Adrian Bay Rehabilitation And Nursing Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes 2677539 and 2677568.Based on observation, interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for two (R3 and R7) of seven reviewed.Findings Include: Resident #3 (R3) Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included sepsis, osteoarthritis, low back pain and spinal stenosis. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/2/25, reflected R3 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).On 12/8/25 at 9:40 AM, R3 was observed in bed and reported taking Norco (opioid/controlled pain medication) as needed. R3 reported there had been a nurse that documented administering Norco to her two times in one day/shift, but she did not receive the medication either time. R3 reported requesting pain medication after wound care and being told by the nurse that it was too soon to have a dose, due to documentation which reflected she received it at 4:00 AM. R3 reported not receiving Norco on another occasion and could not recall the date. Resident #7 (R7) Review of the medical record reflected R7 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included muscle wasting and atrophy, malignant neoplasm (cancerous tumor) of unspecified part of bronchus or lung and fracture of the sacrum. The Quarterly MDS, with an ARD of 6/5/25, reflected R7 scored 11 out of 15 on the BIMS. R7 discharged from the facility on 6/28/25.A Witness Statement for R3, dated 11/18/25 at 2:45 PM, reflected R3 reported a nurse marked down that she took Norco (opioid/controlled pain medication), but she did not get it. R3 reported asking Licensed Practical Nurse (LPN) C if her Norco was marked down (as administered) and was told that it was. R3 stated she knew she did not receive it. R3 reported her pain was not usually too bad, but she had a treatment on her buttocks that day and had level ten out of ten pain on her right side. A Witness Statement for LPN C, dated 11/18/25 at 3:02 PM, reflected R3 asked LPN C to see if her Norco was signed out the night prior. LPN C informed R3 it was signed and the time it was signed out for. According to the Witness Statement, LPN C reported in May (2025) that a nurse was (allegedly) not giving narcotic (controlled medication) that was signed out and was (allegedly) forging signatures. The Witness Statement reflected LPN C reported it to their direct supervisors. A Witness Statement for Registered Nurse (RN) G, dated 11/18/25 at 3:47 PM, reflected R3 requested pain medication the night prior, around 10:00 PM. RN G could not recall if R3 received pain medication that morning. When asked if she gave R3 one or two doses of pain medication on her shift (11/17/25 to 11/18/25), RN G stated just one but could not remember. R3's Controlled Drug Record reflected doses of one tablet of hydrocodone-acetaminophen (Norco) 5/325 milligrams were signed out of the medication cart on 11/17/25 at 9:00 PM and on 11/18/25 at 4:30 AM, with RN G's signature. The November 2025 MAR reflected a dose was documented as administered by RN G on 11/17/25 at 8:52 PM. The dose signed out of the Controlled Drug Record on 11/18/25 at 4:30 AM was not documented on the MAR as being administered to R3. A Witness Statement from LPN C for 11/26/25 reflected she alleged forged signatures ongoing since May (2025), which she first noticed on 5/20/25, pertaining to R7's oxycodone (opioid/controlled pain medication). According to the statement, LPN C alleged since then, there had been several other instances, which had been reported to Director of Nursing (DON) B. The statement reflected LPN C reported discrepancies with her signature for 3/30/25, 5/5/25 and 11/17/25. An investigation binder, provided by the facility, reflected daily timecard punches for LPN C for 5/1/25 to 6/1/25, as well as Controlled Drug Records for residents, which had LPN C's signatures highlighted. LPN C's signatures for May 2025 had notation of work and eMAR (Electronic Medication Administration Record) beside them. In a phone interview on 12/8/25 at 10:17 AM, LPN C reported suspicion of their signature being forged to sign out controlled medications, which Nursing Home Administrator (NHA) A had been made aware of on 11/18/25. LPN C reported controlled medications were being signed out on the Controlled Drug Record but not the MAR and reported suspicion that her signature had been forged for oxycodone on 3/30/25, 5/5/25 and 5/21/25 and for Norco on 11/17/25. In an interview on 12/8/25 at 12:08 PM, LPN E reported being aware that LPN C had concerns pertaining to controlled medications being signed out but not being received by residents in the prior two to three weeks. LPN E reported the DON was aware, and an investigation had been started. LPN E stated LPN C had also made a previous complaint, in April or May of 2025, pertaining to not believing a signature (on a Controlled Drug Record) was hers. LPN E stated that was reported to the DON but was unsure what happened with that concern. LPN E stated LPN D had also reported a concern for a signature (on a Controlled Drug Record) which she did not believe was hers.In a phone interview on 12/9/25 at 12:25 PM, LPN D reported belief that her signature had been forged to sign out Percocet for R1 on 11/20/25. LPN D reported checking the Controlled Drug Record the next date she worked and noticed her signature. She stated she notified the on-call manager. LPN D stated R1 had been sleeping, and she did not give R1 any as needed medication on 11/20/25.In an interview on 12/8/25 at 1:43 PM, when asked if there had been any controlled medication discrepancies prior to 12/8/25, DON B reported the facility had a thick investigation file because R3 reported not receiving two controlled medications. DON B stated that NHA A was made aware, as she was the facility's abuse coordinator. According to DON B, LPN C stated someone was signing out their name (on the Controlled Drug Record) when they were not in the facility. DON B reported they cross-referenced from May to current on C hall and for the entire month of November. DON B reported they did a full investigation, and LPN C had been working the days the medications were signed out. NHA A joined the above interview with DON B on 12/8/25 at 1:54 PM and reported being notified on 11/18/25 that R3 alleged she did not receive her pain medication the prior night. NHA A reported starting a concern form and interviewing R3, who said the nurse documented that she received Norco, but she did not receive it. NHA A reviewed RN G's witness statement and reported that RN G gave R3 as needed pain medication around 10:00 PM the night prior (11/17/25) but could not recall if she gave R3 a dose that morning (11/18/25). During the interview, it was stated that LPN C reported a concern in May (2025) (pertaining to the use of her signature), which the facility audited but did not note any discrepancies. There was no evidence that the facility reported allegations of forged signatures on Controlled Drug Records to the State Agency or Law Enforcement. Additionally, there was no evidence that the facility reported R3's allegation of not receiving controlled pain medication that had been signed out on the Controlled Drug Record. According to the facility's policy pertaining Abuse and Neglect, updated on 6/28/25, .If abuse/neglect is suspected the facility will: 1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care. 2. Notify the appropriate/designated organization/authority (State Agencies) that an investigation is being initiated immediately following intervention for the resident's safety .6. Notify law enforcement authorities and press charges, if indicated. 7. Report the investigation findings to the appropriate State Agencies, as required by law .Reporting/Response: .All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to the appropriate State Agencies immediately after the initial allegation is received. A final investigation report will be submitted to the appropriate State Agencies within 5 working days. If the event that results in allegation of abuse also causes the individual to suspect a crime, the facility will also report to the local law enforcement agency .1150 B Posting Any owner, operator, employee, contractor, or manager of the LTC [Long-Term Care] facility has the obligation to report to the State Agency and at least one local law enforcement agency, any reasonable suspicion of a crime against an individual who is a resident of or is receiving care from the facility .In the event that the cause of reasonable suspicion of a crime - a) results in serious bodily injury, the individual shall report the suspicion immediately but not later than 2 hours after forming the suspicion; and b) does not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion, unless it involves abuse .REPORTING .if the event that caused the allegation involved abuse or resulted in serious bodily injury, the allegation of abuse must be reported to appropriate state agencies immediately and not later than 2 hours after receiving the allegation of abuse or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury .The abuse coordinator must submit a final investigation report to the appropriate State Agencies within five (5) working days of the allegation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes 2677539 and 2677568.Based on observation, interview, and record review, the facility failed to maintain accurate controlled substance and medication administration records for five residents (R1, R3, R4, R5, R6) of six reviewed and two medication carts of two reviewed. Findings include:During an observation and interview with Licensed Practical Nurse (LPN) M, on 12/8/25 at 10:37 AM, it was noted that the controlled substance book indicated 45 controlled medications were in the medication cart. Upon count of the total number of medications, it was observed that 44 controlled medications were in the medication cart. LPN M counted the total amount of medications a second time and was initially unable to explain the discrepancy. LPN M then reported one medication had been removed from the medication cart, after the last dose was administered that morning. LPN M obtained the Controlled Drug Record from the facility's mail room, which noted the last dose of the controlled medication was signed out on 12/8/25 at 7:15 AM.
During count of the individual controlled medications in the medication cart, with LPN M, it was observed that R1's Controlled Drug Record for Morphine Concentrate 100 milligrams (mg) per five milliliters (mL) noted 17 mL remained in the bottle. Observation revealed that more than 20 mL remained in the bottle. When asked how much was in the bottle, LPN M reported the amount to be approximately 23 mL. It was noted that the last entry on the Controlled Drug Record was 11/30/25.
LPN M reported the process for counting controlled medications was for the off-going nurse to read the count from the controlled substance book, while the on-coming nurse verified the count of each medication. LPN M reported the total amount of controlled medications was verified first, followed by count of the individual controlled medications. When removing controlled medications from the medication cart, LPN M reported they noted medication on the Controlled Drug Record but did not record the time until they knew the resident was taking it.
In an interview on 12/8/25 at 12:08 PM, LPN E reported controlled medications were to be signed out after they were administered, in case the resident refused. According to LPN E, the process was to pull the medication (from the package), flag the Controlled Drug Record, then sign the medication out on the Medication Administration Record (MAR) and Controlled Drug Record (after the medication was administered).
In an interview on 12/8/25 at 1:43 PM, Director of Nursing (DON) B reported she was to be contacted if there was a discrepancy with controlled medication count. DON B reported counting controlled medications that day, and R1's Morphine count was over. The Controlled Drug Record reflected 17 mL was in the bottle, however, there was approximately 23 mL remaining, according to DON B.
Resident #1 (R1)
Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included sepsis, chronic pain, muscle spasm and malignant neoplasm (cancerous tumor) of overlapping sites of the lip, oral cavity and pharynx. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/26/25, reflected R1 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
R1 was observed in the hallway on 12/8/25 at 11:57 AM and declined to be interviewed.
R1's November 2025 and December 2025 Medication Administration Records (MARs) reflected a Physician's Order for Percocet (oxycodone-acetaminophen) 10/325 mg by mouth, every four hours, as needed, for pain.
Review of the MARs and the Controlled Drug Records reflected the following discrepancies:
On 11/1/25 at 9:00 AM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1.
On 11/2/25, at an illegible time, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1 for that date.
On 11/4/25, at 4:00 AM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1.
On 11/6/25, at 12:30 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1.
On 11/6/25, at 5:00 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1.
On 11/6/25, at 9:00 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was signed on the MAR as administered to R1 at 8:06 PM.
On 11/7/25, at 5:00 AM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was signed on the MAR as administered to R1 at 5:53 AM.
On 11/14/25, at 12:30 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1.
On 11/17/25, at 9:00 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1.
On 11/18/25, at 5:00 AM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1.
On 11/20/25, at 9:00 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1.
On 11/22/25, at 2:43 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1.
On 12/1/25, at an illegible time, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1 for that date.
On 12/6/25, at 1:10 PM, oxycodone-acetaminophen 10/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R1 for that date.
Resident #3 (R3)
Review of the medical record reflected R3 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included sepsis, osteoarthritis, low back pain and spinal stenosis. The Quarterly MDS, with an ARD of 11/2/25, reflected R3 scored 15 out of 15 (cognitively intact) on the BIMS.
On 12/8/25 at 9:40 AM, R3 was observed in bed and reported taking Norco (opioid/controlled pain medication) as needed. R3 reported there had been a nurse that documented administering Norco to her two times in one day/shift, but she did not receive the medication either time. R3 reported requesting pain medication after wound care and being told by the nurse that it was too soon to have a dose, due to documentation which reflected she received it at 4:00 AM. R3 reported not receiving Norco on another occasion and could not recall the date.
R3's November 2025 and December 2025 MARs reflected a Physician's Order for Hydrocodone-Acetaminophen 5/325 mg by mouth, every four hours, as needed, for pain.
Review of the MARs and the Controlled Drug Records reflected the following discrepancies:
On 11/4/25 at 3:30 AM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was signed out on the MAR as administered to R3 at 4:48 AM.
On 11/4/25, at an illegible time (possibly 8:00 PM or 9:00 PM), hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3.
On 11/6/25 at 1:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was signed out on the MAR as administered to R3 at 2:45 PM.
On 11/6/25 at 5:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3.
On 11/7/25 at 1:38 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3.
On 11/7/25 at 9:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3.
On 11/11/25 at 9:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3.
On 11/14/25 at 8:00 AM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3 for that date.
On 11/14/25 at 1:30 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3 for that date.
On 11/16/25 at 9:00 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3 for that date.
On 11/17/25 at 1:10 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3.
On 11/18/25 at 4:30 AM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3.
On 11/21/25 at 8:00 AM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3.
On 11/27/25 at 2:42 PM, hydrocodone-acetaminophen 5/325 mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R3 for that date.
Resident #5 (R5):
Review of the medical record reflected R5 admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and type 2 diabetes mellitus with diabetic neuropathy. The admission MDS, with an ARD of 10/13/25, reflected R5 scored 15 out of 15 (cognitively intact) on the BIMS.
On 12/8/25 at 11:29 AM, R5 was observed sitting on the edge of their bed. R5 acknowledged taking pain medication, stating they had requested some that morning.
R5's November 2025 and December 2025 MAR reflected a Physician's Order for oxycodone hydrochloride (HCl) five mg by mouth, every six hours, as needed, for moderate to severe pain.
Review of the MARs and the Controlled Drug Records reflected the following discrepancies:
On 11/5/25 at 9:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/7/25 at 7:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/8/25, at an illegible time, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/8/25 at 10:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/9/25 at 4:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/9/25 at 1:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/9/25, at an illegible time, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/12/25 at 5:30 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date.
On 11/12/25 at 12:30 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date.
On 11/13/25 at 4:45 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/14/25 at 5:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/15/25 at 5:15 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date.
On 11/15/25 at 8:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date.
On 11/19/25, at an illegible time (possibly 8:00 PM or 9:00 PM), oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/20/25, at an illegible time (possibly 8:00 PM or 9:00 PM), oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date.
On 11/21/25 at 5:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date.
On 11/23/25 at 4:30 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 11/24/25 at 5:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
On 12/2/25 at 5:00 AM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5 for that date.
On 12/4/25 at 8:00 PM, oxycodone HCl five mg was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R5.
In a phone interview on 12/8/25 at 10:17 AM, LPN C reported suspicion of their signature being forged to sign out controlled medications, which Nursing Home Administrator (NHA) A had been made aware of on 11/18/25. LPN C reported controlled medications were being signed out on the Controlled Drug Record but not the MAR.
In an interview on 12/8/25 at 12:08 PM, LPN E reported being aware that LPN C had concerns pertaining to controlled medications being signed out but not being received by residents in the prior two to three weeks. LPN C reported the DON was aware, and an investigation had been started. LPN E stated LPN D also reported a concern for a signature (on a Controlled Drug Record) which they did not believe was theirs. LPN E stated LPN C had also made a previous complaint, in April or May of 2025, pertaining to not believing a signature (on a Controlled Drug Record) was theirs. LPN E stated that was reported to the DON, and they were unsure what happened with that concern.
In an interview on 12/8/25 at 1:43 PM, when asked if there had been any controlled medication discrepancies prior to 12/8/25, DON B reported the facility had a thick investigation file because R3 reported not receiving two controlled medications. NHA A was made aware, as she was the facility's abuse coordinator. According to DON B, LPN C stated someone was signing out their name (on the Controlled Drug Record) when they were not in the facility. DON B reported they cross-referenced from May to current on C hall and for the entire month of November. DON B reported they did a full investigation, and LPN C had been working the days the medications were signed out.
In a phone interview on 12/9/25 at 12:25 PM, LPN D reported belief that their signature had been forged to sign out Percocet for R1 on 11/20/25. LPN D reported checking the Controlled Drug Record the next time she worked and noticed her signature. LPN D stated R1 had been sleeping, and she knew for a fact she did not give R1 and as needed medication on 11/20/25.
R4
Review of the medical record revealed R4 was admitted to the facility on [DATE] with diagnoses that include polyneuropathy (disease affecting nerves) and low back pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/25 revealed R4 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
On 12/8/25 at 11:02 AM, R4 was observed sitting in her wheelchair in the dining room. R4 reported she takes Norco (hydrocodone-acetaminophen 5-325 milligrams (mg)/controlled opioid pain medication) every six hours as needed for pain.
Review of the Physician's Order dated 10/13/25 revealed an order for hydrocodone-acetaminophen 5-325 mg give one tablet every six hours as needed for pain management.
Review of the Medication Administration Records (MARs) and the Controlled Drug Records revealed the following discrepancies:
On 10/25/25 at 11:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 10/26/25 at 4:45 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 10/26/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 10/26/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 10/29/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 10/29/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 10/30/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 10/30/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 10/31/25 at 3:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 10/31/25 at 8:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/5/25 at 3:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/8/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/8/25 at 12:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was signed out on the MAR as administered to R4 at 2:16 PM.
On 11/9/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/10/25 at an illegible time (possibly 12:00 AM or 5:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4 on 3:19 AM.
On 11/11/25 at 8:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/12/25 at 7:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/12/25 at 2:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/12/25 at 9:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/13/25 at 6:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/13/25 at 6:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/15/25 at an illegible time (possibly 12:00 AM), hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/15/25 at 9:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/19/25 at 9:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/21/25 at 5:15 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/22/25 at an illegible time (possibly 8:00 PM or 10:00 PM), hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/22/25 at an illegible time (possibly 8:00 PM), hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/23/25 hydrocodone-acetaminophen was signed out as administered on the MAR at 12:25 AM but not signed out on the Controlled Drug Record until 4:30 AM.
On 11/26/25 at 6:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/27/25 at 8:00 PM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/28/25 at an illegible time (possibly 8:00 PM or 10:00 PM), hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
On 11/29/25 at 5:00 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record but was not documented on the MAR as administered to R4 until 7:03 AM.
On 12/4/25 at 5:30 AM, hydrocodone-acetaminophen was signed out on the Controlled Drug Record as removed from the medication cart but was not signed out on the MAR as administered to R4.
R6
Review of the medical record revealed R6 was admitted to the facility on [DATE] with a diagnosis of right humerus fracture. Review of the BIMS dated 12/8/25 revealed R6 scored 12 out of 15 (moderate cognitive impairment).
Review of the Physician's Order dated 12/4/25 revealed an order for hydrocodone-acetaminophen 5-325 mg every six hours as needed for pain.
Review of the MAR revealed on 12/7/25 at 10:10 PM, hydrocodone-acetaminophen was documented as administered to R6 however, the medication was not signed out on the Controlled Drug Record as being removed from the medication cart at that time.
Review of the Controlled Drug Record revealed on 12/8/25 at 300 [possibly 3:00 AM], hydrocodone-acetaminophen was signed out as removed from the medication cart. Review of the MAR revealed the medication was not signed out as administered to R6.
On 12/8/25 at 11:28 AM, R6 was observed sitting on the edge of her bed with her right arm in a sling. R6 reported she experienced pain when she moved and that the staff gave her Tylenol for her pain. (It should be noted R6 also had an order for Tylenol as needed). R6 reported there was one night a few nights ago when a male nurse gave her Norco. R6 reported she did not like how the Norco made her feel and preferred to take Tylenol. R6 reported she did not take any Norco for the last two nights.
An observation on 12/8/25 at 11:07 AM with Registered Nurse (RN) K revealed the controlled substance book indicated 34 controlled medications were in the medication cart. Upon count of the medications, 35 controlled medications were observed in the medication cart. RN K was unable to explain the discrepancy and reported it could have been a counting error when medications were removed and new medications added.
In an interview on 12/8/25 at 1:43 PM, Director of Nursing (DON) B reported RN K notified her of the discrepancy noted that day. DON B reported the count should have been 35, but the book revealed 34 total medications. Nursing Home Administrator (NHA) A joined the interview. NHA A and DON B agreed there were discrepancies in R4 and R6's Controlled Drug Records and MARs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes 2677539 and 2677568.Based on observation, interview, and record review, the facility failed to administer medications according to the physician's order for two (R4 and R5) of five reviewed.Findings include:Resident #4 (R4)
Review of the medical record revealed R4 was admitted to the facility on [DATE] with diagnoses that include polyneuropathy (disease affecting nerves) and low back pain. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/25 revealed R4 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
On 12/8/25 at 11:02 AM, R4 was observed sitting in her wheelchair in the dining room. R4 reported she takes Norco (hydrocodone-acetaminophen 5-325 milligrams (mg)/controlled opioid pain medication) every six hours as needed for pain.
Review of the Physician's Order dated 10/13/25 revealed an order for hydrocodone-acetaminophen 5-325 mg give one tablet every six hours as needed for pain management.
Review of the Controlled Drug Record revealed doses were signed out at a frequency greater than every 6 hours on 10/26/25 at 6:00 PM and 7:40 PM, 10/30/25 at 6:00 PM and 8:00 PM, 11/8/25 at 12:00 PM and 1:00 PM, 11/9/25 at 6:00 PM and 8:30 PM, and 11/13/25 at 6:00 PM and 11:00 PM. Of these doses, the Medication Administration Record (MAR) did not reflect documentation on 10/26/25 at 6:00 PM, 10/30/25 at 6:00 PM, 11/8/25 at 12:00 PM and 1:00 PM, 11/9/25 6:00 PM, and 11/13/25 at 6:00 PM.
Resident #5 (R5):
Review of the medical record reflected R5 admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and type 2 diabetes mellitus with diabetic neuropathy. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/13/25, reflected R5 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
On 12/8/25 at 11:29 AM, R5 was observed sitting on the edge of their bed. R5 acknowledged taking pain medication, stating they had requested some that morning.
R5's November 2025 Medication Administration Record (MAR) reflected a Physician's Order for oxycodone hydrochloride (HCl) (opioid/controlled pain medication) five milligrams (mg) by mouth, every six hours, as needed, for moderate to severe pain. According to the MAR, the medication was signed out as administered on 11/9/25 at 7:17 AM and 8:37 PM. There were no further doses signed out as administered on the MAR for 11/9/25.
According to R5's oxycodone HCl five mg Controlled Drug Record, five total doses of the medication were signed out on 11/9/25. The documented times, in order, reflected 4:00 AM, an illegible time, 1:00 PM, 8:40 PM and an additional illegible time.
According to R5's November MAR and the oxycodone HCl five mg Controlled Drug Record, R5's doses were signed out at a frequency of less than every six hours on 11/9/25.
The November 2025 MAR reflected oxycodone HCl five mg by mouth, every six hours, as needed, for moderate to severe pain was signed out as administered on 11/13/25 at 8:45 PM. There were no further doses signed out as administered on the MAR for 11/13/25.
According to R5's oxycodone HCl five mg Controlled Drug Record, two doses of the medication were signed out on 11/13/25. One dose was signed out at 4:45 PM and one dose at 9:00 PM, which was less than six hours apart.
R5's December 2025 MAR reflected oxycodone HCl five mg by mouth, every six hours, as needed, for moderate to severe pain was signed out as administered on 12/4/25 at 6:06 PM. There were no further doses signed out as administered on the MAR for 12/4/25.
According to R5's oxycodone HCl five mg Controlled Drug Record, doses of the medication were signed out less than two hours apart on 12/4/25. One dose was signed out at 6:06 PM and an additional at 8:00 PM.
In a phone interview on 12/8/25 at 3:31 PM, when asked if they knew why there could be discrepancies between documentation on MARs and Proof of Use sheets (Controlled Drug Records), Registered Nurse (RN) G indicated there was so much to do and so much going on that they were forgetting (to document in both places). Regarding timing of as needed medication administration, RN G reported the MAR would indicate if the medication was able to be given and would not allow a nurse to sign a medication out before a resident could have the next dose.
In an interview on 12/9/25 at 9:45 AM, Director of Nursing (DON) B reported the expectation for signing out controlled medications was to look at the log, as the Proof of Use sheet was the most accurate form of documentation. DON B reported nurses should have been signing out controlled medications on the Proof of Use sheet and the MAR. DON B agreed that R4 and R5 had doses of controlled medications that had been administered too close together based on the time parameters in the Physician's Orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document blood sugars prior to holding or administering insulin for one (R10) of six reviewed for unnecessary medications.
Findings include:
Review of the medical record reflected R10 admitted to the facility on [DATE], with diagnoses that included type 2 diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/21/25, reflected R10 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
On 06/10/25 at 1:56 PM, R10 was observed in their room. R10 reported their insulin had been adjusted, and they were receiving long-acting insulin if their blood sugar was above 90 milligrams per deciliter (mg/dL) in the morning.
R10's May 2025 and June 2025 Medication Administration Records (MAR) reflected an order, which was started on 5/28/25, for 25 units of insulin glargine to be administered subcutaneously (under the skin) in the morning. The insulin was to be held if R10's blood sugar was less than 90 mg/dL. The MARs did not reflect documentation of R10's blood sugars from 5/28/25 through 6/12/25.
In an interview on 06/12/25 at 1:37 PM, Licensed Practical Nurse (LPN) Z reported the link was not added to the medical record to prompt the nurses to record R10's blood sugar as supplemental documentation for their insulin order.

Based on interview and record review the facility failed to preserve the dignity for 5 of 5 members of the Resident Council.
Findings include:
Review of the Resident Council minutes dated 3/19, 4/23 and 5/20/25 revealed residents had complaints about staff being on their phones.
On 06/11/25 at 01:02 PM, during the confidential group meeting, 5 of the 5 resident participants reported staff were routinely on their cell phones including in their rooms while providing care. When queried how they felt when this occurred, one resident reported like I am left out and not important. another group participant reported it made them upset because their nurses aid gets distracted while on the phone then forgets a request made by the resident, leaving an unmet need.
On 06/12/25 08:32 AM, during an interview with Nursing Home Administrator (NHA) Ashe reported she was aware of issues brought forth by Resident Council members and was trying to correct the issue.

Based on observation, interview and record review, the facility failed to ensure the Survey Book was easily accessible and readily available, and that the book was maintained to include the facility plan of correction for identified deficiencies. Resulting in the potential for residents and visitors to be uninformed. This had the potential to affect all 80 residents who resided in the facility.
Findings include:
During an interview on 6/12/25 at 10:00 AM, R8 reported had lived at the facility for six months. R8 reported was not aware the facility had a Survey Book that included prior Surveys available to residents and visitors and reported was unsure where it would be located. R8 reported attended outside appointments three times weekly and had never observed a binder labeled public records or survey results.
During an observation on 6/12/25 at 10:28 AM observed binder at ground level, under another 6 inch binder at floor level in the facility lobby with most recent survey dated 5/2023. The binder was not easily accessible and was hidden and not labeled on spine side of binder for public viewing when binders were stacked.
During an interview on 6/12/25 11:35 AM, Nursing Home Administrator (NHA) A reported the survey binder was located in the lobby. NHA A obtain binder from floor level, under another 6 in binder, labeled state of michigan survey results on the front of binder only. NHA A verified most recent survey results were from 2023 and reported facility has had surveys since 2023 that were not in the binder. NHA A verified the binder was not easily accessible to all the facility elder population, labeled or updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149511.
Based on interview and record review, the facility failed to honor code status wishes for one (R333) of two reviewed.
Findings include:
Review of the medical record reflected R333 admitted to the facility on [DATE], with diagnoses that included heart failure, atrial fibrillation, rheumatic mitral stenosis, nonrheumatic aortic valve stenosis, presence of prosthetic heart valve and atherosclerotic heart disease. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R333 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was dependent for transfers.
R333's medical record reflected they had a Do-Not-Resuscitate (DNR/no Cardiopulmonary Resuscitation/CPR) order in place, dated [DATE].
A Progress Note for [DATE] at 11:36 AM reflected R333 became unresponsive during a transfer and was lowered to the floor. The nurse responded immediately and assessed for carotid pulse and respirations. According to the note, life saving measures were initiated while staff checked for R333's code status, which was confirmed to be DNR.
In an interview on [DATE] at 11:56 AM, Licensed Practical Nurse (LPN) Z reported responding to unresponsiveness being paged overhead and promptly assessed R333. LPN Z reported CPR was initiated right away, as she did not know R333's code status. CPR continued until Emergency Medical Services (EMS) arrived, according to LPN Z.
In an interview on [DATE] at 1:37 PM, LPN Z stated the nursing report sheets included resident code status information, and nurses could also look in the Electronic Medical Record (EMR).
In an interview on [DATE] at 1:51 PM, Registered Nurse (RN) T stated the quickest way to verify code status was to look at their report sheet, but they could also look in the EMR. RN T reported it only took seconds to verify a resident's code status. If her report sheet was not on her, it would be located on her medication cart, or it would only take a few seconds to log into the computer (EMR). RN T stated CPR should not be initiated without knowing the code status of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and monitor a change in condition timely for one (R38) of one reviewed.
Findings include:
Review of the medical record reflected R38 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included muscle wasting and atrophy, type 2 diabetes and obstructive and reflux uropathy. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/27/25, reflected R38 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had an indwelling urinary catheter.
R38 was transferred to the hospital on 6/5/25 and was not in the facility at the time of the survey.
A Progress Note for 6/4/25 at 7:19 PM reflected R38 was refusing all meals and stated she was vomiting each time she ate. The note reflected the Certified Nurse Aide (CNA) reported R38 had been having green foul smelling discharge. According to the note, the physician was notified.
A Progress Note for 6/5/25 at 10:48 AM reflected R38 was unresponsive to verbal and tactile stimulation. The note reflected documentation of R38's vital signs and noted that she was pale and diaphoretic, and her upper and lower extremities were cool to touch. The on-call Nurse Practitioner was notified, and orders were given to send R38 to the emergency room (ER).
A Progress Note for 6/5/25 at 1:50 PM reflected the ER reported R38 was receiving intravenous (IV) fluids and IV antibiotics and was expected to return to the facility that day.
A Progress Note for 6/6/25 at 8:23 AM reflected R38 was admitted to the hospital.
In an interview on 06/11/25 at 3:02 PM, CNA W reported the last time they worked with R38, she had green drainage from her vagina, which the nurses were aware of. CNA W stated R38 had green vaginal discharge for approximately one week or so. Some days the discharge was heavy and noted to be in R38's wheelchair. CNA W stated R38's catheter was cloudy, and there may have been some discharge in their catheter tubing as well. They reported staff were performing catheter care twice per shift, using antibacterial soap, because they knew R38 had an infection.
In a phone interview on 06/12/25 at 1:14 PM, CNA X reported R38 had been having mucous-looking vaginal discharge with a foul odor for a couple of weeks, which had been reported and the nurses were aware of. CNA X reported they were performing perineal care more frequently on R38, but she often refused.
R38's Care Plan reflected an intervention dated 1/22/25 for, Monitor/record/report to MD [Medical Doctor] for s/sx [signs/symptoms] UTI [urinary tract infection]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.
In an interview on 06/12/25 at 3:01 PM, Director of Nursing (DON) B reported any time there was vaginal discharge or blood, the expectation was to get a set of vital signs and contact the physician. DON B was unaware of staff reports of vaginal discharge presenting for weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the safe storage of smoking materials for one (R58) of one reviewed for smoking.
Findings include:
Review of the medical record reflected R58 admitted to the facility on [DATE], with diagnoses that included saddle embolus of the pulmonary artery and tobacco use. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/25, reflected R58 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
On 06/10/25 at 10:51 AM, R58 was observed seated on the edge of their bed, eating a banana. They were observed to grab a pack of cigarettes from their overbed table and place them behind their body, on their bed. R58 reported there were designated smoking times at the facility, and they smoked out back, in the corner, independently. R58 reported they stored their cigarettes and lighter in a drawer, in their room.
A Smoking Safety Screen, dated 3/17/25, reflected R58 needed the facility to store their lighter and cigarettes.
In an interview on 06/12/25 at 11:25 AM, Certified Nurse Aide (CNA) H reported there was a safety box at the nurse's station where cigarettes and lighters were stored, which nurses had access to. CNA H reported residents were not permitted to store cigarettes and lighters on them or in their rooms.
In an interview on 06/12/25 at 11:56 AM, Licensed Practical Nurse (LPN) Z reported cigarettes and lighters were stored in a lock box, at the nurse's station. LPN Z reported R58 had short-term memory loss and was non-compliant with giving their cigarettes and lighter to staff. LPN Z stated R58 kept cigarettes and lighters in their top drawer at times, and staff had also observed them on the bathroom counter. LPN Z stated if nurses were handing out cigarettes, they should be getting them back.

During an observation on 6/11/25 at 11:28 am hall A medication cart was unlocked with no staff in area. One resident observed in area able to self propel in wheelchair.
During an interview on 6/12/25 at 1:35 PM, Unit Manager (UM) M reported would expect medication carts to remain locked when staff not present and computer closed. Director of Nursing (DON) B joined interview and reported would expect medication carts to remain locked if nurse not present. UM M reported often monitors for secure medications carts and occasionally observes unlocked and performs education with staff.
Based on observation, interview, and record review the facility failed to ensure proper storage of medication for one residents (R60) of 18 sampled residents and one medication cart of two medication carts reviewed for medication storage.
Findings Included:
Resident #60 (R60)
Review of the medical record demonstrated R60 was admitted to the facility 03/11/2025 with diagnoses that included osteomyelitis (bone infection) of sacral and sacrococcygeal region, sepsis, methicillin resistant staphylococcus aureus infection, type 2 diabetes, chronic obstructive pulmonary disease (COPD), malnutrition, diabetic foot ulcer, chronic pulmonary edema, left below knee amputation, stage 4 pressure ulcer sacrum, stage 4 pressure ulcer sacrococcygeal, hyperlipidemia (high fat content in blood), congestive heart failure (CHF), urinary retention, muscle wasting, end stage renal disease, peripheral vascular disease (PVD), anemia (low amount of red blood cells), hypotension, coronary artery disease (CAD), enlarge prostate, atrial fibrillation, hypothyroidism (low thyroid hormone), osteoarthritis (when flexible tissue at end of bones wears down), bladder cancer, gastro-esophageal reflux disease, and dependence on renal dialysis. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/30/2025, revealed R60 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.
During observation and interview on 06/10/2025 at 12:02 p.m. R60 was observed lying on his bed. A mediation cup (with red liquid) was observed sitting on the table beside his bed. A medication cup, (with one small white pill, three reddish/brown pills, and one large white pill) was observed sitting on the table beside his bed. R60 explained the cups contained some of his medication. R60 did not know what type of medication was in the medication cups. R60 could not explain how long the medication had been sitting on the bedside table. R60 explained that staff usually just leave his medication at his bedside and leave the room.
During observation on 06/10/2025 at 01:46 p.m. one medication cup (with red liquid) was observed on the table beside R60's bed. During that same time one medication cup ,(with one small white pill, three reddish/brown pills, and one large white pill) was observed on the table beside R60's bed. R60 was not observe in his room at this time and the door to the room was observed opened.
During an interview on 06/12/2025 at 07:018 a.m. Director of Nursing (DON) B explained that residents could administer their own medication. DON B explained that a self-medication administration assessment would be conducted by the interdisciplinary team. DON B explained if the assessment demonstrated that the resident was safely capable of administering their own medication a physician order would be obtained, the plan of care would be updated, and a security box would be provided to the resident. DON B explained that the facility did not have any resident that were approved for self-medication administration. DON B explained that it was a professional expectation that the nursing staff would observe the consumption of all medication that was given to the residents. DON B was made aware of what observations were conducted on 06/12/2025 regarding R60's medication at bedside. DON B could not demonstrate documentation that R60 was approved to take medication unsupervised. DON B explained that it was her expectation that medication was not to be left in any location without being secured or observed by a licensed nurse.
Review of R60's medical record did not demonstrate that a self-medication administration assessment was conducted. R60's medical record did not demonstrate that a physician's order had been obtained for R60 to self-administer medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149511.
Based on interview and record review, the facility failed to ensure a complete and accurate medical record for one (R333) of 18 reviewed.
Findings include:
Review of the medical record reflected R333 admitted to the facility on [DATE], with diagnoses that included heart failure, atrial fibrillation, rheumatic mitral stenosis, nonrheumatic aortic valve stenosis, presence of prosthetic heart valve and atherosclerotic heart disease. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R333 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was dependent for transfers.
R333's admission Record, dated [DATE] at 11:38 AM, reflected they were female, however, R333 was male.
R333's medical record reflected they had a Do-Not-Resuscitate (DNR/no Cardiopulmonary Resuscitation/CPR) order in place, dated [DATE].
A Progress Note for [DATE] at 11:36 AM reflected R333 became unresponsive during a transfer and was lowered to the floor. The nurse responded immediately and assessed for carotid pulse and respirations. According to the note, life saving measures were initiated while staff checked for R333's code status, which was confirmed to be DNR. The note reflected R333's time of death was called by a Registered Nurse (RN) at 10:34 AM. Emergency Medical Services (EMS) arrived and additionally pronounced R333 as deceased , per the on-call physician, at 10:44 AM.
In an interview on [DATE] at 11:56 AM, Licensed Practical Nurse (LPN) Z reported responding to unresponsiveness being paged overhead and promptly assessed R333. LPN Z reported CPR was initiated right away, as she did not know R333's code status. CPR continued until Emergency Medical Services (EMS) arrived, since it had already been initiated, according to LPN Z.
During an interview with LPN Z on [DATE] at 1:37 PM, the Progress Note for [DATE] at 11:36 AM was discussed, pertaining to documentation that time of death was called at 10:34 AM, prior to the arrival of EMS. LPN Z acknowledged that she believed CPR continued until EMS arrived.
During an interview on [DATE] at 3:01 PM, Director of Nursing (DON) B reported being unaware that R333 had been noted in their medical record as being female. DON B reported that information was entered by the Admissions Director. DON B reported once CPR was initiated, they could not stop. DON B reported EMS took over CPR upon their arrival to the facility.
An EMS Run report, dated [DATE], reflected facility staff were performing CPR upon EMS arrival. The report reflected staff were transferring R333 via lift when his face turned beat red. R333 did not respond when staff asked if he was ok. Upon noting that R333 was not breathing, he was moved to the floor. Facility staff placed an AED (automated external defibrillator) on R333, but no shock was advised. R333's time of death was called at 10:46 AM.
The Progress Note for [DATE] at 11:36 AM did not reflect that an AED was applied or that CPR continued until EMS arrived on scene. Additionally, the Progress Note reflected that R333's time of death was called at 10:34 AM by an RN and was confirmed by EMS at 10:44 AM.

Based on observation, interview, and record review the facility failed to maintain use of personal protective equipment during resident care for three residents (#45, #60, #70) out of 80 residents at the facility.
Findings Included:
Resident #45 (R45)
Review of the medical record demonstrated R45 was admitted to the facility 5/6/2025 with diagnoses that included hyperkalemia (high potassium levels), hypermagnesemia (high magnesium levels), acute kidney failure, altered mental status, cytomegaloviral disease (herpes virus), history of kidney transplant, type 2 diabetes mellitus, polyneuropathy (general term for peripheral nervous system disorder), immunodeficiency (weakened or compromised immune system), low back pain, muscle wasting, hypoxemia (low oxygen levels), hypertension, hyperlipidemia (high fat content in blood), urinary retention, constipation, sleep apnea, anemia (low red blood cell count) gastro-esophageal reflux, gout (inflammatory arthritis caused from high amounts of uric acid), stage 4 kidney disease, and cognitive communication deficit. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/10/2025, revealed R45 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. R45 was discharged home 06/11/2025.
During medication administration observation for R45 on 06/11/2025 at 08:04 a.m. Licensed Practical Nurse (LPN) N was observed providing R45 a subcutaneous insulin injection by an autopen. The medication was Xultophy 100/3.6mg(milligrams) and LPN N was observed providing 14 units of the insulin medication via an autopen. LPN N was not observed to have placed any gloves on herself prior to administering the subcutaneous injection.
During an interview on 06/11/2025 at 04:44 p.m. Director of Nursing (DON) B explained that it was a professional infection control standard of practice to use personal protective equipment (PPE), specifically gloves, while administering an injection to residents. DON B could not explain why Licensed Practical Nurse (LPN) N was observed administering a subcutaneous insulin injection, to R45 without the use of appropriate PPE.
Resident #60 (R60)
Review of the medical record demonstrated R60 was admitted to the facility 03/11/2025 with diagnoses that included osteomyelitis (bone infection) of sacral and sacrococcygeal region, sepsis, methicillin resistant staphylococcus aureus infection, type 2 diabetes, chronic obstructive pulmonary disease (COPD), malnutrition, diabetic foot ulcer, chronic pulmonary edema, left below knee amputation, stage 4 pressure ulcer sacrum, stage 4 pressure ulcer sacrococcygeal, hyperlipidemia (high fat content in blood), congestive heart failure (CHF), urinary retention, muscle wasting, end stage renal disease, peripheral vascular disease (PVD), anemia (low amount of red blood cells), hypotension, coronary artery disease (CAD), enlarge prostate, atrial fibrillation, hypothyroidism (low thyroid hormone), osteoarthritis (when flexible tissue at end of bones wears down), bladder cancer, gastro-esophageal reflux disease, and dependence on renal dialysis. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/30/2025, revealed R60 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.
During observation on 06/11/2025 at 04:01 p.m. R60 was observed lying in bed. Licensed Practical Nurse (LPN) N was observed to explain to R60 that she going to be changing his dressings on his coccyx pressure wound and his right gluteal fold pressure wound. LPN N was observed to place gloves on both of her hands. LPN N then assisted R60 to role to his left side. LPN N was observed to remove the dressing on the right gluteal fold and then immediately remove the dressing on the coccyx. The removed right gluteal fold dressing was observed to have dark brown drainage, the wound appeared to be a stage 4 pressure wound, and the bed of the wound had red granulation tissue. The removed coccyx wound dressing appeared to have red drainage, the wound appeared to be a stage 4 pressure wound and the bed of the wound was not observed in its entirety and slough tissue was present. LPN N then removed removed her gloves and immediately placed another pair of gloves no, without sanitizing her hands. LPN N was then observed to cleanse the right gluteal fold wound with normal saline and pat dry. LPN N was then observed to cleanse the coccyx wound with normal saline and pat dry. LPN N was then observed to remove her gloves and place on another pair of gloves without sanitizing her hands. LPN N then was observed to apply (with a tongue depressor) a mixture of Medihoney and Triad paste to the right gluteal fold wound bed and packed it with saline soaked gauze. LPN N was then observed to apply 4x4 optifoam dressing. LPN N was then observed to apply (with a tongue depressor) a mixture of Medihoney and Triad paste to the coccyx wound bed and then packed the wound with 0.25% dakins soaked gauzed. LPN N the was observed covering the coccyx wound with 6x6 optifoam dressing. LPN N was then observed to remove her gloves and assisted R60 to pull brief back up.
During an interview on 06/11/2025 at 04:24 p.m. Wound Nurse (WN) M explained that it was professional practice and appropriate infection control standards that resident wounds should be completed independently of each other. WM M also explained that it was professional practice and appropriate infection control standards that hands should be sanitized or washed after removing gloves and/or replacing gloves. WM M also explained that gloves should be changed at times between working with a soiled area of the wound and before applying treatments and covering the wounds.
During an interview on 06/11/2025 at 04:37 p.m. Director of Nursing (DON) B explained that it was professional practice and appropriate infection control standards that resident wounds should be completed independently of each other, not at the same time. She explained that the reason was so that cross contamination did not occur between the wounds. DON B also explained that it was professional practice and appropriate infection control standards that hands should be sanitized or washed after removing gloves and/or replacing gloves. DON B also explained that gloves should be changed at times between working with a soiled area of the wound and before applying treatments and covering the wounds. DON B was informed of what was observed during the dressing changes of R60's wounds. DON B expressed that LPN N did not follow appropriate professional practice and appropriate infection control standards for changing R60s' wounds. DON B could not explain why LPN N did not perform the R60s' dressing change while using professional practice and appropriate infection control standards.
Resident #70 (R70)
Review of the medical record demonstrated R70 was admitted to the facility 12/02/2024 with diagnoses that included encephalopathy (brain disorder affecting brain function), chronic obstructive pulmonary disease (COPD), enterocolitis (inflammation of the small intestines) due to clostridium difficile (bacterial infection of the colon), cancer of the larynx, chronic pain, neutropenia (low number of type of white blood cells), stroke, hemiplegia (paralysis or sever weakness) left side, hypoxemia (low oxygen levels), mood disorder, alcohol dependence, cocaine dependence, cannabis abuse, insomnia, depression, deviate nasal septum, contracture of left hand, contracture of left foot, hypertension, gastro-esophageal reflux, muscle spasms, tobacco use, hyperlipidemia (high fat content in blood), polyneuropathy (nervous system disorder affecting multiple areas of the body), and lymphedema (swelling causes by lymphatic system blockage). Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2025, reveal R70 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15.
During observation on 06/11/2025 at 01:50 p.m. R70s door was observed to have two signs on the closed door. First sign was observed to say Contact precautions. That sign stated:
A.
Perform hand hygiene before entering room and wash hands with soap and water before leaving the room.
B.
Wear gloves when entering room or cubicle, and whenever touching the patient's intact skin, surfaces, or articles in close proximity.
C.
Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces.
D.
Use patient-dedicated or single-sue disposable shared equipment or clean and disinfect shared equipment (BP cuff, thermometers) between patients.
The second sign on the door was observed to say STOP. That sign stated:
a.
No sick visitors
b.
Perform hand hygiene before entering and exit
c.
Gloves, Gown, Mask for Potentially Infectious Materials
d.
No fresh fruit or vegetables
e.
No flowers or potted plants
During observation and interview on 06/11/2025 at 01:51 pm. R70 was observed sitting up in a wheelchair. R70 explained that he was on contact isolation because he had C-Diff (clostridium difficile) and because he was receiving chemotherapy and radiation related to his cancer. R70 explained that most staff wear a gown and gloves. R70 could not answer if staff had been wearing mask when entering his room.
On 06/11/2025 at 02:07 p.m. Physical Therapy Assistant (PTA) R was observed to enter R70's room. PTA R was observed do have personal protective equipment (PPE) of gown and gloves, but no mask.
During an interview on 06/11/2025 at 02:08 p.m. Infection Preventionist (IP) Q confirmed that PTA R was R70s room without a mask. IP Q explained that R70 was supposed to be on protective isolation because he was immunocompromised related to his medical treatment of chemotherapy and radiation for his cancer diagnoses.
Review of R70s medical record revealed a physician order Protective Environmental Precautions for chemotherapy and radiation treatments every shift, written 06/10/2025.
During an interview on 06/12/2025 at 12:03 p.m. Physical Therapy Assistant (PTA) R explained that he was aware that R70 was on protective isolation. PTA R explained that he did have knowledge of and did in fact see the signs on R70's door. PTA R explained that he could not find a mask in the room and did not look any further for a mask. PTA R could not explain why he had not obtained a mask prior to entering R70's room.

Based on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant effecting 80 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and resident accidental falls and/or injury.
Findings include:
On 06/11/25 at 08:15 A.M., A common area environmental tour of the facility was conducted with Director of Maintenance (DM) E and Director of Environmental Services (DES) D. The following items were noted:
Nursing Station: Five sections of Formica laminate surface were observed (etched, scored, particulate, missing), within the interior lower-level desk surface edge. The five damaged sections of Formica laminate measured approximately 2-inches-wide by 1-inch-long, 3-inches-long, 4-inches-long, 8-inches-long, and 18-inches-long respectively.
A-Unit
Beauty Shop: 2 of 3 upholstered chairs were observed severely stained and discolored. (DES) D stated; We have discussed purchasing a fabric upholstery extractor.
B-Unit
Occupational Therapy/Physical Therapy: 2 of 4 rubber end caps were observed missing from the Parallel Bars. (DM) E stated: I not sure if I have rubber caps that large, if not, I will order some new ones.
On 06/11/25 at 09:30 A.M., An environmental tour of sampled resident rooms was conducted with (DM) E. The following items were noted:
A-17: The restroom commode support was observed loose-to-mount. The commode support could be moved from side to side approximately 2-4 inches. The commode seat was also observed (etched, scored, particulate). (DM) E stated: I will replace the entire assembly. The Bed 2 black clip fan was further observed soiled with accumulated and encrusted dust/dirt deposits.
B-2: The restroom commode support was observed loose-to-mount. The commode support could be moved from side to side approximately 2-3 inches.
C-2: The drywall surface was observed with three deep holes, adjacent to Bed 1.
C-4: The Bed 1 overbed light assembly lower 36-inch-long fluorescent bulb was observed non-functional. The pull string extension was also observed missing. The Bed 2 overbed light assembly was additionally observed non-functional. The pull string extension was further observed missing.
C-8: The restroom commode support was observed loose-to-mount. The commode support could be moved from side to side approximately 4-6 inches. (DM) E stated: I will have staff tighten the commode support as soon as possible. The drywall surface was observed (etched, scored, particulate), adjacent to Bed 2. The damaged drywall surface measured approximately 24-inches-wide by 24-inches-long.
C-10: The drywall surface was observed (etched, scored, particulate), adjacent to Bed 2. The damaged drywall surface measured approximately 24-inches-wide by 36-inches-long.
On 06/11/25 at 10:50 A.M., An interview was conducted with (DM) E regarding the facility maintenance work order system. (DM) E stated: We have the TELS program.
On 06/11/25 at 11:40 A.M., An environmental tour of sampled resident rooms was continued with (DM) E. The following items were noted:
D-6: The Bed 2 overbed light assembly actuation switch was observed broken. (DM) E indicated he would have staff replace the faulty switch as soon as possible.
D-12: The drywall surface was observed (etched, scored, particulate), adjacent to the closet and bathroom entrance door. The damaged drywall surface measured approximately 30-inches-wide by 30-inches-long.
On 06/12/25 at 08:00 A.M., Record review of the Policy/Procedure entitled: Physical Environment Preventative Maintenance dated 04/12/2021 revealed under Policy: Each facility will have a preventative maintenance program in place that scheduled preventative maintenance on equipment and the physical plant.
On 06/12/25 at 08:15 A.M., Record review of the Policy/Procedure entitled: Quality of Life Homelike Environment dated 07/11/2018 revealed under Policy: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
On 06/12/25 at 08:30 A.M., Record review of the Policy/Procedure entitled: Physical Environment Bathrooms dated 07/11/2018 revealed under Policy: Bathrooms shall be maintained in a clean and sanitary manner and shall be cleaned on a daily basis. Record review of the Policy/Procedure entitled: Physical Environment Bathrooms dated 07/11/2018 further revealed under Procedures: (1) Bathrooms, including showers, whirlpools, century baths, commodes, etc., will be cleaned daily in accordance with our established procedures.
On 06/12/25 at 08:45 A.M., Record review of the Policy/Procedure entitled: Housekeeping Guidelines dated 03/08/2021 revealed under Policy: To provide guidelines to maintain a safe and sanitary environment for residents, facility staff, and visitors.
On 06/12/25 at 09:00 A.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to install and maintain backflow protection devices and air gaps, resulting in the potential contamination of the facility potable water system, affecting all residents in the facility.
Findings include:
On 7/17/24 at approximately 9:50 AM, during an inspection of the kitchen, the drain lines of the three-compartment sink, were observed to not be provided with an air gap to prevent backflow of gas, liquid, and solid contaminants into the sink basins if a backflow event were to occur. Additionally, the vegetable and fruit preparation sink was observed to not be provided with an air gap in the drain line. At this time, Dietary Manager D confirmed the finding.
On 7/17/24 at approximately 9:55 AM, the steamer at the cookline was observed to not be provided with a backflow protection device to protect the potable water supply.
According to the 2017 FDA Food Code Section 5-203.14 Backflow Prevention Device, When Required. A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under § 5-202.13 P; or (B) Installing an APPROVED backflow prevention device as specified under § 5-202.14.
On 7/17/24 at 9:59 AM, the dietary mop sink was observed to have a wall mounted chemical dispenser connected to the water fixture. At this time, the water was on, using the chemical dispenser as a shut off valve, leaving the Atmospheric Vacuum Breaker (AVB) (a device commonly used in plumbing to prevent backflow of contaminated water into the potable water supply) under pressure. Leaving the AVB under pressure for a continuous amount of time can damage the integrity of the device, reducing the effectiveness of backflow protection.
According to the 2017 FDA Food Code Section 5-202.14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device. P
On 7/17/24 at 2:56 PM, during an inspection of the facility, the housekeeping office mop sink was observed to have a wall mounted chemical dispenser connected to the water fixture. The AVB was observed to be under pressure with the chemical dispenser used as a shutoff valve.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services per standards of practice, facility policy, and per physician's orders for one resident (Resident #575) of one resident reviewed for respiratory services. This deficient practice resulted in respiratory distresss, increased anxiety, missed doses of physician orders nebulizer treatments, and the potential to result in hypoxia [below-normal level of blood oxygen], and respiratory/medical decline with the potential to effect a total of five residents who had nebulizer treatments in the facility.
Findings include:
Review of the facility, Nebulizer (SVN) Policy, dated 7/11/18, reflected, It is the policy of this facility that Small Volume Nebulizer (SVN) treatments will be administered by licensed nurse and/or respiratory therapist, as ordered by a physician .Supplies: Oxygen delivery system or compressed air and connector tube-Nebulizer-Prescribed medication .
Resident #575 (R575)
Review of the Face Sheet dated 7/16/24, reflected R575 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease(COPD), hypertension (high blood pressure), lung cancer with mets, and leagally blind.
Review of R575 Nursing Progress Note, dated 7/15/24 at 5:45 p.m., reflected, Resident arrived via family car, with niece and son in accompany. Resident alertand oriented X4. Full code until DNR signed by Physician. Resident is legally blind. One assist with walker. Verbalizes needs well.
During an observation and interview on 7/16/24 at 11:07 AM, R575 was observed sitting upright in chair leaning forward, appeared short of breath, with oxygen via nasal canula attached to oxygen concentrator set at 3 liters. R575 able to answer questions without any congitive concerns with short responses related to short of breath. R575 room temperature felt warm and humid. R575 reported had admitted to the facility 7/15/24 (yesterday) around dinner time and was upset because facility had not yet provided her with required routine breathing treatments. R575 reported did not sleep well last night related to diffitulting in breathing. R575 reported being told by staff that the facility did not have nebulizer tubing available needed to administer medications.
Review of the Medication Administration Record(MAR), dated 7/15/24 through 7/16/24, reflected R575 had an order for, Budesonide Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation))1 vial inhale orally two times a day for COPD. The MAR reflected R575 missed two doses. Continued review of the MAR reflected R575 had an order for, pratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 unspecified inhale orally four times a day for COPD. The MAR reflected R575 had missed three ordered doses.
During an interview and observation on 7/16/24 at 11:30 AM, Regisered Nurse(RN) N reported nebulizer tubing was located in the storage room, located between Hall A and Hall B, and opened the door. RN N was observed looking through the entire room and reported was unable to locate any nebulizer tubing and reported central supply staff orders supplies.
During an interview and observation on 7/16/24 at 11:38 AM, Central Supply staff (CS) P reported was the facility central supply and reported was responsible for ordering oxygen tubing supplies. CS P reported resident tubing were changed every Monday so supply orders were placed on Tuesdays. CS P verified the facility did not have any nebulizer tubing supplies in the facility currently and reported would place an order for today after looking through supply room. CS P reported was not made aware the facility was out of nebulizer tubing supplies.
During an interview on 7/16/24 at 11:48 AM, R575 contuinued to be in room sitting upright and leaning forward with family in the room and appeared short of breath and able to answer questions with short answers related to breathing. R575 family was discussing with Unit Manager of possibly providing R575 with oral inhaler until oxygen company arrived with nebulizer tubing supplies. R575 family reported nebulizer treatments were more effective.
During an interview on 7/16/24 at 11:52 AM, RN O reported was informed by night nurse that R575 did not get ordered nebulizer treatments because the facility did not have nebulizer tubing equipment available in the building. RN O reported worked the day shift from 7am to 7pm did not call the physician today to notify of three missed nebulizer treatments today because the night nurse had reported had they notified the physician last night. RN O reported not yet assessed R575 respiratory status including lung sounds, respirations, or oxygen saturation since start of shift at around 7:00 a.m. RN O reported R575's last documented oxygen saturation was on 7/15/24 at 8:00 p.m. at 99%. RN O verified the facility did not have any nebulizer tubing equipment available currently.
During an interview on 7/16/24 at 12:01 PM, R575 continued to be in room with additional family at bedside. R575 family reported R575 arrived at the facility yesterday between 4:00 p.m. and 4:30 p.m. and routinely used two types of nebulizer treatments four times daily for COPD and had not yet received any since admission. At 12:06 p.m. R575 another family member had arrived with portable oxygen tank to take R575 home after R575 signed herself out against medical advice(AMA) because she was not receiving ordered breathing treatments. R575 family reported facility did not provide R575 with protable oxygen to move out of room and was at the facility for rehab. R575 continued to have difficulty answering questions related to difficulty in breathing and stated to family, I can't wait to get home to get a treatment.
During an interview and observation on 7/16/24 at 12:15 PM, Maintenance Director(MD) Q reported had worked at the facility for three years and monitors the facility temperatures monthly. MD Q entered R575 room and reported the current temperture by R575 bed, located by the hall door, was 77-78 degrees. MD Q reported the tempurature by the window bed was 75 degrees, located by the air conditioner unit, and the temperaure in the hall was 72 degrees.
During an observation on 7/16/24 at 12:17 p.m., observed R575 being assisted out of facility in wheelchair with portable oxygen on.
During an observation on 7/16/24 at 12:25 p.m., outside tempurture was around 85 degrees and very humid.
During an interview on 7/16/24 12:30 PM, Director of Nursing (DON) B reported R575 was only resident in facility who did not have nebulizer tubing. DON B reported staff exchange all oxygen equipment every mondays and oxygen company supplies facility on wednesdays. DON B verified had checked four other residents that required nebulizer treatments had all been changed and available yesterday. DON B reported this incident propted change in facility policy to have at least 40 nebulizer tubing equipment sets on hand at all times moving forward. DON B reported was not informed the facility was out of nebulizer tubing equipment because staff could have obtained supplies from another local facility and verified was present when R575 was admited.
During an interview on 7/16/24 at 3:35 PM, DON B reported nebulizer tubing equipment had been delivered and was available for use in facility currently.
During an interview on 7/17/24 at 4:05 pm, DON B reported would expect facility to have enough nebulizer tubing equipment on hand. DON B reported would expect staff to follow Physician orders and contact Physician if orders not followed. DON B reported would expect staff to complete respiratory assessment including if Physician ordered treatments were not available to administer and document in Electronic Medical Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to serve the appropriate food consistency for one (Resident 44) of three reviewed for therapeutic diets, resulting in the potential for aspiration and/or choking and continued weight loss. Findings include:
Resident #44 (R44)
Review of the admission Record reflected that Resident 44 (R44) was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficultly swallowing) and cerebral infarction (stroke). The quarterly Minimum Data Set (MDS) assessment, dated for 6/24/24, reflected that R44 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) (a cognitive screening tool). The MDS also reflected that R44 received a soft, bite sized texture for meals.
During an observation and interview on 07/16/24 01:58 PM, R44 was resting in bed and had a family member visiting. R44 explained that she had been experiencing some weight loss. R44 stated that she had a difficult time chewing her food and that she wished that her food, particularly the chunks of eggs and meat, were diced up into a finer consistency so that she was able to consume her meals. R44 stated that she received cottage cheese and yogurt for every meal, however, she loves hamburgers and would order a hamburger nearly every day. R44 stated that her food items come cut up into bite sized pieces, but she didn't feel that the cut up food was small enough for her to safely consume.
During an interview on 07/16/24 01:58 PM, Family Member (FM) L stated that since R44's stroke, she has had a difficult time chewing and swallowing her food. FM 44 stated that a family member or friend was present during meal times to ensure that R44 does not choke. FM L stated that choking is a constant worry for several family members. FM L confirmed that they were present for several meals and that R44's food was a cut up, bite sized consistency.
Review of R44's Electronic Medical Record revealed an active Physician's Order dated for 6/18/24 that reflected R44 was to receive an enhanced diet, soft and bite sized texture, honey like consistency for liquids.
R44's nutrition care plan, with an initiation date of 5/6/24, reflected that R44 had a nutritional problem related to a stroke, weight loss, decreased appetite and the need for an altered texture diet. The interventions included, but were not limited to, RD (Registered Dietician) to evaluate and makes diet change recommendations PRN (as needed)
Review of a Speech Language Pathologist Communication worksheet dated 7/2/24 revealed R44's diet had been downgraded form Soft and bite sized to a puree diet due to coughing and choking during meals.
In an interview on 7/17/24 at 1:57 PM, Certified Nursing Assistant (CNA) E reported that R44 received a soft and bite sized texture diet.
In an interview on 07/17/24 at 3:09 PM, FM M was visiting R44. FM M reported familiarity with R44 and stated that she came in and supervised during meal times for R44. FM M stated that when she comes in, she has to assist with cutting up R44's food to even smaller portions to ensure R44 can safely consume the food. R44 often ordered egg salad, however, the chunks of hard boiled egg were to large for R44 to consume so FM M would assist with cutting up the foods. FMM confirmed that R44 was not an a puree diet.
In an interview on 7/17/24 at 3:37 PM, Registered Dietician (RD) C stated that R44's current diet order was soft and bite sized foods. When asked to review the Speech evaluation dated 7/2/24, RD C stated that the speech evaluation stated that R44 was downgraded to the puree diet, however, that evaluation was missed. RD C confirmed that R44 should have a puree diet order on 7/2/24.
In an interview on 7/17/24 at 4:04 PM, Dietary Manager (DM) D verified that R44 currently had a soft and bite sized texture diet order in place. After review of the 7/2/2024 speech evaluation document, DM D verified that R44 should be on a puree diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00140043 and MI00139259.
Based on observation, interview, and record review, the facility failed to provide meals as planned and posted, in 2 of 11 residents reviewed for dining services (Resident #1 and #4), potentially affecting a census of 77 residents that received meal trays, resulting in decreased quality of life. Findings include:
During a lunch meal observation on 10/23/23 at 11:30 AM, a posting in the dining room indicated lunch was at 11:30 AM, at 11:47 AM no trays had been passed and no beverages were being offered or served, some residents were noted to have brought soda and water cups from their rooms.
Resident #1 (R1)
R1's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 15 (13-15 Cognitively Intact).
During an observation and interview on 10/23/23 at 12:50 PM, R1 stated meals were never ready at the scheduled times including the day of interview.
Resident #4 (R4)
R4's MDS dated [DATE] revealed she admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact).
During an observation on 10/23/23 at 12:05 PM R4 stated to residents dining at the same table that they didn't receive spaghetti as posted.
On 10/23/2023 at 9:30 AM, observed the posted menu in the dining room for 10/23/2023 had spaghetti with meat sauce for the main entrée at lunch and ham and swiss sandwich for the main entrée at supper. Alternate menus were placed at each table in the dining room.
During lunch service on 10/23/2023 at 11:40 AM, it was observed that the main entrée being served was bow tie pasta.
During an interview on 10/23/2023 at 11:40 AM, Certified Dietary Manager (CDM) D stated that they ran out of spaghetti so they decided to use bow tie pasta instead. Posted menu didn't reveal this change.
During an interview on 10/23/2023 at 10:30 AM, Dietary Staff (DS) F said that they don't have ketchup for alternate meals today. DS F also stated, sometimes we can't give alternates to residents since hot dogs don't have buns or condiments aren't available.
During an interview on 10/23/2023 at 10:30 AM, Dietary Staff (DS) G stated that they run out of food a lot. DS G said that sometimes they run out of hamburgers and hotdogs and they run out of bread every week.
During an interview on 10/23/2023 at 2:03 PM, Dietary staff (DS) H reported that things are on the menu and they run out of things and use substitutes.
During an interview on 10/23/2023 at 3:50 PM, DS H stated, This is what I mean. We have ham and swiss sandwich for dinner today and swiss cheese isn't available so I have to use a block of provolone cheese and cut it up which takes a lot of time.
On 10/23/2023 at 5:00 PM, observed posted menu for dinner was, Ham and Swiss Sandwich with no changes noted to the posted menu.
During an interview the week of the complaint survey from 10/23/223 to 10/24/2023, confidential staff (CS) I stated that sometimes the posted menu looks nice but the cook can't find the meat and had to figure out what to use instead. CS I stated, sometimes the residents go 2 to 3 days without juice, milk, coffee, bread and buns.
During an interview on 10/23/2023 at 4:24 PM, Dietary staff (DS) J stated that sometimes the food items aren't available to cook the meal. DS J stated that sometimes milk or bread aren't there but they are trying to figure it out.
During another interview on 10/23/2023 at 4:35 PM, CDM D said that menus should reflect changes that are made. CDM D said she doesn't typically change the posted menu when changes are made.
During an interview on 10/24/2023 at 10:30 AM, Area Manager (AM) C stated that they wanted to use provolone cheese for dinner since they had it on hand.
During an interview on 10/24/2023 at 10:35 AM, CDM D stated that they had spaghetti available in the back but the cook decided to use bow tie pasta since she thought it would be easier. CDM D said the provolone cheese was used instead of swiss cheese since it was on hand so swiss cheese wasn't ordered. She (CDM D) stated, I didn't realize I have to make sure we are serving exactly what is posted on the menu posted until now and it makes sense.

This citation pertains to MI00139259.
Based on observation, interview, and record review the facility failed to ensure proper label and dating of foods, documentation of food and beverage temperatures, and wearing of hair restraints with 77 residents receiving meals from the kitchen (1 resident receives nothing by mouth) resulting in increased the risk of contaminated foods and the risk of food borne illness.
Findings include:
During an initial tour of the kitchen on 10/23/2023 at 9:45 AM, the following was observed in the refrigerator:
Creamed corn in a pan, dated 10/18/2023 with no use by date
Opened package of hot dogs wrapped in saran wrap with no label and date
Opened block of cheese with no label and date
Opened block of ham with no label and date
Opened Sausage with no label and date
Opened Salad bag with no label and date
Opened sliced meat wrapped in saran wrap, dated 10/5/2023 with no label of what it was and no use by date
Hot dogs in shallow pan, covered with foil with no label or date
3 evening (HS) snacks dated from the previous night (10/22/2023) were sitting on a tray in the refrigerator
During the initial tour, the Certified Dietary Manager (CDM) D stated that the staff knew better and these items need to be thrown out and proceeded to throw all of them in the garbage.
Review of the Labeling and Dating Policy dated 2017 revealed, To decrease the risk of food borne illness and to provide the highest quality, foods are labeled with the date received, the date opened and the date by which the item should be discarded.
Review of the 2017 FDA Food Code revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.
(A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in ¶¶ (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.
Review of the production sheets dated 10/1/2023 to 10/23/2023 revealed missing temperatures for menu items and beverages on 10/1/2023, 10/4/2023, 10/6/2023, 10/7/2023, 10/8/2023, 10/9/2023 and 10/21/2023.
During an interview on 10/23/2023 at 10:10 AM, Dietary [NAME] (DC) E stated that she missed checking the temperatures on the meal on 10/21/2023 because she worked all day. DC E said that isn't an excuse but that's what happened.
During an interview on 10/23/2023 at 10:30 AM, Dietary Staff (DS) F stated that the cook checks the steam table temperatures before serving and the aides check the beverage and other items before serving.
On 10/23/2023 at 11:45 AM prior to lunch being served, it was observed that the dietary aides were checking the beverage temperatures and the cook was waiting by the steam stable. DC E stated that they only had 1 thermometer so she was waiting for the aides to check the temperatures of their items and then she could check the steam table temperatures.
During an interview on 10/23/2023 at 2:15 PM, CDM D stated that dietary staff should be checking temperatures for main entrée, beverages, and alternates that are served before every meal. CDM D said that the production sheets aren't consistent with recording temperatures from meal to meal and the dietary staff need education on what temperatures they need to obtain. CDM D stated that they have 2 other thermometers in the kitchen, and she said the staff should have gone into the kitchen to get another thermometer.
During the initial kitchen tour on 10/23/2023 at 9:45 AM, it was observed that CDM D was wearing her hairnet on half of her head with the front uncovered.
On 10/23/2023 at 11:45 AM it was observed that CDM D was behind the steam table during lunch service with her hairnet on half of her head with the front uncovered.
During an interview on 10/23/2023 at 2:15 PM, CDM D stated that hairnets need to be worn completely covering the head. She stated that her hairnet moves down sometimes and she will keep an eye on it or order different hairnets so it stays in place.
Review of the 2017 FDA Food Code revealed, 2-402.11 Effectiveness.
(A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE SERVICE and SINGLE-USE ARTICLES.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00140043.
Based on observation, interview and record review, the facility failed to honor food preferences in 5 of 11 residents reviewed for food preferences (Resident #1, #3, #4, #5, & #8), resulting in resident dissatisfaction and the potential for weight loss. Findings include:
During a lunch meal observation on 10/23/23 at 11:30 AM, a posting in the dining room indicated lunch was at 11:30 AM, the menu was posted in small print for entire week in the dining room. Lunch on 10/23/23 included spaghetti with meat sauce, Italian Blend Vegetables, Apple Crisp, Garlic Bread stick and beverage. At 11:47 AM no trays had been passed and no beverages were being offered or served, some residents were noted to have brought soda and water cups from their rooms. Residents were served meals on cafeteria like trays, the first resident was served their lunch at 11:56 AM.
Resident #1 (R1)
R1's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 15 (13-15 Cognitively Intact).
During an observation and interview on 10/23/23 at 12:50 PM, R1 was observed sitting in a wheelchair and stated meals were never ready at the scheduled times including the day of interview. R1 stated the facility ran out of oatmeal that morning, he had to have cold cereal instead of oatmeal because the facility was only allowed to make so much.
Resident #3 (R3)
On 10/24/23 at 9:19 AM, R3 stated meals were not always served on time in the dining room, they run out of the dressing she likes, foods from the always available menu weren't always available, and the food was cold most of the time.
Resident #5 (R5)
R5's MDS dated [DATE] revealed he admitted to the facility on [DATE], had a BIMS score of 15 (13-15 Cognitively Intact), and had the diagnoses of diabetes mellitus, high cholesterol and anemia.
On 10/23/23 R5's lunch was delivered on a tray at approximately 11:57 AM; R5 removed the items from the tray and placed tray on his walker seat.
R5 stated to residents sitting at the same table that he received carrots again and did not like carrots. Another resident sitting at the same table suggested R5 pick out the carrots from the vegetable blend he had received.
R5's food ticket was observed and indicated dislikes included carrots.
During an interview on 10/24/23 at 11:40 AM, R5 stated only one staff member was able to provide meals on time, otherwise meals were always late. R5 stated the facility had run out of ketchup recently; and run out of salt and pepper all the time. R5 stated the food was often cold and his likes and dislikes were not honored.
Resident #8 (R8)
R8's MDS dated [DATE] revealed she admitted to the facility on [DATE], had a BIMS score of 15 (13-15 Cognitively Intact).
During an interview on 10/24/23 at 7:40 AM, R8 stated dining services have been a problem since she admitted at the facility in March 2023. R8 stated the food was always cold, she didn't receive what she ordered, dining times vary, and the always available menu was not always available. R8 stated she had diabetes, and she always received a regular diet.
In review of Resident Council minutes dated 9/24/23, indicated concerns regarding meal trays for residents eating in their rooms and the always available menu.
In review of Resident Council meeting notes provided by Director of Nursing (DON) B on 10/23/23, from the meeting in the morning of the same day, revealed 6 residents requested to see the Dietician; and concerns regarding being out of oatmeal, not receiving toast with eggs, not sending preferences, and alternate menus not available.
Resident #4 (R4)
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R4 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 15 (score of 13-15 indicates cognitively intact).
During an interview on 10/24/2023 at 8:05 AM, R4 reported that when she wants something off the alternate menu she doesn't always get it because items are missing such as buns or condiments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide therapeutic diets as ordered in 2 of 11 residents reviewed for dietary services (Resident #8 & #11), resulting in risk of not meeting nutrition needs (Resident #11), and fluid overload (Resident #8). Findings include:
Resident #8 (R8)
R8's Minimum Data Set (MDS) assessment dated [DATE] revealed she admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 15 (13-15 Cognitively Intact).
During an observation and interview on 10/24/23 at 7:40 AM, R8 was seated in her wheelchair and stated dining services have been a problem since she admitted to the facility in March 2023. R8 stated the food was always cold, she didn't receive what she ordered, dining times varied, and the always available menu was not always available. R8 stated she had diabetes, and she always received a regular diet.
In review of R8's physician orders dated 9/25/23 a carbohydrate controlled, no added salt diet with regular texture, and an 1800 cubic centimeters (CC) fluid restriction were ordered.
In review of R8's care plans, a fluid restriction was not in the care plan. R8's Nutritional Status Risk care plan, revised 9/12/23, revealed she had the diagnoses of diabetes mellitus electrolyte imbalance, pressure injury to her left heel, and high potassium levels. R8's same care plan included inventions included to honor food preferences, provide and serve diet as ordered, to monitor intake and record every meal, and report changes in consumption to nurse and/or dietitian.
In review of R8's electronic medical record, there was no record of intake consumed per day.
In review of R8's dietary ticket, there was no information regarding her 1800 cc fluid restriction.
During an interview with Registered Dietician (RD) N on 10/24/2023 at approximately 2:00 PM he stated his contract started in middle of August 2023 and worked one to two days a week at the facility. RD N stated therapeutic diets were provided at the facility. RD N stated his last note regarding R8 was before the fluid restriction order and did not receive a notification of the 9/25/23 orders. RD N stated he would have calculated fluids provided at each meal and between meals, update the care plan and write a separate order with that dispersion. RD N stated he did not attend care conference meetings, the certified dietary manager attended resident care conference meetings.
Resident #11 (R11)
In review of R11's physician orders dated 9/25/23, a High Protein Renal diet, and soft and bite-sized texture were ordered; R11 had diagnosis of end stage renal disease.
In review of R11's care plans, he admitted to the facility on [DATE] and had a care plan dated 9/20/23 that indicated a nutritional problem or potential nutritional problem related to diet restrictions, oral intake fluctuations, swallow concern, history of weight loss prior to hospital and weight gain during hospitalization. The same care plan did not indicate R11 had a high protein renal diet ordered.
In review of R11's food ticket, R11's diet was listed as regular, and a high protein renal diet was not included.
Certified Dietary Manager (CDM) D was interviewed on 10/24/23 at approximately 2:00 PM and stated the facility offered therapeutic diets and did not think they had a resident with a high protein renal diet.
CDM D was interviewed on 10/24/23 at 3:00 PM and stated she was not aware R11 had an order for a high protein renal diet, and he had not received that diet.
Director of Nursing (DON) B was interviewed on 10/24/23 at 2:45 PM and 3:05 PM and stated she was not sure why the kitchen was not aware of R8's fluid restriction orders or R11's diet order; and stated the dietary and nursing electronic computer systems communicated with each other.
During an interview on 10/23/2023 at 12:40 PM, dietary staff (DS) G stated therapeutic diets are not served here. Renals and diabetics residents get the same food as everyone else.
During the week of the complaint survey, confidential staff (CS) I reported that the facility doesn't serve diabetic diets. CS I said that high sugar desserts are given to them.

This citation pertains to MI00140043.
Based on interview and record review, the facility failed to have recipes available based on the current census of 78 residents upon entrance with 77 residents receiving meals from the kitchen (1 resident received nothing by mouth) which could potentially result in insufficient food, dissatisfaction with the meal experience, decreased food acceptance and weight loss.
On 10/24/2023 at 7:40 AM, reviewed recipe book which revealed 3 columns, each for 75 servings of food. No other serving sizes were noted on the recipes.
During an interview on 10/24/2023 at 10:50 AM, Dietary [NAME] (DC) H stated that she knows to increase the recipe from 75 in the book by at least 10 since some residents ask for extra servings of food and some residents get double portions. She said she knows how to increase the recipe since she was the normal morning cook.
During an interview on 10/24/2023 at 10:52 AM, Area Manager (AM) C stated that's the way the recipes are printed in the system. AM C stated the census had been below 75 and was at 79 right now. Certified Dietary Manager (CDM) D stated that cooks just need to increase the recipe since they get a census tally sheet daily. When asked how someone new to cooking would know how to cook for a census greater than 75, CDM D said they just increase it. When asked again about how they know by how much they need to increase each part of the recipe, CDM D said that she wasn't sure.
Review of the detailed census report from 10/1/2023 to 10/24/2023 revealed a census of 79 on 10/23/2023 and 10/24/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to promote dignity during meals in 5 of 11 residents reviewed for dietary services (Resident #3, #4, #5, #9 & #10), resulting in decreased quality of life and an unhomelike dining experience. Findings include:
During a lunch meal observation on 10/23/23 at 11:30 AM, a posting in the dining room indicated lunch was at 11:30 AM. At 11:47 AM no meals had been passed and no beverages were being offered or served in the dining room; some residents were noted to have brought soda and water cups from their rooms. Residents were served meals on cafeteria like trays, the first resident was served their lunch at 11:56 AM.
Resident #3 (R3)
R3's Minimum Data Set (MDS) assessment dated [DATE] indicated she admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 06 (00-07 Severely Cognitively Impaired).
R3's Nutrition risk/risk for dehydration care plan, revised 9/12/23 revealed she had multiple medical conditions including dysphagia, Alzheimer's dementia, depression, diabetes mellitus, lung disease, varied oral intake, advanced age, and history of weight loss. The same care plan indicated R3's diet was Regular, Pureed, and with Honey-thick liquids.
R3's Care plan dated 11/22/19 indicated she was resistive/noncompliant with treatment/care (thickened liquids) and had behavior of removing coffee cups from other resident dining room tables. The intervention for R3's behavior was to redirect resident for appropriate liquid texture cup of coffee when she exhibited desire to have coffee cups/attempting to obtain coffee cups from other resident tables.
During an observation of the lunch meal in the dining room on 10/24/23 at 11:35 AM, R3 was sitting at a table with 4 other residents. Staff offered coffee to all the residents sitting at the table, except R3. R3 received coffee on her lunch tray that was delivered later.
Resident #4 (R4)
R4's MDS dated [DATE] revealed she admitted to the facility on [DATE] and had a BIMS score of 15 (13-15 Cognitively Intact).
During an interview on 10/24/23 at 11:45 AM R4 stated the facility trays were warped and wobble when cutting food, making it hard to eat off them.
Resident #5 (R5)
R5's MDS dated [DATE] revealed he admitted to the facility on [DATE], had a BIMS score of 15 (13-15 Cognitively Intact), and had the diagnoses of diabetes mellitus, high cholesterol and anemia.
On 10/23/23 R5's lunch was delivered on a tray; R5 removed the items from the tray and placed tray on his walker seat.
During an interview on 10/24/23 at 11:40 AM, R5 stated he preferred to not to eat his meals on a tray and was later observed removing dishes from the tray to his table.
Resident #9 (R9)
R9's MDS assessment dated [DATE] revealed a BIMS score of 02 (00-07 Severe Impairment). The same MDS revealed R9 required substantial/maximal assistance (helper provided more than half the effort) for eating (ability to use suitable utensils to bring food to the mouth and swallow food once the meal was presented on a table/tray).
During a lunch observation in the dining room on 10/24/23, R9's lunch was delivered on a tray. R9's visitor attempted to cut up R9's chicken and the tray was sliding on the table. R9's visitor then removed R9's dishes from the tray and was able to cut the chicken for R9.
Resident #10 (R10)
R10's MDS dated [DATE] revealed he was admitted to the facility on [DATE], had a BIMS score of 07 (00-07 Severely Impaired), and required substantial/maximal assistance for eating.
During lunch observation on 10/24/23, all 3 residents sitting at R10's table were served lunch. R10 was observed waving at staff and asking for his lunch. R10 was the last person served in the dining room, a staff member moved R10 to another table and assisted him with his meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00139259.
Based on observation, interview and record review, the facility failed to provide meals at scheduled times, in 3 of 11 residents reviewed for dining services (Resident #1, #3, & #5), potentially affecting 77 residents receiving meals from the kitchen (1 resident received nothing by mouth) , resulting in decreased quality of life, and the potential for weight loss and depression. Findings include:
Resident #1 (R1)
R1's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 15 (13-15 Cognitively Intact).
During an observation and interview on 10/23/23 at 12:50 PM, R1 stated meals were never ready at the scheduled times including the day of interview.
Resident #3 (R3)
R3's Minimum Data Set (MDS) assessment dated [DATE] indicated she admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home residents, score of 06 (00-07 Severely Cognitively Impaired).
R3's Nutrition risk/risk for dehydration care plan, revised 9/12/23 revealed she had multiple medical conditions including difficulty swallowing, Alzheimer's dementia, depression, diabetes mellitus, lung disease, varied oral intake, advanced age, and history of weight loss. The same care plan indicated R3's diet was Regular, Pureed, and with Honey-thick liquids.
On 10/24/23 at 9:19 AM, R3 stated meals were not always served on time in the dining room, they run out of the dressing she likes, foods from the always available menu weren't always available, and the food was cold most of the time.
Resident #5 (R5)
R5's MDS dated [DATE] revealed he admitted to the facility on [DATE], had a BIMS score of 15 (13-15 Cognitively Intact), and had the diagnoses of diabetes mellitus, high cholesterol and anemia.
During an interview on 10/24/23 at 11:40 AM, R5 stated there was only one staff member that was able to deliver meals on time, otherwise meals are always late. R5 stated the food was often cold.
On 10/23/2023 at 11:30 AM, observed mealtime posting in the dining room: Breakfast at 7:30 AM, Lunch at 11:30 AM, Dinner at 5:30 PM. Hall cart times were not posted on the sheet.
On 10/23/2023 at 11:40 AM, observed dietary staff were still getting ready for lunch. Dietary [NAME] (DC) E said she was waiting to talk to the Certified Dietary Manager (CDM) D because she didn't have the proper utensils to serve since they just switched to a new menu.
On 10/23/2023 at 11:45 AM it was observed that the dietary aides were checking the beverage temperatures and the cook was waiting by the steam stable. DC E mentioned that they only had 1 thermometer so she was waiting for the aides to check the temperatures of their items and then she could check the steam table temperatures.
During an interview on 10/23/2023 at 2:15 PM, CDM D stated that they have 2 other thermometers in the kitchen, and she said the staff could have gone into the kitchen to get another thermometer.
On 10/23/2023 at 12:01 PM, observed lunch service started in the main dining room. The last hall tray went down the hall at 1:02 PM.
During an interview on 10/23/2023 at 10:30 AM, Dietary Staff (DS) F reported that sometimes on weekends there was only 1 aide all day which puts things behind in the kitchen and then with meal service.
During an interview on 10/23/2023 at 10:30 AM, Dietary Staff (DS) G stated that there was so much work to do and sometimes she wasn't out until 5pm. DS G also said since there was only 1 aide in the evenings, the evening aide gets out late and didn't get out until midnight the other day.
During an interview the week of the complaint survey from 10/23/2023 to 10/24/2023, confidential staff (CS) I stated that it was a very stressful environment to work in since there wasn't enough help to get meals out on time. CS I said she bought paper plates and plastic utensils a few times to help herself to get the meals out on time.
During an interview on 10/24/2023 at 9:00 AM, Certified Nursing Assistant (CNA) K reported that mealtimes vary since they serve the dining room first and then they rotate the first hall trays to a different hall each day so it's hard to know when they are coming or if they are on time or not.
On 10/24/2023 at 9:05 AM, CDM D stated that she wasn't aware that the last lunch hall trays went down the hall at 1 pm on 10/23/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00138570.
Based on observation, interview, and record review, the facility failed to provide care planned interventions to maintain functional strength to prevent falls, in one of three reviewed for falls (Resident #1), resulting in multiple falls and injuries including a fracture. Findings include:
Resident #1 (R1)
R1 was observed sitting in her wheelchair on 9/06/23 at 10:55 AM.
R1's Minimum Data Set (MDS) dated [DATE] indicated she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a brief performance-based cognitive screener, score of 04 (00-07 Severe Impairment). The same MDS indicated R1 required extensive assistance of one person for transfers.
Incident Report dated 3/08/23 at 7:01 AM indicated R1 lowered herself to the floor from her wheelchair. Witness statements dated 3/07/23 indicated R1 fell on 3/07/23 at 11:00 PM when attempting to transfer self. Progress note dated 3/08/23 at 8:51 PM revealed R1's family stated R1 thought she could do things on her own and would not ask for assistance. The same note indicated R1's physician was reviewing R1's medications.
Incident Report dated 4/18/23 at 4:03 PM indicated R1 was observed sitting on a pillow and scooting out to the hallway; and prior to incident had been observed resting in bed. The same report indicated the plan was to keep R1's wheelchair within reach and have physical therapy evaluate.
R1's Physical Therapy Discharge summary dated [DATE], revealed she had received physical therapy services following a fall at the facility. R1 had a history of Alzheimer's Dementia, Depression, Peripheral Neuropathy (nerve damage), and orthostatic hypotension (blood pressure changes when moving from lying to sitting or sitting to standing position). The same discharge summary indicated R1's gait was not functional and should be completed with 2 assist if done by nursing with high top tennis shoes and would benefit from attending exercise based activity programming and recumbent cross trainer bike with staff assist to get on and off the machine. The same note recommended R1 use a recumbent cross trainer three times a week as tolerated.
R1's activities of daily living (ADL) care plan dated 6/04/21, indicated the nurse assistant/nurse were to assist R1 in use of recumbent cross trainer for 10 minutes. In review of R1's care plans, walking with 2 assist with high top tennis shoes or any walking program was not on any of R1's care plan's in order to maintain functional status gained from physical therapy.
Incident Report dated 5/19/23 at 3:50 PM indicated R1 had been observed on the floor in her room.
Incident Report dated 5/27/23 at 4:47 PM revealed R1 was observed crawling on the floor in her room and wanted to get into her wheelchair.
Nurses Note dated 5/28/23 at 2:47 PM revealed R1 had a fall on 5/28/23 at 6:13 PM and was seen by the nurse assistant crawling on the floor in her room next to her bed. The same note revealed R1's care plan was reviewed. The same note revealed a nurse assistant that worked on second and third shift, reported R 1 was restless in the evening time, typical to behavior; and she had a pattern of falling around those times. The same note indicated the intervention to prevent future falls was to refer to Primary Physician or Nurse Practitioner (NP) for a medical review and possible need for any pharmacological interventions.
Incident Report dated 7/02/23 at 7:20 AM revealed R1 was found sitting on the floor next to her bed with a laceration above her left eyebrow. The same report indicated R1 had fell when getting up from her bed. R1 was unable to answer questions including her name, where she was or what year it was. R1 was transferred to the emergency department and a computed tomography (CT) scan was obtained. CT scan dated 7/02/23 at 7:50 AM revealed a supraorbital (above eye) scalp hematoma (blood collects under skin forming a lump) and a new mildly displaced fracture of the right nasal bone as well as an old healed right clavicle (collarbone) fracture.
Incident Report dated 7/23/23 at 11:08 PM revealed R1 was observed on the floor at the side of her bed sitting on top of pillows.
Incident Report dated 8/02/23 at 6:00 PM revealed R1 fell at nurses station from her wheelchair. A medication review was included on the same report to prevent further occurrences.
Incident report dated 8/17/23 at 10:24 PM revealed R1 was observed on the floor in the hallway lying partially on her side; R1 reported she had hit her head. A hematoma was noted on R1's forehead.
Physician Progress Note date 8/22/23 at 12:07 PM indicated since R1's fall on 8/17/23, she had not attempted to get out of bed and was not able to feed herself. R1 was noted with lethargy and followed minimal commands.
8/23/23 at 3:57 PM indicated R1 was transferred to the emergency department due to facial rash and nonspecific skin eruption; it was unclear if the rash was due to the bruise on her forehead versus the rash around her nose and mouth. The same notes indicated a repeat CT scan was obtained and lubricating lotion was recommended for her rash.
Director of Nursing (DON) B was interviewed on 9/07/23 at 2:39 PM and stated the facility did not have a restorative nursing program and the nurse assistants were responsible in providing restorative care. DON B stated in the same interview that only therapy staff assist residents with using the recumbent cross trainer machine. DON B stated in the same interview the interdisciplinary team did not consider a beveled edge walkable floor mat next to R1's bed as a intervention to prevent injury from falls because they did not have those kinds of fall mats at the facility.
Physical Therapist (PT) C was interviewed on 9/07/23 at 3:32 PM and stated therapy did not assist residents with the recumbent cross trainer machine after discharged from therapy. PT C stated in the same interview that nursing was responsible for assisting R1 with the recumbent cross trainer machine recommended by therapy following her discharge from physical therapy.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 73 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.
Findings include:
On 05/03/23 at 09:15 A.M., An initial tour of the food service was conducted with General Manager of Nutritional Services C and Registered Dietician (RD) D. The following items were noted:
The Vulcan convection oven(s) interior and exterior surfaces were observed heavily soiled with accumulated and encrusted food residue.
The Vulcan conventional oven(s) interior and exterior surfaces were observed soiled with accumulated and encrusted food residue.
The Vulcan conventional stove top backsplash was observed heavily soiled with accumulated and encrusted food residue.
The Vulcan griddle backsplash and side guards were observed heavily soiled with accumulated and encrusted food residue. General Manager of Nutritional Services indicated she would have dietary staff thoroughly clean and sanitize the convection and conventional oven(s) interior and exterior surfaces as soon as possible.
The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
On 05/08/23 at 11:45 A.M., Record review of the Policy/Procedure entitled: Kitchen Sanitation dated 03/2021 revealed under Purpose: To promote a clean, safe, and effective environment and to prevent the transmission of disease-carrying organisms. Record review of the Policy/Procedure entitled: Kitchen Sanitation dated 03/2021 further revealed under Policy: Food and Nutrition Services maintains a comprehensive kitchen sanitation program and current Safety Data Sheets for approved chemicals used in cleaning and sanitizing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #28 (R28):
Review of the medical record reflected R28 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, adult failure to thrive, chronic kidney disease and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/15/23, reflected R28 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R28 required extensive assistance of one person for many activities of daily living, including but not limited to bed mobility, transfers, walking in the room, locomotion on and off the unit. R28 was not coded as having any wounds.
R28's medical record reflected a wound to the left foot, documented as an open lesion as of the most recent assessment on 5/5/23. The wound was documented as measuring 0.4 centimeters (cm) in length by (x) 0.5 cm in width. There was no documentation pertaining to the appearance of the wound bed.
During an observation that began on 05/10/23 at 9:09 AM, Licensed Practical Nurse (LPN) S was observed to perform wound care with the assistance of LPN T for resident positioning. Wound care supplies included normal saline, Santyl ointment, kerlix (wrap), ABD pad, tape and cotton tipped applicators. R28 was seated in her wheelchair, in her room. LPN S and LPN T performed hand hygiene and donned (put on) gloves. LPN T removed R28's gripper sock, and the old dressing, dated 5/9/23, was removed from R28's foot. A wound was observed to the bottom of R28's left foot. LPN S removed her gloves, performed hand hygiene and donned new gloves. LPN S cleansed the wound with normal saline, blotted it dry with gauze and used a cotton tipped applicator to apply Santyl to the wound bed. An ABD pad was applied and secured with kerlix and tape. LPN S did not remove her gloves or perform hand hygiene between cleansing the wound and applying the new treatment and dressing.
After the treatment was completed, LPN S was asked when hand hygiene would be performed with wound care. LPN S reported hand hygiene was to be performed before wound care, after removing the (old) dressing, after cleansing the wound and after wound care. LPN S acknowledged that she should have performed hand hygiene after cleansing the wound, prior to placing the new dressing but did not.
During an interview on 5/10/23 at 2:18 PM, Registered Nurse Unit Manager (RN) V reported hand hygiene with wound care should be performed before, during and after. After cleansing the wound, hand hygiene should have been performed prior to application of the new dressing.
Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene practices during wound care for one (Resident #28) and proper catheter tubing placement for one (Resident #34) of 18 reviewed for infection control practices, resulting in the potential for cross contamination, the spread of infection and delayed wound healing.
Findings Include:
Resident #34
Review of an admission Record revealed Resident #34 (R34) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included acute cystitis with hematuria, disorder of the muscle, bradycardia (slow heart rate), hearing loss, syncope, and dementia. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/29/23, reflected R34 scored nine out of 15 (moderately cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R34 required extensive of one person for toileting, transferring, and bed mobility.
Review of a Physicians Order dated 1/30/23 revealed R34 had an order to maintain Foley Catheter .for Urinary retention every shift.
In an observation on 05/08/23 at 12:48 PM, R34 was resting in bed with her eyes closed. Approximately 5 inches of R34's Urinary Foley Catheter tubing was observed on the floor.
In an observation on 05/09/23 at 10:14 AM, R34 was in bed with her eyes closed. Approximately 10 inches of R34's Urinary Foley Catheter tubing was observed on the floor.
According to the Electronic Medical Record, R34 was recently diagnosed with a Urinary Tract Infection and had just completed antibiotic treatment for the Urinary Tract Infection.
In an observation on 5/9/23 at 11:29 AM, R34 was restring in bed with her eyes closed. Approximately 12 inches of the Urinary Foley Catheter tubing was observed resting on the floor.
In an interview on 05/09/23 at 11:55 AM, infection Control Registered Nurse (RN) V reported that catheter tubing on the floor is not something she would like to see, and it is against proper infection control methods for Urinary Catheters.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 73 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.
Findings include:
On 05/04/23 at 08:45 A.M., A common area environmental tour was conducted with Director of Maintenance E and Environmental Services Director F. The following items were noted:
Service Corridor
Staff Break Room: The vinyl base coving was observed missing on 1 of 4 wall surfaces. The missing vinyl base coving measured approximately 16-feet-long. Director of Maintenance E indicated he would make necessary repairs as soon as possible.
A-Hall
Beauty Shop: Two 24-inch-long by 24-inch-wide acoustical ceiling tiles were observed stained from a previous moisture leak.
B-Hall
Soiled Utility Room: The two-door hand sink vanity base was observed etched, scored, bowed, and particulate. The vanity base lower shelf board was also observed severely warped and bent. Director of Maintenance E stated: We plan to replace the vanity base soon.
C-Hall
Fall Prevention Storage Room: The room was observed in severe disarray. Fall prevention devices were stored and scattered throughout the room.
Soiled Utility Room: The two-door hand sink vanity base was observed etched, scored, bowed, particulate. The vanity base lower shelf board was also observed severely warped and bent.
D-Hall
Two 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from previous moisture leaks, adjacent to the facility mail room entrance.
Shower Room: A 9-inch-wide by 48-inch-long section of ceramic tile squares was observed cracked and broken in the shower stall.
Hazardous Waste Storage Room: The entrance door lockset was observed severely bent and warped. The perimeter vinyl coving base was also observed missing. The missing vinyl coving base measured approximately 9-feet-long.
Multi-Purpose Room: The accordion door was observed exceedingly difficult to close. The upper mounting track and glides were also observed functioning poorly. One of four tables were also observed rocking and unlevel.
On 05/04/23 at 10:15 A.M., An interview was conducted with Environmental Services Director F regarding the facility maintenance work order system. Environmental Services Director F stated: We have a manual work order form and system. Environmental Services Director F also stated: The work order forms are completed and attached to the Director of Maintenance's office door for processing.
On 05/04/23 at 12:15 P.M., An environmental tour of sampled resident rooms was conducted with Environmental Services Director F. The following items were noted:
A-5: The Bed 1 overbed light assembly switch was observed broken.
A-9: The restroom commode support was observed loose-to-mount. The commode support could be moved from side to side approximately 4-6 inches. The restroom interior door surface was also observed etched, scored, particulate.
B-7: The Bed 2 overbed light assembly switch was observed broken.
C-4: The Bed 1 lower 48-inch-long fluorescent light bulb was observed non-functional.
C-8: The restroom hand sink faucet aerator was observed partially obstructed and mineralized with calcium and lime deposits.
D-1: The exterior window screen was observed worn and torn. The damaged window screen opening measured approximately 3-inches-wide by 3-inches-long. The Bed 2 drywall surface was also observed etched, scored, particulate. The damaged drywall surface measured approximately 2-feet-wide by 6-feet-long. The restroom hand sink faucet assembly was further observed loose-to-mount.
D-3: The window screen was observed worn and torn. The damaged window screen measured approximately 1-inch-wide by 3-inches-long. The restroom hand sink faucet assembly was also observed loose-to-mount.
D-10: The Bed 2 overbed light assembly upper 48-inch-long fluorescent light bulb was observed non-functional. Environmental Services Director F indicated she would have maintenance replace the faulty bulb as soon as possible.
D-15: The drywall surface was observed etched, scored, particulate, adjacent to Bed 1. The damaged drywall surface measured approximately 6-inches-wide by 30-inches-long.
D-16: The restroom commode support was observed loose-to-mount. The commode support could be moved from side to side approximately 4-6 inches. The drywall surface was also observed etched, scored, particulate, adjacent to the Bed 1 headboard.
On 05/08/23 at 08:00 A.M., Record review of the Manual Maintenance Work Order Form revealed the following: (1) Date, (2) Department, (3) Work Requested By, (4) Priority (Urgent, High, Medium, Low), (5) Location, (6) Description, (7) Date Repair Completed, and (8) Completed By.
On 05/08/23 at 08:30 A.M., Record review of the Policy/Procedure entitled: Patient Care Services/Non-Clinical Unit: Environmental Services Scope of Service 2023 dated (no date) revealed under Purpose: The Environmental Services Department provides a wide range of services for our customers providing an aseptic, sanitary, and attractive environment. Environmental Services will reduce and control the spread of germs; to provide a clean, orderly, safe, and friendly environment for our patients, visitors, and employees; to achieve a high level of patient satisfaction; to grow our staff and leadership through training, education, coaching, and recognition. Record review of the Policy/Procedure entitled: Patient Care Services/Non-Clinical Unit: Environmental Services Scope of Service 2023 dated (no date) further revealed under Goals: Exceed expectations. Maintain a clean, safe, and disinfected environment.
On 05/08/23 at 09:00 A.M., Record review of the Manual Maintenance Work Order Forms for the last 30 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on interview and record review, the facility failed to accurately track and document staff COVID-19 vaccination status and implement a process ensuring all staff were fully vaccinated for COVID-19, resulting in an inaccurate vaccination matrix, staff who were not vaccinated or partially vaccinated, and the potential for the transmission of COVID-19.
Findings include:
Review of the facility's Infection Control Manual: Chapter 10 Screening and Vaccinations revealed Both the annual influenza vaccine and the COVID-19 vaccines are mandatory for employees unless the individual has an approved medical contraindications or an approved religious exemption.
Review of the COVID-19 Staff Vaccination Status for Providers provided by NHA A on 5/3/23 at 10:36 AM revealed the facility had 89 total staff of which 5 were partially vaccinated, 73 completely vaccinated, 0 pending exemptions, 8 granted exemptions, 9 were temporary delay/new hire, and 3 were not vaccinated without exemption/delay.
Review of the COVID-19 Staff Vaccination Status for Providers provided by NHA A on 5/4/23 at 3:49 PM and labeled as corrected form. The matrix revealed 90 total staff of which 5 were partially vaccinated, 73 were completely vaccinated, 5 had pending exemptions, 4 had granted exemptions, 0 temporary delay/new hire, and 3 were not vaccinated without exemption/delay.
Review of the COVID-19 Staff Vaccination Status for Providers provided by NHA A on 5/8/23 at 11:06 AM and labeled as corrected info revealed the facility had 90 total staff of which 5 were partially vaccinated, 73 completely vaccinated, 0 pending exemptions, 9 granted exemptions, 0 temporary delay/new hire, and 3 not vaccinated without exemption/delay. This calculated as 91.1% of staff vaccinated.
Certified Nursing Assistant (CNA) H was hired 3/28/23 and was marked for unvaccinated without exemption or delay. On 5/10/23 COVID-19 vaccination/exemption information was requested for CNA H. The facility provided a Request for a Religious Exemption to the COVID-19 Vaccination Requirement. The form had CNA H's typed name in the signature line and was dated 5/10/23. The questions on the form were not filled out.
The COVID-19 Staff Vaccination Status for Providers also listed CNA M and Registered Nurse (RN) N as unvaccinated without exemption or temporary delay. When COVID-19 vaccination/exemption information was requested for CNA M and RN N, the facility provided vaccination cards reflecting both staff were fully vaccinated for COVID-19.
CNA J was hired on 10/19/22 and was listed as partially vaccinated on the COVID-19 Staff Vaccination Status for Providers. Review of the COVID-19 Vaccination Record Card revealed CNA J received one dose of a two-dose series COVID-19 vaccination on 8/1/22. CNA J was eligible for the second dose.
Payroll Clerk (PC) I was hired on 1/9/23 and was listed as partially vaccinated on the COVID-19 Staff Vaccination Status for Providers. Review of PC I's vaccination history revealed PC I received one dose of a two dose series COVID-19 vaccination on 1/26/23. PC I was eligible for the second dose.
The COVID-19 Staff Vaccination Status for Providers listed three more staff as partially vaccinated, but in fact those staff had either been fully vaccinated or had an approved religious exemption on file.
Review of the timecards for CNA H, CNA J, and PC I revealed all three staff had worked multiple times in the last four weeks.
In an interview on 05/10/23 at 2:46 PM, Human Resources Director (HRD) G reported she tracked staff COVID-19 vaccinations. HRD G reported new hires were required to provide a copy of their COVID-19 vaccinations or request an exemption. HRD G reported staff were responsible for tracking when their second dose of a two-dose series was due. HRD G reported CNA H filled out the religious exemption on 5/10/23 after CNA H's vaccination information was requested by the survey team. HRD G agreed that none of the questions on the exemption form were completed. HRD G reported PC I received his first dose of a two-dose series at the facility and did not think he needed the second dose. HRD G reported she believed CNA J was fully vaccinated because it was a requirement for a class she attended in March. HRD G reported CNA J had not yet brought in proof of the second dose of the two-dose series. HRD G reported the staff were notified on 5/10/23 that they would have to provide proof of being fully vaccinated.
Review of the COVID-19 Staff Vaccination Status for Providers provided by HRD G on 5/10/23 at 1:51 PM revealed 90 total staff of which 2 were partially vaccinated, 77 completely vaccinated, 0 pending exemptions, 11 granted exemptions, 0 temporary delay/new hire, and 0 not vaccinated without exemption/delay. This calculated as 93.3% of staff vaccinated.
Review of the facility's Mandatory COVID-19 Vaccination Policy dated 11/19/21 and reviewed/revised 11/15/22 revealed employees must be fully vaccinated with COVID-19 vaccination. Employees are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defied here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. Employees may request an exemption from mandatory vaccination if the vaccine is medically contraindicated for them or medical necessity requires a delay in vaccination. Employees also may be legally entitled to a reasonable accommodation if they cannot be vaccinated and/or wear a face covering (as otherwise required by this policy) because of a disability, or if the provisions in this policy for vaccination, and/or testing for COVID-19, conflict with a sincerely held religious believe, practice, or observance. Requests for exemptions must be initiated by completing the Request for a Medical Exemption to the COVID-19 Vaccination Requirement for, or the Request for a Religious Exemption to the COVID-19 Vaccination Requirement form .Employees and volunteers are required to provide proof of COVID-19 vaccination. Employees are required to provide proof of COVID-19 vaccination and any boosters that employees may receive to their local HR .Employees/Volunteers who are partially vaccinated (i.e., one dose of a two dose vaccine series) submit proof of vaccination that indicates when the first dose of vaccination was received, followed by proof of the second dose when it is obtained .All new employees are required to comply with the vaccination requirements (as defined by CMS and recommended by the CDC) outlined in this policy as a condition of employment.
If vaccinated, new hires submit proof of vaccination that indicates dates of dose(s) to their local HR designee. If not vaccinated upon hire, new employees receive their first dose of vaccination or begin the exemption process (see Section IV. EXEMPTIONS) prior to providing any care, treatment, or other services for a [name of corporation] facility and/or its patients. The HR designee tracks completion.
Review of the Request for a Religious Exemption to the COVID-19 Vaccination Requirement revealed To request a religious exemption or delay from the COVID-19 vaccination requirement using this form: 4. The employee must complete the questions on this form. 5. The employee must submit the form to your agency's designated point of contact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to 1) ensure Do-Not-Resuscitate (DNR) documents were accurately and completely filled out for three (Resident #11, #28 and #42) of three reviewed; and 2) ensure updated and accurate letters of Guardianship were in the medical record for one (Resident #42) of one reviewed, resulting in the potential for code status wishes not being followed in an emergency situation and medical decisions not to be made by the legal Guardian of record.
Findings include:
Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 reflected, .An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons:
(a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant.
(b) The declarant's attending physician.
(c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir.
(3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence .
Further review of this Act reflected, .Sec. 4. A do-not-resuscitate order executed under section 3, 3a, or 3b must include, but is not limited to, the following language, and must be in substantially the following form:
DO-NOT-RESUSCITATE ORDER
This do-not-resuscitate order is issued by _______________________________________, attending
physician for _________________________________________.
(Type or print declarant's, ward's, or minor child's name)
Use the appropriate consent section below:
A. DECLARANT CONSENT
I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import.
_______________________________________ _______________
(Declarant's signature) (Date)
_______________________________________ _______________
(Signature of person who signed for declarant, if applicable) (Date)
_______________________________________
(Type or print full name)
B. PATIENT ADVOCATE CONSENT
I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law.
_______________________________________ _______________
(Patient advocate's signature) (Date)
_______________________________________
(Type or print patient advocate's name) .
D. GUARDIAN CONSENT
I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law.
_______________________________________ _______________
(Guardian's signature) (Date)
_______________________________________
(Type or print guardian's name)
_______________________________________ _______________
(Physician's signature) (Date)
_______________________________________
(Type or print physician's full name)
ATTESTATION OF WITNESSES
The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not)received an identification bracelet.
________________________________ ________________________________
(Witness signature) (Date) (Witness signature) (Date)
________________________________ ________________________________
(Type or print witness's name) (Type or print witness's name)
THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE
MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT .
(https://www.legislature.mi.gov/(S(izncxegpu4xl2mqzb3v3ru45))/documents/mcl/pdf/mcl-Act-193-of-1996.pdf)
Resident #11 (R11):
Review of the medical record reflected R11 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction, flaccid hemiplegia affecting left non-dominant side and unspecified intellectual disabilities. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/24/23, reflected R11 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R11 did not walk and required extensive assistance of one to two or more people for most activities of daily living.
Review of R11's DNR documents reflected R11, their Resident Representative and two witnesses signed the DNR with a date of 12/26/18. The Physician signature was dated 12/26/19.
During an interview on 05/04/23 at 1:17 PM, Social Worker (SW) O reported it looked like the Physician signed R11's DNR wrong, with the wrong date. When asked if she had noticed the discrepancy herself, SW O stated she had not. When going over code status, she looked at the DNR status in the Electronic Medical Record (EMR) rather than the actual DNR forms. According to SW O, all signatures on a DNR had to be the same date. She reported that would be a legal DNR.
Resident #28 (R28):
Review of the medical record reflected R28 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, adult failure to thrive, chronic kidney disease and diabetes. The Significant Change in Status MDS, with an ARD of 4/15/23, reflected R28 scored 13 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R28 required extensive assistance of one person for many activities of daily living, including but not limited to bed mobility, transfers, walking in the room and locomotion on and off the unit.
R28's DNR order reflected that the Attending Physician and Resident name were not noted in the designated areas of the document. Additionally, the witness signatures were undated.
During an interview on 05/04/23 at 1:17 PM, SW O reported the DNR process included having two competent residents sign as witnesses to the signature of the person signing the DNR. Witnesses had to have a BIMS score of 15 (cognitively intact). The Medical Director also had to sign the document. According to SW O, all signatures on a DNR had to be the same date. She reported that would be a legal DNR. When asked how it could be determined that the DNR belonged to R28, as there was no Physician name or Resident name on the top of the form, SW O stated because the resident signed it.
Resident #42 (R42):
Review of the medical record reflected R42 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included sepsis, squamous cell carcinoma of skin of lip, neoplasm related pain and malignant neoplasm of overlapping sites of lip, oral cavity and pharynx. The Quarterly MDS, with an ARD of 3/16/23, reflected R42 scored nine out of 15 (moderate cognitive impairment) on the BIMS and was independent for activities of daily living.
According to the medical record, R42 had a legal Guardian. R42's medical record reflected an Order Regarding Appointment of Guardian of Incapacitated Individual, which listed former Guardian HH as R42's legal Guardian. R42's EMR Profile listed Guardian II as R42's legal Guardian. There was no documentation in R42's medical record indicative of a change in legal Guardian.
R42's medical record reflected a DNR order signed by former Guardian HH on 7/15/19.
During an interview on 05/04/23 at 1:17 PM, SW O reported code status was reviewed at the time of admission, when doing Baseline Care Planning, Care Plans, MDS assessments and when residents went out to the hospital. SW O reported if she was just looking in the chart, she reviewed code status and stated she was constantly reviewing it. For a resident that was not their own Responsible Party, she made sure they had advance directives and Durable Power of Attorney (DPOA) paperwork uploaded in the EMR. SW O acknowledged that R42 had a change in Guardian but was not sure when the change took place. Upon review of R42's paper medical record, SW O acknowledged she did not see paperwork naming Guardian II as R42's legal Guardian.
Review of the EMR on 05/09/23 at 2:27 PM reflected a document of new Guardianship paperwork was uploaded to the EMR on 5/5/23. The document, dated for a hearing on 9/14/20, reflected the Guardian changed from HH to Guardian II.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 2 (Resident #13 and #34) out of 18 residents reviewed for care plans, had a comprehensive care plan that was revised for resident care needs, resulting in the potential for all care needs not being met.
Findings Include:
Resident #13
Review of an admission Record revealed Resident #13 (R13) admitted to the facility on [DATE] with pertinent diagnoses which included bilateral hearing loss, anxiety, osteoporosis, major depressive disorder, overactive bladder, delusional disorders, vascular dementia, and cognitive communication deficit. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/6/23, reflected R13 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R13 did not walk and required extensive of two or more people for transferring and toileting.
In an observation on 05/03/23 at 09:58 AM, R13 was observed resting in bed with her eyes closed. R13 had a Broda chair (wheelchair that provides tilt-in-space positioning, recline and leg rest adjustments) in her room. R13 did not have a non-skid mat on the seat of the Broda chair. R13's television was off.
In an observation on 05/04/23 at 01:01 PM, R13 was seated in her Broda with a blanket covering her, slightly reclined back. R13 had a tablet on a stand in front of her but was not watching the content playing on the device. R13 had a blanket but did not have any other materials with her at the time of observation.
In an observation on 05/04/23 at 01:50 PM, R13 was observed seated on her bottom on the floor in front of R13's Broda chair. Staff members were assessing and assisting to R13.
In an observation on 05/04/23 at 01:53 PM, R13 was assisted back into the Broda chair and wheeled to the vicinity of the nurse's station. R13 had a blanket on her but had no other materials with her at the time of observation. An observation was made of the seat of the Broda chair, and it did not appear that R13 had a non-skid mat underneath her bottom on the seat of the chair.
In an observation on 5/04/23 at 1:56 PM, the staff member at the nurse's station left the area. R13 was left unsupervised by facility staff members for approximately five minutes.
In an observation 05/04/23 at 02:37 PM, R13 was seated in her Broda chair and slightly reclined back in the vicinity of the nurse's station. R13 appeared to have slid down significantly from her previous position with her buttocks towards the edge of the seat. R13 was attempting to lean up out of chair. A staff member approached R13 and wheeled R13 away from the nurse's station and down the hall. R13 was not repositioned in the Broda chair.
In an interview on 05/04/23 at 02:05 PM, Licensed Practical Nurse (LPN) CC reported that she did not witness the fall that R13 sustained. LPN CC reported that the iPad in front of her prior to falling was for entertainment purposes, to watch tv and stuff.
Review of the Care Plan revealed R13 had an At Risk for Falls Care Plan initiated on 12/1/2020. Some listed interventions included assist patient near nurses' station if she is becoming restless in her chair, ensure patient has her baby doll when sitting in her chair, leave TV [television] on at bedtime with low volume, non-skid surface to wheelchair, reposition in Broda chair when noted restless or agitated, and watching iPad while in Broda chair of favorite show and music.
Review of the Care Plan revealed R13 had an increased risk of fracture related to
Osteoporosis Care Plan initiated on 01/16/2022. Interventions included to monitor for risk of falls and educate resident, family/caregivers on safety measures that needed to be taken in order to reduce risk of falls.
Review of the same Care plan revealed R13 had bilateral hearing loss and an Activities of Daily Living deficit Care Plan which revealed R13 wore glasses.
Review of the Assessment tab located in the Electronic Medical Record revealed R13 had 18 Fall Assessments from falls sustained from 1/1/23 until 5/8/23.
In an observation on 05/08/23 at 09:58 AM, R13's Broda chair was in R13's room. R13 was using the restroom at the time. There was no non-skid mat observed on R13's Broda chair.
In an interview on 05/08/23 at 12:53 PM, Certified Nursing Assistant (CNA) EE reported that R13's fall interventions included ensuring R13's toileting needs were tended to, ensuring the bed is in the lowest position, not leaving R13 unattended in her room, and leaving her up by the nurse's station for increased supervision purposes. CNA EE stated that R13 does not respond much to the iPad. When queried about the non-skid pad that is Care Planned as a fall intervention, CAN EE reported that she [R13] used to have one but the facility got rid of them. CAN EE also reported that R13 had hearing loss but did not have hearing aids and has glasses, but they were in her drawer and not used.
In an observation on 05/08/23 at 10:08 AM, R13 was wheeled out of her room by a staff member and parked in the vicinity of the nurse's station. The staff member walked away from R13. At 10:32 AM, a staff member approached R13 and removed her from the nurse station and into her room. R13 had no direct supervision for the 24 minutes that R13 was left in the vicinity of the nurse's station.
In an observation on 05/08/23 at 10:46 AM, R13 was resting in bed with her eyes closed. R13's television was turned off and the Broda chair did not have a non-skid mat on the seat.
In an observation on 05/09/23 at 10:15 AM, R13 was observed in the hall seated in her Broda chair, slightly reclined back, with a blanket. R13 did not have a baby doll with her at the time of observation.
In an interview on 05/08/23 at 02:29 PM, LPN CC stated that fall interventions for R13 included keeping her at the nurse's station, toileting before and after meals, ensuring she had her blanket and baby doll and providing fluids after meals. When quired about the non-skid mat, LPN CC reported that the facility got rid of them and was no aware of any alternative for the non-skid mat. LPN CC reported that R13 did not having hearing aids or require the use of glasses.
In an interview on 05/11/23 at 10:28 AM, Director of Nursing (DON) B reported that she was aware of R13's frequent falls and was going to start implementing risk management meetings with the facilities Interdisciplinary Team in the near future to monitor, track and trend resident falls. DON B confirmed that one of R13's fall interventions was to park her near the nurse's station to provide increased supervision. DON B reported that the facility does have and utilize the use of non-skid mats but was not certain why R13 did not have one on her Broda chair.
Resident #34
Review of an admission Record revealed Resident #34 (R34) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included acute cystitis with hematuria, disorder of the muscle, bradycardia (slow heart rate), hearing loss, syncope, and dementia. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/29/23, reflected R34 scored nine out of 15 (moderately cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R34 required extensive of one person for toileting, transferring, and bed mobility.
In an observation on 05/04/23 at 12:52 PM, R34 was seated in her wheelchair holding a television remote. R34's wheelchair appeared to be a standard wheelchair and was not fitted with any anti rollback or auto lock mechanisms.
Review of a Progress Note dated 6/22/2022 at 11:41 PM revealed R34 was in her room and staff heard a loud noise from the room and they went to the room and observed Pt [patient] on the floor lying on her back. Pt [patient] was bleeding from back of her head and stated she hit her head to the floor . R34 was transferred to the local Emergency Department for evaluation.
Review of a Progress Note dated 6/23/2022 at 09:27 AM revealed R34 returned to the facility from the Emergency Department with four staples to the back of her head.
Review of a Patient Safety Note dated 6/23/2022 at 3:42 PM revealed that the Interdisciplinary Team reviewed the fall that R34 sustained on 6/22/23. Resident stated she stood up out of wheelchair and fell backwards . New intervention toupdate [sic] plan of care includes wheelchair safety with auto lock and anti-rollback wheelchair .
Review of the Safety section of the [NAME] (portion of the Electronic Medical Record commonly used by Certified Nursing Assistants to communicate resident's needs) revealed R34 required call light signage, nonskid footwear, blood sugar check at bedside as well as a bedtime snack, and anti-rollback and auto lock on R34's wheelchair.
In an observation on 05/08/23 at 12:57 PM, R34's wheelchair appeared to be the same standard wheelchair without anti rollback or auto lock mechanisms fitted to the wheelchair.
In an interview on 05/08/23 at 01:01 PM, Certified Nursing Assistant (CNA) EE
reported R34's fall interventions included having her bed in the lowest position, call light within reach as well as R34's other commonly used items. CNA EE reported that R34 does self-transfer herself although she is a one assist. CNA EE verified that R34 has a regular wheelchair and R34 is supposed to have those things on her wheelchair.
In an interview on 05/08/23 at 02:35 PM, Licensed Practical Nurse (LPN) CC reported that R34 self-transfers despite required assistance of one staff member. LPN CC also verified that R34 had a standard wheelchair.
In an interview on 05/11/23 at 10:21 AM, Director of Nursing B agreed that the anti-rollback and auto lock mechanisms were listed as a current fall intervention on R34's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement comprehensive Care Plans for two (Resident #11 and #27) of 18 reviewed, resulting in the potential for unmet care needs and adverse events.
Findings include:
Resident #11 (R11):
Review of the medical record reflected R11 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction, flaccid hemiplegia affecting left non-dominant side and unspecified intellectual disabilities. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/24/23, reflected R11 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R11 did not walk and required extensive assistance of one to two or more people for most activities of daily living. R11 was coded for fall with major injury.
On 05/03/23 at 1:51 PM, R11 was observed in bed, with the head of the bed elevated and the bed height in a low position. Upon entering the room, R11 was asking for help. He was lying with his head towards the wall at the right bedside while trying to maneuver his body towards the left side of the bed. R11 was saying help me. A pillow was observed on the floor at the left bedside. With his requests for help, R11 was asked how he alerted staff of his needs. R11 indicated he wanted up.
An Incident Report for a fall on 1/30/23 at 12:59 PM reflected the CNA informed nurse that R11 had fallen out of his wheelchair. Upon entering R11's room, he was observed lying on the floor in front of his wheelchair. He was assessed for injuries, placed in his wheelchair via hoyer lift (mechanical lift), vital signs were obtained, and the call light was placed in reach. The cause of the fall was documented that R11 slid out of his wheelchair, onto the floor. The corrective action reflected R11 was assessed for injuries, placed in his wheelchair and vital signs were obtained.
The Investigation Report for the same fall reflected R11 had a history of sliding out of his wheelchair, and a non-slip grip would be placed in the wheelchair.
R11's Care Plan reflected an intervention that was initiated on 1/30/23 and created on 2/2/23 to encourage use of non-slip pad in wheelchair and encourage/assist R11 to be out in common area of nursing station when out of bed, for enhanced safety.
An Incident Report for a fall on 1/30/23 at 1:32 PM reflected the CNA informed the nurse that R11 was on the floor in the hallway. The nurse observed R11 in the hallway, lying in front of his wheelchair. He was assessed for physical injury, vital signs were obtained, R11 was hoyered into bed, positioned for comfort, bed placed in lowest position and call light placed in reach. The cause was documented as R11 sliding himself to the floor. The corrective action was to remove his wheelchair.
The Investigation Report for the same same fall reflected when R11 was out of bed, offer and assist him to sit in the hallway, close to the nurse's station, for closer supervision, as R11 allowed.
R11's Care Plan reflected an intervention that was initiated and created on 1/31/23 for offering and assisting R11 to sit in the hallway, close to the nurses station, for closer supervision when out of bed, as R11 allowed.
An Incident Report for a fall on 2/18/23 at 9:20 AM reflected R11 was found on the floor by the nurse around 8:50 AM. There was a significant amount of blood on the floor. Once R11 was cleaned up, he was noted to have a gash on the bridge of his nose, some swelling and a bruise on the side of his forehead. R11 was assessed for visible injuries and pressure was held related to bleeding. Emergency Medical Services (EMS) was called, and R11 sent to the emergency room (ER) for evaluation due to hitting his head. The documented cause of the fall reflected R11 fell out of his wheelchair while in his room. The corrective action reflected staff was re-educated about encouraging R11 to sit at the nurse's station or out in hallway while up in his wheelchair.
Hospital Records reflected R11 had a laceration to the bridge of his nose, requiring three sutures (stitches). Additionally, there were comminuted left and right nasal bone fractures and probable remote type I odontoid process (part of the neck) fracture without displacement.
R11's Care Plan reflected an intervention for routine safety checks when R11 preferred to stay in his room, dated 2/19/23.
During an interview on 05/08/23 at 9:57 AM, CNA P reported she was not sure if R11 would be classified as a fall risk. She reported R11 had fallen a few times when she had been on duty and had trips to the ER.
R11's Risk for Falls Care Plan reflected an intervention for a bariatric bed with a perimeter mattress that was initiated on 11/7/19, created on 11/8/19 and revised on 1/14/21.
On 05/09/23 at 2:51 PM, R11 was observed lying in bed, with the bed height in low position. R11 had a standard size bed, not a bariatric bed, as indicated on the Care Plan.
On 05/11/23 at 9:12 AM, R11 was observed seated in a specialty wheelchair, watching TV in his room. Rear anti-tip bars were observed on the wheelchair. No call light was observed in R11's reach. A perimeter mattress without linens was observed on the bed. The mattress was observed to be a standard size, not bariatric as care planned. An overbed table was near R11's right side. A bottle of pop with a straw was observed on the dresser, under R11's TV. When asked if staff had offered to take him out of his room this morning, R11 denied.
On 05/11/23 at 9:19 AM, CNA Z stated R11 had been up since about 6:00 AM and had been in his room since after breakfast.
On 05/11/23 at 9:23 AM, R11 continued to be observed seated in his room, in a specialty wheelchair. He was observed using his feet to slightly and intermittently move the wheelchair back and forth. At 9:24 AM, he was observed moving the wheelchair towards the dresser and was attempting to move his torso forward. Upon entering the room and speaking with R11, he asked for his pop (which was on the dresser). R11's roommate overheard the request and stated he turned the call light on for R11. R11's roommate reported R11 had a call that he used, but it was probably on his bed. At 9:30 AM, Licensed Practical Nurse (LPN) GG entered R11's room, in response to the call light. R11's roommate notified LPN GG that he had the call light on for R11. LPN GG was overheard asking R11 if he wanted his pop and stated to R11 that he was on thickened liquids, so he had to thicken the pop before giving it to him. The cap was placed on the pop, which was left on R11's dresser. The nurse exited the room at 9:32 AM, after telling R11 he would get him pop that was thickened.
An order dated 12/2/22 reflected R11 was on a regular diet with pureed texture, .2 Mildly Thick consistency [liquids].
R11's Care Plan reflected an intervention that was initiated and created on 7/1/19 and revised 12/22/22 for, Diet: Regular, Pureed, Mildly thick.
During an interview on 05/11/23 at 10:25 AM, CNA Z reported when R11 was up in his chair, she kept an eye on him all the time. She reported R11 went to the dining room that morning and returned to his room around 9:00 AM. CNA Z reported R11 could not be in the bathroom alone but thought he could be in his room, in his wheelchair, alone.
Resident #27 (R27):
Review of the medical record reflected R27 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral vascular disease and diabetes. The Significant Change in Status MDS, with an ARD of 3/21/23, reflected R27 scored 15 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R27 did not walk and required extensive to total assistance of two or more people for most activities of daily living. According to the MDS, R27 had upper and lower extremity impairment on one side that interfered with daily functions or placed her at risk for injury. R27 was not coded for receiving Restorative Nursing Programs for at least 15 minutes per day in the last seven calendar days, including but not limited to range of motion or splint or brace assistance.
On 05/04/23 at 9:42 AM, R27 was observed seated in a wheelchair, in her room. Her legs were elevated. An arm bolster was on the left side of her wheelchair. She stated she had a stroke in approximately 2014 and had left sided deficits related to the stroke. She showed that her left wrist was flexed and a rolled cloth was in her left hand. She denied getting any therapy or restorative services. R27 reported she had a brace for her left hand at one time, but she lost it quite a while ago, and it was not replaced. After she lost the brace, her hand and wrist started contracting, per her report. She reported having a boot in place for her left foot.
On 05/08/23 at 9:52 AM, R27 was observed lying in bed. Her wheelchair was observed at the left bedside, with an orthotic boot in the seat of the wheelchair. R27 reported she wore the boot when up and had it for eight or nine years, since her stroke. R27 denied that staff did any exercises or Range of Motion (ROM) with her and never had.
R27's Care Plan was reflective of an intervention created on 2/23/23 and initiated on 3/9/23 for ROM (active or passive) with activities of daily living care.
Review of the Electronic Medical Record (EMR) task documentation on 5/8/23 reflected there was no task for ROM. R27's [NAME] (CNA Care Guide) was not reflective of ROM or orthotic devices.
During an interview on 05/08/23 at 9:57 AM, CNA P reported she used the [NAME] and Care Plan to know the care needs of each resident. She stated she was unsure if it contained the same information as the nursing Care Plan and had not seen any that were longer than three pages. CNA P reported she generally looked at the [NAME] every week. R27 had a boot that she wore on her left foot when out of bed, according to CNA P.
On 05/08/23 at 10:35 AM, an email was received from Director of Nursing (DON) B, in response to an earlier email request for documentation pertaining to prevention and management of contractures/ROM limitations on 5/8/23 at 9:39 AM. The email response included a [NAME] that had been modified since the original email request to reflect ROM (active or passive) with activities of daily living care.
During an interview on 05/08/23 at 11:04 AM, DON B reported she did not see ROM under the task documentation for R27. Upon review of R27's [NAME], DON B reported ROM was on the [NAME] and not the tasks, so there would not be documentation of it (ROM). Upon being asked when ROM was added to R27's Care Plan, DON B responded that it had been added that day, 5/8/23, by Nursing Home Administrator (NHA) A. When DON B was asked if R27 had any devices, splints or anything of that nature that was being used, DON B reported she did not see any splints. When asked if she saw anything pertaining to an orthotic boot, DON B reported she did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately complete Minimum Data Set (MDS) assessments for two (Resident #28 and Resident #29) of 18 reviewed, resulting in inaccurate assessments and the potential for unmet care needs.
Findings include:
Resident #29 (R29)
Review of the medical record revealed R29 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer to the left heel, diabetes, and chronic kidney disease stage 3. Review of the MDS with an Assessment Reference Date (ARD) of 3/13/23 revealed R29 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), required extensive assistance of two people for bed mobility, was not on a turning/repositioning program, and had an unstageable pressure ulcer-suspected deep tissue injury present on admission.
On 05/03/23 at 09:41 AM, R29 was observed sitting in a wheelchair in her room. Both feet were wrapped with kerlix and boots were in place. R29 reported she developed a pressure ulcer on her left heel due to her heel rubbing in the bed. R29 did not recall elevating her feet off the bed prior to the development of the pressure ulcer. R29's bed was observed with a bariatric mattress that was not an alternating pressure mattress.
On 5/8/23 at 10:05 AM, R29 was observed in bed while staff were providing care. R29 did not have an alternating pressure mattress on her bed.
Review of the Admission/re-admission Evaluation dated 3/6/23 revealed Stage 1 pressure ulcer-staged by RN [Registered Nurse] to R29's left heel.
Review of the Skin & Wound Evaluation dated 3/7/23 (day after admission) revealed R29 had a stage one pressure ulcer that measured 0.9 centimeters (cm) x 0.5 cm. The Skin & Wound Evaluation dated 3/11/23 revealed R29's pressure ulcer was now a deep tissue injury measuring 0.8 cm x 1.2 cm.
In an interview on 05/08/23 at 3:20 PM, MDS Coordinator L reported R29's pressure ulcer was initially a stage 1 on admission. MDS Coordinator L was unable to explain why she coded the pressure ulcer as unstageable-suspected deep tissue injury present on admission.
In an interview on 05/08/23 at 11:08 AM, Director of Nursing (DON) B reported on 3/7/23, R29's pressure ulcer was a stage 1 and on 3/11/23, it was a suspected deep tissue injury.
Resident #28 (R28):
Review of the medical record reflected R28 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, adult failure to thrive, chronic kidney disease and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/15/23, reflected R28 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R28 required extensive assistance of one person for many activities of daily living, including but not limited to bed mobility, transfers, walking in the room and locomotion on and off the unit.
On 05/04/23 at 9:26 AM, R28 was observed in her room. She stated her weight was usually between 145 pounds (#) to 150#, and she was surprised when they told her she was about 137#. She stated, I guess I'm not eating a lot. She reported she tried to eat a little of what was on the tray. R28 reported she liked the food and had no food complaints.
The admission MDS, with an ARD of 2/9/23, reflected a weight of 165#. The Significant Change in Status (SCSA) MDS, with an ARD of 4/15/23, reflected a weight of 144# (12.73% weight loss). Question K0300 (Weight Loss), Loss of 5% or more in the last month or loss of 10% or more in last 6 months was coded as no or unknown on the SCSA MDS.
Review of the medical record reflected that on 02/06/2023, R28 weighed 164.6#. On 05/08/2023, R28 weighed 140# which was a 14.95 % weight loss.
A Nutrition Progress Note for 5/3/2023 at 10:52
AM reflected, Resident continues with 4% wt [weight] loss over 30 days, 16% wt loss in 90 days .
During an interview on 05/09/23 at 10:17 AM, Dietary Manager C did not recall doing any charting on R28.
Registered Dietitian D was out of the country at the time of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1) follow their bowel management protocol for constipation; 2) ensure the accurate classification of a wound; 3) ensure comprehensive wound assessments were performed according to facility policy; and 4) ensure wound treatment and interventions were implemented timely and according to Physician recommendations
for one (Resident #28) of 18 reviewed, resulting in constipation and the potential for delayed wound healing and/or worsening wounds.
Findings include:
Review of the medical record reflected R28 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, adult failure to thrive, chronic kidney disease and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/15/23, reflected R28 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R28 required extensive assistance of one person for many activities of daily living, including but not limited to bed mobility, transfers, walking in the room, locomotion on and off the unit. R28 was not coded as having any wounds.
On 05/03/23 at approximately 10:40 AM, R28 was observed seated in a wheelchair in her room. R28 stated she had some sores but was unsure if they were present before she admitted to the facility.
On 05/04/23 at 9:21 AM, R28 indicated it was normal for her to go a day or so without having a bowel movement (BM), but she was not having BM's as often as she normally would.
R28's BM documentation for the prior 30 days was reviewed (4/9/23 to 5/8/23) and reflected no BM on 4/15/23, 4/16/23, 4/17/23 and 4/18/23 (four days). No BM's were documented on 4/21/23, 4/22/23, 4/23/23, 4/24/23 or 4/25/23 (five days).
R28's Physician's Orders included GaviLAX Powder (Polyethylene Glycol 3350) 17 grams by mouth one time a day for constipation, ordered on 4/6/23. Additionally, R28 had an order for Milk of Magnesia Suspension 400 milligrams per 5 milliliters (mL) (Magnesium Hydroxide) 5 mL to be given by mouth every 24 hours as needed for no BM for three days, ordered 4/20/23.
The April 2023 TAR reflected as needed Milk of Magnesia was given on 4/25/23 and was effective. There was no documentation of additional as needed medication interventions for constipation.
The facility's undated Bowel Management Protocol reflected, 1. If a resident fails to have a bowel movement (BM) for three [days] the resident will receive a laxative per physician order. 2.
If the resident fails to have a BM 24 hours after receiving the laxative, an order for a suppository per physician order. 3. If the resident fails to have a BM 24 hours after receiving the suppository, an order for an enema per physician order. 4. If no results from the enema, the physician will be notified for additional orders. 5. Nurses must check the BM tracking daily. Documentation will occur on the 24 hour report and in [the] medical record for those residents that need to have a BM. Results from the laxative, etc. will be documented on the 24 hour report and medical record.
During an interview on 05/11/23 at 9:48 AM, Director of Nursing (DON) B reported she did not see that any additional interventions had been provided to R28 for no BM on 4/15/23, 4/16/23, 4/17/23 and 4/18/23. She reported a Progress Note for 4/20/23 reflected R28 had not had a BM for three days, and the BM protocol was initiated. Regarding no BM documented for 4/21/23, 4/22/23, 4/23/23, 4/24/23 and 4/25/23, DON B reported she would have called the doctor to ask for a stool softener related to R28 being on Morphine. DON B stated nurses kept track of the clinical dashboard, and there was an alert from the CNA charting that would say there was no BM for three days. According to DON B, they did some education with staff on bowel protocol, as a few of the nurses did not know the clinical dashboard was there.
R28's medical record reflected the following Skin and Wound Evaluations of the left medial foot:
4/6/23: An open lesion, present on admission, measuring 1.9 centimeters (cm) in length by (x) 1.6 cm in width. There was no documentation pertaining to the wound bed appearance or characteristics.
4/21/23: An open lesion, present on admission, measuring 2.3 cm x 3.2 cm. The wound bed was documented as 100% slough (non-viable yellow, tan, gray, green or brown tissue).
The above wound documentation reflected no wound assessments were conducted for 15 days (between 4/6/23 and 4/21/23).
4/28/23: An open lesion, present on admission, measuring 3.6 cm x 4.0 cm. The wound bed was documented as having 30% granulation (pink-red moist tissue that fills an open wound when it starts to heal) and 50% slough.
5/5/23: An open lesion, present on admission, measuring 0.4 cm x 0.5 cm. There was no documentation of wound bed appearance or characteristics. Review of wound photos reflected an area that appeared larger than the 0.4 cm x 0.5 cm measurements, as indicated on the assessment.
R28's medical record reflected she readmitted to the facility on [DATE]. The April 2023 Treatment Administration Record (TAR) reflected a treatment for the left foot wound was not implemented until 4/16/23, when an order was initiated to cleanse the wound with normal saline, pat dry and cover with optifoam daily.
During an interview on 05/08/23 at 11:04 AM, Director of Nursing (DON) B reported R28's left foot wound was a pressure ulcer. She noticed when running wound reports that it was documented as an open lesion. DON B reported the wound measurements for 5/5/23 were auto-generated. She reported the measurement (of 0.4 cm x 0.5 cm) was the area of tissue that appeared as eschar (dead, devitalized tissue that is usually black, brown or tan in color). DON B reported the whole area (of the wound) should have been measured. DON B described the surrounding tissue as having some slough. She reported the area of eschar would make the wound unstageable.
During the interview, DON B reported there should have been documentation of wound bed appearance, and wound assessments were typically done weekly. DON B acknowledged that she did not see that a treatment was in place upon return from the hospital on 4/6/23.
On 05/08/23 at 1:00 PM, R28 was observed seated in her wheelchair, in her room, watching TV. She was wearing gripper socks on both feet, with both feet resting on the floor.
A visit note by Wound Doctor Q on 4/21/23 reflected R28 had a left foot diabetic foot ulcer with rolled wound edges, peripheral wound, epibole (rolled edges) and slough noted at the wound bed. The wound measured 2.28 (centimeters in length) by 3.23 (centimeters in width). There were no signs of infection, and the periwound area was normal in color and temperature, according to the note. The note reflected treatment would include the use of a prevalon boot, floating the heel and offloading the area. The note was signed on 5/8/23 at 9:30 AM.
R28's Care Plan and [NAME] did not reflect an intervention for a prevalon boot. R28 was not observed to wear a prevalon boot, nor was one observed in her room during the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00131462.
Based on observation, interview, and record review, the facility failed to implement pressure ulcer interventions and treatments for two (Resident #28 and Resident #29) of three reviewed, resulting in the worsening of a pressure ulcer for Resident #29 and the potential of a worsening pressure ulcer for Resident #28.
Findings include:
Review of the medical record revealed R29 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer to the left heel, diabetes, and chronic kidney disease stage 3. Review of the MDS with an Assessment Reference Date (ARD) of 3/13/23 revealed R29 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), required extensive assistance of two people for bed mobility, and was not on a turning/repositioning program.
Review of the Braden Scale for Predicting Pressure Sore Risk dated 3/6/23, revealed R29 scored 16 (15-18 is at risk).
Review of the Admission/re-admission Evaluation dated 3/6/23 revealed Stage 1 pressure ulcer-staged by RN [Registered Nurse] to R29's left heel.
Review of the Skin & Wound Evaluation dated 3/7/23 (day after admission) revealed R29 had a stage one pressure ulcer that measured 0.9 centimeters (cm) x 0.5 cm.
Review of R29's Physician's Orders and Treatment Administration Records (TARs) revealed on 3/6/23, border form was ordered for R29's left heel but was never applied or implemented. The order was discontinued on 3/7/23. No treatments were documented as completed on 3/6/23 or 3/7/23. Starting on 3/8/23, skin prep was ordered to apply to bilateral heels every day for protection. Skin prep was discontinued on 3/15/23.
Review of R29's At Risk for Alteration in Skin Integrity care plan initiated on 3/7/23 revealed elevate heels as able was implemented on 3/7/23, pressure redistributing device on bed/chair was implemented 3/7/23, use pillows/positioning devices as needed was implemented 3/7/23, and EHOB boots to bilateral feet were implemented on 3/12/23.
The Skin & Wound Evaluation dated 3/11/23 revealed R29's pressure ulcer was a deep tissue injury (persistent non-blanchable deep red, maroon, or purple discoloration) that measured 0.8 cm x 1.2 cm. The wound bed was documented as 100% eschar (dead tissue/unstageable).
Review of R29's Pressure Ulcer to Left Heel care plan initiated 3/13/23 revealed EHOB boots were implemented 3/13/23, pressure redistributing support surface was implemented 3/13/23, and repositioning during Activities of Daily Living (ADLs) was implemented on 3/13/23.
According to the TAR on 3/15/23, a Hydrofera Blue dressing was applied to R29's left heel. The order was to change the dressing every three days. The dressing was changed four days later, on 3/19/23. The Hydrofera Blue dressing was discontinued on 3/23/23.
The Skin & Wound Evaluation dated 3/19/23 revealed a 1.7 cm x 2.3 cm deep tissue injury with light serious drainage and macerated surrounding tissue.
According to the Order Summary and TAR, on 3/23/23 the treatment order was changed to cleanse with normal saline, apply skin prep, and apply optifoam every two days. The treatment was not documented as completed and the order was discontinued on 3/24/23. On 3/24/23 the order was changed to normal saline, medi honey, and a dry dressing daily.
The Skin & Wound Evaluation dated 3/24/23 revealed a1.2 cm x 0.8 cm unstageable (obscured full-thickness skin and tissue loss) pressure ulcer due to slough and/or eschar; however, the wound bed was documented as 20% granulation tissue without any documentation of the amount of slough and/or eschar.
Review of the MP Wound Progress Note dated 3/24/23 revealed I am going to change the plan .3. pressure reducing seat cushion, 4. pressure reducing heel boot, 5. pressure reducing air mattress, 6. turn and reposition per facility .
The Skin & Wound Evaluation dated 3/31/23 revealed a 2.4 cm x 1.6 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 70% granulation tissue and 30% slough.
Review of a General Progress Note dated 4/6/23 revealed .consider referral to wound clinic .Elevate left heel off bed at all times .
The Skin & Wound Evaluation dated 4/7/23 revealed a 1.7 cm x 2.1 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 100% eschar.
Review of the Wound Care Initial Consultation, History and Physical dated 4/7/23 revealed R29's pressure ulcer was 100% stable black eschar and measured 1.73 cm x 2.06 cm. The consultation revealed If patient sits in bed, appropriate offloading mattress .Frequent turning and positioning every two hours to the best of her ability to offload the area. Review of the care plans revealed turning and repositioning every two hours was not implemented.
The Skin & Wound Evaluation dated 4/14/23 revealed a 3.1 cm x 1.6 cm unstageable pressure ulcer due to slough and/or eschar. The assessment did not reflect any additional wound characteristics (i.e. wound bed, drainage).
The Skin & Wound Evaluation dated 4/21/23 revealed a 2.5 cm x 1.8 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 100% eschar.
Review of the Radiology Report dated 4/21/23 revealed R29's left heel soft tissues appear swollen with ulceration .findings suspicious for calcaneal osteomyelitis [inflammation of bone due to infection], recommend MRI.
The Skin & Wound Evaluation dated 4/28/23 revealed a 1.3 cm x 2.2 cm unstageable pressure ulcer due to slough and/or eschar with a wound bed of 100% eschar.
Review of the MRI dated 5/4/23 revealed R29 had osteomyelitis of the left heel. R29 was on IV antibiotics for osteomyelitis.
The Skin & Wound Evaluation dated 5/5/23 revealed a 2.6 cm x 1.8 cm unstageable pressure ulcer due to slough and/or eschar; however the wound bed was documented as 60% granulation without any documentation of the amount of slough and/or eschar.
On 05/3/23 at 09:41 AM, R29 was observed sitting in a wheelchair in her room. Both feet were wrapped with kerlix and boots were in place. R29 reported she developed a pressure ulcer on her left heel due to her heel rubbing on the bed. R29 reported she was on IV antibiotics for an infection in her left heel. R29 did not recall elevating her feet off the bed prior to the development of the pressure ulcer. R29's bed was observed with a bariatric mattress that was not an alternating pressure mattress.
On 5/8/23 at 10:05 AM, R29 was observed in bed while staff were providing care. R29 did not have an alternating pressure mattress on her bed.
In an interview on 05/8/23 at 11:08 AM, Director of Nursing (DON) B reported it was her understanding that R29 was admitted to the facility with the left heel deep tissue injury. DON B reviewed R29's wound assessments and agreed that on 3/6/23 and 3/7/23, the wound was documented as a stage 1 pressure ulcer to the left heel. DON B reported R29 now had osteomyelitis to the left heel. DON B reported the facility's standard mattresses were foam mattresses and that R29 should have had an alternating pressure mattress in place since 3/13/23. DON B reported the skin prep was started on 3/8/23 and agreed there was no documented preventative treatment completed on 3/6/23 or 3/7/23. DON B entered R29's room and reported the mattress on the bed was a standard foam mattress and not an alternating pressure mattress.
On 05/9/23 at 09:41 AM, Licensed Practical Nurse (LPN) K was observed performing a skin check on R29. LPN K reported R29 was also due for dressing changes. LPN K began by removing R29's boots and dressings dated 5/8/23 from both feet. LPN K then placed both of R29's heels directly on a bath blanket. R29 had a pillow under her legs, but the pillow did not prevent her heels from resting on the bed. R29's left heel was observed with a a pressure ulcer. LPN K completed the remainder of the skin check and then left the room to obtain wound care supplies. When asked about the left heel pressure ulcer, R29 stated I just didn't get moved enough. R29 went on to further explain that she thought staff put something under her legs to elevate her heels when she first came in, but her heels still touched the mattress. LPN K returned at 10:00 AM to perform wound care. R29's heels were still resting on the mattress at that time. LPN K cleansed R29's left heel with normal saline, patted dry, applied betadine to the wound, applied calcium alginate to the wound, placed an ABD pad over, and then wrapped with kerlix.
Review of the Physician's Order dated 5/7/23 revealed left heel cleanse with NS [Normal Saline] apply collagen to heel and wrap with kerlix every day and PRN [as needed]. The treatment was scheduled for Mondays, Wednesdays, and Fridays.
In an interview on 05/9/23 at 10:26 AM, LPN K was asked about the treatment orders for R29's left heel. LPN K showed the order for betadine to left heel, soak 4x4 gauze with betadine, and wrap with kerlix. There was not an active treatment for 5/9/23 which reflected the order that was placed on 5/7/23 for normal saline, collagen, and kerlix.
In an interview on 05/9/23 at 11:34 AM, DON B reported R29's betadine order was supposed to be discontinued and the order for collagen was to be completed on Mondays, Wednesdays, and Fridays. DON B reported she did not recall that calcium alginate was ever an order for R29's pressure ulcer. DON B reported R29 now had an alternating pressure mattress in place.
In an interview on 05/10/23 at 09:34 AM, Maintenance Director (MD) E reported work orders were usually not filled out for mattresses. MD E reported Housekeeping Director (HD) F kept track of when specialty mattresses were put into place.
In an interview on 05/10/23 at 09:38 AM, HD F reported as of 1/1/23, she did not keep track of mattresses; however, the requests were still done through email. HD F reported she looked back and found that the only conversation related to R29's bed was for a bariatric mattress and a trapeze. HD F reported R29 first received an alternating pressure mattress on 5/8/23.
Resident #28 (R28):
Review of the medical record reflected R28 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included metabolic encephalopathy, adult failure to thrive, chronic kidney disease and diabetes. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/15/23, reflected R28 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R28 required extensive assistance of one person for many activities of daily living, including but not limited to bed mobility, transfers, walking in the room, locomotion on and off the unit. R28 was not coded as having any wounds.
On 05/03/23 at approximately 10:40 AM, R28 was observed seated in a wheelchair in her room. R28 stated she had some sores but was unsure if they were present before she admitted to the facility.
On 05/04/23 at 9:15 AM, R28 was observed lying on her left side in bed, watching TV. She reported she had absolutely no concerns with her care. Everyone has been really super. She reported she was able to turn and reposition herself in bed and sit up independently. She stated they told her she had fallen since she had been here. She reported sliding out of the bed. Upon interview, she acknowledged there are things she does not remember.
A Skin and Wound Evaluation for 4/16/23 reflected an in-house acquired open lesion to the sacrum, measuring 1.1 centimeters (cm) in length by (x) 0.8 cm in width. There was no description of the wound bed, and there were no additional assessments of the area after 4/16/23. Progress of the wound was marked as New.
During an interview on 05/08/23 at 11:04 AM, Director of Nursing (DON) B reported R28 had a spot on her sacrum that measured 1.1 cm x 0.8 cm and healed on 4/16/23. DON B reported the picture showed a pink area with a bit of a scab on it. She reported the staff nurse was supposed to document that the area was healed, and Nursing Home Administrator (NHA) A closed (healed) the wound assessment on 4/25/23 at 11:47 AM. DON B reported R28 had a history of a pressure ulcer to that area.
DON B was notified of the request to observe R28's skin, including her sacrum/coccyx and left foot during scheduled treatments on 5/9/23.
On 05/08/23 at 1:00 PM, R28 was observed seated in her wheelchair, in her room, watching TV. She was wearing gripper socks on both feet, with her feet resting on the floor.
Review of wound notes by Wound Doctor Q reflected R28 was seen on 4/14/23 for an open sacral lesion that measured 1.1 x 0.8. The note reflected treatment was going to include MediHoney, collagen and foam dressing, to be changed three times a week and as necessary.
Review of the April 2023 TAR reflected those orders were not implemented and continued to reflect Coccyx: cleanse with NS [normal saline], pat dry and place optifoam over wound every day shift for wound care.
During an interview on 05/09/23 at 12:15 PM, DON B was notified that R28's treatments had already been documented as completed for the day, and the Survey Team had not been made aware for the previously requested observation. DON B was asked if she knew why the treatment was not updated to reflect Wound Doctor Q's treatment recommendation for the coccyx, as referenced in his Progress Note for 4/14/23. DON B believed Wound Doctor Q healed that area and that there was no need for the recommended treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure appropriate treatment and services for contracture management for one (Resident #27) of one reviewed, resulting in the potential for worsening contractures and pain.
Findings include:
Review of the medical record reflected R27 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral vascular disease and diabetes. The Significant Change in Status MDS, with an ARD of 3/21/23, reflected R27 scored 15 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R27 did not walk and required extensive to total assistance of two or more people for most activities of daily living. According to the MDS, R27 had upper and lower extremity impairment on one side that interfered with daily functions or placed her at risk for injury. R27 was not coded for receiving Restorative Nursing Programs for at least 15 minutes per day in the last seven calendar days, including but not limited to range of motion or splint or brace assistance.
On 05/04/23 at 9:42 AM, R27 was observed seated in a wheelchair, in her room. Her legs were elevated. An arm bolster was on the left side of her wheelchair. She stated she had a stroke in approximately 2014 and had left sided deficits related to the stroke. She showed that her left wrist was flexed and a rolled cloth was in her left hand. She denied getting any therapy or restorative services. R27 reported she had a brace for her left hand at one time, but she lost it quite a while ago, and it was not replaced. After she lost the brace, her hand and wrist started contracting, per her report. She reported having a boot in place for her left foot.
On 05/08/23 at 9:52 AM, R27 was observed lying in bed. Her wheelchair was observed at the left bedside, with an orthotic boot in the seat of the wheelchair. R27 reported she wore the boot when up and had it for eight or nine years, since her stroke. R27 denied that staff did any exercises or Range of Motion (ROM) with her and never had.
R27's Care Plan was reflective of an intervention created on 2/23/23 and initiated on 3/9/23 for ROM (active or passive) with activities of daily living care.
Review of the Electronic Medical Record (EMR) task documentation on 5/8/23 reflected there was no task for ROM. R27's [NAME] (CNA Care Guide) was not reflective of ROM or orthotic devices.
During an interview on 05/08/23 at 9:57 AM, CNA P reported she used the [NAME] and Care Plan to know the care needs of each resident. She stated she was unsure if it contained the same information as the nursing Care Plan and had not seen any that were longer than three pages. CNA P reported she generally looked at the [NAME] every week. R27 had a boot that she wore on her left foot when out of bed, according to CNA P. CNA P reported R27 had left sided weakness and no mobility on the left side. She reported when providing care, she softly stretched R27's arm about ten times and tried to do some ROM with R27's left leg. CNA P did not believe they documented performance of ROM anywhere.
On 05/08/23 at 10:35 AM, an email was received from Director of Nursing (DON) B, in response to an email request for documentation pertaining to prevention and management of contractures/ROM limitations on 5/8/23 at 9:39 AM. The email response included a [NAME] that had been modified since the original email request to reflect ROM (active or passive) with activities of daily living care.
During an interview on 05/08/23 at 11:04 AM, DON B reported she did not see ROM under the task documentation for R27. Upon review of R27's [NAME], DON B reported ROM was on the [NAME] and not the tasks, so there would not be documentation of it (ROM). When asked how CNAs knew to do a ROM program, DON B reported each day the CNAs had to review the [NAME], then they would know what tasks to do for the day. When asked how they would know to do ROM if it was not on the [NAME], DON B reported CNAs had to go through nursing classes and would have been taught to do it for the stroke side.
Upon being asked when ROM was added to R27's Care Plan, DON B responded that it had been added that day, 5/8/23, by Nursing Home Administrator (NHA) A. When DON B was asked if R27 had any devices, splints or anything of that nature that was being used, DON B reported she did not see any splints. When asked if she saw anything pertaining to an orthotic boot, DON B reported she did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #11 (R11):
Review of the medical record reflected R11 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included cerebral infarction, flaccid hemiplegia affecting left non-dominant side and unspecified intellectual disabilities. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/24/23, reflected R11 scored nine out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R11 did not walk and required extensive assistance of one to two or more people for most activities of daily living. R11 was coded for fall with major injury.
On 05/03/23 at 1:51 PM, R11 was observed in bed, with the head of the bed elevated and the bed height in a low position. Upon entering the room, R11 was asking for help. He was lying with his head towards the wall at the right bedside while trying to maneuver his body towards the left side of the bed. R11 was saying help me. A pillow was observed on the floor at the left bedside. With his requests for help, R11 was asked how he alerted staff of his needs. R11 indicated he wanted up.
Review of R11's Incident Reports since 1/1/23 reflected four falls.
An Incident Report for a fall on 1/21/23 at 10:31 AM reflected the Certified Nurse Aide (CNA) yelled down the hall to nurse at 9:55 AM and stated R11 was lying on the floor. Upon entering the room, R11 was observed lying on the floor, turned to his side, in front of his wheelchair. R11 laughed and stated he was fine. The documented cause reflected R11 slid out of wheelchair onto floor and when asked if he wanted to lay down, he said yes. The corrective action reflected R11 was assessed and an intervention for R11 to lie down between meals if he is wanting to lie down.
R11's Care Plan reflected an intervention that was initiated and created on 1/21/23 and revised on 1/24/23 to offer/assist R11 to return to bed for rest after breakfast.
An Incident Report for a fall on 1/30/23 at 12:59 PM reflected the CNA informed nurse that R11 had fallen out of his wheelchair. Upon entering R11's room, he was observed lying on the floor in front of his wheelchair. He was assessed for injuries, placed in his wheelchair via hoyer lift (mechanical lift), vital signs were obtained, and the call light was placed in reach. The cause of the fall was documented that R11 slid out of his wheelchair, onto the floor. The corrective action reflected R11 was assessed for injuries, placed in his wheelchair and vital signs were obtained.
The Investigation Report for the same fall reflected R11 had a history of sliding out of his wheelchair, and a non-slip grip would be placed in the wheelchair.
R11's Care Plan reflected an intervention that was initiated on 1/30/23 and created on 2/2/23 to encourage use of non-slip pad in wheelchair and encourage/assist R11 to be out in common area of nursing station when out of bed, for enhanced safety.
An Incident Report for a fall on 1/30/23 at 1:32 PM reflected the CNA informed the nurse that R11 was on the floor in the hallway. The nurse observed R11 in the hallway, lying in front of his wheelchair. He was assessed for physical injury, vital signs were obtained, hoyered into bed, positioned for comfort, bed placed in lowest position and call light placed in reach. The cause was documented as R11 sliding himself to the floor. The corrective action was to remove his wheelchair.
The Investigation Report for the same same fall reflected when R11 was out of bed, offer and assist him to sit in the hallway, close to the nurse's station, for closer supervision, as R11 allowed.
R11's Care Plan reflected an intervention that was initiated and created on 1/31/23 for offering and assisting R11 to sit in the hallway, close to the nurses station, for closer supervision when out of bed, as R11 allowed.
An Incident Report for a fall on 2/18/23 at 9:20 AM reflected R11 was found on the floor by the nurse around 8:50 AM. There was a significant amount of blood on the floor. Once R11 was cleaned up, he was noted to have a gash on the bridge of his nose, some swelling and a bruise on the side of his forehead. R11 was assessed for visible injuries and pressure was held related to bleeding. Emergency Medical Services (EMS) was called, and R11 sent to the emergency room (ER) for evaluation due to hitting his head. The documented cause of the fall reflected R11 fell out of his wheelchair while in his room. The corrective action reflected staff was re-educated about encouraging R11 to sit at the nurse's station or out in hallway while up in his wheelchair.
Hospital Records reflected R11 had a laceration to the bridge of his nose, requiring three sutures (stitches). Additionally, there were comminuted left and right nasal bone fractures and probable remote type I odontoid process (part of the neck) fracture without displacement.
R11's Care Plan reflected an intervention for routine safety checks when R11 preferred to stay in his room, dated 2/19/23.
During an interview on 05/08/23 at 9:57 AM, CNA P reported she was not sure if R11 would be classified as a fall risk. She reported R11 had fallen a few times when she had been on duty and had trips to the ER.
On 05/09/23 at 2:51 PM, R11 was observed lying in bed, with the bed height in low position. R11 had a standard size bed, not a bariatric bed, as indicated on the Care Plan.
On 05/11/23 at 9:12 AM, R11 was observed seated in a specialty wheelchair, watching TV in his room. Rear anti-tip bars were observed on the wheelchair. No call light was observed in R11's reach. A perimeter mattress without linens was observed on the bed. The mattress was observed to be a standard size, not bariatric as care planned. An overbed table was near R11's right side. A bottle of pop with a straw was observed on the dresser, under R11's TV. When asked if staff had offered to take him out of his room this morning, R11 denied.
On 05/11/23 at 9:19 AM, CNA Z stated R11 had been up since about 6:00 AM and had been in his room since after breakfast.
On 05/11/23 at 9:23 AM, R11 continued to be observed seated in his room, in a specialty wheelchair. He was observed using his feet to slightly and intermittently move the wheelchair back and forth. At 9:24 AM, he was observed moving the wheelchair towards the dresser and was attempting to move his torso forward. Upon entering the room and speaking with R11, he asked for his pop (which was on the dresser). R11's roommate overheard the request and stated he turned the call light on for R11. R11's roommate reported R11 had a call that he used, but it was probably on his bed. At 9:30 AM, Licensed Practical Nurse (LPN) GG entered R11's room, in response to the call light. R11's roommate notified LPN GG that he had the call light on for R11. LPN GG was overheard asking R11 if he wanted his pop and stated to R11 that he was on thickened liquids, so he had to thicken the pop before giving it to him. The cap was placed on the pop, which was left on R11's dresser. The nurse exited the room at 9:32 AM, after telling R11 he would get him pop that was thickened.
An order dated 12/2/22 reflected R11 was on a regular diet with pureed texture, .2 Mildly Thick consistency [liquids].
During an interview on 05/11/23 at 10:25 AM, CNA Z reported when R11 was up in his chair, she kept an eye on him all the time. She reported R11 went to the dining room that morning and returned to his room around 9:00 AM. CNA Z reported R11 could not be in the bathroom alone but thought he could be in his room, in his wheelchair, alone.
Based on observation, interview and record review, the facility failed to implement effective interventions to prevent falls for four (Resident #11, #13, #20, and #464) of five reviewed for accidents, resulting in reoccurring falls (Resident #13), falls with the potential for major injury (Resident #464) and falls with major injury (Resident #11 and #20).
Findings Include:
Resident #13
Review of an admission Record revealed Resident #13 (R13) admitted to the facility on [DATE] with pertinent diagnoses which included bilateral hearing loss, anxiety, osteoporosis, major depressive disorder, overactive bladder, delusional disorders, vascular dementia, and cognitive communication deficit. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/6/23, reflected R13 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R13 did not walk and required extensive of two or more people for transferring and toileting.
In an observation on 05/03/23 at 09:58 AM, R13 was observed resting in bed with her eyes closed. R13 had a Broda chair (wheelchair that provides tilt-in-space positioning, recline and leg rest adjustments) in her room. R13 did not have a non-skid mat on the seat of the Broda chair. R13's television was off.
In an observation on 05/04/23 at 01:01 PM, R13 was seated in her Broda with a blanket covering her, slightly reclined back. R13 had a tablet on a stand in front of her but was not watching the content playing on the device. R13 had a blanket but did not have any other materials with her at the time of observation.
In an observation on 05/04/23 at 01:50 PM, R13 was observed seated on her bottom on the floor in front of R13's Broda chair. Staff members were assessing and assisting to R13.
In an observation on 05/04/23 at 01:53 PM, R13 was assisted back into the Broda chair and wheeled to the vicinity of the nurse's station. R13 had a blanket on her but had no other materials with her at the time of observation. An observation was made of the seat of the Broda chair, and it did not appear that R13 had a non-skid mat underneath her bottom on the seat of the chair.
In an observation on 5/04/23 at 1:56 PM, the staff member at the nurse's station left the area. R13 was left unsupervised by facility staff members for approximately five minutes.
In an observation 05/04/23 at 02:37 PM, R13 was seated in her Broda chair and slightly reclined back in the vicinity of the nurse's station. R13 appeared to have slid down significantly from her previous position with her buttocks towards the edge of the seat. R13 was attempting to lean up out of chair. A staff member approached R13 and wheeled R13 away from the nurse's station and down the hall. R13 was not repositioned in the Broda chair.
In an interview on 05/04/23 at 02:05 PM, Licensed Practical Nurse (LPN) CC reported that she did not witness the fall that R13 sustained. LPN CC reported that the iPad in front of her prior to falling was for entertainment purposes, to watch tv and stuff.
Review of the Care Plan revealed R13 had an At Risk for Falls Care Plan initiated on 12/1/2020. Some listed interventions included assist patient near nurses' station if she is becoming restless in her chair, ensure patient has her baby doll when sitting in her chair, leave TV [television] on at bedtime with low volume, non-skid surface to wheelchair, reposition in Broda chair when noted restless or agitated, and watching iPad while in Broda chair of favorite show and music.
Review of the Care Plan revealed R13 had an increased risk of fracture related to
Osteoporosis Care Plan initiated on 01/16/2022. Interventions included to monitor for risk of falls and educate resident, family/caregivers on safety measures that needed to be taken in order to reduce risk of falls.
Review of the same Care plan revealed R13 had bilateral hearing loss and an Activities of Daily Living deficit Care Plan which revealed R13 wore glasses.
Review of the Assessment tab located in the Electronic Medical Record revealed R13 had 18 Fall Assessments from falls sustained from 1/1/23 until 5/8/23.
In an observation on 05/08/23 at 09:58 AM, R13's Broda chair was in R13's room. R13 was using the restroom at the time. There was no non-skid mat observed on R13's Broda chair.
In an interview on 05/08/23 at 12:53 PM, Certified Nursing Assistant (CNA) EE reported that R13's fall interventions included ensuring R13's toileting needs were tended to, ensuring the bed is in the lowest position, not leaving R13 unattended in her room, and leaving her up by the nurse's station for increased supervision purposes. CNA EE stated that R13 does not respond much to the iPad. When queried about the non-skid pad that is Care Planned as a fall intervention, CAN EE reported that she [R13] used to have one but the facility got rid of them. CAN EE also reported that R13 had hearing loss but did not have hearing aids and has glasses, but they were in her drawer and not used.
In an observation on 05/08/23 at 10:08 AM, R13 was wheeled out of her room by a staff member and parked in the vicinity of the nurse's station. The staff member walked away from R13. At 10:32 AM, a staff member approached R13 and removed her from the nurse station and into her room. R13 had no direct supervision for the 24 minutes that R13 was left in the vicinity of the nurse's station.
In an observation on 05/08/23 at 10:46 AM, R13 was resting in bed with her eyes closed. R13's television was turned off and the Broda chair did not have a non-skid mat on the seat.
In an observation on 05/09/23 at 10:15 AM, R13 was observed in the hall seated in her Broda chair, slightly reclined back, with a blanket. R13 did not have a baby doll with her at the time of observation.
In an interview on 05/08/23 at 02:29 PM, LPN CC stated that fall interventions for R13 included keeping her at the nurse's station, toileting before and after meals, ensuring she had her blanket and baby doll and providing fluids after meals. When quired about the non-skid mat, LPN CC reported that the facility got rid of them and was no aware of any alternative for the non-skid mat. LPN CC reported that R13 did not having hearing aids or require the use of glasses.
In an interview on 05/11/23 at 10:28 AM, Director of Nursing (DON) B reported that she was aware of R13's frequent falls and was going to start implementing risk management meetings with the facilities Interdisciplinary Team in the near future to monitor, track and trend resident falls. DON B confirmed that one of R13's fall interventions was to park her near the nurse's station to provide increased supervision. DON B reported that the facility does have and utilize the use of non-skid mats but was not certain why R13 did not have one on her Broda chair.
Resident #20
Review of an admission Record revealed Resident #20 (R20) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included traumatic subdermal hemorrhage with loss of consciousness, adult failure to thrive, dementia, Alzheimer's disease, repeated falls, glaucoma, and visual disturbance. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/23, reflected R20 scored zero out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R20 required extensive of one person for transferring and toileting.
In an observation on 05/04/23 at 01:01 PM, R20 was seated in a wheelchair in her room with a blanket on her lap. R20's call light was clipped to her right side but was hanging out of reach. R20 yelled out can I go back to bed now? There was no response from staff.
In an observation on 05/04/23 at 01:14 PM, R20 yelled out Can I go back to bed? There was no response from staff even though there were two staff members approximately 6 feet outside of R20's room.
In an observation on 05/04/23 at 01:22 PM, R20 called out I need to go to the bathroom, and I need to go back to bed. A staff member passed by as R20 was calling out but did not respond to the request.
In an observation on 05/04/23 at 01:37 PM, a Certified Nursing Assistant (CNA) approached this surveyor for an interview when R20 called out I need to go to the bathroom. The CNA then tended to R20.
In an observation on 05/08/23 at 12:44 PM, R20 was seated in her wheelchair and parked in the middle portion of her room. R20 did not have a call light within reach.
Review of a Progress Note dated 3/7/2023 at 5:39 PM revealed .on 3/4/23 @ [at] 930am, staff observed resident [R20] resting on the floor on her eft [sic] side near the bed of her roommate, her walker upright in front of her. She was unsure if her head made contact with anything. She stated she was trying to go back to bed after using the restroom following breakfast . She was incontinent at time of incident Immediate intervention: assist w/ [with] toileting following breakfast. CP (care plan) updated.
Review of an Incident report dated 3/4/23 at 9:35 AM revealed resident observed lying on the floor on her left side near roommates' bed .fall interventions already in place: have commonly used articles within reach, provide assistance to transfer and ambulate as needed. New intervention toilet before and after meals .
Review of a Progress Note dated 4/10/2023 at 07:38 AM revealed R20 observed lying on the floor face/body down next to bed. Resident stated, I was trying to get back into bed. Resident states hitting head and having 7/10 pain in head .Resident assisted off floor by EMS [Emergency Medical Service] and transported to ER [Emergency Department] for further evaluation.
An Incident Report dated 4/10/23 revealed that the fall occurred at 4/10/23 at 7:15 AM.
The Incident report provided by a Certified Nursing Assistant on 4-10-23 revealed resident toileted on midnight shifting [sic] observed resting in bed approx. 0700 [AM]. fell 0710 [AM].
A Patient Safety Note dated 4/11/2023 at 10:47 AM revealed R20 states she was getting up to go to bathroom .New intervention to update plan of care includes bed against wall. Interventions in place at time of fall include commonly used articles within reach, assist to use restroom after breakfast, encourage to change positions slowly .
Review of the Hospital Paperwork dated 4/11/23 revealed R20 sustained a subdermal hematoma (A condition due to bleeding under the membrane covering the brain called, the dura) and was admitted to the Critical Care Unit.
Review of the Care Plan revealed R20 had an At Risk for Falls Care Plan initiated on 4/6/2020. Interventions included administer medications per physician's order, encourage to transfer and change positions slowly, evaluate medications if patient demonstrates changes in mental status, provide assistance to transfer and ambulate as needed, refer to the therapy plan of treatment in the medical record for more detail, and therapy evaluation and treatment per orders.
In an interview on 05/08/23 at 02:37 PM, Licensed Practical Nurse CC reported that R20 is hard of hearing and seldomly uses her call light. R20's preferred method of asking for assistant was to call out.
Review of the Kardex (portion of the Electronic Medical Record commonly used by Certified Nursing Assistants to communicate residents needs) revealed R20 required assistance to the restroom after breakfast and before staff leave room, place call light in patient hand for ease to access .
In an interview on 05/10/23 at 10:03 AM, Certified Nursing Assistant (CNA) FF reported that R20 makes her needs known by calling out for help but at times, R20 will use the call light appropriately. CNA FF reported that staff will pin the call light to R20 to help with locating the call light when needed.
In an observation in 05/11/23 at 09:17 AM, R20 was in bed with her eyes closed. R20's bedside table was located at foot of bed. R20's water was located on the bedside table, which was out of reach from R20. R20's call light was observed on the floor, out of reach from the resident.
In an interview on 05/11/23 at 10:28 AM, Director of Nursing (DON) B reported that R20 did sustain a fall in April when R20 rolled out of bed and was transferred out to the hospital. DON B reported that R20's current fall interventions included assisting R20 to the restroom after breakfast, have R20's bed against wall, transfer change position slowly, evaluate medications, and keep commonly used articles within reach. When asked to define commonly used articles, DON B stated drinks, bedside table, call light, and whatever the resident preference might be.
Resident #464
Review of an admission Record revealed Resident #464 (R464) admitted to the facility on [DATE] with pertinent diagnoses which included heart failure, dementia, difficulty in walking, cognitive communication deficit, weakness, anxiety, major depressive disorder, and expressive language disorder. A Social Services Note dated 4/24/23 revealed that R464 scored 4 out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R464's Kardax (computer program that communicates resident's care needs to staff) reflected R464 requires one person guidance and physical assistance for transfer.
In an observation on 05/03/23 at 12:02 PM, R464 was seated in the dining room at a table and speaking with a Hospice staff member. R464 was in his wheelchair and wearing standard socks.
A Progress Note dated 4/23/2023 at 2:45 PM revealed R464 was observed crawling on the floor in his room. When asked what happened, patient states, This is the only way I can get around.
An Incident Report dated 4/23/23 revealed R464 was discovered on the floor by his bed, sitting on his bottom. R464 did not sustain any injuries but was unsure how he fell out of his bed.
A Progress Note dated 4/24/2023 at 10:15 PM revealed R464 was discovered crawling on the floor in his room at 9:30 PM. When asked why he was on the floor, R464 replied I was trying to get up.
An Incident Report dated 4/24/23 revealed R464 was attempting to stand throughout the shift and was eventually discovered on the floor in his room during a routine check. The same Incident Report revealed that R464 was in need of incontinent care at the time of the fall. R464 was educated to use his call light if he needed anything.
A Progress Note dated 4/25/2023 at 02:01 AM revealed R464 was observed sitting on his bottom on the floor in his room. R464 was wearing one shoe on his foot and incontinent at the time of his fall.
An Incident Report dated 4/25/23 confirmed R464 was incontinent upon discovery. R464 was placed in his wheelchair and moved out into the hallway.
A Progress Note dated 4/30/2023 at 7:34 AM revealed R464 was observed on the floor in the dining room. R464 was unable to describe how the fall occurred.
An Incident Report dated 4/30/23 revealed R464 self-transferred out of his bed and into his wheelchair. R464 propelled himself down to the dining room where the fall took place.
Review of the Care Plan revealed R464 had an At Risk for Falls Care Plan initiated on 4/21/23. Interventions included reenforce the need to call for assistance, provide assistance to transfer and ambulate as needed, and have commonly used articles within easy reach. On 4/26/23 additional interventions were added to include refer to the therapy plan of treatment located in the medical record and preference to crawl on the floor.
Review of the same At Risk for Falls Care plan revealed addition interventions were added on 5/8/23 to include decrease activity and stimulation at times of increased anxiety and stress.
In an interview on 05/08/23 at 12:58 PM, Certified Nursing Assistant (CNA) EE reported that R464 will occasionally crawl on the floor. CAN EE reported that R464 is a one assist for transfers but occasionally self-transfers.
In an interview on 05/09/23 at 11:58 AM, Director of Nursing (DON) B reported that Incident Reports are completed by staff after a fall and any interventions implemented after a fall should go into the care plan. The staff should also be implementing an immediate fall intervention after a resident sustains a fall. If staff requires assistance formulating an intervention, the fall can be referred to the Interdisciplinary Team to help come up with additional or appropriate interventions. Regarding R464's fall on 4/23/23, the intervention was to care plan R464's preference to crawl on the floor. After the fall on 4/24/23 the intervention was staff to assist with call light within reach and educated on call light use. When queried if R464 was likely to benefit from reeducation with a low BIMS, DON B responded that he would not. After R464's fall on 4/25/23, DON B reported that the intervention was to refer to Physical and Occupational therapy for an evaluation. After the fall that R464 sustained on 4/30/23, DON B reported that the fall intervention implemented was to decrease activity stimulation at all times to decrease anxiety and review the care plan. When asked if DON B would consider a more appropriate intervention such as a toileting schedule considering R464 was incontinent for two of his four falls, she replied that she felt that would be an appropriate intervention.
An email was sent on 5/9/23 to Nursing Home Administrator (NHA) A requesting documentation of R464's Physical and Occupational therapy evaluation. NHA A responded via email at 3:39 PM reporting None- he came in hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to justify rationale for clinically contraindicated gradual dose reductions (GDRs) of psychotropic medications for two (Resident #16 and #52) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications.
Findings include:
Resident #52 (R52):
Review of the medical record reflected R52 admitted to the facility on [DATE], with diagnoses that included stage four chronic kidney disease, diabetes, anxiety disorder and major depressive disorder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/4/23, reflected R52 scored 15 out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R52 was not coded for having behaviors and scored zero out of 27 on the PHQ-9 mood interview.
On 05/03/23 at 2:10 PM, R52 was observed to sit herself up independently in bed. A bandage was observed on her left arm, which she reported was from dialysis that day.
Additional MDS history for R52 reflected they did not have any behaviors and scored two out of 27 on the PHQ-9 for the Annual MDS with an ARD of 10/2/22. For the Quarterly MDS with an ARD of 1/2/23, R52 had no behaviors and scored zero out of 27 on the PHQ-9.
A Pharmacy Medication Regimen Review note for 3/30/2023 reflected irregularities were noted and recommendations suggested a trial dose reduction of Escitalopram Oxalate (Lexapro/antidepressant medication) 10 milligrams (mg) daily. The note reflected, .If clinically contraindicated, provide documentation to support ongoing use . The Pharmacy recommendation was marked for, Decline the recommendation(s) above and do not wish to implement any changes due to the reason(s) below: The handwritten rationale, signed by the Physician on 3/31/23, reflected, stable [no] need to [change].
An undated handwritten note on the bottom of the Pharmacy Medication Regimen Review reflected the Interdisciplinary Team (IDT) recommended to decrease Lexapro to 5 mg per day for five days, then discontinue the medication.
R52's Physician's Orders reflected R52's Escitalopram Oxalate 10 mg daily for depression had a start date of 9/25/21.
A Progress Note for 3/31/2023 at 9:48 PM reflected, .Recommendation made for a GDR trial. IDT agreed, [Physician] disagreed. Order was not updated.
During an interview on 05/10/23 at 10:54 AM, Social Worker (SW) O reported R52 did not have any behaviors or mood issues, was happy go lucky and a great resident. According to SW O, R52's PHQ-9 (mood interview/score) was always spot on and happy. SW O did not know why the Physician did not want to do a GDR for R52's Lexapro. When reviewing the pharmacy recommendation for a GDR of Lexapro for 3/30/23, SW O stated that was the note that the doctor wrote to state why they did not want a GDR. The Survey Team requested any additional documentation from that time period (3/2023) to support a decision not to conduct a GDR and why it was clinically contraindicated.
On 05/10/23 at 11:25 AM, SW O reported her and Director of Nursing (DON) B looked and could not find any additional documentation from the Physician pertaining to declining a GDR.
In an interview on 05/11/23 at 9:48 AM, DON B verified they were unable to find any additional documentation from the Physician pertaining to declining a Lexapro GDR.
Resident #16
Review of an admission Record revealed Resident #16 (R16) admitted to the facility on [DATE] with pertinent diagnoses which included disorder of the muscle, cirrhosis of the liver, right below the knee amputation, left below the knee amputation, anxiety, and major depressive disorder. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/23, reflected R16 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R16 required supervision to perform activities of daily living including toileting, transferring, and eating.
Review of the Physician's Order dated 12/11/2020 revealed an order for Trazodone (Desyrel; an antidepressant) 150 milligrams (mg) daily for depression.
Review of R16's Annual Mood MDS assessment dated [DATE] revealed R16 received a Severity Score of 00 indicating that R16 had not exhibited any depressive behaviors such as having little to no interest in doing things, feeling down, depressed, or hopeless, feeling bad about themselves, poor appetite, and thoughts that they would be better off dead.
Review of R16's Quarterly Mood MDS assessment dated [DATE] revealed R16 received a Severity Score of 00 indicated that R16 had not expressed any depressive behaviors since the previous review on 12/18/22.
A Pharmacy Medication Regimen Review note for 3/30/2023 reflected irregularities were noted and recommendations suggested a trial dose reduction of Trazadone (Desyrel/antidepressant medication) 125 milligrams (mg) daily. The note reflected, .If clinically contraindicated, provide documentation to support ongoing use . The Pharmacy recommendation was marked for, Decline the recommendation(s) above and do not wish to implement any changes due to the reason(s) below: The handwritten rationale, signed by the Physician on 3/31/23, reflected, pt (patient) is stable.
An undated handwritten note on the bottom of the Pharmacy Medication Regimen Review reflected the Interdisciplinary Team (IDT) feels this is a good reccomendation.
Review of R16's medical record failed to reveal any further documentation regarding the clinical justification for not attempting a dose reduction.
In an interview on 05/11/23 at 09:48 AM, Director of Nursing (DON) B: reported that the process for Gradual Dose Reduction includes meeting with the Interdisciplinary Team (IDT) to discuss the topic. The IDT then presents it to the Physician to review. Typically, the Physician would perform a risk verse benefit screening for the dose reduction to determine if it would be clinically indicated to reduce the dose. DON B reported that she talks to R16 every day and R16 has not had any change in overall mood or function in the past few months. At that time, any documentation regarding the medication and the clinical rational to decline attempting a dose reduction was requested. The documentation was not received prior to the survey exit.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent when two medication errors were observed from a total of twenty-seven opportunities for one resident (Resident # 374) of six reviewed for medication administration, resulting in a medication error rate of 7.41% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects.
Findings include:
Review of the medical record revealed that Resident # 374 (R374) admitted to facility 4/20/23 with diagnoses including orthostatic hypotension, paroxysmal atrial fibrillation, essential hypertension, and type 2 diabetes mellitus. Active orders noted to include Insulin Glargine 30units daily and Metoprolol Succinate 25mg (milligrams), give 12.5mg daily, with a parameter to hold for blood pressure less than 100/60 or heart rate lower than 60.
On 5/04/23 at 8:05 AM, Licensed Practical Nurse (LPN) GG was observed to prepare multiple oral medications and an insulin pen for administration to Resident #374 (R374). LPN GG entered R374's room with prepared oral medications including one individually packaged medication labeled metoprolol succinate 25mg tablet, Glargine Insulin Pen, and a plastic basket containing a glucometer, test strips, lancets, and alcohol swabs. LPN GG placed blood pressure cuff to R374's left arm with electronic blood pressure reading of 129/59 and heart rate of 82 noted on machine. LPN GG stated that the indicated blood pressure of 129/59 was within the ordered parameters for metoprolol administration, proceeded to open the individually packaged medication, broke the scored metoprolol succinate 25mg tablet in half to equal the ordered 12.5mg dose, added the half tablet to the medication cup with the remainder of the prepared oral medications, and handed the medication cup to R374 at which time R374 proceeded to take all medications, including the half tablet of metoprolol succinate.
After obtaining R374's blood sugar value, LPN GG removed gloves, washed hands, exited room to obtain needle for insulin pen, reentered room, sanitized hands, placed gloves, removed cap from Glargine Insulin Pen, and placed disposable insulin needle directly on pen without first cleansing the rubber hub at the top of the insulin pen with an alcohol swab. LPN GG was then observed to dial the insulin pen to 30 units, cleansed back of R374's left upper arm with an alcohol swab, and injected insulin. At no time prior to the insulin administration was LPN GG observed to prime (remove the air from the pen vial) the insulin pen. LPN GG was then observed to exit room and proceeded to document all oral medications and Glargine Insulin as given in R374's electronic medical record.
In an interview on 5/04/23 at 8:35 AM, LPN GG stated that he had been a nurse for eight years and contracted through the facility since January 2023. Per LPN GG, the steps to preparing an insulin pen for administration included removing the insulin pen cap and placing the disposable insulin needle. LPN GG did not verbalize the step to clean the rubber hub at the top of the insulin pen with an alcohol swab nor the step to prime the insulin pen after application of the disposable needle. When questioned regarding the priming of an insulin pen, LPN GG stated Can you explain that step? and confirmed that he did not know what priming was nor did he prime any insulin pen prior to dialing the pen to the ordered number of units for insulin administration.
In an interview on 05/04/23 at 10:05 AM, Director of Nursing (DON) B stated that the facility used both insulin pens and vials for diabetic management. DON B stated that the procedure for insulin pen preparation included cleansing the top of the pen with an alcohol swab, applying the disposable needle, and then priming the needle with 2 units of insulin with the pen held in an upright position.
During the same interview, DON B stated that the assigned nurse generally checked a resident's blood pressure and pulse prior to the administration of cardiac medications and that the associated parameters, when ordered, typically included holding of the medication for a systolic blood pressure (the top number in a blood pressure reading) of less than 110 or a heart rate of less than 60. Upon review of R374's medical record, DON B stated that the physician had been adjusting R374's cardiac medications due to orthostatic hypotension (a form of low blood pressure that occurs when moving from a lying to a sitting or standing position) and confirmed that the metoprolol succinate order included parameters to hold the medication for a blood pressure of less than 100/60. DON B confirmed that based on the ordered parameters, R374's metoprolol succinate should not have been administered for the blood pressure of 129/59 obtained that morning as the diastolic blood pressure (the bottom number in a blood pressure reading) of 59 was less than the ordered parameter of 60. DON B further stated that an ordered cardiac medication typically did not have diastolic blood pressure parameters in addition to the systolic blood pressure and heart rate parameters and that multiple parameters for the same medication could be confusing to the staff.
Review of the facility policy titled Subcutaneous injection with a revised date of May 20, 2022, indicated, Critical Notes .Using Insulin Pen Delivery Systems .Attach: Scrub rubber stopper. Attach new safety pen needle .Prime: Before each injection, hold upright and prime the pen to remove air bubbles and to ensure the needle is open and working .Dial: Dial to prescribed dose .Hold: Inject by fully depressing push button. Keep the needle inserted in the skin while depressing button for an additional 5 - 10 seconds .
Review of the facility policy titled Medication and Treatment Administration Guidelines, Long-Term Care dated 2023 indicated, .Medication and Treatment Orders: A complete medication order includes: date and time, name of the patient, name of the medication .medication specific parameters, if applicable .Medication Administration: Medications are administered in accordance with the following rights of medication administration or per state specific standards .right patient, right medication, right dose, right route, right time, right documentation .Documentation: Medication and treatments administered are documented immediately following administration or per state specific standards .Vital signs are taken and recorded prior to the administration of vital sign dependent medications in accordance with medical practitioner's orders .