staff member passed by and closed the door between the COVID-19 unit and the remainder of the facility. A Simultaneous observation of CNA V was conducted for proper PPE usage. CNA V delivered a meal tray to room [ROOM NUMBER] (Resident #39) on the SNU unit and performed a setup of the tray, touching the environment of the COVID-19 positive room. CNA V preformed doffing of her PPE starting with her gown and gloves, then failed to perform hand hygiene before removing the surgical mask covering her N95 mask and contaminated her N95 mask and face.
On 2/1/23 at 9:00 a.m., CNA V delivered a meal tray for room [ROOM NUMBER] (Resident #10) and provided set-up, including handing of food items and touched the environment. CNA V doffed gown and gloves and then failed to perform hand hygiene before removing an outer mask covering her N95 and contaminated her N95 and face.
During an interview on 2/1/23 at 2:30 p.m., CNA T verbalized understanding when concerns brought up regarding hand hygiene between doffing gown and gloves and before removing an N95 mask and putting on a new N95 mask. CNA T also acknowledged the concern with not forming the metal stay to her nasal area for the (Makrite) N95. When asked if fully vaccinated, CNA T stated she was fully vaccinated,. When asked if she had a COVID-19 infection, CNA T stated she had COVID-19 in January or February of 2022.
On 2/2/23 at approximately 9:50 a.m., the infection control concerns were brought to the attention of the Director of Nursing (DON). When asked about the concerns with hand hygiene observed during the survey for CNA T, U, and V, the DON agreed the lack of hand hygiene before bring hands to their face was a breach of infection control and acknowledged hand hygiene should have been performed between doffing gown and gloves before doffing any face mask. The DON also confirmed N95 masks should be conformed to the user's face before entering a room and both straps should be in place. The DON confirmed the door to the COVID-19 unit should be closed when not in use to go on or off the unit.
A review of the Makrite N95 instructions on the box read as follows:
Step 1 Hold the respirator in had with the nosepiece at your fingertips, allowing the head bands to hang freely below your hand.
Step 2 Press the respirator firmly against your face with the nosepiece on the bridge of your nose.
Step 3 Stretch and position the top band high on the back of the head. Stretch the bottom band over the head and position below your ears.
Step 4 Using both hands, mold the nosepiece to the shape of your nose.
Step 5 To test fit: a) Cup both hands over the respirator being careful not to distrub (sic) position, and b) inhale vigorously. If air leaks around the edges, reposition the straps or adjust strap tension for better fit. Please carefully follow these instructions during each use to achieve proper fit.
A review of the Direct Supply N95 instructions on the box read as follows:
Step 1 Hold the respirator in hand with the nosepiece at your fingertips, allowing the head bands to hang freely below your hand.
Step 2 Press the respirator firmly against your face with the nosepiece on the bridge of your nose.
Step 3 Stretch and position the top band high on the back of the head. Stretch the bottom band over the head and position below your ears.
Step 4 Using both hands, mold the nosepiece to the shape of your nose.
Step 5 To test fit: Cup both hands over the respirator while careful not to disturb placement, then inhale deeply. If air leaks around the edges, reposition the straps or adjust trap (sic) tension for better fit. Follow these fitting instructions during each use to achieve proper fit.
A review of the facility hand hygiene policy, no date, read in part:
1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.
2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .
. 6. Additional considerations:
a. The use of glove does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
Hand Hygiene Table:
. After handling contaminated objects .
. Before applying and after removing personal protective equipment (PPE), including gloves .
. Before and after providing resident care to residents in isolation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident or the resident representative, in writing, of the reason for a transfer out of the facility to the hospital and failed to notify a representative of the Office of the State Long-Term Care Ombudsman for 2 Residents (#9 and #40) of 3 residents reviewed for notice of transfer. This deficient practice resulted in the potential for residents and their representatives being uninformed of the reason for transfer and unnecessary or undesired transfers. Findings include:
Resident #9
A review of Resident #9's Minimum Data Set (MDS) assessment, dated 11/20/2022, revealed a discharge date of 11/20/2022 with the discharge status listed as the Acute hospital. Further review of Resident #9's MDS assessments revealed a reentry to the facility on [DATE] from the Acute hospital.
A review of Resident #9's Electronic Medical Record (EMR) and paper chart revealed no written notification of transfer or discharge for the Resident's hospitalization on 11/20/2022.
On 1/31/2023 at 1:37 p.m., a review of the listing sent to the representative of the Office of the State Long-term Care Ombudsman, provided by the Administrator Assistant, Staff L and notifying the Ombudsman of residents transferred or discharged from the facility in November 2022, revealed Resident #9's transfer and hospitalization on 11/20/2022 was not included on the notification list.
Resident #40
A review of Resident #40's MDS assessment, dated 12/18/2022, revealed a discharge date of 12/18/2022 with the discharge status listed as the Acute hospital. Further review of Resident #40's MDS assessments revealed a reentry to the facility on [DATE] from the Acute hospital.
A review of Resident #40's EMR and paper chart revealed no written notification of transfer or discharge for the Resident's hospitalization on 12/18/2022.
On 1/31/2023 at 1:37 p.m., a review of the listing sent to the representative of the Office of the State Long-term Care Ombudsman, provided by the Administrator Assistant, Staff L and notifying the Ombudsman of residents transferred or discharged from the facility in December 2022, revealed Resident #40's transfer and hospitalization on 12/18/2022 was not included on the notification list.
During an interview on 2/02/2023 at approximately 1:30 p.m., Staff L stated there were no written notifications of transfer or discharge completed for Resident #9's hospitalization on 11/20/2022 or Resident #40's hospitalization on 12/18/2022. Staff L confirmed Resident #9 was not listed on the Ombudsman's notification list for residents transferred and discharged in November 2022 nor was Resident #40 listed on the December 2022 notification list as being discharged on 12/18/2022. Staff L stated she was unsure why Resident #9's and Resident #40's hospitalizations were overlooked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #44
A review of the care plan section of the Electronic Medical Record (EMR) for Resident #44 revealed no evidence of dementia or behavioral care planning.
A review of the Medication Orders in the EMR revealed the following:
(Brand name) [antipsychotic medication] Oral Tablet 0.5 MG [milligrams] (Risperidone)
Give 1 tablet by mouth at bedtime related to VASCULAR DEMENTIA, MODERATE, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F01.B0)
(Brand name) [antidepressant medication] HCl [hydrochloride] Tablet 25 MG
Give 1 tablet by mouth one time a day related to VASCULAR DEMENTIA, MODERATE, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY (F01.B0)
A review of the 9/6/22 admission Minimum Data Set (MDS) assessment for Resident #44, revealed a PHQ-9 (depression assessment) of 3 (depression severity none) and no hallucinations or delusions noted in the behaviors section of the MDS. Resident #44 scored 10 on the Brief Interview for Mental Status (BIMS) assessment, indicating there was moderately impaired cognition present.
A review of the 12/7/22 quarterly MDS for Resident #44, revealed a PHQ-9 of 0 and no hallucinations or delusions noted in the behaviors section of the MDS. Resident #44 scored 8 out of 15 on the BIMS assessment indicating a decline in cognition from the previous assessment.
A review of September 2022 through December 2022 behavior logs which were present in the EMR, revealed behavior tracking, but no behavioral interventions were identified for staff to implement in the event of behaviors.
A review of 9/30/22, 10/21/22 and 12/2/22 effective dates for physician progress notes revealed no evidence of consideration for Gradual Dose Reduction (GDR) consideration for any of his psychotropic medications.
A review of the face sheet for Resident #44 revealed admission to the facility on 8/31/22, with diagnoses including vascular dementia with agitation, depression, and anxiety.
There was no evidence of consents found in the EMR to approve the use of psychotropics or antipsychotics for Resident #44.
A review of the care plan on 2/2/23 at 11:30 a.m., revealed minimal care planning in place for Resident #44. The care plan was reviewed by the Nursing Home Administrator (NHA) and this surveyor. The NHA stated she recognized care planning has been an issue and the facility has been continuing to work on them as residents come up for clinical review and MDS assessments. The NHA stated the facility recognized care planning had improvements which still needed to be made.
The care plans for Resident #44 were noted to be revised by Activities Director (AD) S on 2/2/21 after the facility was informed of the concern regarding lack of dementia care planning.
Resident #37
Review of the MDS assessment, dated 12/29/22, revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive neurological condition of movement which often causes stiffness, incoordination, and tremors), coronary artery disease (narrowing of the heart blood vessels), congestive heart failure (a progressive heart disease causing fatigue and shortness of breath), acute respiratory failure with hypoxia (lack of oxygen), and hearing loss. Resident #37 required extensive two-person assistance for transfers and toileting, and extensive one-person assistance for bed mobility, dressing, and personal hygiene. The BIMS assessment revealed a score of 13/15, which showed Resident #37 had intact cognition.
During an observation on 01/31/23 at 12:16 p.m., Resident #37 was observed in their room sitting upright in their manual wheelchair, reading. Resident #37 was receiving oxygen via a nasal canula running at 2L (liters), and the oxygen concentrator tubing extending from the concentrator to their nose was undated.
During an interview on 01/31/23 at approximately 12:22 p.m., Certified Nurse Aide (CNA) Q was asked why Resident #37 was wearing the oxygen. CNA Q reported, [Resident #37] is [medically] declining.
Review of Resident #37's Care Plan, accessed 02/02/23 at 3:14 p.m., revealed, [Resident #37] has a dx [diagnosis] of heart disease; she has a pacemaker .Revision on: 06/14/2021. Administer medication as ordered. Date initiated: 04/21/2020 There was no mention of respiratory compromise or oxygen administration, including PRN.
During an interview on 02/02/23 at 8:15 a.m., the DON reviewed the Electronic Medical Record (EMR) and concurred there was no mention of the oxygen use or care in Resident #37's Care Plan. The DON reported the care planning may have been missed as Resident #37 returned recently from the emergency room (ER) wearing oxygen. The DON clarified despite Resident #37 wearing oxygen as needed, it should have been documented in the Care Plan and on the TAR (Treatment Administration Record). The DON confirmed Resident #37 was needing oxygen PRN recently due to cardiac diagnoses, including progression of congestive heart failure, and medical/respiratory decline.
During an interview with the Nursing Home Administrator (NHA) on 02/01/23 at 1:48 p.m., they reported they understood the concern regarding oxygen use and care not being reflected in Resident #37's Care Plan.
Based on observation, interview and record review, the facility failed to develop comprehensive, person-centered care plans for four Residents (#9, #29, #37 and #44) of 14 residents reviewed for care planning. This deficient practice resulted in the potential for unidentified and unmet care needs. Findings include:
Resident #9
A review of Resident #9's Minimum Data Set (MDS) assessment, dated 12/02/2022, revealed she was admitted to the facility on [DATE] and had diagnoses including heart failure and chronic pain syndrome. Further review the MDS assessment revealed in the five days prior to the assessment, Resident #9 received scheduled and as needed (prn) pain medication, and non-medication interventions to treat pain. The MDS assessment also revealed Resident #9 experienced Shortness of breath or trouble breathing with exertion during the assessment lookback period. Resident #9 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact.
An observation on 1/31/2023 at 4:05 p.m., revealed Resident #9 sitting up in her bed wearing a nasal cannula with tubing attached to a portable oxygen concentrator running at 2.5 L (two- and one-half liters) per minute. During an interview at the time of the observation, Resident #9 reported she no longer got out of bed due to being short of breath and having severe pain in her left knee. Resident #9 stated she often had pain in her left knee and lower back that worsened when standing. The Resident reported she was particular about administration of her scheduled pain medication and stated she needed to have the medication during the scheduled timeframe's, or the pain was difficult to catch up with. When asked how often she required the use of supplemental oxygen, Resident #9 stated she used oxygen continuously due to ongoing trouble with breathing and being short of breath.
A review of Resident #9's physician orders on 2/02/2023 at approximately 8:00 a.m., with Licensed Practical Nurse (LPN) D revealed the following:
Hydrocodone-acetaminophen Tablet 10-325 MG (milligram), Give 1 tablet by mouth four times a day for chronic pain, give every 6 hours. Order date: 1/16/2023 1206 (12:06 p.m.). Further review of the order revealed scheduled times for administration of 5:00 a.m., 10:00 a.m., 3:00 p.m. and 8:00 p.m.
During an interview at the time of the record review. LPN D reported Resident #9's pain medication administration times were recently changed due to the Resident wishing not to be awakened in the night for medication administration. LPN D stated Resident #9 preferred to stay in bed due to increased pain when transferring and ambulating. When asked what non-pharmacological interventions were in place to manage Resident #9's pain, LPN D stated staff had attempted to use ice for pain control but Resident #9 often refused. LPN D was unsure what other interventions were attempted or why the Resident refused the care.
A review of Resident #9's care plan revealed no focus area, goals or interventions related to the Resident's chronic pain. Further review revealed no focus area, goals or interventions related to Resident #9's congestive heart failure, shortness of breath and trouble breathing or the Resident's use of continuous oxygen.
During an interview on 2/02/2023 at 2:10 p.m., the Director of Nursing (DON) reported she would expect care plans to accurately reflect resident's conditions and include interventions needed to appropriately provide care based on each resident's specific needs. The DON stated there was a possibility of unmet care needs when care plans were incomplete.
Resident #29
A review of Resident #29's MDS assessment, dated 12/09/2022 revealed Resident #29 was admitted to the facility on [DATE] and had diagnoses including bipolar disorder (mood disorder characterized by extreme shifts in mood from mania to depression). Further review of the assessment revealed Resident #29 was administered an antipsychotic medication on all days of the seven-day lookback period.
A review of Resident #29's hospital Discharge summary, dated [DATE], revealed Resident #29 was previously hospitalized related to signs and symptoms of bipolar disorder.
A review of Resident #29 Medication Administration Record (MAR) for January and February 2023 revealed she was ordered and administered the following:
Olanzapine (antipsychotic medication used to treat signs and symptoms of mood disorders) and (name brand) (an antidepressant medication].
A review of Resident #29's care plan revealed the following:
Need: (Resident #29) is prescribed psychotropic medication (related to) her (diagnosis) of bipolar. Date Initiated: 6/09/2022. Goal: (Resident #29) will be free from discomfort or adverse reactions related to medication therapy through the review dated. Date Initiated: 6/09/2022. Interventions: Give antidepressant medications ordered by physician. Observe and report to (physician) for side effects and effectiveness. Date Initiated: 6/09/2022.
The care plan revealed no target behaviors or non-pharmacological interventions listed related to Resident #29's bipolar disorder, depression and anxiety, as listed on the 12/09/2022 MDS assessment and as evidenced by Resident #29's administration of antipsychotic and antidepressant medications.
A review of the facility policy titled Care Planning - Resident Participation, provided by the Assistant Administrator, Staff L, and dated 11/17/2022, revealed the following, in part: The care planning process will include an assessment of the resident's strengths and needs .
On 2/02/2022 at approximately 2:30 p.m., Staff L was asked if the facility had a policy related to how care plans were developed and what care plans were to include. Staff L stated the facility had no policy related to initial development of comprehensive care plans to include criteria for development of the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate grooming for one Resident (#44) of two residents reviewed for activities of daily living. This deficient practice resulted in Resident #44 having long fingernails and long facial hair stubble, appearing unshaven. Findings include:
Review of the Minimum Data Set (MDS) assessment, dated 12/07/22, revealed Resident #44 was admitted to the facility on [DATE], with diagnoses including kidney disease, septicemia (systemic infection), dementia, depression, anxiety disorder, muscle weakness, and palliative care (specialized care for people living with serious illness). Resident #44 required extensive two-person assistance for transfers, toileting, and extensive one-person assistance for bed mobility, dressing, and personal hygiene (which included combing hair, brushing teeth, and shaving). The Brief Interview for Mental Status (BIMS) assessment revealed a score of 08/15, which showed Resident #15 had moderate cognitive impairment.
During an observation on 01/31/23 at 11:08 a.m., Resident #44 was observed in their bed wearing a hospital gown, with their hair disheveled, and long facial hairs above their lip, and covering their chin, 1/4 in length. Resident #44 was asked about his facial hair stubble, and stated he did not like his facial hair this long. Resident #44 reported he liked to be cleanly shaven, and needed assistance to shave. Resident #44's fingernails of both hands were observed with dirt and residue under the nail edges, which extended 1/8 to 1/4 in length beyond the nail body. Resident #44 was asked about his longer fingernails, and explained it bothered him.
During an observation on 02/01/23 at 8:58 a.m., Resident #44 was observed again with some long facial hairs, and stubble under his lip. When asked about his facial hair, Resident #44 stated, Shave it off,, and explained he was not happy with being partly shaven. Resident #44's nails remained 1/8 to 1/4 long at the nail edges. Resident #44 stated, I wish they were trimmed.
During an observation on 02/02/23 at 8:40 a.m.,with the Director of Nursing (DON), Resident #44 appeared partially and unevenly shaven, with the left side of his face showing long facial stubble. Resident #44's fingernails of both hands remained 1/8 to 1/4 in length, at the nail edges, with dirt and residue remaining underneath their fingernails. The DON nodded in apparent understanding during the observation, then left the room, and did not comment.
Review of Resident #44's tasks, accessed 02/02/23 at 10:11 a.m., in the Electronic Medical Record (EMR), revealed personal hygiene (which included brushing teeth, shaving .and washing and drying hands) was to be completed at least once daily with one-person assistance. The 30-day look back revealed Resident #44 was marked as having personal hygiene completed daily, one to three times per day. There was no separate delineation to show how often shaving was completed.
Review of Resident #44's last two skin assessments dated 01/23/22 and 01/29/22, accessed from the EMR on 02/02/22 at 10:11 and 10:13 a.m., showed Resident #44's nails were marked as not needing to be trimmed on those dates.
During an interview on 02/02/23 at 11:26 a.m., Certified Nurse Aide (CNA) P was asked about Resident #44's long nails and untrimmed facial hair stubble. CNA P reported they observed (on 02/02/23) Resident #44 needed to be shaven, and stated they would assist him. CNA P reported residents' nails were trimmed twice a week during showers. They stated, They [fingernails] may not be getting done [trimmed]. They will get done [trimmed] today.
During an interview on 02/02/23 at 1:37 p.m., the Nursing Home Administrator (NHA) reported they understood the concern, per Surveyor description of observations.
During an interview on 02/02/23 at approximately 2:15 p.m., the Administrative Assistant, Staff L, reported there was no policy respective to resident activities of daily living care, including for shaving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #10
On 1/31/23 at 10:56 a.m., Resident #10's room had a fall mat observed in place on the floor next to the bed. Resident #10 was sitting in a wheelchair and the fall mat was between Resident #10 and the bed. During this observation, Resident #10 moved around in the wheelchair almost constantly with her legs. A pommel (cushion with raised area between the legs) cushion was observed in place, which was suggestive of Resident #10 making attempts to rise from the wheelchair unassisted. The floor mat appeared to be a hazard to Resident #10 if she were to rise and attempt to ambulate to the bed or attempt to propel toward the bed in her wheelchair. The wheelchair did not have anti-tip bars in place for the front of the wheelchair. Resident #10 made attempts to get to the bed propelling in her wheelchair during the observation.
On 1/31/23 at 1:59 p.m., during a review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 had two or more falls.
On 2/1/23 at 3:00 p.m., a review of the falls sustained by Resident #10, provided by the facility, revealed no injuries over four falls dated 10/22/22, 11/1/22, 12/9/22, and 1/4/23.
Review of Falls Incident Reports:
1/4/23 fall at 2:30 p.m. with no injuries at the time. Resident #10 was found sitting on the activities floor. Resident #10 was in the activities room coloring.
Resident #10 was sitting on her buttocks and legs outstretched in front of sink. The fall was unwitnessed and reported by Activities Director AD S.
11/1/22 fall at 9:30 p.m. with no injuries. Resident #10 was observed two minutes prior out in the common area and then was found on the floor by staff at 9:20 p.m.
12/9/22 fall at 5:15 a.m. and Resident #10 was in her wheelchair. The fall was unwitnessed and per the report, Resident #10 appeared to be sitting on a couch in the common area and was found in that area on the floor.
10/22/22 fall (time cut off) where Resident #10 was found with no injury in the hallway on the floor at 8:50 p.m., and was unwitnessed.
9/10/22 fall (time cut off) where Resident #10 was visualized sleeping by several staff before waking up and she spontaneously fell. She was observed next to a recliner in the room.
During an interview on 2/2/23 at approximately 11:30 a.m., Assistant Administrator (AA) L stated she disagreed with the fall mat being a tripping hazard because it had a beveled edge. AA was informed of the observation of Resident #10 attempting to propel toward her bed, but could not do so because of the floor mat in place.
Based on observation, interview and record review, the facility failed to 1) ensure use of safe transfer techniques for one Resident (#12) and, 2) failed to ensure an environment free of hazards for one Resident (#10) of two Residents reviewed for accidents and hazards. This deficient practice resulted in the potential for injury. Finding include:
Resident #12
A review of Resident #12's Minimum Data Set (MDS) assessment, dated 12/07/2022, revealed the Resident was admitted to the facility on [DATE] and had diagnoses including dementia, renal insufficiency and respiratory failure. A review of the assessment Section G - Functional Status revealed Resident #12 required extensive, two-person physical assistance with transfers and the Resident's Balance During Transitions and Walking was assessed as Not steady, only able to stabilize with human assistance. Resident #12 scored three out of 15 on the Brief Interview for Mental Status (BIMS), indicating she had severe cognitive impairment.
An observation on 1/31/2023 at 12:30 p.m., revealed Certified Nurse Aide (CNA) M and Registered Nurse (RN) N preparing Resident #12 to transfer from her bed to a wheelchair. Resident #12 was seated on the left side of her bed with her feet on the floor. CNA M positioned the wheelchair parallel to the bed to the right of the seated Resident and proceeded to position himself facing Resident #12 while RN N stood with the wheelchair between her and the Resident. CNA M was observed placing his hands under the Resident's arms and pulling the Resident up to her feet. Resident #12 did not straighten her legs upon standing and remained in a seated position with her knees bent at approximately 70 degrees and her buttocks pointing out. All of Resident #12's weight was observed to be supported by CNA M holding the resident up with his hands placed under her arms and pulling up to lift the resident up under her shoulders. During the observation Resident #12 called out don't let me fall.
An observation on 1/31/2023 at 12:44 p.m., revealed CNA M and RN N preparing Resident #12 to transfer from the toilet to a wheelchair positioned in the bathroom facing the toilet. CNA M placed his hands under the Resident's arms and instructed Resident #12 to hold the metal grab bar attached to the wall on the right side of the toilet. Further observation revealed the Resident holding the grab bar while CNA M lifted the Resident to standing position by pulling the Resident up with his hands placed under the Resident's arms. Resident #12 did not straighten her legs upon standing and remained in a seated position while RN M grabbed the back waistband of the Resident's pants and pulled the Resident's buttocks toward the wheelchair seat. CNA M then lowered the Resident down onto the seat with his hands remaining under Resident #12's arms.
RN N and CNA M did not use a gait belt (assistive device used to help Residents with gait and balance issues to safely transfer) to aid in stabilizing the Resident during either of the observed transfers. At the time of the transfers, a tan-colored gait belt was observed to be hanging near a glove rack attached to the wall to the left of the Resident's bathroom door.
During an interview immediately following the observation, RN N was queried regarding the use of gait belts during transfers. RN N stated she believed gait belt use was only required for specific residents and was unsure if Resident #12 required the use of a gait belt during transfers.
During an interview on 1/31/2023 at 12:53 p.m., CNA M was queried regarding the use of a gait belt while transferring residents. CNA M reported he was trained in the use of gait belts and should have used a gait belt when transferring Resident #12. CNA M stated he was aware of the gait belt hanging on the wall in Resident #12's room.
On 2/01/2023 at 5:09 p.m., the Assistant Administrator, Staff L reported the facility did not have a policy related to safe transfers or gait belt use.
During an interview on 2/02/2023 at 2:10 p.m., the Director of Nursing (DON) reported the facility required use of gait belts during transfers for all residents requiring assistance. The DON acknowledge the potential for injury related to unnecessarily pulling on Resident's arms during transfer and a risk of falls when gaits belts were not utilized.
During an interview on 2/02/2023 at 3:00 p.m., Occupational Therapist (OT) O reported the use of gait belts while transferring residents was a standard of practice for safe transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to date, label, and change out oxygen tubing for one Resident (#37) of one resident reviewed for oxygen services. This deficient practice resulted in the potential for infection, and deterioration of the tubing. Findings include:
Review of the Minimum Data Set (MDS) assessment, dated 12/29/22, revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease (a progressive neurological condition of movement which often causes stiffness, incoordination, and tremors), coronary artery disease (narrowing of the heart blood vessels), congestive heart failure (a progressive heart disease causing fatigue and shortness of breath), acute respiratory failure with hypoxia (lack of oxygen), and hearing loss. Resident #37 required extensive two-person assistance for transfers and toileting, and extensive one-person assistance for bed mobility, dressing, and personal hygiene. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 13/15, which showed Resident #13 had intact cognition.
During an observation on 01/31/23 at 12:16 p.m., Resident #37 was observed in their room sitting upright in their manual wheelchair, reading. Resident #37 was receiving oxygen via a nasal canula running at 2L (Liters), and the oxygen concentrator tubing extending from the concentrator to their nose was undated. Resident #37 appeared comfortable and did not appear to be in respiratory distress.
During an interview on 01/31/23 at approximately 12:22 p.m., Certified Nurse Aide (CNA) Q was asked why Resident #37 was wearing the oxygen. CNA Q reported, [Resident #37] is [medically] declining.
Review of Resident #37's physician orders revealed, .Respiratory Distress .: Check oxygen saturation PRN (as needed), start oxygen at 2L per minute per nasal canula. Recheck oxygen saturation PRN and titrate [continuously measure and adjust the balance of] oxygen to maintain saturation >90%. Notify Nurse Practitioner/Physician PRN .
Review of Resident #37's Care Plan, accessed 02/02/23 at 3:14 p.m., revealed, [Resident #37] has a dx [diagnosis] of heart disease; she has a pacemaker .Revision on: 06/14/2021. Administer medication as ordered. Date initiated: 04/21/2020 There was no mention of recent respiratory compromise requiring oxygen administration, or dating, labeling, or changing out oxygen tubing weekly.
During an observation on 02/01/23 at approximately 9:40 a.m., CNA R was asked if they saw a date on the Resident #37's oxygen tubing. CNA R reported they did not see a date on the tubing, but saw a flattened area in the tubing, so they would replace the tubing for Resident #37. CNA R reported Resident #37 only wore the oxygen as needed, and the tubing was changed weekly.
During an observation on 02/02/23 at 8:11 a.m., the Director of Nursing (DON) was asked to observe Resident #37's oxygen tubing with Surveyor. Both observed there was no date on the tubing. The DON reported, There should be a sticker [label] on it .every Sunday [it was changed].
During an interview on 0202/23 at 8:15 a.m., the DON reviewed the Electronic Medical Record (EMR) and concurred there was no mention of the oxygen use or care in Resident #37's Care Plan. The DON reported Resident #37's oxygen orders were standing orders and indicated the oxygen tubing labeling and care planning may have been missed as Resident #37 returned recently from the emergency room (ER) wearing oxygen. The DON confirmed there was no order to change the oxygen tubing in the nursing tasks, i.e., on the Medication Administration Record (MAR) or on the Treatment Administration Record (TAR) as well. The DON clarified despite Resident #37 wearing oxygen as needed, oxygen use should have been documented in Resident #37's Care Plan and on their TAR. The DON showed Surveyor bright orange mailing labels where the nurses documented the dates the oxygen was changed, which was weekly. The DON reported the labels slipped off easily, and this may have been why the tubing was not labeled and dated. The DON explained Resident #37 was needing oxygen PRN recently due to cardiac diagnoses, including progression of congestive heart failure, and medical/respiratory decline.
During an interview with the Nursing Home Administrator (NHA) on 02/01/23 at 1:45 p.m., they reported they understood the concern, and going forward medical tape would be labeled, dated, and secured to the oxygen tubing for any facility resident wearing oxygen.
Review of the policy, [Facility Name], Policy and Procedure For: Cleaning and Changing Oxygen Supplies, undated, received from the Administrative Assistant on 02/02/23, Staff L, revealed, Policy: It is the Policy of [Facility Name] to maintain clean oxygen equipment for residents who receive continuous or intermittent oxygen. Procedure: 1. The oxygen .connecting tubing and cannula or mask will be changed weekly. 2. The .oxygen tubing and nebulizer tubing will have the resident's initials, date, and be initialed by the nurse changing them .All oxygen equipment will be changed weekly whether it has been used or not. Oxygen concentrator filters are to be taken out, cleansed, dried and placed back in concentrator weekly.