Orchard Creek Skilled Nursing

Based on interview and record review, the facility failed to obtain complete and comprehensive informed consents prior to the administration of psychotropic medications for three Residents (#4, #17, and #20) of five residents reviewed for unnecessary medications.Findings include:Resident #17 (R17)Review of R17's electronic medical record (EMR) revealed initial admission to the facility on 7/1/25 with diagnoses including cerebral infarction (stroke) and vascular dementia. Review of R17's most recent Minimum Data Set (MDS) assessment, dated 7/15/25, revealed a Brief Interview for Mental Status (BIMS) score of 3, indicative of severe cognitive impairment.Review of R17's EMR revealed the following pharmacy order, initiated 7/1/25: Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG (milligram) [an antidepressant (psychotropic) medication], Give 1 capsule by mouth two times a day for depression/pain.Review of R17's EMR revealed a document titled, Consent for Psychoactive Medications which read, in part: The resident's provider has ordered the following psychoactive medications. Duloxetine. Do you consent to the use of the above medications? The following area had a space for the resident or responsible party to select, Yes or, No.Further review of the form revealed it was signed by both the R17 and their Durable Power of Attorney (DPOA), but the consent to treatment had not been checked.Resident #20 (R20)Review of R20's EMR revealed initial admission to the facility on 7/14/25 with diagnoses including left shoulder dislocation and chronic kidney disease.Review of R20's EMR revealed the following pharmacy order, initiated 7/22/25: Duloxetine HCl Oral Capsule Delayed Release Particles 20 MG (Duloxetine HCl), Give 2 capsule by mouth at bedtime for pain.Review of R20's EMR revealed a document titled, Consent for Psychoactive Medications which read, in part: The resident's provider has ordered the following psychoactive medications. Duloxetine. Do you consent to the use of the above medications? The following area had a space for the resident or responsible party to select, Yes or, No.Further review of the form revealed it was signed by R20 but the consent to treatment had not been checked.Resident #4 (R4)Review of R4's EMR revealed initial admission to the facility on 8/13/25 with diagnoses including congestive heart failure and localized edema.Review of R4's EMR revealed the following pharmacy orders, initiated 8/13/25: Escitalopram Oxalate Oral Tablet 5 MG [an antidepressant (psychotropic) medication], Give 1 tablet by mouth one time a day for depression. Buspirone HCl Oral Tablet 5 MG [an anti-anxiety (psychotropic) medication], Give 1 tablet by mouth three times a day for anxiety.Review of R4's EMR revealed a document titled, Consent for Psychoactive Medications which read, in part: The resident's provider has ordered the following psychoactive medications. Buspirone, Escitalopram. Do you consent to the use of the above medications? The following area had a space for the resident or responsible party to select, Yes or, No.Further review of the form revealed it was signed by R4 but the consent to treatment had not been checked.On 9/4/2025 at 10:26 AM, an interview was conducted with Assistant Director of Nursing (ADON) A regarding her expectations for completeness of psychotropic consent forms. ADON A stated each form should indicate if the individual consented or declined the psychotropic medication by either checking yes or no. ADON A stated, I need to provide additional education to the nursing staff to ensure the form is completed.Review of the facility policy titled, Antipsychotic Medication Use, undated, read, in part: .residents who are receiving a psychoactive medication will also require a consent for the use of the medication signed by the resident of responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from neglect by facility staff for one Resident (#4) of one residents reviewed for abuse and neglect. This deficient practice resulted in actual harm when Resident #4 experienced unnecessary pain and persistent feelings of fear and anxiety.Findings include:Resident #4 (R4)
Review of R4's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/13/25 with diagnoses including congestive heart failure, difficulty in walking, and pain in right shoulder. Review of R4's most recent Minimum Data Set (MDS) assessment, dated 8/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.
On 9/2/2025 at 12:22 PM, an interview was conducted with R4 regarding their satisfaction with the level of care they were receiving at the facility. R4 stated a couple nights ago she needed to use the restroom while in bed, so a certified nursing assistant (CNA) placed her on a bedpan at 5:00 AM. R4 recalled, They [the CNA] didn't leave me a button pusher [call-light], so I was on the bedpan until 7:00 AM. The door was closed. I couldn't get to it [the call-light] . So, it was two hours I laid here. When asked if they experienced pain from the extended period on top the bed pan, R4 stated, Well, yeah! I can't use my right arm at all. I finally got the bed pan from under me with the left hand. I was very uncomfortable.
Review of R4's Medication Administration Record (MAR) revealed the following order:
Oxycodone HCl Oral Tablet 10 MG (milligram), give 1 tablet by mouth every 4 hours as needed for severe pain. A dosage of oxycodone was administered on 8/30/25 at 9:48 AM for a recorded pain level of 10/10.
Review of R4's EMR revealed an interdisciplinary team (IDT) meeting note, dated 8/27/25 at 14:58 [2:58 PM], read, in part:
.Bed mobility: modA [moderate assistance]. Toileting: [NAME] [maximum assistance].10/10 pain arthritis in R [right] shoulder.
On 9/04/2025 at 7:21 AM, a follow-up interview was conducted with R4 who admitted she still thought about the event. R4 stated, It was scary . I didn't have my buzzer [call-light] or anything. I'm concerned it might happen again.
On 9/3/25 at approximately 11:30 AM, an interview was conducted with Certified Nurse Aide (CNA) K who verified that she was the oncoming aide to be working with R4 the morning of 8/30/25. CNA K stated that she came into R4's room around 6:45-7:00 AM to obtain a set of vitals when she observed the bed pan on R4's bed. CNA K stated, She (R4) told me that the bed pan was placed under her at 5:00 AM, she couldn't ring for help because she didn't have a call light, and she had to remove the bed pan herself which caused her a lot of pain. I ended up calling the night shift who don't remember putting a bed pan underneath her, but she (R4) is not able to do it herself. Everything (R4) is telling you is true.
On 9/4/2025 at 10:11 AM, an interview was conducted with Licensed Practical Nurse (LPN) C who verified she was working at the time R4 was left on the bedpan. LPN C stated she was aware the bedpan was left under R4 for an extended period but was unaware of the exact duration. LPN C recalled when she entered R4's room, It [the bedpan] was pushed to the side of the bed, kind of halfway out from beneath her [R4]. When asked if she conducted a skin assessment to verify no breaches in skin integrity, LPN C stated, It was dark [in R4's room]. I helped her get cleaned up, but I didn't see much. LPN C stated she did not report the event to the Director of Nursing (DON) but may have informed the oncoming nurse during shift change.
On 9/4/2025 at 11:22 AM, an interview was conducted with the DON regarding the incident with R4. The DON stated she was unaware of the incident as it was never reported to her. When asked if it should have been reported the DON stated, Yes, I would have investigated it. The DON verified a call-light should always be placed within reach of a resident when a staff member exits a resident room. When asked about possible adverse outcomes of a resident spending approximately two hours on a bedpan the DON replied, Well, she's [R4] already got a mark on her bottom . she's got a stage one [pressure ulcer], I think.
Review of a document titled, Wound Evaluation, dated 8/28/25, read, in part:
Pressure – Stage 1. Body Location: Coccyx. Acquired: In-House Acquired.
Review of a document titled, Wound Evaluation, dated 8/30/25, read, in part:
Pressure – Stage 2. Body Location: Coccyx. Acquired: In-House Acquired. Progress: Deteriorating.
Review of the facility's Abuse, Neglect, Misappropriation or Exploitation Policy/Procedure, undated, read, in part, .The res resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.It is the responsibility of our employees.to immediately report any witnessed, reported, alleged or suspected incident of abuse, neglect, misappropriation of resident property, and exploitation to the Administrator and Director of Nursing.Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being of residents. Findings include:
On 9/3/25 at approximately 11:30 a.m. an interview was conducted with Certified Nurse Aides (CNA) J and K in regard to complaints of low staffing numbers. CNAs J and K confirmed that during shift change, residents can wait 30 to 45 minutes after report for staff to come and assist. CNA K stated, Sometimes it can be up to 45 minutes before we are out on the floor and then we have to get people up, get them dressed, toilet, vitals, breakfast, etc. When there are only two of us, it can be a challenge, and they (residents) have to wait a long time. Both CNA J and K confirmed that the current population of residents is requiring more lifts and two person transfers, which causes them both to tend to one resident at a time. CNA J stated, We don't have enough (staff), with the high number of residents who need two staff assistance, it isn't enough.
Review of the facility's assessment, last reviewed 8/6/24, revealed the required number of staff per census in the facility yielded results as follows:
Staffing Levels Based on Census, Diagnosis, Resident Acuity and (Facility Name) Staff Experience: Certified Nursing Assistants
20 Census 6-2 (6:00 a.m. to 2:00 p.m.)shift = 4 CENA 2-10 (2:000 p.m. to 10 p.m.) shift = 310-6 (10 p.m. to 6 a.m.) shift = 2
16 Census 6-2 (6:00 a.m. to 2 p.m.) shift = 3 CENA 2-10 (2 p.m. to 10 p.m.) shift = 210-6 (10 p.m. to 6 a.m.) shift = 2
A request of the daily working schedules for CNA's revealed that the facility did not follow their staff levels based on their assessment:
8/17/25 two CNA's from 6 a.m. – 10 a.m. census at facility 178/21/25 two CNA's from 6 a.m. – 2 p.m. census at facility 16 8/28/25 three CNA's from 6 a.m. – 2 p.m. census at facility 20 8/29/25 three CNA's from 6 a.m. – 2 p.m. census at facility 20
An interview was conducted with the Director of Nursing (DON) on 9/4/25 at approximately 11:20 a.m. The DON reviewed the daily staffing sheets along with the facility assessment and confirmed that the facility did not follow the required staffing levels.
Resident #4 (R4)
Review of R4's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/13/25 with diagnoses including congestive heart failure, difficulty in walking, and pain in right shoulder. Review of R4's most recent Minimum Data Set (MDS) assessment, dated 8/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition.
On 9/2/2025 at 12:22 PM, an interview was conducted with R4 regarding their satisfaction with the level of care they were receiving at the facility. R4 stated a couple nights ago she needed to use the restroom while in bed, so a certified nursing assistant (CNA) placed her on a bedpan at 5:00 AM. R4 recalled, They [the CNA] didn't leave me a button pusher [call-light], so I was on the bedpan until 7:00 AM. The door was closed. I couldn't get to it [the call-light] . So, it was two hours I laid here. When asked if they experienced pain from the extended period on top the bed pain, R4 stated, Well, yeah! I can't use my right arm at all. I finally got the bed pan from under me with the left hand. I was very uncomfortable. When asked if staffing levels were sufficient, R4 replied, I can go into the bathroom and sit there for 20 or 30 minutes . I know they don't have enough help.
Review of R4's EMR revealed an interdisciplinary team (IDT) meeting note dated 8/27/25 at 2:58 pm, which read, in part:
.Bed mobility: modA [moderate assistance]. Transfers: Max [maximum assistance].Toileting: [NAME].
Resident #17 (R17)
Review of R17's EMR revealed initial admission to the facility on 7/1/25 with diagnoses including cerebral infarction (stroke) and vascular dementia. Review of R17's most recent MDS assessment, dated 7/15/25, revealed she required moderative assistance with bed mobility, toileting hygiene, toilet transfers, and ambulating ten feet.
On 9/3/2025 at 10:06 AM, a phone interview was conducted with R17's Durable Power of Attorney (DPOA) H who stated she visited the facility every-other-day. When asked her perception of the facility staffing levels, DPOA H responded, If my mom (R17) needs something like using the bathroom, especially around mealtimes or shift changes, I don't even bother [using the call-light]. I'll just take her to the toilet myself.
Review of the [Provider Name] Facility Assessment, reviewed 8/6/24, read, in part:
.Primary Services and Care Offered: . Bowel/bladder: Toileting schedules, urinary assessment, use of intermittent and indwelling urinary catheters, ostomy care, peri-care, 2 hour incontinent checks, encouraging resident's independence/assist with care, providing and assisting with resident's requests to use the bathroom/toilet promptly in order to maintain continence and dignity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure that procedures were developed and implemented for consistent and accurate processing of medication orders for two Residents (#8 and #15) of six residents reviewed for pharmacy services. This deficiency resulted in Resident #8 being administered the incorrect dosage of an anxiolytic medication and the potential for the inaccurate administration of an anticoagulant for Resident #15. Findings include: Resident #8 (R8)Review of the Minimum Data Set (MDS) assessment, dated 3/24/2025, revealed R8 was admitted to the facility on [DATE] and had diagnoses including coronary artery disease, chronic obstructive respiratory disease (COPD) and anxiety.Review of R8's March 2025 medication administration record (MAR) revealed the following orders: Ativan (a controlled medication used to treat anxiety) Oral Tablet 1 MG [milligram] . Give 4 tablet[s] by mouth every 4 hours for anxiety. Start Date: 3/19/2025 1800 [6:00 PM]. D/C [discontinued] Date: 3/20/2025 1305 [1:05 PM]. Further review revealed the medication was documented as administered on 3/20/2025 at 10:00 AM. Ativan Oral Tablet 2 MG. Give 2 tablet[s] by mouth every 4 hours for anxiety/restlessness. Start Date: 3/19/2025 0200 [2:00 AM]. Hold Date: From 3/19/2025 1545 [3:45 PM] to 3/20/2025 1304 [1:04 PM]. D/C Date: 3/20/2025 1306 [1:06 PM].Review of a Medication Related Incident Report, dated 3/20/2025 and gleaned from R8's electronic medical record (EMR) revealed the following: 3/20/2025 10:00 AM. Incident Type: Wrong dose. Did an adverse drug reaction occur as a result of the medication error? Yes . On 3/19/25 only 1mg [Ativan] tablets available. Order read Ativan 1mg x 4 tabs q4h [every four hours]. 3/20/25: 2mg Ativan tabs available. Order not updated to reflect strength change of tablets. Nurse gave 4 - 2mg tablets [at] 10:00 AM on 3/20/25.On 9/4/2025 at 10:00 AM, the Director of Nursing (DON) reported the error which resulted from the pharmacy sending higher strength tablets of the Ativan in the form of 2mg tablets with new instructions to give two tablets every four hours. The DON presented R18's Ativan Controlled Medication Dispensing Logs, which revealed the following: Lorazepam [Ativan] 1MG Tablet. Take 4 tablets (4MG) by mouth every four hours (take until 2MG tablets are in stock).The DON reported she believed the nurse was distracted by activity within the facility at the time of administration and due to the order not being reconciled with the pharmacy recommendation, and the order for Ativan 1mg tablets not being discontinued upon receipts of the Ativan 2mg tablets, the incorrect amount of Ativan was administered.Resident #15 (R15)Review of the MDS assessment, dated 8/25/2025, revealed R15 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation (a-fib), an open, abdominal skin ulcer and necrotizing fasciitis (serious bacterial infection that destroys tissue under the skin).Review of R15's EMR revealed a Warfarin Dosing Form, signed by Pharmacist I and dated 9/2/2025, revealed the following: Current warfarin dose: Warfarin (Coumadin, a medication used to inhibit the rate of blood clotting, a blood thinner] 5mg M/W [Mondays and Wednesdays]; 2.5mg all other days.Further review of the Warfarin Dosing Form, revealed R15's INR (International Normalized Ratio, a blood test to determine the effectiveness of blood-thinning medications) was reported as 2.7 on 9/02/2025 and Pharmacist I recommended the following: Recommended Dose: Start warfarin 5mg Wed [Wednesday]; 2.5mg all other days. Next INR: Monday 9/8/25.It was noted in review of R15's EMR and the Warfarin Dosing Form, there was no indication on the form of when the recommendation was received or who the recommendation was reviewed by at the facility.Review of R15's medication orders was conducted on 9/3/2025 at 10:15 AM and revealed the following orders for Resident's warfarin dosing in response to the pharmacist's recommendation on 9/2/2025: Warfarin sodium Oral Tablet 5 MG. Give 1 tablet by mouth at bedtime every Mon [Monday], Wed [Wednesday] for coag [coagulation]. Start Date: 8/27/2025 2000 [8:00 PM]. D/C [discontinued] Date: 9/02/2025 1505 [3:05 PM]; warfarin sodium Oral Tablet 2.5 MG. Give 1 tablet by mouth at bedtime every Tue [Tuesday], Thu [Thursday], Fri [Friday], Sat [Saturday], Sun [Sunday] for treating/preventing blood clots. Start Date: 8/26/2025 2000 [8:00 PM]. D/C Date: 9/02/2025 1506 [3:06 PM]. Warfarin sodium Oral Tablet 5MG. Give 1 tablet by mouth at bedtime every Mon [Monday], Wed [Wednesday] for coag [coagulation]. Start Date: 9/03/2025 2000 [8:00 PM]; warfarin sodium Oral Tablet 2.5 MG. Give 1 tablet by mouth at bedtime every Tue [Tuesday], Thu [Thursday], Fri [Friday], Sat [Saturday], Sun [Sunday] for treating/preventing blood clots. Start Date: 9/02/2025 2000 [8:00 PM].Review of R15's September 2025 MAR revealed the order for warfarin 5mg did not reflect the current recommendation issued by the pharmacist on 9/02/2025 to decrease the dosage to warfarin 5mg on Wednesdays only and 2.5mg on all other days of the week.During an interview on 9/4/2025 at 8:45 AM, the DON reported the pharmacy dosed resident's warfarin dosages based on INR results. The DON reviewed R15's 9/2/2025 pharmacy recommendation for warfarin dosing and confirmed the dosage should have been changed to reflect the recommendation to decrease the dosage to 5mg on Wednesdays only and 2.5mg all other days of the week. When asked what the process was for reviewing the pharmacy recommendations, the DON could not articulate the facility procedure for a specific staff person responsible for receiving and reviewing pharmacy recommendations. The DON stated the nurses on duty at the time the Warfarin Dosing Form, was received should an act on the recommendations and obtain additional verification by a second nurse.During interview on 9/4/2025 at 9:20 AM, Assistant Director of Nursing (ADON) A reported pharmacy recommendations are reviewed by nurses on the night shift. After review and follow through on the recommendations, the Warfarin Dosing Forms, are added to the documents to be scanned into the EMR. ADON A stated she attempted to review all pharmacy recommendations for completion and accuracy but had not been able to get around to verifying the pharmacy recommendations and orders regarding R15's warfarin dosing for the current week. When asked if the facility had a policy related to receiving, reviewing and response to pharmacy recommendations, ADON A reported, not that I am aware of.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by:Failing to label, date, and discard expired food in the reach-in refrigerator, walk-in refrigerator, walk-in freezer, and dry storage. Failing to ensure kitchen utensils were stored in a sanitary manner.Failing to ensure the ice cube machine/bin was free from mold accumulation.These deficient practices have the potential to result in food borne illness among any or all of the 17 residents in the facility.Findings include:
On 9/2/25 at 11:24 PM, an initial tour of the kitchen was conducted with Dietary Manager (DM) G. The following observations were made in the reach-in refrigerator:
Undated, unidentifiable meat in a plastic tub covered with plastic wrap. DM G identified this as sliced steak from the previous day's lunch meal.
A bowl of what appeared to be cooked onion rings, covered with plastic wrap, undated.
A bowl of cubed pineapple, covered in plastic wrap, undated.
Two bagels in an unsecured bag, undated.
An uncovered, undated sandwich sitting on a plate.
On 9/2/25 at 11:29 PM, the following observations were made in the reach-in freezer:
Unidentified meat patties, in an unzipped bag, undated
Undated, pre-prepared chicken patties.
During the kitchen tour on 9/3/25 at 9:00 AM the following deficiencies were noted:
All foods stored in the reach in refrigerator were not properly labeled with a use by date (UBD)
Two containers of clam flavored soup base located in the walk-in refrigerator were expired in December 2024.
Mold was observed inside the ice machine located near the dry storage room.
All foods located in the reach in freezer were not properly labeled with a UBD. A bag of frozen cookies stored in a Ziplock style bag were not properly sealed.
Bread rolls and Danish pastries located on the bread rack did not have a date opened/made or a UBD.
A storage drawer was observed to have copious amounts of crumbs touching multiple kitchen utensils.
An interview with Dietary Manager (DM) G on 9/4/25 at 10:12 a.m. confirmed that staff do not label foods with a UBD. DM G also confirmed that the expired foods should have been properly disposed, and the kitchen should be kept in a clean sanitary manner.
Review of the Food and Drug Administration (FDA) 2017 Food Code, read, in part,
4-602.11 Equipment Food-Contact Surfaces and Utensils.ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.
6-405.10 Receptacles, Waste Handling Units, and Designated Storage Areas.Waste materials and empty product containers are unclean and can be an attractant to insects and rodents. Food, equipment, utensils, linens, and single-service and singleuse articles must be protected from exposure to filth and unclean conditions and other contaminants.
3-5 LIMITATION OF GROWTH OF ORGANISMS OF PUBLIC HEALTH CONCERN .(D) A date marking system that meets the criteria stated in ¶¶ (A) and (B) of this section may include: (1) Using a method APPROVED by the REGULATORY AUTHORITY for refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under ¶ (B) of this section; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the REGULATORY AUTHORITY upon request.

Based on interview and record review, the facility failed to annually review and update the required Facility Assessment, resulting in the potential for unidentified resources necessary to provide care and services to the resident population.Findings include: Review of the Facility Assessment document provided by the facility revealed the Facility Assessment was last completed, updated, or reviewed on 8/6/24.In an interview on 9/4/25 at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed that the Facility Assessment had not been completed, updated, or reviewed since 8/6/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure the implementation of Enhanced Barrier Precautions (EBP) according to physician order and current standards of practice for two Residents (#10 and #18) of four residents reviewed for EBP utilization.Findings include:Resident #10 (R10)Review of the Minimum Data Set (MDS) assessment, dated 9/8/2025, revealed R10 was admitted to the facility on [DATE] and had diagnoses including left femur fracture, breast cancer and anxiety. Further review of the MDS assessment revealed R10 required substantial/maximal assistance with bathing, lower body dressing and transfers, and partial/moderate assistance with toileting hygiene.Review of R10's electronic medical record revealed R10 had a Stage 2 (partial-thickness tissue loss) pressure injury to her spine. Review of R10's Wound Evaluation, dated 8/31/2025, revealed the pressure injury measured 0.67 centimeters (cm) in length and 0.51 cm in width. Review of the photograph attached to the Wound Evaluation, revealed an area of redness over R10's spinous process located mid-back. The center of the reddened area was open with a depth of approximately 0.5 cm and a white wound bed.Review of R10's physician orders revealed the following, active order: Follow EBP guidelines during wound and foley care as well as during high contacts resident care activities (dressing, showering, transferring, changing linens or briefs . Active 8/22/2025.An observation of R10's wound care was conducted on 9/4/2025 at 7:50 AM. During care, Licensed Practical Nurse (LPN) C was observed removing a two inch by two inch (2x2) bordered foam dressing from R10's mid back to reveal a round open area, approximately 0.5 cm in diameter. LPN C cleansed the wound with wound cleanser, applied skin prep and covered the area with a clean bordered foam dressing. It was noted during wound care LPN C wore gloves but did not where a protective gown.Immediately following the wound care observation, R10 requested assistance to use the toilet. LPN C and Certified Nursing Assistant (CNA) D were observed transferring R10 from her wheelchair to the toilet using a sit-to-stand lift. CNA D was observed to assist R10 with toileting hygiene and both CNA D and LPN C transferred R10 from the toilet to her wheelchair. It was noted in observation, neither LPN C or CNA D wore protective gowns in the care of R10.During an interview immediately following the observation, CNA D was queried as to when the use of enhanced barrier precautions (EBP) was necessary in the care of residents. CNA D reported EBP would be utilized if there was a sign posted alerting staff for the need of EBP. CNA D stated, like for resident with wounds, catheters or IVs [intravenous lines].During an interview on 9/04/2025 at 8:30 AM, LPN C was queried about what the indications were for the use of EBP in resident care. LPN C confirmed she should have implemented the use of EBP during wound care and toileting of R10. LPN C reported a sign should have been posted in the doorway of R10's room alerting staff to the need to use EBP. An observation at the time of the interview revealed no EBP signage present in R10's doorway. During the interview, the Assistant Director of Nursing (ADON), who also served as the facility's Infection Preventionist, reported she was unsure why there was no sign posted for the use of EBP in R10's care. The ADON confirmed EBP was ordered for the care of R10 due to her having an open wound.Further observation at the time of the interview revealed Resident #18 (R18) calling out from his room for assistance. Upon hearing R18, LPN C was observed entering R18's room and assisting the resident to reposition his legs and feet before proceeded to adjust R18's bedding to cover the Resident. During the observation, it was noted R18 had urinary catheter tubing leading from the Resident to a dependent drainage bag attached to the left lower bedframe. LPN C did not wear a protective gown during care provision for R18. A sign was observed to be attached to the doorway to R18's room alerting staff to the need for EBP during all high contact care activities. Further review of the sign revealed the following: Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities . providing hygiene, changing briefs and assisting with toileting, device care or use: . feeding tube . wound care . Do not wear the same gown and gloves for the care of more than one person.Review of R18's EMR revealed the following physician order: Follow EBP guidelines during wound and foley care as well as during high contacts resident care activities (dressing, showering, transferring, changing linens or briefs) . Active 8/21/2025.Review of the facility policy titled, Enhanced Barrier Precautions, dated 5/07/2025, revealed the following: EBP should be used during contact with all residents who have any of the following . Wound(s) regardless of MDRO [multidrug-resistant organism] colonization status. Indwelling medical devices (e.g., central line, IUC [indwelling urinary catheter], feeding tube, tracheostomy, ventilator) . Enhanced Barrier Precautions includes the following practices: . Hand hygiene . Gloves . Gowns .

Based on interview and record review, the facility failed to maintain an effective abuse training program for two out of five staff members reviewed for new hires and annual training. Findings include:A review of staff education records and competencies on 9/4/25 revealed the following staff members had not completed the required abuse, neglect and exploitation training:Certified Nurse Aide (CNA) E - Hired on 7/16/25 and had not completed abuse training prior to start date.CNA F - Hired on 8/21/23 with last completed abuse training on 6/26/24.An interview conducted with the Director of Nursing (DON) on 9/4/25 at approximately 10:30 a.m. confirmed staff abuse training had not been completed per the facilities policy.Review of the facility's Abuse, Neglect, Misappropriation or Exploitation Policy/Procedure, undated, read, in part, .employees will receive training regarding abuse, neglect, exploitation, misappropriation of property, or mistreatment during new employee orientation and on an annual basis.

Based on interview and record review, the facility failed to ensure a consent was signed for psychoactive medication use and an AIMS (Abnormal Involuntary Movement Scale) assessment was completed appropriately for one Resident (R12) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for the unnecessary use of mind-altering medications, negative side-effects of medications and decreased quality of life. Findings include:
Review of R12's Electronic Medical Record (EMR) revealed admission to the facility on 9/16/24 with diagnosis including dementia with behaviors, delirium, and anxiety. Review of R12's 9/23/24 admission Minimum Data Set (MDS) assessment revealed a 10/15 on the Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. R12 was noted in Section N of the MDS assessment to be taking an antipsychotic medication on a routine basis only.
An interview was conducted with Registered Nurse (RN) F on 10/2/24 at 9:52 a.m. RN F confirmed R12 was currently receiving an antipsychotic medication.
A request was made to the Director of Nursing (DON) on 10/2/24 at 9:55 a.m. for R12's AIMS assessment and consent for psychoactive medications.
Review of R12's Medication Administration Record (MAR) for September 2024 and October 2024 revealed the following antipsychotic medications:
Seroquel 25 mg (milligrams); Give 1 tablet by mouth at bedtime for mental health; Start Date: 9/16/24; D/C (discontinued) Date: 9/17/24
Seroquel 25 mg; Give 2 tablet by mouth at bedtime for Dementia w/ (with) behavioral disturbances; Start Date: 9/17/24; D/C Date: 9/18/24
Seroquel 50 mg; Give 1 tablet by mouth at bedtime for psychosis; Start Date: 9/18/24
Review of R12's Consent for Psychoactive Medications form presented on admission and dated 9/16/24 did not have R12's Seroquel medication listed, the purpose of the medication, or the Resident or Responsible Party's consent for the use of medication.
Review of R12's AIMS form dated 9/16/24 read, in part, .Is this Resident currently taking an Anti-Psychotic Medications? No .
An interview was conducted with the DON on 10/2/24 at 10:05 a.m. The DON confirmed the facility had inaccurately completed the AIMS form for R12 and failed to obtain a singed consent for the use of psychoactive medications. The DON stated that the AIMS form should have been completed upon admission and then again on 9/30/24 and the consent should have been completed upon admission.

Based on interview and record review, the facility failed to develop an abuse policy consistent with current regulatory language for reporting allegations of abuse to the State Agency, resulting in the potential for allegations of abuse to not be reported timely to the State Agency for all eight facility residents.
Findings include:
Review of the facility's undated Abuse, Neglect, Misappropriation, or Exploitation Policy/Procedure revealed
1.
When an alleged or suspected incident of abuse, neglect, misappropriation of resident property, and exploitation, the facility Administrator, or his/her designee, will notify the following persons or agencies of such incident.
a.
The facility Medical Director
b.
The resident's responsible party
c.
The State licensing agency responsible for surveying/licensing the facility .
Reporting time line requirements:
Within 2 hours of receiving an allegation of abuse or forming suspicion of abuse if there is serious bodily injury.
Within 24 hours of receiving an allegation of abuse or forming suspicion of abuse if there is not serious bodily injury .
Reporting/Response: Upon receipt of an allegation of abuse or neglect, the employee will assure the resident is safe and then immediately report the incident to the Administrator and DON [Director of Nursing]. The Administrator, DON and/or employee must report an incident with any suspicion of a crime or serious bodily harm to Dept of HHS, local police and state agency within 2 hours of the incident being reported. If no serious bodily harm has occurred, the incident must be reported within 24 hours of the incident. The Administrator or DON then has 5 business days to fully investigate the incident and submit a written report to the state agency. (The current regulatory language requires any allegation of abuse to be reported to the State Agency within 2 hours).
In an interview on 10/24/23 at 11:37 AM, Nursing Home Administrator (NHA) A reported it was the facility's policy to report to the State Agency within two hours if there was an injury and within 24 hours if there was no injury.

Based on interview and record review, the facility failed to annually review and update the facility-wide assessment to address the resident population, acuity, staffing levels, physical environment and risk assessment which had the potential to affect all 8 residents residing at the facility. This deficient practice resulted in the increased likelihood for insufficient resources to provide for resident care and emergency/disaster needs.
Findings include:
On 10/23/23 at 9:33 AM, during the entrance conference for the annual survey, a copy of the Facility Assessment was requested. NHA A reported the current census was 8 related to a recent COVID-19 outbreak.
Review of the facility's assessment, failed to reveal the following:
1). Evaluation of all contracts, memorandums of understanding including third party agreements for the provision of goods, services, or equipment to the facility during both normal operations and emergencies.
2). Staff competencies details that were necessary to provide for the level and types of care needed for the resident population.
3). An evaluation of the facilities training program to ensure any training needs were met for all staff.
4). An evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet resident's needs.
5). Health information technology resources details, such as managing resident records and electronically sharing information with other organizations.
6.) Overall details and evidence of annual review.
Continued review of the Facility Assessment reflected no mention of planning/staffing for COVID-19(had been informed on entrance COVID-19 unit was open as of 10/23/23). The Facility Assessment included, Average number of residents (2017 and 2018) = 19 per day .
On 10/25/23 at 12:01 PM, an interview was conducted with the NHA A during the review of the facility Quality Assessment and Assurance program and the Quality Assurance and Performance Improvement program. The NHA A was queried regarding the incomplete Facility Assessment Summary. NHA A reported it was brought to our attention last year and we should have updated it then. The NHA A looked and then stated he had no documentation for an annual review of the facility assessment and reported it had not been updated annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6 (R6)
Review of the medical record revealed R6 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cerebral infarction, dysphagia, protein-calorie malnutrition, diabetes, chronic obstructive pulmonary disease, and epilepsy. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/26/23 revealed R6 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R6 had an activated durable power of attorney for healthcare (DPOAH).
On 10/23/23 at 3:31 PM, R6 was observed lying in bed.
Review of the Michigan Physician Orders for Scope of Treatment (MI-POST), revealed R6's DPOAH chose for R6 to be a Do Not Resuscitate (DNR) and signed the form on 8/8/23.
Review of the medical record revealed R6 did not have a DNR order refelctive of the Michigan Do Not Resuscitate Procedure Act.
Based on observation, interview, and record review, the facility failed to ensure accurate advance directive information was in place for three Residents (R6, R9, and R10) of three Residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers.
Findings Include:
Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed, 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 revealed, Sec. 4. A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall 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 or ward'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 (Date) declarant, if applicable)
_______________________________________
(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)
C. 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.
Resident #9
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R9 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included recent fall with fracture left clavicle and ribs, urinary tract infection, and respiratory failure. The MDS reflected R9 had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required two person physical assist with bed mobility, transfers, toileting, dressing, and one person physical assist with walking in room and corridor, hygiene, and bathing.
During an observation and interview on 10/23/23 at 11:35 AM, R9 was sitting in her room and appeared well groomed, calm and able to answer questions without difficulty.
Review of the Michigan Physician Orders for Scope of Treatment (MI-POST), revealed R9 chose to be a Do Not Resuscitate (DNR) and signed the form on 9/15/23.
Review of the medical record revealed R9 did not have a DNR order reflective of the Michigan Do Not Resuscitate Procedure Act.
During an interview on 10/23/23 at 4:28 PM, Social Worker (SW) I reported they had worked at the facility for about 6 months. SW I reported they met with new admission residents within 36 hours of admission and would expect resident or responsible party to complete an MI-POST which included two witness signatures if a resident wished to be a Do Not Resuscitate(DNR). SW I verified R9 MI-POST indicated DNR with no witness signatures. SW I reported facility started to use new MI-POST document recently and did not notice form did not have spot for two witness signatures. SW I reported MI-POST form recently went live and verified date of form was 8/22 from MDHHS-5836. SW I reported new form used due to administrative changes to the document to provide a clearer understanding. Director of Nursing (DON) B joined the interview and reported the facility planned training for next month for the new (MI-POST) form that just went live and referenced email guidance. SW I reported R9 did not have a DNR Physician order other than the MI-POST form.
On 10/24/23 at 9:15 AM, review of the provided MI-POST guidance reflected, Members should be aware that a validly executed MI-POST may be used as a medical order in an assisted living community. Residents admitted to a skilled nursing facility with an active MI-POST are advised to also complete a Michigan Do Not Resuscitate Form . Review of the link on the provider guidance for frequently asked questions included, Q: How is a MI-POST different from a Michigan Out of Hospital Do-Not-Resuscitate form? A: A MI-POST is intended only for adults who may have advanced illness or frailty with a life expectancy of 1 year or less. A Michigan Out of Hospital Do-Not Resuscitate form is intended for adults, or minors with advanced illness, with a life expectancy greater than 1 year .MDHHS MI-POST website.
During an interview on 10/24/23 at 9:43 AM, SW I verified R9 did not have a physician signed DNR order.
Resident #10
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R10 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted to the facility on [DATE] and 10/17/23 related to acute urinary tract infections and inflammatory reaction due to indwelling urethral catheter, with other diagnoses that included recent fall with fracture left hip, urinary retention, macular degeneration, respiratory failure, acute renal failure, and weakness. The MDS reflected R10 had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact.
During an observation and interview on 10/23/23 at 9:15 AM, R10 was observed laying in bed wearing hospital pants and had some difficulty answering questions.
Review of the Michigan Physician Orders for Scope of Treatment (MI-POST), revealed R10 chose to be a Do Not Resuscitate (DNR) and signed the form on 7/6/23.
Review of the medical record revealed R10 did not have a DNR order reflective of the Michigan Do Not Resuscitate Procedure Act.
During an interview on 10/23/23 at 4:56 PM, SW I verified R10 had an older version MI-POST form which indicated R10 wished to be DNR. SW I verified R10 was DNR and that he was own responsible person. SW I reported facility had an Interdisciplinary (IDT) team that met weekly to discuss resident plans including any changes in code status. SW I reported the facility did not do quarterly Care Conferences because the IDT team met weekly to discuss each resident . SW I then stated she meets with resident and family to discuss care planning discussed at IDT meeting.
During an interview on 10/24/23 at 9:43 AM, SW I verified R10 did not have a physician signed DNR order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of visitor to resident verbal abuse to the State Agency for one Resident (#6) of one resident reviewed, resulting in an allegation of abuse that was unreported to the State Agency and the potential for further abuse allegations to go unreported.
Findings include:
Resident #6 (R6)
Review of the medical record revealed R6 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included anxiety. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/26/23 revealed R6 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R6 had an activated power of attorney in place.
Review of the Health Status Note dated 10/4/2023 and written by Director of Nursing (DON) B revealed I was notified by the charge nurse that the resident's son [name redacted] was yelling and swearing at the resident in his room. I approached him and instructed him to leave the bedside. He became argumentative with me, insisting that he was responding to an earlier communication that he had had with the resident. I instructed him that he would not be permitted to verbally abuse the resident and that he needed to leave to collect himself before he would be allowed to speak with the resident again. Met with him in my office, where he reported that the resident had accused him of stealing his money and that he felt that the resident was being ungrateful for his help with his finances. The conversation ended amicably, and he left the building. When speaking to the resident, he was shaken by the encounter but reported that he did not think any further intervention from [facility name redacted] staff.
On 10/23/23 at 3:31 PM, R6 was observed lying in bed. R6 was unable to recall the incident with his son.
In an interview on 10/24/23 at 10:34 AM, Licensed Practical Nurse (LPN) L reported she was in R6's room on 10/4/23 when R6's son came to visit. LPN L reported R6's son started yelling at [R6] saying you ungrateful son of a b*tch if you ever talk to me like that again, I'm going to cut you loose. You owe me $100,000. LPN L reported she notified DON B of the incident.
In an interview on 10/24/23 at 11:14 AM, DON B reported R6's son came in, went to his room, started yelling at [R6] saying he was ungrateful and owed him money. DON B reported she intervened and informed R6's son that he needed leave and could not treat R6 like that. DON B reported she informed Nursing Home Administrator (NHA) A and the incident was discussed but not reported to anyone.
In an interview on 10/24/23 at 11:37 AM, NHA A reported he knew very little about the incident between R6 and his son. NHA A reported he knew they were heated but was not aware there was any yelling or name calling. NHA A reported if he had been aware, he would have followed up for possible verbal abuse by a family member and possibly report to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to investigate an allegation of visitor to resident verbal abuse for one Resident (#6) of one resident reviewed, resulting in an allegation of abuse that was not investigated and the potential for further abuse to occur.
Findings include:
Resident #6 (R6)
Review of the medical record revealed R6 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included anxiety. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/26/23 revealed R6 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R6 had an activated power of attorney in place.
Review of the Health Status Note dated 10/4/2023 and written by Director of Nursing (DON) B revealed I was notified by the charge nurse that the resident's son [name redacted] was yelling and swearing at the resident in his room. I approached him and instructed him to leave the bedside. He became argumentative with me, insisting that he was responding to an earlier communication that he had had with the resident. I instructed him that he would not be permitted to verbally abuse the resident and that he needed to leave to collect himself before he would be allowed to speak with the resident again. Met with him in my office, where he reported that the resident had accused him of stealing his money and that he felt that the resident was being ungrateful for his help with his finances. The conversation ended amicably, and he left the building. When speaking to the resident, he was shaken by the encounter but reported that he did not think any further intervention from [facility name redacted] staff.
On 10/23/23 at 3:31 PM, R6 was observed lying in bed. R6 was unable to recall the incident with his son.
In an interview on 10/24/23 at 10:34 AM, Licensed Practical Nurse (LPN) L reported she was in R6's room on 10/4/23 when R6's son came to visit. LPN L reported R6's son started yelling at [R6] saying you ungrateful son of a b*tch if you ever talk to me like that again, I'm going to cut you loose. You owe me $100,000. LPN L reported she notified DON B of the incident.
In an interview on 10/24/23 at 11:14 AM, DON B reported R6's son came in, went to his room, started yelling at [R6] saying he was ungrateful and owed him money. DON B reported she intervened and informed R6's son that he needed leave and could not treat R6 like that. DON B reported she informed Nursing Home Administrator (NHA) A and the incident was discussed but not reported to anyone.
In an interview on 10/24/23 at 11:37 AM, NHA A reported he knew very little about the incident between R6 and his son. NHA A reported he knew they were heated but was not aware there was any yelling or name calling. NHA A reported if he had been aware, he would have followed up for possible verbal abuse by a family member and possibly report to the State Agency. NHA A reported the allegation of abuse was not investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12 (R12)
Review of the medical record revealed R12 admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/12/23 revealed R12 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and received an antidepressant medication for seven days out of the seven-day look back period.
Review of the Physician's Orders revealed on 7/31/23, R12 was started on 25 milligrams (mg) of Trazodone (antidepressant medication) at bedtime for insomnia. On 8/7/23, the Trazodone was increased to 50 mg at bedtime for insomnia. On 8/14/23 the Trazodone was increased to 75 mg at bedtime for insomnia. On 8/18/23, the Trazodone was increased to 100 mg at bedtime for insomnia. On 8/23/23, the Trazodone was increased to 150 mg at bedtime for insomnia. On 8/25/23, the Trazodone was increased to 200 mg at bedtime for insomnia.
Review of the Health Status Note dated 8/4/23 revealed R12 had not experienced any improvement in insomnia. The Health Status Note dated 8/15/23 revealed R12 reported minimal improvement in sleeping. The Health Status Note dated 8/28/23 revealed R12 reported slight improvement in sleeping but was still having trouble staying asleep.
Review of the care plans revealed R12 did not have a care plan for insomnia and the use of Trazodone.
In an interview on 10/24/23 at 3:25 PM, Director of Nursing (DON) B reported the Interdisciplinary Team (IDT) discussed what should be care planned for each resident. DON B reported she was not aware R12's Trazodone dose had been increased and reported it had not been discussed amongst the IDT.
Based on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for 2 Residents ( #5 & #12) of 7 residents reviewed resulting in the potential for unmet care needs.
Resident #5 (R5)
Review of the medical record revealed R5 was admitted to the facility on [DATE] with diagnoses that included type two diabetes with unspecified complications, Covid 19 and anemia in chronic kidney disease. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 10/13/23 revealed R5 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
In an observation and interview on 10/23/23 at 9:23 AM, R5 was seated in her room watching television. R5 reported she had recently contracted coronavirus so she was unable to attend outside community service appointments, but was able to attend her dialysis appointments which were scheduled for Mondays, Wednesday, and Friday.
Review of the Care Plan revealed R5 had a focus area which reflected resident has diagnosis of ESRD (End Stage Renal Disease) and requires a therapeutic diet and fluid restriction initiated on 7/14/2023. Some of the interventions included encouraging a large breakfast on dialysis days, monitoring fluids to one liter per day, offer renal diet, and monitor weights and labs as ordered. R5's comprehensive care plan did not include information such as identification of the type of dialysis, where provided and by whom, how often and if the treatment is in accordance with the dialysis prescription.
Further review of the same Care Plan revealed no focus area for site assessment and pre/post dialysis monitoring.
Review of the Physician Order set revealed an absence of a Physician Order for dialysis including identification of the type of dialysis, where provided and by whom, how often and if the treatment is in accordance with the dialysis prescription.
In an interview on 10/24/23 at 1:31 PM, Registered Nurse H reported she does a majority of the care plans for the residents. RN H stated, when a staff member puts in an Physician Order, it will prompt her to completed a care plan that corresponds with the order.
In an interview on 10/24/23 at 3:19 PM, Director of Nursing (DON) B reported, care plans are started when a resident has care needs that fall outside standard care. When queried if R5 should have an order set for dialysis, DON B stated that R5's dialysis days are communicated to staff by sticky note and, it would be smart for it to be in an order.
A Potential for complications secondary to hemodialysis care plan with interventions to monitor the vascular access site, monitor weights, vitals, and hydration status was added on 10/24/23, however, the added care plan did not include information regarding R5's dialysis schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to assist residents/representatives to engage/participate in the care planning process, including attendance at care planning conferences with facility Interdiciplinary Team(IDT) for one Resident (R10), of seven residents reviewed, resulting in the liklihood of unmet care needs and delay in discharge planning.
Findings:
Review of the facility, Care Planning - Interdisciplinary Team Policy, dated 8/31/22, reflected, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are
encouraged to participate in the development of and revisions to the resident ' s care plan .Care plan meetings will be held as needed and every effort will be made to schedule care plan meetings at
the best time of the day for the resident and family .
Resident #10 (R10)
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R10 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted to the facility on [DATE] and 10/17/23 related to acute urinary tract infections and inflammatory reaction due to indwelling urethral catheter, with other diagnoses that included recent fall with fracture left hip, urinary retention, macular degeneration, respiratory failure, acute renal failure, and weakness. The MDS reflected R10 had a BIM (assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with bed mobility, transfers, dressing, and one person physical assist with walking in room and corridor, hygiene, toileting, and bathing.
During an observation and interview on 10/23/23 at 9:15 AM, R10 was observed laying in bed wearing hospital pants with some difficulty answering questions.
During an interview on 10/23/23 at 4:56 PM, Social Worker (SW) I reported the facility had IDT team which met weekly to discuss residents plan including any changes in code status. SW I reported the facility did not have quarterly Care Conferences because IDT team meets weekly to discuss each resident and SW then meets with resident and family to discussed care plan discussed at IDT meeting. SW I reported resident and family were not present at the IDT meeting to be given an oppurtunity for input related to care needs. SW I stated she was unsure why the facility does not have new admission and quarterly Care Conferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00137609.
Based on interview and record review, the facility failed to prevent a fall for one Resident (#18) of one resident reviewed, resulting in Resident #18 falling with staff present and sustaining multiple fractures requiring hospitalization and surgery.
Findings include:
Resident #18 (R18)
Review of a Post Fall/Incident Note dated 4/8/2023 revealed R18 fell in the bathroom while the Certified Nursing Assistant (CNA) was with her. The note revealed [Patient] washed her hand, turned to get towel, and lost balance. fell on left side of face and body. Injuries included laceration on left eyebrow, bleeding around scab on left elbow, and bruising lateral side of left calf. The note revealed R18 was transferred to the hospital. The note also revealed resident should be CGA (Contact Guard Assist).
Review of the hospital's History and Physical dated 4/8/23 revealed Patient states she was up with a 1 handed walker going to the restroom with assistance. Upon completion, she went to wash her hand and upon letting go of her walker she fell to her left side. This was witnessed and her assistants were quick to her aid.
Review of R18's Hospital Summary dated 4/8/23 revealed diagnoses this visit included fall, maxillary fracture (upper jaw), orbital (surrounding the eye) fracture, multiple fractures of thoracic spine, and lumbar compression fracture. R18 was admitted to the hospital on [DATE], underwent surgery for the maxillary and orbital fractures on 4/11/23, and discharged from the hospital on 4/18/23.
In a telephone interview on 10/24/23 at 2:13 PM, CNA E reported CGA required the use of a gait belt and hands on the gait belt. CNA E reported she did not witness R18's fall but heard it from the hallway. CNA E reported when she entered the bathroom, she observed R18 on the floor with a gait belt around her. CNA E reported R18 had used a hemi walker, which was new for her.
In a telephone interview on 10/25/23 at 5:54 AM, CNA F reported she was with R18 in the bathroom when R18 fell. CNA F reported R18 was standing at the sink drying her hands and just before I could even grab her, she went sideways. CNA F reported R18 used a hemi walker, let go, and just fell. CNA F stated, I didn't realize she was going to reach up. I didn't expect that. CNA F reported she believed R18 was CGA which meant the use of a gait belt and hands on. CNA F reported R18 had a gait belt on, but reported she did not have hands on the gait belt when R18 fell, otherwise I would have grabbed her. CNA F reported she believed she was turned around, placing something in the garbage can when R18 began to fall.
Review of the medical record revealed R18 admitted to the facility on [DATE] with diagnoses that included left femur fracture and fracture of left humerus from a fall at home. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/15/23 revealed R18 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), required extensive assistance of two people for transfers, extensive assistance of one person for toilet use, and had a history of falls with fracture prior to admission.
Review of the Fall Risk assessment dated [DATE] revealed R18 used assistive devices and requires hands-on assistance to move from place to place. R18 scored 20 on the fall risk assessment which indicated she was a high risk for falls.
Review of R18's Risk for Falls care plan initiated on 3/15/23 revealed an intervention dated 3/15/23 that included one to two people assist with transfers.
Review of the Physical Therapy (PT) Evaluation & Plan of Treatment for the certification period of 3/9/23 through 4/7/23 revealed R18 felt unsteady when standing, felt unsteady when walking, was worried about falling, required partial/moderate assistance with sit to stand transfers, substantial/maximal assistance with toilet transfers, and used a hemi-walker during transfers.
Review of the Interdisciplinary Team (IDT) Meeting Note dated 3/20/2023 revealed R18 required moderate assistance with the use of a hemi walker during transfers and patient often leans back during transfers and requires the placement of a hand to steady.
Review of the Physical Therapy (PT) Note dated 4/1/23 revealed client fatigues with activities and standing, needs frequent breaks.
Review of the Daily Note dated 4/2/2023 revealed R18 transferred with moderate assist of one and a hemi walker.
Review of the IDT Meeting Note dated 4/3/2023 revealed R18 toileted with contact guard assist and had weakness.
Review of the PT Note dated 4/4/23 revealed R18 upgraded using the NBQC [narrow base quad cane] for transfers in the room with staff.
Review of the Daily Note dated 4/6/23 revealed R18 was a fall risk and was CGA with pivot for transfers. The Daily Note dated 4/7/23 revealed R18 was a fall risk and transferred with one assist with a quad cane.
In a telephone interview on 10/24/23 at 5:27 PM, Registered Nurse (RN) D reported she was working the night R18 fell but was not in the bathroom with R18. RN D reported when the fall occurred, R18 was standing at the sink, washing her hands, turned to grab the paper towel and fell before the CNA could catch her. RN D reported R18 was transferred to the Emergency Department.
In an interview on 10/25/23 at 8:47 AM, Physical Therapist (PT) G reported contact guard assistance required the use of a gait belt and for staff to always hold onto the gait belt. PT G reported R18's transfer and ambulation status was contact guard assist because she loses balance backwards.
In an interview on 10/24/23 at 11:14 AM, Director of Nursing (DON) B reported she was unsure how R18 fell with a staff member present. DON B reported the facility did not have an incident report for R18's fall and DON B reported she did not recall speaking with the staff present during the fall. On 10/25/23 at 10:05 AM, DON B reported contact guard assist required hands on the resident at all times while moving. DON B reported she was not aware staff did not have a hold of R18's gait belt when she fell.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: (1.) prevent Urinary Tract Infections (UTI's); (2.) failed to follow up with urology appointment; and (3.) provided catheter care per CDC standards of practice for one Resident (#10) of one resident reviewed for catheters and UTI's, resulting in the likelihood of signs and symptoms of catheter complications going unnoticed, catheter dislodgment, missed urology follow up appointment, and catheter associated urinary tract infection with hospitalization and prolonged illness.
Findings include:
Resident #10 (R10)
Review of the Face Sheet and Minimum Data Set (MDS) assessment dated [DATE], reflected R10 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted to the facility on [DATE] and 10/17/23 related to acute urinary tract infections and inflammatory reaction due to indwelling urethral catheter, with other diagnoses that included recent fall with fracture left hip, urinary retention, macular degeneration, respiratory failure, acute renal failure, and weakness. The MDS reflected R10 had a Brief Interview for Mental Status (BIMS- a cognitive screener assessment tool) score of 14 which indicated his ability to make daily decisions was cognitively intact, and he required two person physical assist with bed mobility, transfers, dressing, and one person physical assist with walking in room and corridor, hygiene, toileting, and bathing.
During an observation and interview on 10/23/23 at 9:15 AM, R10 was observed laying in bed wearing hospital pants and foley catheter in place. R10 was noted to have some difficulty in answering questions.
Review of R10's Hospital Discharge summary, dated [DATE], reflected, The patient is a [AGE] year-old who fractured his left hip on 7/3/2023 and was admitted to [NAME], had it surgically repaired and
was discharged on 7/6/2023 for rehabilitation to [named facility]. He returned 2 days later after experiencing low blood pressure and hypoxia. The patient was seen in the emergency room by that time his blood pressure had normalized and he was oxygenating well. His creatinine was elevated at 1.97 and he had acute urinary retention of over 1000 cc of urine and a Foley catheter was placed.
Patient had pyuria and was started empirically on antibiotics but after 2 days of treatment it was decided that this pyuria/bacteriuria was due to colonization and treatment was discontinued. His blood pressures were followed and were thought to be similar to his norm, with a systolic BP frequently in the 90s. He did not show any signs of sepsis. He experienced confusion and even some
hallucinations during hospitalization and this apparently was new for him. It appeared to be consistent with hospital delirium and likely exacerbated by his blindness and poor hearing. He was seen in consultation by urology who recommended keeping the urinary catheter in place and following up in the urology clinic within 1 to 2 weeks .
Review of the Electronic Medical Record(EMR), dated 7/6/23 through 10/24/23, reflected no evidence of urology follow up.
During an interview on 10/24/23 at 5:15 pm, Director of Nursing (DON) B reported R10 returned from hospital with re-admission on [DATE] and had a foley catheter. DON B stated the facility uses standing orders to change foley catheters every 30 days and reported they were not aware this was not recommended by Centers for Disease Control (CDC). DON B reported they were unable to locate evidence R10 was seen by urology for any follow-up after the 7/12/23 hospital discharge with orders to be seen in 1 to 2 weeks. DON B reported urology was terrible about providing documentation. DON B stated they would expect consult notes to be part of the Electronic Medical Record (EMR) and documentation should reflect accurate notes.
Review of the Physician orders, dated 7/12/23, reflected an order to change R10's foley catheter every 30 days.
Review of the Nurse Practitioner notes, dated 7/31/23, reflected, Chief Complaint / Nature of Presenting Problem: Follow up on urine culture final results History Of Present Illness:
The patient is seen and examined today to follow-up on the above. Urine culture final result reveals >100,000 organisms/mL of Pseudomonas as well as Enterococcus faecalis. Upon initial review of sensitivities, enterococcus is not listed to be susceptible to ciprofloxacin which patient is currently receiving for treatment of Pseudomonas. Patient has allergy to penicillin. Contacted the lab and microbiology via telephone, who were able to confirm on their end that Enterococcus was susceptible to ciprofloxacin, susceptibilities on the final lab results were updated to make this visible. Patient denies recent fever, chills, abdominal pain, dysuria. He has follow-up with urology scheduled for tomorrow .
Review of the EMR on 10/25/23 at 8:00 a.m., reflected R10 had a urology follow up appointment note from 8/29/23 that was faxed to the facility on [DATE] at 7:51 a.m. The note reflected, Trial Void
#1: Pt presents today, with [named family], for trial void, after hip fx/surgery, currently in rehab at [named facility]. Cleared by orthopedics to go home and will be discharged home when no longer has a catheter . The note reflected R10 foley catheter was removed on 8/29/23 and failed trial void #1. The notes reflected catheter left out with direction to push fluids and to re-insert foley catheter in 4 to 6 hours if no urination. The note reflected if catheter had to be re-inserted to follow up with urology in one month other wise 10/17/23.
Review of the EMR, dated 8/29/23, reflected no evidence of monitoring R10 intake or output. Continued review reflected orders for post void residuals, dated 8/30/23 through 9/1/23 with straight catheter insertion. Continued review reflected re-insertion of foley catheter on 9/1/23.
Review of R10 Nurse Practitioner note, dated 10/9/23, reflected, [R10] is seen today for an acute visit at staff request due to new onset fever and hypoxia .Staff report increased lethargy. Patient does have a Foley catheter in place, staff report dark hazy urine .chronic indwelling Foley, continue routine Foley care. follows with urology .
Review of R10 Nurse Practitioner Note, dated 10/19/23, reflected, Chief Complaint / Nature of Presenting Problem: COVID-19 Catheter associated UTI Toxic encephalopathy AKI (Acute Kidney Injury) History Of Present Illness: The patient is seen today for follow-up of the above problems. He was readmitted to this facility on 10/17/2023 following hospitalization at (Local Hospital). He was hospitalized on [DATE] and diagnosed with acute cystitis, acute kidney injury, COVID-19 viremia and nocturnal visual hallucinations. He was treated for cystitis with 5 days of cefepime IV (intravenous). Acute kidney injury was mild at presentation and felt to be secondary to dehydration .
During an interview on 10/25/23 at 9:58 AM, Nurse J reported R10 had dark urine with sediment and fever and physician ordered urinalysis and IV fluid related to possible UTI.
During an interview on 10/25/23 at 10:21 AM, Unit Clerk (UC) K reported schedules outside appointments for facility and was also transport staff. UC K verified R10 was sent for appointment on 8/29/23 to urology and did not have record of follow up appointment.
During an interview on 10/25/23 at 10:25 AM, DON B reported they had just received R10's 8/29/23 urology consult note today and verified they had missed R10's 10/17/23 follow up appointment. DON B verified the 8/29/23 consult noted reflected detailed orders for catheter re-insertion if failed void in 4 to 6 hours with no evidence of documentation. DON B reported would expect staff to document R10's response to post removal of foley catheter. DON B verified R10's foley catheter was re-inserted on 9/1/23. DON B reported they were not aware until today that urology wanted a follow up in 1 month if the catheter had to be re-inserted for R10.

Based on observation, interview, and record review the facility failed to ensure proper label and dating of foods with the potential to effect 7 of 8 residents (1 resident receives nothing by mouth) resulting in the increased risk of food borne illness.
Findings include:
During an inspection of a refrigerator located in the resident dining room on 10/23/2023 at 11:41 AM, the following was observed:
Opened container of Thick and Easy clear Hydrolyte Thickened Water, no opened date
Opened package of cheddar cheese cubes, no opened date
Two containers of coffee creamer, no opened date
Opened 20 ounce Diet Pepsi, no opened date
Two loaf of white bread, No opened or use by date
An observation on of a sign displayed on the face of the refrigerator in the dining room revealed all items in this refrigerators must be sealed/covered, labeled and dated or they will be discarded. Items may only be kept for a maximum of three days .
In an interview on 10/25/23 at 9:02 AM, Dietary Manager C stated items were discarded after three days so the expectation would be to label the item when opened with the opened date.