Every finding on record at Four Seasons Nursing Center of Westland

This citation pertains to intake 3018809.Based on interview and record review, the facility failed to identify the correct resident for an Intravenous (IV) placement for one resident (R703) out of six reviewed for medication administration. Findings include:A review of a complaint called into the State Agency noted the following, [R703] was given an IV that was meant for another patient. It is unknown what was in the IV. It is unknown if the IV caused any interactions with [R703]. Nothing is documented about the IV.A review of the medical record revealed R703 was admitted into the facility on 4/29/2026 with the following medical diagnoses, heart disease with Heart Failure and Weakness. Further review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating an impaired cognition. R703 also required staff assistance for bed mobility and transfers.Review of a progress note dated 5/2/2026 noted the following, After the IV line was inserted, the resident became uncomfortable and [R703] started calling [their] daughter about [their] right hand in great pain. Writer immediately called the unit manager, and she asked the writer to immediately remove the IV line and dressed the IV site aseptically. Contacted NP (Nurse Practitioner) [Name] and left a voicemail.On 7/1/2026 at 12:58 PM, an interview was conducted with Registered Nurse (RN) D and confirmed they were the nurse that put the IV in place for R703. RN D reported they came over to put the IV in for the nurse after being asked to then returned back to their assigned set of residents. RN D reported they did not hang anything (administer any fluids or medication) and was unaware of what R703 needed the IV for.On 7/1/2026 at 1:10 PM, an attempted phone call was made to R703's assigned nurse, Licensed Practical Nurse (LPN) E.On 7/1/2026 at 2:02 PM, a phone interview was conducted with RN A who reported they worked the night of 5/1/2026, midnight shift, and confirmed R703 had no IV in place. RN A reported when they came in the next night, R703 had an IV in place and complaining of pain in their right wrist. The nurse then looked at the physician orders and did not see any orders regarding R703 needing an IV. RN A said they then called the Unit Manager who took out the IV and called all necessary parties. RN A reported R703 did not receive any medications through the IV and the intended resident was one room over.On 7/1/2026 at 2:36 PM, an interview was conducted with Unit Manager (UM) C who reported a resident in another room needed the IV fluids and LPN E was entering the order. UM C reported RN D to place the IV for LPN E. UM C reported they got a call around 8:00 PM from RN A stating they did not see an order for R703 and was wondering why they had an IV placed. UM C reported they came up to the facility and saw the IV was in the wrong patient (R703) and subsequently they took the IV out and called all necessary parties.A review of a facility policy stated, Medication Errors noted the following, To prevent medication errors and ensure safe medication administration, nurses should verify the following information: Right resident and right documentation.

Based on observation, interview and record review, the facility failed to timely complete annual PASARR (Pre-admission Screening and Annual Resident Review - Level I) assessments and review to the appropriate State - appointed authority for six residents (Resident #5, #6, #11, #14, #59 and #117) of six reviewed for PASARR Level I assessments. The Pre-admission Screening/Annual Resident Review (PASARR) in Michigan is a two-step screening and evaluation process. The purpose of the PASARR process is to encourage community care by supporting the placement of individuals with Mental Illness (MI) or those with Intellectual/Developmental Disabilities (ID/DD) in a nursing facility only when their medical needs clearly indicates that the resident requires the level of care provided by a nursing facility. Resident #5On 4/07/26 the medical record for R5 was reviewed and revealed the following: R5 was initially admitted to the facility on [DATE] with diagnoses that included: Schizoaffective Disorder, Depressive Disorder and Vascular Dementia with Behavioral Disturbance. A review of R5's Minimum Data Set assessment revealed a Brief Interview for mental status (BIMS) score of 15/15 indicating intact cognition. On 4/07/26 further review of R5's medical record revealed a PASARR (Pre-admission Screening and Annual Resident Review / Level I) assessments dated 2/16/26. There were no updated PASARR Level II / 3878 acknowledging the mental illness diagnoses noted in the record. Resident #6 On 4/07/26 the medical record for R6 was reviewed and revealed the following: R6 was initially admitted to the facility on [DATE] with diagnoses which included: Major Depressive Disorder, and Anorexia. A review of R6's MDS (Minimum Data Set) assessment revealed a BIMS score (brief interview for mental status) assessment score of 3/15 indicating severely impaired cognition. On 4/07/26 further review of R6's medical record revealed a PASARR (Pre-admission Screening and Annual Resident Review/3878) assessments dated 1/22/26 for hospital exempted discharge. There was no updated PASARR/ 3878 noted in the record acknowledging diagnosis of Dementia or referral for level II. Resident #11 On 4/07/26 the medical record for R11 was reviewed and revealed the following: R11 was admitted to the facility on [DATE] with diagnoses which included: Psychotic Disorder with Delusions, Dementia, and Hemiplegia and Hemiparesis. A review of R11's MDS (Minimum Data Set) assessment revealed a BIMS score (brief interview for mental status) assessment score of 9/15 indicating impaired cognition. On 4/07/26 further review of R11's medical record revealed a PASARR Level I (3877) assessment dated [DATE]. There was no updated PASARR/ 3878 noted in the record acknowledging diagnosis of Dementia or other mental illnesses was noted in the record. Resident #14On 4/07/26 the medical record for R14 was reviewed and revealed the following: R14 was initially admitted to the facility on [DATE] with diagnoses including: Post Traumatic Stress Disorder, Major Depressive Disorder, Dementia and Anxiety Disorder. A review of R14's MDS (Minimum Data Set) assessment revealed a BIMS score (brief interview for mental status) assessment score of 13/15 indicating intact cognition. On 4/07/26 further review of R14's medical record revealed a PASARR (3877) assessment dated [DATE]. There was no updated PASARR /3878 noted in the record acknowledging diagnosis of Dementia and mental illness. On 4/09/26 at 2:00 PM, the Nursing Home Administrator (NHA) was interviewed regarding the PASARR documentation. The NHA stated that they were aware of the PASARR assessments not being up to date and they were working with the Director of Social Work (DSW K) to bring them up to date. The NHA stated that their expectation is that all residents will be assessed and updated as needed per the policy. On 4/09/26 at 2:45 AM, K was interviewed in regard to PASARR assessments. The DSW K stated that the residents PASARR updates were missed due to having a shortage with social service staff. When asked what their expectation for updating Pre-admission Screening and Annual Resident Reviews, they stated that residents are monitored and assessed appropriately per policy. R59 A review of R59's medical record revealed they were initially admitted into the facility on 1/19/24 with diagnoses that included Bipolar disorder and Dementia. Review of the resident's most recent minimum data set assessment (MDS) dated [DATE] revealed that the resident had a moderately impaired cognition. Further review of the resident's medical record revealed a Level II evaluation dated 3/28/25 which indicated that it required re-evaluation by 3/25/26. On 4/9/26 at 1:00 PM, a request for R59's Level II evaluation was made to the facility, and the surveyor was provided with a copy of the resident's Level I screening with a written note stating the following, Waiting for [Doctor] to sign [Level II]. R117 R117 was admitted to the facility on [DATE] with the following relevant diagnoses: Bipolar Disorder, Dementia with Psychotic Disturbance, and Anxiety Disorder. R117's Minimum Data Set (MDS) Assessment reveals a Brief Interview for Mental Status score of 00/15 indicating severe cognitive impairment. On 4/7/26 review of the medical record revealed a Level I Screening for the Preadmission Screening Annual Resident Review (PASAAR) was completed on 3/18/26 indicating resident had a current diagnosis for mental illness and dementia. Further review of the medical record revealed R117 received treatment for a mental illness and received psychotropic medications within the last 14 days. Further review of the medical record failed to reveal a Level II screening had been submitted and signed by the physician. A review of the PASRR - Preadmission Screen and Resident Review policy dated 6/01/2011 and revised 3/10/2025 revealed, It is the policy of the facility to screen any resident with mental illness and/or intellectual/developmental disabilities through the PASARR process to ensure appropriate nursing facility services and specialized services are provided. The Social Service employee, or designee, is responsible for verifying that the PAS and/or ARR processes are completed appropriately and timely. The PASARR process must be completed in the following situations: Prior to admission to a nursing facility; After a significant change in the resident's physical or medical condition; Not less than annually.

Based on observation, interview, and record review, the facility failed to apply orthotic equipment (hand splints, knee braces, heel lift boots, and elbow extensions) for four residents (R9, R22, R48, and R144) out of four reviewed for limited range of motion. Findings include:R9A review of the medical record revealed R9 admitted into the facility on [DATE] with the following medical diagnoses, Muscle Weakness and Peripheral Vascular Disease. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 0/15 indicating impaired cognition. R9 also required staff assistance with bed mobility and transfers. Further review of the medical record revealed the following on the Medication Administration Record (MAR) for April 2026, Orthosis/Splint to be applied to Left RHS (Resting Hand Splint) and Rt. (Right) elbow splint 4 hrs (hours) check skin integrity pre and post application of splint/braces every day shift for contracture prevention. Start date: 11/14/2025.Additional review of the MAR showed checkmarks April 1st-April 9th, indicating that R9 had their Splint/Brace applied on those days.On 4/7/2026 at 10:00 AM and 2:18 PM, R9 was observed sitting in a Geri chair in the dining room and then in then hallway. R9 was observed to have a contracture to their left hand. R9 was unable to answer any interview questions. No splint or brace was noted to be applied.On 4/9/2026 at 1:19 PM, no splint or brace was noted to be applied to R9.R22A review of the medical record revealed that R22 admitted into the facility on 9/27/2019 with the following medical diagnoses, Muscle Weakness and Stiff-Man Syndrome (Neurological disorder characterized by severe muscle stiffness). A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R22 also required staff assistance with bed mobility and transfers. Further review of the progress notes revealed that R22 had been seen by Pain Management and Rehabilitation on 3/30/2026 and a recommendation for PRAFO (Pressure Relieving Ankle-Foot Orthosis) boots was made to address R22's foot drop.Further review of the care plan revealed the following intervention, Date initiated:9/27/2019.Bil (Bilateral) PRAFO donn (put on) for 2-3 hours as tolerated.Further review Medication Administration Record (MAR) for April 2026 revealed the following, Orthosis/Splint to be applied to: Apply PRAFO boots BLE (Bilateral Lower Extremities) for 2-3 hours as tolerated. Check skin issues upon application and removal. Every day shift for contracture prevention. Start Date-11/14/2025.Additional review of the MAR showed checkmarks April 1st-April 9th, indicating that R22 had the PRFAO boots applied on those days.On 4/7/2026 at 2:01 PM, R22 was observed laying in bed. R22 was noted to have dry, flaky feet, and their heels were resting on the air mattress.On 4/8/2026 at 3:12 PM, R22 was noted to be in bed with their heels resting on the mattress. No PRAFO boots were observed in place, or in the room. R22 reported they had not worn the boots in quite some time and did not know where they were at. R22 reported that they were not asked if they would like the PRAFO boots applied.On 4/9/2026 at 9:41 AM, R22 was noted to be in bed with their heels resting on the mattress. No PRAFO boots were observed in place, or in the room. R22 reported that they were not asked if they would like the PRAFO boots applied.On 4/9/2026 at 11:01 AM, Wound Care Nurse (WCN) L observed R22 without their PRAFO boots in place. WCN L reported R22 is supposed to have the boots on for their foot drop and contractures.R48On 4/7/2026 at 1:04 PM, R48 was observed lying in bed with a towel rolled up in their right hand. A knee brace was observed sitting in the windowsill. R48 was unable to be interviewed.A review of the medical record revealed that R48 was admitted into the facility on 6/1/2024 with the following medical diagnoses, Spinal Stenosis and Muscle Weakness. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental status score of 0/15 indicating an impaired cognition. R48 also required staff assistance with bed mobility and transfers. Further review of the Medication Administration Record (MAR) for April 2026 revealed the following, Orthosis/Splint to be applied to: Bil (Bilateral) PRAFO boot, Rt. Knee splint, Rt. Palm guard 6 hrs. Ensure Lt. RHS and Rt. PRAFO applied, Check skin integrity pre and post application of splint/braces. Every day shift for contracture prevention. Start Date-11/14/2025.Additional review of the MAR showed checkmarks April 1st-April 9th, indicating that R48 had a palm protector and knee brace applied on those days.On 4/7/2026 at 1:04 PM, R48 was observed lying in bed with a towel rolled up in their right hand. A knee brace was observed sitting in the windowsill. R48 was unable to be interviewed.On 4/8/2026 at 8:41 AM and 2:03 PM, R48 was observed lying in bed. No right palm protector or right knee brace was observed to be in place.On 4/9/2026 at 9:00 AM, R48 was observed lying in bed. No right palm protector or right knee brace was observed to be in place.On 4/9/2026 at 9:05 AM, an interview was conducted with Restorative Aide (RA) M. RA M reported they usually apply R48's devices on after mealtime and they wear it for 4-5 hours. RA M reported they were going to put the palm protector and brace on shortly. R144On 4/7/2026 at 2:10 PM, R144 was observed lying in bed and eating lunch. R144 was noted to have a left-hand contracture. A splint was observed sitting in the windowsill. R144 reported that the splint is not applied regularly. R144 reported that if they ask, then they will apply it however sometimes they forget to ask and then it does not get applied.A review of the medical record revealed that R144 admitted into the facility on 8/10/2024 with the following medical diagnoses, Cerebral Infarction (Stroke) and Muscle Weakness. A review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status assessment score of 13/15 indicating an intact cognition. R144 also required staff assistance with bed mobility and transfers. Further review of the Medication Administration Record (MAR) for April 2026 revealed the following, Orthosis/Splint to be applied to: Left RHS 6-8 hrs, Lt. PRAFO 4 hrs, Rt elbow extension 4-6 hrs, Check skin integrity pre and post application of splint/braces. Every day shift for contracture prevention. Start Date-11/14/2025.Additional review of the MAR showed checkmarks April 1st-April 8th, indicating that R48 had a palm protector and knee brace applied on those days.On 4/8/2026 at 9:08 AM and 2:04 PM, R144 was observed lying in bed. No splint/braces were applied. R144 reported they were not asked if they wanted the splint and/or brace applied.On 4/9/2026 at 9:05 AM, an interview was conducted with RA M. RA M reported they apply R144's splint, but they usually only apply the hand splint because R144 does not like the knee brace very much.On 4/9/2026 at 1:01 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they expect that if it is checked on the MAR, then it should be completed and if not, it should be documented as to why.A review of a facility policy titled, Equipment and Assistive Devices noted the following, Certain equipment and devices that assist with resident mobility, safety, and independence are provided for residents. These may include but are not limited to .Orthotic equipment (such as AFOS, splints, braces, etc.).

Based on observation, interview, and record review, the facility failed to obtain consent and provide risk versus benefits of psychotropic medication use for one severely cognitively impaired resident (R109) of five residents reviewed for unnecessary medications. Findings include: On 4/7/26 at 9:10 AM, R109 was observed sitting in the dining room eyes closed, drifting in and out of sleep. Attempts to speak with the resident were to no avail due to their cognition. A review of R109's medical record revealed they were admitted into the facility on 6/5/25 with diagnoses which included Alzheimer's Disease, Depression and Anxiety. Further review revealed the resident was severely cognitively impaired and required assistance with Activities of Daily Living. In addition, the resident had a medical power of attorney dated 4/18/16 in place granting their son as the representative. Review of the resident's active physician's orders revealed the resident was prescribed the following psychotropic medications:Seroquel (anti-psychotic) Oral Tablet 25 MG (milligrams), ordered, 2/25/26.Buspirone HCl (anti-anxiety) Oral Tablet 10 MG, ordered, 7/30/25.Sertraline HCl (anti-depressant) Oral Tablet 100 MG, ordered 6/5/25. Further review of R109's medical record revealed a consent for the medication use dated 6/20/25, indicating the resident, not their representee (son), was provided with education regarding risks versus benefits, and consented to the use of the medication. On 4/9/2026 at 1:30 PM, the Nursing Home Administrator was asked about medication consents being completed by the appropriate party, and explained the social worker is responsible for ensuring the consents are accurate. A review of the facility's, Psychotropic Medication Use policy revealed the following, .For any resident taking a psychotropic medication, the Social Service employee or designee will obtain informed consent from the resident and/or authorized representative using the Psychotropic Medication Consent UDA in the resident's electronic medical record. (*psychotropic medication consents prior to the release of the UDA may be on paper in the resident's medical record). The Social Service employee, or designee, will review the medication prescribed, dosage, side effects, and risks versus benefits of the medication, which are outlined on the psychotropic informed consent evaluation. The Social Service employee, or designee, will discuss any Black Box Warnings associated with the psychotropic prescribed to the resident or authorized presentative so that they are aware of the potential risks. After review, the resident and/or authorized representative will either consent or refuse the psychotropic medication

Based on interview and record review, the facility failed to timely coordinate with the appropriate State-appointed authority to complete a PASARR (Preadmission Screening and Resident Review) Level II Comprehensive Evaluation (used to determine the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) for one resident (R38) of five residents reviewed for PASARR Level II recommendations. Findings include: A review of R38's medical record revealed they were initially admitted into the facility on 9/23/19 with diagnoses of Depression, Anxiety, and Psychotic Disorder. Further review revealed the resident was cognitively intact and required assistance with Activities of Daily Living. Further review of the resident's medical record revealed a Comprehensive Level II Evaluation dated 7/7/2022 which was noted as being the Annual Resident Review which Require Re-Evaluation in 363 days. On 4/9/26 at 12:59 PM, a request for R38's Level II evaluation was made to the facility, and surveyor was provided with a copy of the resident's Level I screening with a written note stating the following, no level 2 OBRA (Omnibus Budget Reconciliation Act) since 7/7/2022. On 4/9/26 at 2:00 PM, the Nursing Home Administrator (NHA) was interviewed regarding the PASARR documentation. The NHA stated that they were aware of the PASARR assessments not being up to date and they were working with the Director of Social Work (DSW K) to bring them up to date. The NHA stated that their expectation is that all residents will be assessed and updated as needed per the policy. A review of the facility policy, PASARR - Preadmission Screen and Resident Review revealed the following, It is the policy of the facility to screen any resident with mental illness and/or intellectual/developmental disabilities through the PASARR process to ensure appropriate nursing facility services and specialized services are provided.

Based on interview and record review, the facility failed to ensure the timely appointment of a guardian for one resident (R99) out of one resident reviewed for medically related social services. Findings include:A review of the medical record revealed R99 admitted into the facility on 7/19/2024 with diagnoses of depression, Parkinson's Disease, and anxiety disorder. A review of the most recent Minimum Data Set assessment (MDS) for R99 dated 1/26/2026 revealed a Brief Interview for Mental Status (BIMS) score of 11/15, indicating impaired cognition.Further review of the medical record of R99 revealed a physician's note dated 8/16/2024 indicating that R99 is not capable of making their own medical decisions, as well as a petition for guardianship form that was submitted by the facility dated 4/7/2025.On 04/09/2026 at 9:30 AM, an interview was conducted with the Director of Social Work DSW. The DSW stated that R99 was their own responsible party on admission but was found to be incapacitated (unable to make their own medical decisions) and needed to have a guardian appointed. The DSW stated that a petition was sent for guardianship in April of 2025 and received a court hearing for June 2025. The DSW reported they did not attend the court case due to being at another hearing at that same time, and the case for R99 was adjourned. The DSW stated they were informed they would need to resubmit the petition. The DSW reported R99's petition for guardianship was left behind due to many other residents being in more urgent need of guardianship.A review of a facility policy titled Decision Making Capacity, last reviewed 1/15/25, revealed If the resident has no legal paperwork in place, the social worker will speak to the resident's family member and/or emergency contact about applying for guardianship through the probate court system. If the family member and/or emergency contact is not interested in obtaining guardianship or fails to obtain guardianship, the facility, or contracted vendor, should petition the probate court system for a third-party court appointed guardian.

Based on observation, interview, and record review, the facility failed to maintain clean privacy curtains for two residents (R13 and R64) of three reviewed for homelike environment. Findings include:R13 On 4/7/26 at 9:00 AM, an observation was made of R13's privacy curtain being soiled with a dried brownish substance on the bottom of the curtain. On 4/9/26 at 10:54 AM, R13's privacy curtain was observed to continue to be soiled. R13 was asked about the curtain and stated, I think it's dried blood. It's not good. On 4/9/26 at 11:15 AM, Floor Services Staff (FSS) I was observed removing R13's privacy curtain and indicated to the surveyor that it would be cleaned. FCS I was asked if there was a cleaning schedule for residents' privacy curtains. FSS I indicated that staff made referrals if they noticed a dirty privacy curtain and they were changed per request. A review of R13's electronic medical record (EMR) revealed that R13 was admitted to the facility on [DATE] with diagnoses that included Bi-polar disorder and Osteoarthritis (Joint disease). A review of R13's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R13 had an intact cognition. R64 On 4/7/26 at 9:03 AM, an observation was made of multiple white stains being present on R64's privacy curtain. On 4/9/26 at 10:59 AM, multiple stains continued to be observed on R64's privacy curtain. R64 was asked about their privacy curtain and indicated that it was last changed approximately four months ago. A review of R64's EMR revealed that R64 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (Narrowing of the Spine) and Heart Disease. A review of R13's most recent quarterly MDS dated [DATE] revealed that R64 had an intact cognition. On 4/9/26 at 11:19 AM, Environmental Services Director (ESD) J was interviewed regarding the observation of the stained privacy curtains. ESD J indicated that they had recently placed an order for some new privacy curtains. ESD J further indicated that they were planning to develop a curtain changing schedule binder. ESD J was asked about their expectations for how often privacy curtains should be changed. ESD J indicated that privacy curtains should be changed on a consistent basis, including when a resident had moved out of a room. On 4/9/26 at 1:45 PM, the Nursing Home Administor (NHA) was interviewed regarding the observation of soiled privacy curtains and indicated that the curtains should be cleaned when a room is deep cleaned. A review of a facility policy titled, Cleaning and Disinfection of Resident .Equipment Reviewed Date: 2.4.2026 revealed the following, Policy Overview: Resident .equipment can be a source of indirect transmission of pathogens .resident .equipment will be cleaned and disinfected in accordance with CDC (Center for Disease Control) recommendations in order to break the chain of infection.

This citation pertains to Intake number 2980818.Based on observation, interview, and record review, the facility failed to protect the resident's (R82) right to be free from physical abuse by another resident (R45) out of five reviewed for abuse. Findings include:A review of an Incident and Accident (I/A) report dated 4/6/2026 noted the following, Nurse was called to the front lobby to remove the resident (R45). Front desk coordinator stated that The resident (R45) began hitting and grabbing onto another resident (R82) from a different unit. This all occurred in the lobby and was witnessed.Further review of a progress note in R82's medical record dated 4/6/2026 noted the following, At 18:58 (6:58pm) resident was hit in the head by another resident, writer assessed resident, skin and pain assessment complete, 1/10 pain, BP( Blood Pressure) 126/64, RR (Respiration Rate) 17 P (Pulse) 90, unit manager A, NP (Nurse Practitioner [Name]), administrator and family notifiedA review of the medical record revealed R82 admitted into the facility on 1/8/2026 with the following medical diagnoses, Anemia and Muscle Weakness. A review of a Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 11/15 indicating an impaired cognition. R82 also required staff assistance with bed mobility and transfers.On 4/8/2026 at 8:48 AM, an interview was conducted with R82. R82 reported they were sitting in the front lobby with some other residents and R45 followed them to the front lobby. R82 reported R45 came behind them and started banging them in the head and yelling. R82 reported somebody moved them away from R45 and a couple nurses came and took R45 to their room. R82 reported they were then taken to their room and the nurse checked them out. A review of the medical record revealed R45 was most recently admitted into the facility on 8/16/2025 with the following medical diagnoses, Major Depressive Disorder and Vascular Dementia with Agitation. R45 was noted to have impaired cognition.Further review of R45's behavior care plan initiated on 1/10/2022 noted the following focus, [R45] exhibits Alt (Alteration) in BEHAVIORS/MOOD aeb (As Evidenced By) periods of increased agitation, physical threatening behaviors of holding [their] fist up at others, yelling, irritability, resistive w/ (with) care, taking showers, noted phy.(physical) altercation w/other res's (residents) of punching, hit by another res, personal space concerns and confrontational behaviors w/others, easily agitated/angered. Recent rm (room) change off of the Dementia /Behavioral unit and at time difficult to redirect .On 4/8/2026 at 2:11 PM, R45 was observed in their wheelchair, rolling down the hallway independently where R82 resided. R45 was unable to be interviewed regarding the incident.On 4/8/2026 at 12:28 PM, a phone interview was conducted with Receptionist B. Receptionist B reported R82 was at their desk and R45 was seen following behind R82. Receptionist B reported they were getting money for another resident when they heard yelling and screaming so they turned around and saw R45 hitting R82 Receptionist B reported they immediately removed R82 and called the nurse for R45.On 4/8/2026 at 12:47 PM, an interview was conducted with Unit Manager (UM) A. UM A reported they were working on a nurse's cart that day and was called over after the incident. UM A reported they helped take R45 to their room and informed the nurse on duty on who to call and had the visitors write down their statements. UM A reported R45 does have aggressive behaviors and can be agitated when someone is in their space. UM A was asked what interventions have been put in place since the incident, and they responded, I just keep a close eye on them.On 4/8/2026 at 1:56 PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA reported they reviewed the video from the incident and were still collecting statements from witnesses. The NHA reported at 6:51 PM, R82 came and sat in the front lobby and about 10 seconds later R45 came behind them and began swatting R82 towards the left shoulder and neck. The NHA reported the video showed Receptionist B then moved R82 and a nurse came to move R45 who was being resisting and aggressive. The NHA said based on the camera footage, they were unable to substantiate physical contact was actually made, despite R82 and Resceptionist B confirming physical contact was made. The NHA was asked what interventions had been put in place for R45 to ensure this does not happen again. The NHA reported the psychiatrist would be in to see them on 4/10/2026, and they had increased monitoring for R45.A review of R45's behavior care plan showed the most recent interventions were initiated on 3/20/2024. No updated interventions, such as increasing monitoring of the resident were noted on the behavior care plan. Further review of the progress notes for R82 and R45 did not reveal any updated progress notes since the resident-to-resident incident occurring on 4/6/2026.On 04/9/2026 at 12:57 PM, an interview was conducted with the Director of Nursing (DON) about the incident. The DON reported they were still completing their investigation within the facility. The DON reported that while the investigation is being completed, they are doing increased monitoring and watching R45's triggers. A review of a facility policy titled, Abuse revealed the following, Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.

This citation pertains to Intake: 274990Based on observation, interview, and record review, the facility failed to protect the resident's privacy for four residents (R904, R905, R906, and R907) of four residents reviewed for resident rights. Findings include: A review of documentation submitted to the State Agency (SA) revealed the following, On 2/12/26 at approximately 8:30pm Administrator was notified by Corporate Compliance Officer that a call had come in that employee [Licensed Practical Nurse, LPN B] posted a [Social Media] Story Clip of resident [R904] in the [NAME] Day room at approximately 7:50pm . On 3/4/26 at 12:53 PM, an attempt to contact LPN B via phone was to no avail.A review of the facility's interview of LPN B revealed she recorded a fall as part of the facility fall investigation process using her personal phone. She explained she thought she deleted the video prior to leaving the facility and was notified by a previous facility employee that she had posted the video to her social media account. A review of photo stills taken from LPN B's social media account shows residents sitting in the common area of the facility, faces clearly shown.A review of R904's medical record revealed they were admitted into the facility on 1/9/18 with a diagnosis of Alzheimer's Disease. The resident is severely cognitively impaired.A review of R905's medical record revealed they were admitted into the facility on 6/18/25 with a diagnosis of Schizophrenia and a moderate cognitive impairment. A review of R906's medical record revealed they were admitted into the facility on 5/10/25 with a diagnosis of Dementia and a moderate cognitive impairment. A review of R907's medical record revealed they were admitted into the facility on 3/26/25 with a diagnosis of Dementia and a severe cognitive impairment. On 3/4/26 at 3:10 PM, the Director of Nursing (DON) was interviewed regarding the incident and explained that LPN B took a video of the camera system using her cell phone to better understand the resident's fall. He reports he thought the video was encrypted and would be deleted prior to her leaving the facility. He further explained the situation was an accident that should not have occurred.A review of the facility's Social Media and Electronic Communications policy revealed the following, .1. Employees are strictly prohibited from transmitting by way of any electronic media any resident-related image or information that may be reasonably anticipated to violate resident rights to confidentiality or privacy. This includes information that could degrade or embarrass the resident. 2. Employees will not post or share posts that would disseminate any information regarding a resident .During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Element 1-Identification of Affected ResidentGuardians/POAs (Power of Attorneys) of all residents identifiable in the posted content were contacted and informed of the incident.Element 2-Identification of Resident with Potential to be AffectedAll residents residing in the facility had the potential to be affected by the deficient practice. No additional residents were identified in the social media post beyond those already identified.Element 3-Systemic Changes ImplementedFacility policies on Telephone Usage including Communication devises and Social Media and Electronics reviewed.All staff received re-education on the above policiesFacility Management and IDT (Interdisciplinary team) members were re-educated on the same policiesManagement and IDT were instructed that only the Administrator may access and set up video camera playback; the door lock to the camera rooms was changed to restrict access.[LPN B] was suspended, interviewed, and computer access removed and received disciplinary action.The Director of Nursing received education related to oversight responsibilities. Element 4-Monitoring to Ensure Ongoing ComplianceThe Administrator or designee will conduct weekly audits three times per week for four weeks on random unit to ensure staff are not using cell phone in resident care areas.The Administrator or designee will conduct random staff queries regarding Cell Phone and Social [NAME] policies three times per week for four weeks. Element 5-Date of ComplianceThe Administrator is responsible for ensuring full compliance.Compliance was achieved on 2/13/26.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake: 2789064Based on interview and record review, the facility failed to administer medications properly to one resident (R901) of one reviewed for medication administration. Findings include:A review of information submitted to the State Agency (SA) revealed the following, .[R901's] sister was in facility visiting and was laying in the patient's bed .The nurse came in and administered the patient's medications to the family member .911 had to be called and the family member had to be transported to the hospital .A review of R901's medical record revealed they were admitted into the facility on 2/16/26 with diagnoses which included Diabetes, Other Cirrhosis of the Liver, and Heart Failure. Further review revealed the resident was cognitively intact and required assistance with activities of daily living.On 3/4/26, a request for documentation including transfers to the hospital was requested from the facility. A document was provided indicating the following, On 2/24/26 at approximately 0930 (9:30am), the sister of resident [R901] was present in the resident's room and was observed lying in the resident's bed while the resident was not in the room. When the nurse [Licensed Practical Nurse -LPN A], entered the room to administer the resident's morning medications for [R901]. The nurse subsequently left the medications with the sister. Shortly thereafter the sister independently contacted 911 .the medications delivered to the resident's room included Metformin (used to lower blood sugar levels), spironolactone (water pill), and Flomax (used to make urinating easier) .On 3/4/26 at 11:43 AM, an interview was completed with LPN A regarding their R901's sister consuming R901's medications. LPN A explained he went into the resident's room to administer medications and observed the resident's sister lying in the bed. R901's sister indicated to him that she would ensure R901 took the medications when they returned to the room. LPN A acknowledged he left the medications in the resident's room and shortly after was informed the sister had contacted 911 and was transported to the hospital. On 3/4/26 at 2:26 PM, R901 was interviewed regarding their sister consuming their medications. R901 explained they were in the dining room, and their sister was in their room. Upon returning, the sister informed them they had taken their medications left in the room by the nurse. R901 explained the sister indicated they were feeling dizzy and called 911 and was subsequently transported to the hospital. A review of R901's active physician orders and February Medication Administration Record (MAR) revealed the resident was ordered and was checked off as being administered the following at 9:00am on 2/24/26: Metformin HCl Oral Tablet 1000 MG (milligrams), Tamsulosin HCl Oral Capsule 0.4 MG, Lactulose Oral Solution 10 GM/15ML (Lactulose), and House Liquid Protein. On 3/4/26 at 2:57 PM, the Director of Nursing (DON) was asked about the incident regarding the consumption of medications by R901's sister and explained the nurse should have followed the five rights of medication administration, and ensured the resident took the medication.A review of the facility's Medication Administration policy revealed the following, .medications are administered in accordance with the following rights of medication administration: right resident, right medication, right dose, right route, right time and frequency, right documentation, right of resident to refuse, and right clinical indication .procedure: .Administer medication: remain with resident until administration of medication is complete .

This citation pertains to Intake 2569649.Based on observation, interview, and record review, the facility failed to protect one resident's right (R703) out of one reviewed to be free from mental abuse and verbal abuse by staff.An allegation of staff to resident abuse involving Staff F and R703 was submitted to the state agency around 7/9/25.On 7/30/25 at 9:45 AM, R703 was observed sitting up in their wheelchair in their room. When the resident was asked about the incident involving Certified Nursing Assistant (CNA) F on 7/9/25, they said the nursing assistant came in that morning to empty my catheter bag. I told them to be sure it was closed because it has been leaking. The nursing assistant got smart with me and said she knew how to do her job. So, I called her a B**** and spelled it out to her. We argued. The nursing assistant then proceeded to pull my covers off me and throw them on the floor and threw water at me. I was trying to use my call light to call for help, but she pulled it away from me and put it on the wheelchair where I could not get to it. The nursing assistant then threatened to come and give me a black eye.On 7/30/25 at 11:55 AM, an interview was held with Registered Nurse (RN) H. RN H was asked about the incident on 7/9/25. RN H said the resident requested to see me because they trust me in which I visited the resident in their room. The nurse reported that during morning rounds the nursing assistant came in the room and threw water on them. RN H confirmed they immediately got the Nursing Home Administrator (NHA).On 7/30/25 at 1:45 PM, CNA F was interviewed via telephone. CNA F was asked what happened on the morning of the incident involving R703. CNA F explained they went into the room and turned on the light. R703 said asked to turn the light off. R703 asked to make sure to empty my catheter bag. I explained that it is done every day. R703 started saying, that I don't do s*** and calling me names. R703 kept calling names and I ignored them. The resident started hitting me in the back with the remote control. As I was removing the roommates old water cups, the resident knocked it out of my hand, and it got all on the covers. CNA F explained they then took the remote control from the resident and placed it on the roommate's table, pulled the blankets off them because they were wet. R703 asked, if they were going to get more covers and I told them I am not bringing you covers. I will someone else bring you covers. You can get the cover yourself. and did not go back in the room once they left. On 7/30/25 at 2:45 PM, the Director of Nursing (DON) was interviewed. The DON confirmed the incident between CNA F and R703. When asked what their expectation for residents and abuse. The DON replied, My expectation is that residents will be free from abuse and neglect.R703 medical record was reviewed and revealed the resident was admitted to the facility on [DATE] and had diagnoses of Multiple Sclerosis, Depression, and Type II Diabetes with poly neuropathy. R703's Brief Interview for Mental status assessment dated [DATE] was a 14/15 indicating intact cognition. A review of the Abuse Policy and Procedure dated 5/24/23 revealed, 'Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. The facility will develop and implement written policies and procedures that include: Screening potential employees and prospective residents. Training new and existing staff on prohibiting, preventing, and identifying abuse, neglect, exploitation, mistreatment, and misappropriation of resident property, reporting procedures, dementia and behavior management. Prohibiting, Preventing, and Identifying abuse, neglect, mistreatment, exploitation, and misappropriation of resident property. Reporting any allegations of abuse, neglect, mistreatment, exploitation, and misappropriation or resident property including reporting a reasonable suspicion of a crime to the State Survey Agency and other officials in accordance with state law. Investigating allegations of abuse, neglect, misappropriation, mistreatment, and exploitation to include protecting residents during the investigation, and taking necessary actions as a result of the investigation. Establishing coordination with the QAPI program.' During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the following: Element #1 Immediately suspended employee upon notification from resident. Resident was assessed, no injuries noted, and no pain was reported. Physician and family were notified of alleged incident . Resident's roommates were interviewed. Staff statements were taken. Facility Social Work completed 3 days well check visits for Resident. Behavioral Health Psychiatric Services offered to Resident. Police were called, and a report was filed, Detective was assigned, and the case was closed. CNA was given disciplinary action related to Resident Right resulted in Termination. Element #2 1. Interview able residents within the assignment set were queriedElement #31. Facility policy on Resident Rights and Abuse was reviewed and deemed appropriately2 . Facility staff were reeducated on Resident Rights and Abuse Policies was reviewedElement #4 1. Administrator or designee will conduct weekly audits x 4 weeks of random interviewable residents to ensure they have not received rough treatment or inappropriate verbal conversation from staff and have call lights available to them within their reach.2. Administrator or designee will conduct weekly audits x 4 weeks of random staff to ensure proper knowledge of Resident Rights to have call lights within reach and are aware and able to provide examples of to what Verbal Abuse is.Element #51 . Administrator is responsible for overall compliance by 7/16/25Findings will be reviewed and submitted monthly for review and further recommendations until substantial compliance is achieved and maintained. The facility was able to demonstrate monitoring of the corrective action and maintained compliance by 7/16/25.

This citation pertains to Intake 1246198Based on observation, interview, and record review, the facility failed to apply compression stockings for one resident (R700) out of two reviewed for following physician orders. Findings include:A review of Intake called into the State Agency noted R700's legs are swollen and painful.On 7/30/2025 at 9:48 AM, R700 was observed lying in bed. R700 was observed to have heel boots on and nothing else. R700 reported they are supposed to have compression stockings on to help with the swelling in their legs, but the facility staff have only been put them on once or twiceA review of the medical record revealed R700 was admitted into the facility on 3/20/2024 with the following medical diagnoses, Muscle Weakness and Disorder of Muscle. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 12/15 indicating an impaired cognition. R700 also required staff assistance with bed mobility and transfers.A review of active physician orders revealed the following, please apply (name of compression stockings) to BLE (Bilateral Lower Extremities) .Schedule: on at 6:00 AM and doff (take off) at 10:00 PM. It was noted on the Medication Administration Record (MAR) the compression stockings were signed off by the nurse as having been applied at 6:00 AM on 7/30/2025.On 7/30/2025 at 10:41 AM and 11:48 AM, R700 was observed in bed. No compression stockings were applied or in place to the bilateral lower extremities.At 1:15 PM Licensed Practical Nurse (LPN) C was queried about the resident compression stockings. LPN C was shown the physician's order and confirmed that R700 did not have any on. LPN C went on to say they would try and find some for R700.On 7/30/2025 at 1:48 PM, an interview was conducted with the Director of Nursing (DON). The DON stated they were aware of the issue and reported they expect compression stockings to be applied as ordered.A review of a facility policy titled, Physician and Practitioner Orders did not address following physician orders.

This citation pertains to Intake 2564064Based on interview and record review, the facility failed to prevent the development of an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) for one resident (R702) out of one reviewed for pressure ulcers. Findings include:A review of Intake called into the State Agency noted R702 admitted into the facility with their skin intact and developed an unstageable pressure ulcer on their coccyx/buttocks while in the facility due to not being turned and repositioned, as well as delayed incontinence care.A review of the medical record revealed R702 was admitted into the facility on 5/7/2025 with the following medical diagnoses, Muscle Weakness and Lymphedema. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating an intact cognition. R702 also required staff assistance with bed mobility and transfers.Further review of the admission skin evaluation dated 5/7/2025 noted R702 did not have any skin abnormalities.Further review of progress notes revealed an open area was observed on R702's buttocks 6/4/2025.Further review of a skin evaluation dated 6/11/2025 noted the wound measured 6.4 cm (centimeters) x 3.5 cm x 2.5 with a depth of 0.2 cm with progress of wound noted as deteriorating.On 7/30/2025, an interview was completed with Wound Care Nurse (WCN) A. WCN A reported the day they were doing wound rounds; they were informed that R702 had an open area. WCN A reported they immediately had the wound care physician assess them and put in an order and interventions. WCN A was asked what interventions were put in place for R702 prior to them developing the wound. WCN A reported they implement turning and repositioning for all at risk patients. WCN A reported they are unsure how R702 developed the wound.On 7/30/2025 at 1:52 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they were informed about the wound when the WCN informed them about it. The DON reported they only knew that it was discovered on 6/4/2025 and the WCN saw it immediately and treated it and implemented interventions.A review of a facility policy titled, Skin and Wound Guidelines did not address the prevention of wound development.

This citation pertains to Intake MI0015340. Based on interview and record review, the facility failed to ensure appropriate documentation of administration and accountability of controlled substances for one (R903) of four residents reviewed for medication administration. Findings include: Review of a complaint filed with the State Agency included allegations that R903 was admitted for a five-day hospice respite stay and did not receive their medications either at all, or as prescribed, including controlled substances (liquid morphine-for pain and lorazepam-antianxiety). Review of the clinical record revealed R903 was admitted into the facility on 5/27/25 and discharged on 6/1/25. Diagnoses included: encounter for palliative care, multiple sclerosis, pseudobulbar affect, attention-deficit hyperactivity disorder, other seizures, stiff-man syndrome, and diplopia. According to the Minimum Data Set (MDS) assessments, there was only an entry assessment documented and a discharge return not anticipated assessment with an Assessment Reference Date (ARD) of 6/1/25 that was In Progress (incomplete). Review of R903's medication order summary and Medication Administration Records (MARs) from 5/27/25 - 6/1/25 included the following: Lorazepam Injection Solution 2 MG/ML (Milligram/Milliliters) Inject 4 mg intramuscularly as needed (prn) for Anxiety One time Max a day. Per the MAR, there were no prn administrations documented. Lorazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 8 hours as needed (prn) for Anxiety/Restlessness/Muscle spasm. Per the MAR, there were no prn administrations documented. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML Give 0.25 ml by mouth every 4 hours as needed (prn) for Pain/SOB (Shortness of Breath). Per the MAR, there were no prn administrations documented. There were no controlled substance records available for review in R903's electronic medical record. On 6/10/25 at 4:55 PM, the Director of Nursing (DON) was requested to provide all controlled substance records for R903, including what was provided at the time of admission and what was provided at the time of discharge. On 6/11/25 at 9:00 AM, the DON provided the controlled substance proof of use records for R903's morphine sulfate and lorazepam and reported the medication was handed off by the EMS (Emergency Medical Staff) staff upon admission and provided to EMS at time of discharge. The DON was asked to review the controlled substance forms to verify the nurse's initials and documentation included on these forms. The following was included on these controlled substance records: Lorazepam 0.5 MG Give 1 tablet by mouth every 8 hours prn for anxiety/restlessness - Amt. Received: 30 tablets; Date Received 5/27/25. The documented removal included: 5/29 0700 (7:00 AM) QTY (Quantity) USED 1 QTY REM (Remaining) 29. Initialed by Nurse 'G'. 5/29 1100 (11:00 AM) QTY USED 1 QTY REM 28. Initialed by Nurse 'G' and another Nurse that was illegible. 5/29 1800 (6:00 PM) QTY USED 1 QTY REM 27. Initialed by Nurse 'G' and another Nurse that was illegible and scribbled out. 5/30 0800 (8:00 AM) QTY USED 1 QTY REM 26. Initialed by Nurse 'G'. 5/30 12P (12:00 PM) QTY USED 1 QTY REM 25. Initialed by Nurse 'G'. 5/30 6P (6:00 PM) QTY USED 1 QTY REM 24. Initialed by Nurse 'G'. 5/30 1800 (6:00 PM) QTY USED 1 QTY REM 23. Initialed by Nurse 'G'. 5/30 11PM (11:00 PM) QTY USED 1 QTY REM 22. Initials illegible and the DON was unable to identify the Nurse's initials. This document was initialed by Nurse 'D' and unknown EMS staff (as reported by the DON on the day of discharge) and was not dated. Morphine Sul (Sulfate) Sol (Solution) 100mg/5mL Give 0.25 ML by mouth Q (Every) 4 hours PRN (As needed) for PAIN/SOB - Amt. Received: 30ML; Date Received 5/27/25. The documented removal included: 5/29 0800 (8:00 AM) QTY USED 0.25 QTY REM 29.75. Initialed by Nurse 'G'. 5/29 1300 (1:00 PM) QTY USED 0.25 QTY REM 29.75. Initialed by Nurse 'G'. 5/29 1700 (5:00 PM) QTY USED 0.25 QTY REM 29.75. Initialed by Nurse 'G'. All of the above entries were scribbled out and marked as ERROR and FULL with Nurse 'G's initials. This document was initialed by Nurse 'D' and unknown EMS staff (as reported by the DON on the day of discharge) and was not dated. None of the above morphine or lorazepam were documented as administered on the MAR (the MAR was left blank); nor were there any progress notes or other documentation to explain why this medication was removed. The progress notes and vital signs documented R903 as having 0 pain and there was nothing identified about the resident having anxiety/restlessness to correspond with the above medication removal. On 6/11/25 at 9:13 AM, the DON reported Nurse 'F' initialed the receipt of the medication upon admission to the facility on 5/27/25 and Nurse 'D' at discharge on [DATE]. The DON reported the other Nurse's initials for the documented removal of the medication was Nurse 'G'. The DON was unable to confirm the third set of initials, acknowledged the illegible initials and multiple error entries for the liquid morphine medication and reported they weren't sure who or why some of the entries had additional illegible initials. When asked why Nurse 'G' would document three removals of the liquid morphine on the same day, at three separate times, then make an scribbled entry of ERROR and FULL if the medication had been removed separately and no documented wasting of the medication, the DON reported maybe the nurse made an error. When asked if the error occurred the first time, how were the other two errors done, the DON offered no further explanation. When asked what the facility's process was for the documentation of removal and administration of controlled substances, the DON reported the nurses should be documenting the administration on the MAR. When asked how it could be determined the resident received the medication if it was documented as pulled but not administered, the DON acknowledged the concern but offered no further explanation. They were requested to provide a copy of the documentation provided and a policy regarding controlled substances. On 6/11/25 at 11:40 AM, Nurse 'G' was attempted to be contacted by phone. There was no answer, and the mailbox was full unable to accept any messages. On 6/11/25 at 11:43 AM, Nurse 'G' was sent a detailed text message to return the call. There was no response from Nurse 'G' by the end of the survey. On 6/11/25 at 12:12 PM, a phone interview was conducted with the Hospice RN (Registered Nurse) Clinical Manager (Nurse 'Q'). When asked about the discrepancies with R903's medications, Nurse 'Q' reported that they could review Nurse 'R's notes from their visit with the resident on 5/29/25. Nurse 'Q' reported Nurse 'R' noted concerns with a seizure medication being found on the floor, need for an updated medication list to be sent to the facility, and that they had spoken to and sent Unit Manager 'B' the updated medication list. On 6/11/25 at 12:45 PM, an interview was conducted with Unit Manager 'B'. When asked about R903's concerns with medication and discussion with the hospice nurse on 5/29/25, Unit Manager 'B' reported they couldn't recall specific details but did recall the hospice nurse was going to get an updated medication list sent over. When asked if that ever happened, Unit Manager 'B' reported that did not and further reported it was later in the day on a Friday, recall there being a lot going on at that time and the resident discharged that Sunday (6/1/25). Unit Manager 'B' was asked to review the controlled substance records and acknowledged the concerns. When asked if they had identified any concerns prior to this review, Unit Manager 'B' reported they had not. They were informed of that this surveyor wanted to conduct an interview with Nurse 'G' but had not responded to phone call, or text message and Unit Manager 'B' reported they had attempted to reach Nurse 'G' at least ten times today and was not responding to them either. Unit Manager 'B' was asked why a nurse would document three separate times of removal of liquid morphine, then document all as an ERROR and FULL if each administration would be documented at the time of removal/administration and there was no documentation of the medication being wasted, Unit Manager 'B' reported they were not able to offer any further explanation as to why that was done. According to the facility's policy titled, Controlled Medication Guidelines dated 3/20/2024: .When the licensed nurse removes the controlled medication from the package, they will document the quantity removed and the quantity left on the Controlled Drug Receipt/Record/Disposition Form. After Administration of the controlled medication the licensed nurse will document the administration on the medication administration record .

Based on observation, interview and record review, the facility failed to ensure proper storage and discarding of medications in one of eight medication carts affecting three residents (R906, R907 and R908) of three residents reviewed for medication storage. Findings include: On 6/11/25 at 10:28 AM, upon walking onto the Spring Unit, an unlocked medication cart was observed with no licensed staff present. Additionally, the monitor on the top of the cart was left open with personal information in view to anyone that walked by for R907. The medication cart had an insulin pen (Lantus Solostar for R907) stored directly on top of the cart. Upon opening the unlocked top drawer of the medication cart, there were several clear medicine cups with pills in each cup. One of the cups contained five pills (later identified by Registered Nurse, RN 'E', as medication for R906); one cup had a white pill and another cup contained a white pill. At 10:30 AM, RN 'E' was observed exiting a seperate resident's room. When asked about the unlocked cart, open monitor and insulin stored on top of the cart, RN 'E' proceeded to engage the lock and stated another resident needed their help so they just went in. When asked what the protocol was for when they left the medication cart, RN 'E' reported they should've locked the cart before helping the resident. RN 'E' was asked to open the top drawer and when asked about the pill cups in the top drawer and reported they were for R906. When asked to confirm the medications in the cup, RN 'E' identified the medication as Levetiracetam 500 MG (Milligrams), Duloxetine 60 MG, Atenolol 25 MG, Amlodipine 2.5 MG, and Losartan Potassium 100 MG. When asked about the other two cups, RN 'E' reported the other two cups had to be wasted. When asked who they were for and what the pills were, RN 'E' reported one is for R908 it's it's their shaking pill. RN 'E' reported that pill was on the floor so they were going to waste it. When asked why it wasn't wasted immediately, they offered no response. When asked about the third cup of medication, RN 'E' reported it was for R908 they don't get it anymore in the morning so I was going to waste it. When asked why the medication would be removed for administration if the order had been verified as part of the current/acitve medication administration, RN 'E' offered no response. On 6/11/25 at 10:42 AM, an interview was conducted with the Director of Nursing (DON). When informed of the observations of the medication storage and interview with RN 'E', the DON reported that should not have occurred. The DON was asked what their facility's process was for storage and disposal of medication, the DON reported they would have to defer to their facility policy but further reported the medications should not be stored in the cart if not administered, the cart should not have been left unlocked, with insulin stored on the top of the cart. According to the facility's policy titled, Medication and Treatment Storage dated 8/7/2023: .All medications and biologicals will be stored in locked compartments (i.e., medication carts .During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .

This citation pertains to Intake MI00153683 Based on observation, interview, and record review, the facility failed to provide nail care to one (R703) of five residents observed for nail care. Findings include: R703 was admitted on [DATE] with the following relevant diagnoses: Sequelae of Cerebral Infarction (Stroke); Functional Quadriplegia, Anxiety. R703 required substantial staff assistance for all activities of daily living (ADL's) and mobility. On 5/29/2025 at 1:35 PM, an observation of R703's fingernails revealed the nails were very long, about 3/4 of an inch beyond the end of the finger and contained debris, some was yellow and some darker in color. On inquiry, R703 revealed they wanted them trimmed and had some anxiety about having them cut, afraid the skin may get nipped. During an interview with Registered Nurse (RN) Dat 2:45 PM, they confirmed the resident's should get regular nail care. An interview with Assistant Director of Nurse (ADON) revealed regular nail care should be carried out as part of ADL's.

This citation pertains to Intake MI00153683 Based on observation, interview and record review facility failed to answer call light in a timely manner for one (R703) of five residents reviewed for timely call lights. Findings include: R703 was admitted on [DATE] with the following relevant diagnoses: Sequelae of Cerebral Infarction (Stroke); Functional Quadriplegia, Anxiety. R703 required substantial assistance for all activities of daily living (ADLs) and mobility. On 5/29/2025 at 1:35 PM, R703 was observed lying in bed. On inquiry R703 reported after activating the call light, it often takes a very long time saying, if I put it on to much they (facility staff) don't like it. On 5/29/25 at 1:51 PM, Registered Nurse (RN) D came in the room making rounds. R703 indicated they needed a brief change and their feet hurt due to being against the footboard. RN D replied they would notify R703's Certified Nurse Assistant (CNA) they needed assistance. ON 5/29/25 at 2:06 PM, CNA B entered the room, turned the call light off and told R703 their assisgned CNA was down the hall conducting rounds and would be with them soon. CNA B did not ask resident what they needed. On 5/29/2025 at 2:24 PM (33 minutes later), CNA A entered room and asked R703 what they needed. R703 indicated they were wet and needed to be changed. At this point, R703 was very anxious about being wet. CNA A told R703 not to be so dramatic and would change and reposition them. An interview with at 2:45 PM, with Registered Nurse (RN) D revealed their expectation for answering call lights is 10 minutes, 20 minutes at most if the CNA is in another room assisting another resident. RN D further indicated when a CNA answers a light they are expected to address the residents needs, not turn it off and leave the room to find the covering CNA, but rather determine what the resident needs and assist them. An interview at 2:55 PM, with Assistant Director of Nurse (ADON) revealed their expectation is the call lights should be answered timely, 10-20 minutes, and the person answering the light should address resident needs.

Based on observation, interview, and record review, the facility failed to ensure pureed food items were of the proper consistency. This deficient practice had the potential to affect all 9 residents receiving a pureed diet texture. Findings include: 02/10/25 at 12:15 PM, the lunch tray-line service was observed in the main kitchen. A pan of pureed carrots was observed on the steam table. The mixture was observed with visible small chunks of orange carrot bits, mixed in with a pale orange viscous substance. On 02/10/25 at 12:25 PM, a puree test tray was obtained. A taste test of the pureed carrots revealed small chunks of carrots, that required chewing before swallowing. On 02/10/25 at 12:30 PM, Dietician M and Chef L were shown the pureed carrots and asked if the texture looked acceptable for a pureed diet. Both stated the pureed vegetable was not the proper consistency, and that the vegetable would be pulled from the steam table and re-made. According to an IDDSI (International Dysphagia Diet Standardization Initiative) chart posted in the facility kitchen, for a pureed diet, the appearance should be smooth, and the texture should be like pudding with no lumps.

Based on observation, interview and record review the facility failed to provide timely repositioning for four dependent residents (R34, R44, R97, R118) of five reviewed for positioning. Findings include: Resident #34 On 02/10/25 at 9:38 AM, 12:29 PM, 1:54 PM, and 2:35 PM, R34 was observed to be on their backside in a specialty bed with the head of the bed elevated around 30-45 degrees and a foam wedge was on the mattress at the foot of bed. On 02/11/25 at 8:10 AM, 8:35 AM, 9:30 AM, and 11:41 AM, R34 was observed to be on their backside in bed and a foam wedge was on the mattress at the foot of bed. The head of the bed was up around twenty or thirty degrees. On 02/11/25 at 12:09 AM, 12:39 PM, and 12:43 PM, R34 was observed to be in bed dressed in a hospital style gown, turned toward the door. A foam wedge was visible behind the torso on the left side. At 12:51 PM, 2:02 PM, and 2:59 PM, the head of the bed was around 45 degrees and the wedge was behind the torso at the left side. R34 leaned over to the right edge of the bed. At 2:01 PM staff entered the room. At 2:02 PM, R34 was observed to be in bed as before with the wedge to the left side. On 02/12/25 at 8:04 AM, R34 was observed to be in bed with the head of the bed up around 45 degrees and the foam wedge was behind the torso at the left side. R34 leaned over to right edge of the bed. A review of the record for R34 revealed R34 was admitted into the facility on [DATE]. Diagnoses included Dementia, Diabetes, Heart Disease and Stroke. A review of the care plan initiated 05/23/19 documented, .has alteration in mobility . reposition in bed or gerichair at least q (every) two hours and prn (as needed) . The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition, impaired range of motion to the upper and lower extremities on one side, and required substantial or maximal assistance to roll left and right. R34 required substantial or maximal assistance or was dependent for all activities of daily living except eating. Resident #44 On 02/10/25 at 9:53 AM and 12:31 PM, R44 was observed to be on their backside in a specialty bed. On 02/11/25 at 8:20 AM, 9:27 AM, and 11:51 AM, R44 was observed to be on their backside in bed dressed in a hospital style gown. At 12:13 PM, hospice staff entered the room and elevated the head of the bed R44 remained on their backside in bed. At 12:42 PM and 1:45 PM, R44 appeared on their backside in bed with the head of the bed elevated around 45 degrees. A review of the record for R44 revealed R44 was admitted into the facility on [DATE]. Diagnoses included Parkinson's, Pulmonary Disease and Stroke. A review of the care plan initiated 12/18/22 documented a self care deficit and bed mobility was a two person assist and R44 required frequent turning and repositioning. The Minimum Data Set (MDS) assessment dated [DATE] documented impaired cognition, impaired range of motion to one or both the upper and lower extremities, and required substantial or maximal assistance to roll left and right. R34 required substantial or maximal assistance or was dependent for all activities of daily living. Resident #97 On 02/10/25 at 4:01 PM, R97 was observed to be on their backside in bed, dressed in a hospital style gown, their head was on the left corner of the pillow and the body down in the bed. The head of the bed was elevated. R97's legs were flexed in a frog legged position. No positioning devices were visible at the sides. On 02/11/25 at 8:21 AM, 8:55 AM, 11:39 AM, 12:46 PM, and 12:52 PM, R97 was observed to be on their backside in bed with the head of the bed elevated around 45 degrees. R97's legs were flexed in a frog legged position. No positioning devices were visible at the sides. On 02/12/25 at 9:34 AM and 1:52 PM, R97 was observed to be on their backside in bed with the head of the bed elevated around 45 degrees. R97's legs were flexed in a frog legged position. No positioning devices were visible at the sides. A review of the record for R97 revealed R97 was admitted into the facility on [DATE]. Diagnoses included Dementia, Paralysis of the left side, Stroke and Contracture of the Left Knee. The care plan initiated 05/23/20 documented a self care deficit and bed mobility required a two person assist. The risk for pressure ulcer formation care plan documented the need for surface support, pressure redistribution, position changes and offloading. The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition, impaired range of motion to both the upper and lower extremities, and required substantial or maximal assistance to roll left and right. R97 required substantial or maximal assistance or was dependent for all activities of daily living. Resident #118 On 02/10/25 at 12:00 PM, 12:54 PM, 2:06 PM and 4:06 PM, R118 was observed to be on their backside in bed on a specialty mattress, specialty boots on the feet, and the head of the bed around 20-30 degrees. No devices were observed to position R118. Per a physician note dated 2/6/25, R118 had a pressure wound to the coccyx (tailbone). On 02/11/25 at 11:55 AM, 12:55 PM, 2:06 PM, and 2:33 PM. R118 was observed to be on their backside in bed with the head of the bed around 20-30 degrees. No devices were observed at the sides of the torso to position R118 off the coccyx wound area. The resident did not make any attempts to move. On 02/11/25 at 2:33 PM, Certified Nursing Assistant (CNA) C entered the room of R118. At 2:39 PM, along with CNA C , R118 was observed with no positioning devices seen at the sides of the torso. On 02/11/25 at 2:59 PM, R118 appeared in the same position as before. On 02/12/25 at 10:05 AM, R188 was returned from dialysis to the hallway outside their door. R188 was on their backside in the recliner. On 02/12/25 at 11:27 AM, a wound observation of the coccyx wound was completed with the wound care nurse. R118 was observed to be on their backside in bed. A flat pillow was observed under the left shoulder area of R118. The pillow did not provide any visible turn or position change. A review of the record for R118 revealed R118 was admitted into the facility on [DATE]. Diagnoses included Dementia, Diabetes and Pressure Ulcer of the Sacral (lower back, coccyx) Region. The care plan initiated 03/22/24 documented a self care deficit and bed mobility required a two person assist. The actual pressure injury care plan also documented the need for .frequent turning and repositioning . The Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognition, impaired range of motion to both the upper and lower extremities, and R118 was dependent on staff to roll left and right. R118 was dependent for all activities of daily living. On 02/12/25 at 8:11 AM, the Director of Nursing (DON) reported residents unable or who don't reposition themselves should be turned frequently and did not provide specific time frames. It was noted that the standard was to reposition every two hours at least. At 11:14 AM the DON reported repositioning was required even with a specialty mattress in place. A review of the facility policy titled, Repositioning issued 08/09/23 revealed, The purpose of this procedure is to provide guidelines to promote comfort, assist in preventing skin breakdown, promote circulation and provide pressure relief for bed bound and chairbound residents . Resident who are immobile and/or dependent on staff for repositioning should be repositioned at least every two hours .

Based on observation, interview, and record review, the facility failed to administer the correct tube feeding formula for one resident (R119) of four reviewed for tube feeding. Findings include: On 2/10/25 at 9:46 AM, R119 was observed lying in bed. A bottle of Jevity 1.5 tube feeding dated 2/9/25 was observed to be hanging on a pole in their room. On 2/11/25 at 9:19 AM, two bottles of Jevity 1.5 tube feeding, one of which was dated 2/10/25 and the other dated 2/9/25 was observed in the trash can next to R119's bed. A review of R119's record revealed they were admitted to the facility on [DATE] with the following diagnosis: Benign Neoplasm of Meninges (brain tumor) and Dysphagia, oropharyngeal (inability to swallow). Further record review revealed a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment. A review of R119's physician orders revealed the following: active order dated 1/29/25 Enteral feed two times a day Nutren 2.0 @88ml/hr (milliliters per hour) x 12 hours providing 1056ml (hang 5 pm to 5 am) with autoflush of 80ml/hr x 12 hrs providing 960ml fluids. A second active order dated 1/25/25 Jevity 1.5 55ml/hr provides 1320ml, Flush 30ml to provide 1873ml one time a day for nutrition. A review of R119's Febuary 2025 Medication Administration Record (MAR) revealed both Nutren and Jevity were listed and both marked as given on 2/1/25-2/10/25 A review of R119's progress note revealed the following dietician notes: 1/27/25 Resident readmitted to facility, TF (tube feeding) orders adjusted with plans plans to get resident back to TF orders that (they) were on prior to going out to facility. WIll continue to monitor resident's tolerance of titrating up to goal of 88ml/hr (mililiters per hour) x 12 hrs (hours) with autoflush of 80ml/hr x 12 hrs. Current orders are Nutren 2.0 @65ml/hr x16 hrs with autoflush of 60ml/hr (hang 4pm to 8 am). Resident is noted to have significant weight gain upon returning to facility. Resident did recieve IV (intravenous) fluids in hospital which could have contributed to weight gain. Full nutritional assessment in progress. 1/28/25 Increase feedings to 75ml/hr X 14 hrs providing 1050ml, 2100Kcal, 88gm protein, 726ml free water with autoflush of 70ml/hr x14 hr providing 960ml additional fluids plus 20-30ml with medications, and 150ml q (every) shift-100% needs met via PEG (percutaneous endoscopic gastrostomy). WIll continue to monitor tolerance of new orders. 1/29/25 .Resident is NPO (nothing by mouth) diet order and enteral feedings. ENN (enteral nutrition) is 1900-2100 for wt (weight) gain. Residents goal for enteral feeding is Nutren 2.0 88ml/hr x 12 hrs providing 1056ml, 2112kcal (kilocalories), 88gm (gram) protein, and 739ml fluids with autoflush of 80ml/hr x 12 hrs with 150ml flush q (every) shift and additional fluids of 20-30ml with medications . On 2/12/25 at 9:52 AM, Licensed Practical Nurse (LPN B) confirmed R119 has been getting Jevity 1.5 tube feeding from 5 pm to 5 am daily. After reviewing R119's orders, LPN B confirmed R119 should have been receiving Nutren instead of Jevity and explained both tube feeding orders were active but the order for Nutren was placed by the dietician and was more recent than the order for Jevity. On 2/12/25 at 10:23 AM, The Registered Dietician (RD) explained they write the orders for tube feeding and the formula and rate is calculated based on the individual resident's nutritional needs and R119 was receiving Nutren 2.0 at 88ml/hr for 12 hours to provide their nutritional needs. After reviewing R119's record the RD confirmed there was also an order for Jevity 1.5 that had been entered by a nurse. The RD explained nurses do not typically enter tube feeding orders. After reviewing R119's February 2025 MAR the RD confirmed both Nutren and Jevity were marked as given on 2/1/25-2/10/25. On 2/12/25 at 10:42 AM the Director of Nursing (DON) explained there should only be one order for tube feeding entered by the dietician and that order should be followed. A review of the facility's policy titled Tube Feeding-Formula Administration, Flushing, and Unclogging revealed: Verify physicians order. Prior to administration.

This citation pertains to Intake Number MI00149416. Based on interview and record review, the facility failed to address a change in condition in a timely manner for one (R801) of two residents reviewed for changes in condition, resulting in the resident being transferred to the hospital where they were found to have a blood sugar of 1200 (normal range 60-120 mg/dl - milligrams per deciliter), fever, and difficulty breathing requiring mechanical ventilation. Findings include: A review of a complaint submitted to the State Agency (SA) revealed an allegation that R801's family member noticed R801 had swelling in his arms, legs and belly starting around 12/11/24. It was brought to the nurse's attention that R801 was sleeping more and wouldn't wake up fully .was slow to wake and it was not normal . It was documented R801's condition was more noticeable a week prior to resident being sent out to hospital on 1/3/25. The complaint alleged that nobody did anything about R801's change in condition until 1/3/25 when a nurse called to notify the complainant that R801 was not breathing good, was given a breathing treatment, and was sent to the hospital an hour later. It was alleged when R801 got to the hospital, they had sepsis, sugar level was 1200, oxygen level was very low, breathing was not good, eyes were rolling in the back of his head and the resident vomited which went into his lungs. R801 required mechanical ventilation. On 1/10/25 at 12:24 AM, an interview was conducted with one of R801's family members (Family Member 'A') via the telephone. Family Member 'A' reported they visited R801 on 12/21/24, 12/23/24, 12/25/24, 12/26/24, 12/28/24, 12/30/24, and 1/1/25. On 1/1/25, Family Member 'A' reported they spoke with the nurse because R801 appeared swollen, was sleeping a lot, and had no control of his arm. Family Member 'A' reported if they picked up R801's arm, it would fall back down. Family Member 'A' reported the nurse said R801 was not swollen and that a physician would be in on Thursday or Friday to check on the resident (1/2/25 or 1/3/25). It was explained by Family Member 'A' that when they saw R801 on 1/1/25, he looked like he was in pain, was not responding as much, and sleeping more. According to Family Member 'A', the physician came on 1/3/25 but it was too late and he had to be rushed to the hospital. Family Member 'A' said they first noticed a change with R801 on 12/21/25 which was reported to the nurse and multiple Certified Nursing Assistants (CNA). On 12/25/24, he just did not seem right and they had to shake him real hard to wake him up. A review of R801's clinical record revealed R801 was admitted into the facility on [DATE], readmitted on [DATE], and discharged to the hospital on 1/3/25 with diagnoses that included: acute kidney failure, type 2 diabetes mellitus, dysphagia (difficulty swallowing), dementia, seizures, hypertension, and aphasia (difficulty speaking). R801 received all nutrition and medication via a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube inserted into the stomach to deliver nutrition). A review of R801's Minimum Data Set (MDS) assessment dated [DATE], R801 had unclear speech, severely impaired cognition, physical and verbal behaviors, rejected care at times, and was dependent on staff for most activities of daily living (ADLs). A review of R801's progress notes revealed the following: On 12/21/24 at 10:30 AM, Licensed Practical Nurse (LPN) 'C' documented, Resident complained he did not feel like himself and refused to get up this morning x 3, residents vitals signs were taken (they were within normal limits) .will continue to monitor . There were no additional progress notes in the clinical record until 1/3/25. On 1/3/25 at 10:30 AM, LPN 'D' documented, Resident observed in bed with difficulty breathing. Coarse crackles can he heard on inspiration. Resident only responds to painful stimuli. SPO2 (blood oxygen level) 80 (percent), BP (blood pressure) 106/90, P (Pulse) 92, R (respirations) 24, T (temperature) 99.2 (degrees Fahrenheit - F). DR (doctor) notified orders are to transfer to ER (emergency room ). family notified. On 1/3/25, Physician 'G' documented, Called by nurse and texted to come to see the patient for acute resp (respiratory) failure, breathing heavy, vitals abnormal, reached and the nurse had suctioned lot of mucus but still patient was breathing at rate of 24-28 and low BP and gurgling, o2 was low around 80-87% on oxygen, neb (nebulizer) treatment given, pt seemed uncomfortable and using accessory muscles, called the floor in charge nurse, called family, called 911 and signed out to them the case and paperwork given to them. 40 minutes with patient . A review of a Hospital Transfer Form for R801 revealed R801 was transferred to the hospital on 1/3/25 at 11:00 AM for Respiratory Infection. R801's vitals at that time were BP 142/96, HR 96, RR 18, Temp 99.8, O2 Sat 89. A review of R801's hospital records revealed R801 arrived at the emergency roiagnom on [DATE] at 11:35 AM. Further review of the hospital records revealed the following: An Emergency Department Encounter Note dated 1/3/25 revealed, .presents to emergency department with report of altered mental status. Initial report was obtained from EMS (emergency medical services) who states they were called for altered mental status and found the patient essentially unresponsive with severe tachypnea (rapid, shallow breathing), saturating in the 70s. They placed the patient on a nonrebreather mask .glucose read as high and they transported the patient here .Further history was provided later in the stay by patient's sister who states that she has been concerned that his mental status has been declining for several days and he has appeared more bloated .Upon arrival .patient is spontaneously fluttering his eyes but will not track and does not respond to pain. He is tachycardic (elevated heart rate) and profoundly tacypneic with a respiratory rate in the 40s or 50s with very wet lung sounds. He is also hot to the touch with an axillary temperature of 103 degrees (F). Respiratory therapy was present upon arrival and attempted oral suctioning, patient did not gag and thick whitish secretions were removed with some improvement in lung sounds . R801 required intubation because they were concerned that failure to secure his airway would lead to death within hours with high concern for aspiration, possible CHF (congestive heart failure), and sepsis. The note further documented, Soon after intubation, a number of laboratory studies returned confirming high glucose which had been shown earlier however this was greater than 1200 mg/dl with accompanying worsening of renal function, severe hyponatremia (low sodium in the blood. However this could be a typo as (R801's) sodium was elevated per laboratory results) adequate <sic> potassium .need to multiple medications in the setting of septic shock, HHS (Hyperosmolar Hyperglycemic State - a serious complication of diabetes that causes very high blood sugar, dehydration and confusion), and severe acid-base derangements .(antibiotics) were provided for broad-spectrum coverage for presumptive aspiration pneumonia and patient was transferred to the ICU (intensive care unit) in critical condition .I provided a brief recounting of patient's critical condition sharing that he may not survive the hospitalization . A review of R801's vital signs during triage in the ED revealed his temperature was 103.5 degrees F, heart rate was 125 beats per minute, and respiratory rate was 64 breaths per minute. On 1/9/25 at 4:15 PM, an interview was conducted with LPN 'D' via the telephone. LPN 'D' was the nurse assigned to R801 on 1/3/25 when he was transferred to the hospital. LPN 'D' reported when she arrived for her shift (day shift) on 1/3/25, the previous shift nurse reported R801 seemed congested and that he required suctioning. LPN 'D' reported seeing the suction machine at R801's bedside. LPN 'D' said it was reported that R801 was fighting with the CNAs less during care and seemed to have less energy. LPN 'D' reported that during her rounds around 7:00 AM, R801 was observed sleeping. Around 10:00 AM, LPN 'D' found R801 in respiratory distress and explained R801 was congested, had a low pulse ox, and was having a hard time breathing. After R801 was found in that condition, LPN 'D' said she contacted Physician 'G' who asked her to text him what was going on. LPN 'D' reported Physician 'G' said to wait to send R801 out until the family gave consent so the family was contacted. About 40 minutes later, Physician 'G' showed up at the facility and LPN 'D' explained she was unaware he was coming to the facility. Physician 'G' told LPN 'D' to give the resident oxygen which she said she already did and to give R801 a nebulizer treatment. LPN 'D' remembered R801's oxygen was low and his blood sugar was high, but blood pressure was stable. When queried about whether applying oxygen improved the oxygen levels, LPN 'D' reported it did not and so then she gave him the nebulizer treatment. LPN 'D' explained she had to leave the resident to find a mask in order to give the breathing treatment. LPN 'D' said she reported R801's change in condition to the Unit Manager (LPN 'B') and told her she was calling the doctor. Once R801 was evaluated by Physician 'G', the decision was made to send R801 out via 911. LPN 'D' reported that it was within an hour between the time she first discovered R801 had a change in condition and the time the physician arrived and R801 was sent to the hospital. On 1/10/25 at 10:00 AM, an interview was conducted via the telephone with CNA 'F', who was regularly assigned to R801 and worked the midnight shift on 1/2/25. CNA 'F' reported she was very familiar with R801. When queried about any changes that were noticed with R801 leading up to his hospitalization on [DATE], CNA 'F' reported around Christmas time R801 seemed like he had a little fever and felt warm so that day she did not get him out of bed. CNA 'F' explained that she notified the nurse on duty and R801 stayed in bed that day and he was okay the following day. When queried about anything unusual on 1/2/25 midnight shift, CNA 'F' said R801 was a little congested and the nurse had to suction him on the morning of 1/3/25. CNA 'F' reported that R801 was sleeping more often that before. On 1/10/25 at 10:42 AM, an interview was conducted via the telephone with Registered Nurse (RN) 'E', who was assigned to R801 on the midnight shift of 1/2/25 going into the morning of 1/3/25. When queried about R801's presentation on the midnight shift of 1/2/25, RN 'E' stated, nothing was unusual during the night, that he slept through the night as usual, and that he typically woke up during morning rounds and did not like to be bothered. RN 'E' reported she usually sees him around 5:00 AM to give him morning medications, but on that day got to him around 6:00 AM. On that day, when RN 'E' took R801's vital signs he just looked at me and was more compliant. According to RN 'E', R801's typical behavior was he fights me when taking vital signs and on 1/3/25, he didn't argue which was not typical behavior for him. RN 'E' reported she did not remember anything abnormal with R801's vital signs. RN 'E' reported R801 had congestion and said that was normal for him. RN 'E' reported R801's mouth was dirty and so she attempted to clean his mouth. The CNA that changed him around 6:30 AM reported that R801 was quieter than normal and was not resistant to care as he often was. When queried about whether R801 required suctioning, RN 'E' reported R801 was trying to spit whatever was in his mouth out, but had difficulty, that she tried to suction R801's mouth, but he clenched his mouth and gripped his teeth and she was unable to suction his mouth. When queried about whether the physician was notified of R801's change in behavior and need to be suctioned, but unable to do it, RN 'E' reported she did not contact the doctor because it was already after 7:00 AM and she was there late. When queried about why she did not document any of the changes and behavior exhibited by R801, RN 'E' reported she documented the vital signs only. On 1/10/25 at approximately 10:55 AM, an interview was conducted with LPN 'B', the unit manager for the Spring Unit where R801 resided. When queried about the unit manager's responsibility during a resident's change in condition, LPN 'B' reported she typically followed up once the event was documented or if a nurse reported something to her, she would let them know what they were supposed to do next. LPN 'B' reported if a nurse asked for help, she would assist. LPN 'B' reported she would follow up during a change in condition, depending on what was going on. When queried about what occurred with R801 on the morning of 1/3/25, LPN 'B' reported she arrived at the facility, looked at the 24 hour report (there was nothing regarding R801 on there), rounded on the [NAME] and Spring unit. At some point, R801's nurse told her the resident was having a change in condition and that she was going to call the doctor. LPN 'B' said she told the nurse to let her know if she needed anything and left the Spring unit to go to the [NAME] unit. About an hour later, LPN 'B' was paged overhead to report to Spring Unit. Physician 'G' was in the hallway and said This nurse needs help now! and said to give R801 intravenous Lasix (a diuretic) which they did not have in the facility and he said to call 911. At that time, LPN 'B' called 911 and got the paperwork ready to transfer R801 to the hospital. When queried about expectations for documenting and/or calling the physician if a resident did not present as usual and/or if they required suctioning, LPN 'B' reported she would have expected a progress note and the physician to be called, as well as a note on the 24 hour report so that any additional monitoring or follow up could be completed. On 1/10/25 at 12:04 PM, an interview was conducted via the telephone with Physician 'G'. When queried about what occurred with R801 on the day he was sent to the hospital, Physician 'G' reported the nurse texted him and reported R801 had trouble breathing, had high respiratory rate, and was gurgling. Physician 'G' reported he ordered suctioning and a breathing treatment and told her to call 911. Physician 'G' said they always want to see if they can stabilize and handle a change in condition in the facility before sending the patient out, but when he saw R801 you could see on his face he was going down. When queried about whether he was notified of R801's need to have his mouth suctioned and that the nurse was unable to do it on the midnight shift of 1/2/25, Physician 'G' reported he was not aware and it was expected that if there were any significant changes, even if vital signs were stable, to contact him to ensure no additional monitoring or treatment was needed. Physician 'G' reported he was always available via text message. On 1/10/24 at approximately 12:15 PM, an interview was conducted with the Director of Nursing (DON). When queried about what the facility's protocol was when a resident had a change in condition, the DON reported the nurse should document a progress note and/or on the change of condition assessment, contact the physician, assess the resident. When queried about the midnight nurse having to suction R801's mouth on the early morning of 1/3/25 and that she said she was unable to, and what should have been done, the DON did not offer a response. When queried about whether LPN 'C' should have contacted the physician on 12/21/24 when R801 presented with not feeling well and not getting out of bed as usual, the DON said based on the documentation, LPN 'C' assessed R801 appropriately. When queried about whether additional monitoring should have been done afterward, the DON did not offer a response. A review of the facility's policy titled, Change in Condition Notification revealed, .The nurse will notify .the resident's physician/practitioner .when there is .A significant change in the resident's physical, mental, or psychosocial status .The nurse will document in the resident's medical record information relative to the resident's change in medical/mental condition or status (i.e. assessment, notifications, interventions, and response) .

Based on observation, interview, and record review the facility failed to provide activities of daily living care in a safe manner, for one resident (R701), resulting in a fall from bed with injury of a fractured vertebrae. Findings include: This citation pertains to Intake MI00139950. A review of the Intake noted, Allegations: Details: It was alleged the resident fell off the bed while receiving care and sustained a fractured vertebrae. On 10/9/23 at 2:45 PM, R701 was observed at the nurses station, sitting in a wheelchair, with a neck brace on. A review of R701's progress notes revealed, 9/17/2023 21:08 Nursing - Progress Note Text: resident fall out of bed when CNA (certified nursing assistant) was changing [R701] onto floor, small skin tear on head, vital signs stable called DON (Director of Nursing), applied ice pack to head. On 10/09/23 at 1:22 PM, the Unit Manager was asked if R701 pushed away from the care provider during care, and explained, yes CNA A did turn away from R701. The Unit Manager further explained that CNA A only work on weekends. On 10/09/23 at 1:55 PM, CNA A was called via phone and asked about the incident regarding R701. CNA A stated, I was changing [R701], I turned away to go and get the towels from behind me. I think [R701] may have reached for something. I tried to catch [R701] but I couldn't. CNA A was asked if this was their first time taking care of R701 and stated, No. CNA A explained that R701 reaching for items and falling was a new behavior that R701 had started doing. A review of R701 x-ray results dated 9/17/23 noted, Bilateral C1(cervical spine) posterior arch fractures. A review of R701 Incident and accident report noted, 9/17/23. Incident Description: CNA (CNA A) was in room changing resident and when she went to bathroom resident (R701) fell out of bed onto floor, small skin tear on forehead, called dr. (Doctor) and wants [R701] sent to hosp (hospital) for ct of head. Immediate Action Taken: vitals signs stable, will send to hsp (hospital), gave Tylenol for pain. Met with IDT (intradiciplinary team), discussed incident. Resident fell from bed. Intervention: Inservice/educate CNA. Taught about resident confused and needs more supervision. Witness statement: [CNA A] Date 9/22/23. Statement: I had turned my back to get a towel, the resident stated to fall from bed, I tried to catch [R701] to prevent from falling but was unable to reach [R701] in time. I called for the nurse. A review of CNA A's in-service noted, Individual in-service form- Staff member [CNA A]. Education Topic: Proper lifting and moving technique to prevent injury/to pull a patient in the right position. Details: Safety . Roll patient towards you during care, do not leave unattended. Signed: [CNA A]. Date: 9/22/23. R701 was admitted to facility on 2/8/22 and readmitted [DATE]. On 10/09/23 at 2:27 PM, the DON was asked the facility's expectation for safety during care. The DON explained, that an Aide not walk away from the bed and leave resident unattended.

Based on observation, interview, and record review the facility failed to maintain safety during a bed bath, for one of seven residents (R44) reviewed for falls, resulting in a fall from bed and a fracture femur. Findings include: On 9/20/22 at 1:40 PM, R44 was observed lying in bed with their right leg observed with a healing surgical cut. R44 was asked what had happen to their leg and stated, I fell from the bed to the floor about seven weeks ago. R44 was asked how it happened and stated, A CNA was giving me a bed bath. R44 continued and explained that they broke their femur and had surgery to repair the break. On 9/22/22 at 12:04 PM, CNA E was called for a phone interview, a voice message was left, CNA E did not return the call by the end of this survey. A review of the facility's written statement from CNA E, noted, On Friday July 1, 2022, I [CNA E] where assign to the summer hall. I gave resident a bed bath 219-2 as I pull the pad towards me to turn [R44] onto [their]] left side, to complete washing [R44] I turn pivot to retrieve the lotion that I placed on the other bed. Never once leaving the resident side. turning back around I notice [R44] sliding off the bed holding on to the rail of the bed. I then hurried around over to her to see if [R44] was ok. I then notice [R44's] legs was on the legs of the side table. toes was press against the vent. I ran to get the nurse they look [R44] over , ask [R44] questions what hurt and then we proceed to pick [R44] up put resident back in bed. [CNA E]. On 9/22/22 at 12:36 PM, R44 was asked more about the fall out of bed and stated, It was bath day and I asked her (CNA E) are you going to take me to get my bath. She told me 'No. I am going to give you a bed bath.' R44 explained, that CNA E prepared them to get a bed bath, during the bed bath it was time to roll over on their side. R44 stated, Once I got on my side, I guess I wasn't far enough, so she pushed me. I knew I was about to fall and said I'm falling. R44 was asked if CNA was putting lotion on their back when they were asked to roll to the side and stated, She was washing my back. There wasn't anything about any lotion. R44 explained that they came to the facility after a stroke and couldn't move lower legs and that the fall out of bed was the worse. R44 stated, I did nothing but scream at the hospital. It still hurts. On 9/22/22 at 12:52 PM, Nurse F was asked about the incident with R44 and CNA E and stated I was the nurse that day, [R44] was my resident, [R44] needed a bath that day and I thought [R44] was a two person assist, so I told the CNA to let me know when she was going to give the bath. Nurse F explained that CNA E did not come to them for assistance before starting the bed bath. Nurse F was asked the condition of R44 when they walked into the resident's room and explained, R44 was in a lot of pain, a full body assessment was completed and R44 had a discolored area on their leg and was unable to move. Review of R44's Self Care Deficit (ADLs) careplan initiated 9/26/19 revealed an intervention that was initiated on 10/27/20 which stated, BED MOBILITY: 2 Person Assist. A review of R44's medical record revealed the following progress notes, 7/1/2022 10:29 Nursing - Progress Note Text: At 1030 am, other summer unit nurse told writer to come into room 219 because the pt (patient) fell . Upon entry of room writer saw pt sitting on floor. Writer (Nurse F) asked what happened and CNA (Certified Nursing Assistant, CNA E) explained that she was giving the pt a bed bath and she turned her back to grab lotion and she heard pt slide out of the bed. CNA (CNA E) asked if [R44] was okay and went to get the nearest nurse. Nurse completed a full body assessment. Nurse asked pt if [they] hit [their] head [R44] stated no. Writer noted pt's left toes were purple. Writer asked if [R44] toes hurt and [R44] stated [R44] never really had feeling in [their] toes. Nurse asked CNA [if] [R44's] toes were purple prior to fall and she stated no. Pt was also crying and said [their] Right knee hurts. Nurse obtained a full set of vitals . When asked the pain out of 10. Pt stated 10. Nurse gave pt a PRN (as needed) [MEDICATION(S)] and is icing knee 15 minutes on 15 minutes off. Writer notified director of Nursing (DON) of fall. Writer notified NP (Nurse Practitioner) of fall and ordered two STAT x-rays of the L (left). foot and R (right) knee. NP stated if pt feels [they] needs to go to the hospital [R44] can but pt denied wanting to go to the hospital. Currently waiting on x-ray results. (Nurse F). 7/1/2022 10:40 Nursing - Progress Note Text: Writer also noticed raised purple contusion on leg. Measures 3 1/4 in. Pt had brown discolorations on LE (lower extremities) bilaterally. Pt has a history of PVD ([CONDITION(S)]). Pt has no redness swelling or warmth. Asked CNA if it was there while she was giving a bed bath she stated yes. Writer assessed capillary refill and was present in both feet < 3 seconds. Notified wound care. (Nurse F). 7/1/2022 16:15 (4:15 PM) Nursing - Progress Note Text: Writer went to check on pt status and assess [R44's] knee, shin and toes. Writer noticed the pt had redness and warmth around the contusion on [R44's] left leg. Writer sent a picture to the doctor. Doctor . said [R44] needed to go to the hospital because [R44] is prone to blood clots and [R44] could have an infection. Writer spoke with pt regarding contusion and [R44] agreed to go to the hospital. Notified DON. Notified son. Writer called 911. EMS (Emergency Medical Services) arrived with a stretcher. Gave report to EMS and gave them appropriate paper work regarding pt. (Nurse F). 7/9/2022 19:48 (7:48 PM) Nursing - Progress Note Text: Resident into building at 530pm. Waiting for report NP notified and will see resident and write/clarify orders. Splint/brace in place RLE (Right Lower Extremities) toes warm and moveable. 7/12/2022 18:43 (6:43 PM) Nursing - Progress Note Text: cna attempted to given resident shower via (by way of) shower bed. resident stated I changed my mind, I want a bed bath instead cause scared of hurting leg. bed bath given. no complaints or other concerns noted at this time. Further review of R44's medical record noted, R44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Fracture of Right Femur, Chronic [CONDITION(S)] with Hypercapnia, Muscle Weakness, and [CONDITION(S)]. A review of R44's Minimum Data Set (MDS) assessment dated , 7/1/22, noted, R44's cognition intact and bed mobility as extensive assistance with one-person physical assist. On 9/22/22 at 1:50 PM, the DON was asked about the incident with CNA E and stated, The only thing she (CNA E) did and was in-serviced on, was to turn [R44] towards her and not away from her. A review of the facility's policy titled, Fall Risk / Injury Prevention dated, 06.20.2022, did not address the above concern. A review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting dated, 10/21, noted, Policy Interpretation and Implementation 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable . The policies did not address the positioning of the aide and resident during a bed bath.

This citation pertains to intake MI 492 Based on observation, interview, and record review, the facility failed to prevent the development of pressure injuries, turn and reposition in a timely manner for one sampled Resident (R700) out of one reviewed for skin, resulting in the potential for pain, the worsening of existing pressure injuries, and the development of a new pressure injuries. Findings include: A review of intake MI 492 noted the following, .[R700] has wounds all over her body. It appears she is not being turned in bed properly. There are bilateral right and left stage four pressure ulcers on her heels with (sic) are turning into necrotic wounds. There is also stage 3 pressure ulcer on her tail bone. Bone fragments are in the wounds and there an odor coming from the wounds. A review of the medical record revealed that R700 admitted into the facility on [DATE] with a readmitted [DATE] with the following diagnoses, Dysphagia, Changes in Skin Texture, and [CONDITION(S)]. R700's quarterly Minimum Data Set (MDS) assessment, with a Assessment Reference Date (ARD) of 2/2/2022 reflected a Brief Interview for Mental Status score of 11/15 (indicating mild impaired cognition), no unhealed pressure ulcers, and required extensive to dependent two person assistance with bed mobility and transfers. Further review of R700's MDS's revealed a significant change MDS with an ARD date of 2/21/2022 that now reflected R700 had an unhealed full thickness unstageable (known but not stageable due to coverage of wound bed by Slough [a mass of dead tissue separating from an ulcer, characterized as being yellow, tan, green or brown in color and my be moist, loose and stringy in appearance] and/or Eschar [dry, thick, leathery tissue that is often brown or black in color]) pressure ulcer. On 6/15/2022 at 11:12 AM, an interview was conducted with Wound Care Physician (WCP) B regarding R700's wounds. WCP B stated, [R700] last admission was on 5/16/2022 and [they] had an unstageable to their left ischium. [R700's] right ischium and coccyx were facility acquired. WCP B stated that, R700's wounds get better and then they get worse. A review of the most recent wound care note dated 6/15/2022 at 5:35 PM noted the following, Wound Consult - Re-eval: Seen for facility wound care consult, Right anterior foot- vascular ulcer, Right lateral lower leg- Vascular ulcer re-open, Left front foot- Vascular ulcer, Right medial heel Vascular ulcer, Right heel- Vascular ulcer extending up to the right ankle, Left posterior heel- Vascular ulcer and Coccyx and adjoining buttocks now closed, stage 4 right Ischial area, unstageable left ischial area. See physician's wound rounds notes, skin and wound evaluation assessment tab for description and measurements. New order in place. Treatment initiated and will continue to monitor. Pain r/t Wound: Is the resident experiencing pain related to the wound? Yes. Pain medication order in place? Yes. New order implemented? Yes. Non-verbal demonstrated: Guarding, Irritability. Interventions Initiated: Non-Pharmacological interventions initiated (Turn & Reposition). Frequency: Episodic. Is resident cognitively impaired? No. Present level of pain: Hurt's a Little Bit. Comments: Recommended frequent turning and repositioning every 2 hours and as tolerated offloading to the affected areas. Foot repositions with pillow as tolerated, protection boot in place. On 6/16/2022 at 8:18 AM, an interview was conducted with Wound Care Nurse (WCN) C regarding R700's wounds. WCN C revealed that if there was a facility acquired wound then they call the physician and the family, and let them know what is going on. R700's left ischium pressure ulcer was developed in the community and R700's right ischium and coccyx pressure ulcers were facility acquired, however R700's coccyx was now closed. On 6/16/2022 at 8:25 AM, a wound observation was completed with WCN C. R700 was observed to have a large wound to their right ischium, and their coccyx was observed to have no open area but was slightly bleeding. R700 was positioned on their back with no positioning, off-loading pillows or wedges. WCN C was asked how often R700 should be repositioned and if they should be laying on their back. WCN C stated, [R700] should be turned every two hours and should not be on their back. On 6/16/2022 at 10:36 AM and 12:36 PM R700 was observed laying on their back with no positioning or off-loading pillows or wedges. On 6/16/2022 at 12:39 PM, an interview was conducted with the Director of Nursing (DON) regarding R700's wounds. The DON shared that they expected for R700 to be turned and repositioned every two hours. The DON was queried as to how they tracked if someone is being repositioned or not. The DON replied, I do not think there is a turning program here, that is something I will have to look into. The DON was queried as to how R700 developed the pressure injuries while in the facility. The DON revealed that R700 has been declining and there was not much else they could do because the guardian refused hospice. The DON continued to say that R700 recently received a peg tube, had been doing better and they should be able to manage R700's wound better because of better nutrition. A review of a facility policy titled, Skin-Pressure Ulcer Guidelines and dated 8/13/2020 revealed the following, POLICY: Based on the Comprehensive Assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

THIS CITATION PERTAINS TO INTAKE NUMBER MI 769 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PREVENT THE SEXUAL ABUSE OF ONE RESIDENT(RESIDENT #503) OF FIVE RESIDENTS REVIEWED FOR ABUSE AND NEGLECT FROM A TOTAL SAMPLE OF NINE RESIDENTS, RESULTING IN IMMEDIATE JEOPARDY FOR RESIDENT #503 WHEN RESIDENT #503 WAS SEXUALLY ABUSED AT THE NURSING HOME BY ONE OF THE MAINTENANCE STAFF MEMBERS WHO SUPERVISED HER DURING SMOKING BREAKS. THIS DEFICIENT PRACTICE CAUSED RESIDENT #503 MENTAL AND EMOTIONAL DISTRESS- INCLUDING A PSYCHIATRIC hospitalization DUE TO SUICIDAL THOUGHTS, THE POTENTIAL FOR EXPOSURE TO [MEDICAL CONDITION] AND PLACED ALL RESIDENTS RESIDING IN THE FACILITY AT RISK FOR ABUSE. FINDINGS INCLUDE: RECORD REVIEW ON 2/5/13 AT 2:00 P.M. REVEALED THAT RESIDENT #503, A [AGE] year-OLD FEMALE, WAS ORIGINALLY admitted to the facility on [DATE] AND RE-admitted on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF THE MOST CURRENT MINIMUM DATA SET (MDS) ASSESSMENT, DATED 11/8/12, INDICATED THAT RESIDENT #503 WAS COGNITIVELY INTACT. IN AN INTERVIEW ON 02/06/2013 AT 11:45 A.M., RESIDENT #503 EXPLAINED THAT SHE WAS A SMOKER AND DID NOT GO OUT TO SMOKE WITH THE OTHER RESIDENTS BECAUSE SHE DID NOT GET ALONG WITH SOME OF THE FEMALE RESIDENTS WHO SMOKED. RESIDENT #503 EXPLAINED THAT SHE WAS TAKEN OUT TO SMOKE INDIVIDUALLY BY SOMEONE FROM THE MAINTENANCE DEPARTMENT. THE RESIDENT REPORTED THAT ONE OF THE MAINTENANCE MEN (#23) WOULD COERCE HER TO PERFORM ORAL SEX IN ORDER FOR HER TO BE ABLE TO SMOKE A CIGARETTE. RESIDENT #503 CRIED AND SAID, "HE MADE ME GIVE HIM BLOW JOBS. I FELT LIKE A WHORE." RESIDENT #503 REFUSED TO REVEAL THE IDENTITY OF THE STAFF MEMBER ACCUSED OF ABUSING HER, BECAUSE SHE WAS AFRAID OF BEING "KICKED OUT" OF THE FACILITY. RESIDENT #503 DID NAME SEVERAL MAINTENANCE STAFF MEMBERS "WHO WERE NOT" THE EMPLOYEE WHO WAS ABUSING HER. RESIDENT #503 WAS TEARFUL AS SHE EXPLAINED THAT SHE FELT ASHAMED FOR HER ACTIONS. WHEN QUERIED ABOUT THE LOCATION WHERE THE ALLEGED SEXUAL ABUSE TOOK PLACE, RESIDENT #503 STATED "OUTSIDE ON THE PATIO AND SOMETIMES IN THE BOILER ROOM." WHEN ASKED IF THE FACILITIES VIDEO SURVEILLANCE CAMERAS WERE IN THE LOCATIONS THAT THE ABUSE TOOK PLACE, RESIDENT #503 STATED, "HE'S (THE ABUSER) NOT STUPID. HE KNEW NOT TO DO IT IN VIEW OF THE CAMERAS." RESIDENT #503 THEN STATED THAT "AS OF YESTERDAY (02/05/2013), SOMEONE DECIDED THAT MAINTENANCE EMPLOYEES CAN'T TAKE ME OUT TO SMOKE ANYMORE. I HAVE TO GO OUT WITH A NURSE AIDE NOW." AN INTERVIEW WAS CONDUCTED WITH RESIDENT #503'S LEGAL GUARDIAN (LG) #27 ON 02/06/2013 AT 12:25 P.M. LG #27 EXPLAINED THAT SHE ATTENDED A MEETING AT A PSYCHIATRIC HOSPITAL IN DECEMBER WITH RESIDENT #503, AND HOSPITAL STAFF. ACCORDING TO THE LG #27, RESIDENT #503 REPORTED THAT FOR THE PAST TWO YEARS, A MALE NURSING HOME STAFF MEMBER FORCED HER TO PERFORM ORAL SEX ON HIM IN EXCHANGE FOR THE ABILITY TO SMOKE A CIGARETTE. LG #27 SAID THAT WHEN SHE FIRST BECAME AWARE OF THE SEXUAL ABUSE AT THE DECEMBER MEETING, SHE CONTACTED ADULT PROTECTIVE SERVICES AND A COMPLAINT WAS MADE WITH THE STATE OF MICHIGAN ON 12/03/2012. MAINTENANCE DIRECTOR #22 WAS INTERVIEWED ON 02/06/2013 AT 1:05 P.M. AND WAS ASKED WHY THE MAINTENANCE DEPARTMENT WAS INSTRUCTED TO NO LONGER SUPERVISE RESIDENT #503 DURING SMOKING BREAKS. MAINTENANCE DIRECTOR #22 STATED THAT "THE MEETING HAPPENED AFTER I LEFT FOR THE DAY" AND HE DENIED KNOWING THE REASON FOR THE CHANGE. ON 02/06/2013 AT APPROXIMATELY 1:30 P.M., DURING AN INTERVIEW, STAFF #23 STATED THAT ALTHOUGH HE REGULARLY SUPERVISED RESIDENT #503 DURING SMOKING PERIODS, HE DENIED THAT ANYTHING INAPPROPRIATE HAD EVER HAPPENED. WHEN QUERIED ABOUT THE DIRECTIVE GIVEN YESTERDAY (02/05/2013) FOR MAINTENANCE STAFF TO NO LONGER SUPERVISE RESIDENT #503 DURING SMOKING, STAFF #23 STATED THAT "(EXECUTIVE DIRECTOR #12) TOLD US NOT TO TAKE HER (#503) OUT ANYMORE, BUT I DON'T KNOW WHY." ON 02/06/2013 AT 2:45 P.M., MAINTENANCE DIRECTOR #22 WAS ASKED IF HE WAS AWARE OF ANY UNWANTED SEXUAL ADVANCES THAT INVOLVED ONE OF HIS MAINTENANCE STAFF AND RESIDENT #503. MAINTENANCE DIRECTOR #22 DENIED HAVING KNOWLEDGE OF SEXUAL ABUSE INVOLVING RESIDENT #503. ON 02/06/2013 AT 3:00 P.M., EXECUTIVE DIRECTOR #12 WAS QUERIED ABOUT WHY THE DIRECTIVE WAS MADE FOR MAINTENANCE STAFF TO NO LONGER SUPERVISE RESIDENT #503 DURING SMOKING. SHE EXPLAINED THAT THE REASON WAS "BECAUSE WE LIKE NURSING TO HAVE A BETTER HOLD OF THE SMOKING TIMES. THE MAINTENANCE DEPARTMENT WILL NO LONGER SUPERVISE (RESIDENT #503) ON HER SMOKE BREAKS." EXECUTIVE DIRECTOR #12 WAS QUERIED OF HER KNOWLEDGE OF ALLEGED SEXUAL ABUSE INVOLVING RESIDENT #503 AND A MAINTENANCE STAFF MEMBER AND SHE (#12) DENIED HAVING ANY KNOWLEDGE OF SUCH A SITUATION. ON 02/06/2013 AT APPROXIMATELY 3:30 P.M., SOCIAL WORKER #5 WAS QUERIED ABOUT HER KNOWLEDGE OF SEXUAL ABUSE ALLEGATIONS INVOLVING RESIDENT #503. SW #5 DENIED HAVING KNOWLEDGE OF SEXUAL ABUSE INVOLVING RESIDENT #503. "IT WAS NEVER BROUGHT TO MY ATTENTION." ON 02/11/2013 AT 3:00 P.M., DIRECTOR OF NURSING (DON) #2 INFORMED THE SURVEYOR THAT RESIDENT #503 HAD COME FORWARD WITH ALLEGATIONS THAT STAFF MEMBER #23 HAD BEEN SEXUALLY ABUSING HER (#503) FOR ALMOST TWO YEARS ON A DAILY BASIS. DON #2 STATED THAT THE POLICE WERE CALLED AND STAFF MEMBER #23 HAD BEEN ARRESTED DUE TO THESE ALLEGATIONS. ON 02/12/2013 AT 9:30 A.M., DON #2 EXPLAINED THAT RESIDENT #503 DIVULGED THAT STAFF #23 WOULD TAKE HER TO THE FACILITY BOILER ROOM AND THE FACILITY PATIO TO INITIATE THE FORCED SEX ACTS. ADDITIONALLY, ACCORDING TO DON #2, RESIDENT #503 REPORTED THAT STAFF #23 ALSO TOOK HER INTO THE FACILITY'S [MEDICAL TREATMENT] ROOM AND THE [MEDICAL TREATMENT] OVERNIGHT ROOM, BECAUSE THERE WERE NO CAMERAS IN THOSE LOCATIONS. THE DON FURTHER STATED THAT RESIDENT #503 EXPRESSED THAT SHE HAD THOUGHTS OF SUICIDE AFTER SHE CAME FORWARD WITH THE SEXUAL ABUSE ALLEGATION AND HAD BEEN PUT ON ONE-TO-ONE SUPERVISION. RECORD REVIEW OF NURSE'S NOTES, DATED 02/11/2013, REVEALED "7:30 P.M. WRITER AND SOCIAL WORKER CALLED TO RESIDENT ROOM DUE TO RESIDENT STATING SHE WANTS TO DIE. STATES SHE WANTS TO PUT HER HEAD THROUGH THE WINDOW OR ANYTHING SO SHE WON'T WAKE UP. RESIDENT CRYING AND STATING EVERYONE HATES ME..." ON 02/12/2013 AT 11:15 A.M., AN INTERVIEW WAS CONDUCTED WITH POLICE DETECTIVE #28 WHO REPORTED THAT STAFF #23 WAS IN POLICE CUSTODY BECAUSE HE (#23) HAD CONFESSED TO THE ALLEGATIONS OF SEXUAL ACTIVITY WITH RESIDENT #503. THE DETECTIVE #28 STATED, "HE (STAFF #23) DISCLOSED THAT SHE (RESIDENT #503) HAD BEEN GIVING HIM BLOW JOBS. HE admitted TO AT LEAST 10 TIMES OUTSIDE OF THE FACILITY (ON THE PATIO) AND ONE TIME IN THE BOILER ROOM." POLICE DETECTIVE #28 FURTHER STATED THAT STAFF #23 REPORTED THAT HE (STAFF #23) EJACULATED IN RESIDENT #503'S MOUTH ON AT LEAST TWO OCCASIONS AND SHE CONSEQUENTLY SWALLOWED THE SEMEN. POLICE DETECTIVE #28 EXPLAINED THAT STAFF #23 SAID THAT THE SEX WAS CONSENSUAL. ON 02/12/2012 AT 12:20 P.M., RESIDENT #503 WAS INTERVIEWED AND EXPLAINED THAT SHE CAME FORWARD WITH THE INFORMATION ABOUT THE SEXUAL ABUSE BECAUSE "HE TRIED IT ONE MORE TIME, BUT I REFUSED." RESIDENT #503 WAS ASKED IF THE MAINTENANCE STAFF WAS STILL SUPERVISING HER DURING HER SMOKING PERIOD, AND THE RESIDENT SAID "YES, THEY (FACILITY STAFF) WERE STILL ALLOWING MAINTENANCE TO TAKE ME OUT ON THE PATIO TO SMOKE. THERE WERE SUPPOSED TO BE TWO GUYS AT A TIME BUT SOMEBODY DIDN'T COME IN THAT DAY SO HE TOOK ME OUT HIMSELF." RESIDENT #503 WAS UNCLEAR ABOUT THE EXACT DATE THAT STAFF #23 ATTEMPTED TO SEXUALLY ABUSE HER AGAIN. RESIDENT #503 DENIED THAT THE SEX WAS CONSENSUAL. RESIDENT #503 WAS TEARFUL WHEN SHE EXPLAINED, "HE FORCED ME TO DO THE SEX ACTS. EVERY TIME THAT HE TOOK ME OUT (TO SMOKE) HE WOULD PULL HIS PENIS OUT AND PLAY WITH HIMSELF. WHEN IT GOT HARD HE WOULD PUSH MY HEAD DOWN ON IT. I HAD TO DO THAT BEFORE HE WOULD GIVE ME A CIGARETTE." RESIDENT #503 WAS ASKED IF SHE FELT THREATENED BY (STAFF #23) AND SHE STATED, "YES, HE HAD A TEMPER." RESIDENT #503 FURTHER STATED "HE WOULD MAKE ME SWALLOW IT (SEMEN). ON ONE OCCASION, WE WERE ON THE PATIO, AND HE WAS ABOUT TO CUM (EJACULATE) AND HE WANTED ME TO SWALLOW IT SO THERE WOULD BE NO EVIDENCE, BUT I PULLED MY HEAD BACK AND HIS SPERM WAS ON THE CEMENT NEAR THE BAR-B-QUE GRILLS. HE WAS MAD ABOUT THAT." RESIDENT #503 WAS ASKED IF THE FACILITY tested HER FOR THE POTENTIAL EXPOSURE OF [MEDICAL CONDITION] AND SHE ANSWERED "NO." WHEN RESIDENT #503 WAS ASKED HOW THE SEXUAL ACTIVITY COULD GO ON UNNOTICED BY THE OTHER SMOKERS WHEN THE OTHER SMOKERS WERE TAKEN OUT TO SMOKE ON THE PATIO. RESIDENT #503 EXPLAINED THAT "HE (#23) USUALLY TOOK ME OUT TO SMOKE EARLIER. HE WOULD TAKE ME AT 6:30 P.M. AND THE OTHER SMOKERS WENT OUT AT 7:00 P.M." ON 02/12/2013 AT 1:00 P.M., OBSERVATIONS WERE MADE WITH RESIDENT #503 OF THE LOCATIONS THAT STAFF MEMBER #23 HAD TAKEN HER FOR SEX. THESE LOCATIONS INCLUDED THE FACILITY PATIO AND THE FACILITY BOILER ROOM. ACCORDING TO RESIDENT #503, "HE (STAFF #23) MADE SURE THAT WE WERE NOT IN VIEW OF THE SURVEILLANCE CAMERAS WHEN IT HAPPENED." THE DETAILS PROVIDED TO THE POLICE DETECTIVE #28 BY STAFF #23 DID CORROBORATE THE INFORMATION PROVIDED BY RESIDENT #503 REGARDING THE TYPE OF SEX ACTIVITY AND THE LOCATIONS WHERE IT TOOK PLACE. RESIDENT #503 EXPLAINED THAT ALTHOUGH THERE WAS A SURVEILLANCE CAMERA IN THE PATIO AREA, STAFF #23 WOULD EITHER TAKE HER TO AN AREA LOCATED BEHIND TWO LARGE BAR-B-QUE GRILLS (WHICH BLOCKED THE VIEW OF THE CAMERAS) AND ALSO NEAR THE PATIO DOOR WHERE THEY ALSO WOULD NOT BE IN VIEW OF THE CAMERA. RESIDENT #503 ALSO EXPLAINED THAT HE WOULD SOMETIMES TAKE HER TO THE [MEDICAL TREATMENT] ROOM AND THE [MEDICAL TREATMENT] OVERNIGHT ROOM, WHICH ALSO DID NOT HAVE CAMERAS. ON 02/12/2013 AT 1:30 P.M., AN INTERVIEW WAS CONDUCTED WITH MAINTENANCE DIRECTOR #22 WHO WAS ASKED IF THE MAINTENANCE STAFF WAS STILL TAKING RESIDENT #503 OUT FOR HER SMOKE BREAKS. MAINTENANCE DIRECTOR #22 INITIALLY DENIED THAT MAINTENANCE HAD CONTINUED SUPERVISING RESIDENT #503, BUT LATER RECANTED AND SAID, "ACTUALLY, TWO GUYS HAVE BEEN TAKING HER OUT TOGETHER." MAINTENANCE DIRECTOR #22 WAS ASKED ABOUT THE SURVEILLANCE CAMERAS IN THE FACILITY AND HE SAID "NO ONE KNOWS ABOUT THE 'BLIND SPOTS' (AREAS IN THE FACILITY THAT THE SURVEILLANCE CAMERAS CANNOT DETECT ACTIVITY) EXCEPT THE MAINTENANCE STAFF. I WAS SURPRISED TO LEARN THAT (RESIDENT #503) KNEW ABOUT THE BLIND SPOTS." ON 02/14/2013 AT 2:30 P.M., STAFF #23'S PERSONNEL FILE WAS REVIEWED. ALTHOUGH STAFF #23 DID NOT HAVE ANY CURRENT DISCIPLINARY ACTIONS INCLUDED IN THE FILE, STAFF #23 had a history of [REDACTED]. DISCIPLINARY REPORT DATED 11/12/2003 "...ENGAGING IN RUDE, BOISTEROUS OR DISORDERLY BEHAVIOR, CONDUCT OR HORSEPLAY. EMPLOYEE BROUGHT FRIEND TO WORK WAS WALKING AROUND BUILDING WITH BOISTEROUS, DISORDERLY BEHAVIOR ... AN ATTACHED EMPLOYEE STATEMENT REVEALED "BOTH MEN SMELLED OF ALCOHOL..." THE ACTION TAKEN BY THE FACILITY WAS A FIVE DAY SUSPENSION FOR THE EMPLOYEE. ANOTHER EMPLOYEE DISCIPLINARY REPORT DATED 06/07/2004 DOCUMENTED "...REPORTING FOR DUTY UNDER THE INFLUENCE ALCOHOL 0.09 PER (OCCUPATIONAL CARE) CLINIC (BLOOD ALCOHOL LEVEL GREATER THAN 0.08 CONSIDERED INTOXICATED) AND admitted TO HAVING BEEN DRINKING EARLIER THAT DAY...ANY FURTHER INCIDENTS OF WORKING UNDER THE INFLUENCE OF ALCOHOL OR ILLEGAL DRUGS WILL RESULT IN IMMEDIATE TERMINATION..." THE EMPLOYEE RECEIVED ANOTHER FIVE DAY SUSPENSION AS A RESULT OF THIS INCIDENT. A DOCUMENT FROM A LOCAL POLICE DEPARTMENT INDICATED A PROBATION VIOLATION ON 11/02/2005. IN ADDITION, A NAME INQUIRY RESPONSE REVEALED SEVERAL OLD FELONYS AND MISDEMEANORS THAT RESULTED IN GUILTY VERDICTS FOR STAFF #23. ON 02/15/2013 AT 9:00 A.M., DON #2 REPORTED THAT RESIDENT #503 HAD BEEN TRANSFERRED TO A PSYCHIATRIC FACILITY THE EVENING BEFORE (02/14/2013). ON 02/15/2013, REVIEW OF RESIDENT TRANSFER FORM DATED 02/14/2013 REVEALED THE REASON FOR TRANSFER WAS "SUICIDAL THOUGHTS." ACCORDING TO THE CLINICAL CERTIFICATE, DATED 02/14/2013 AT 06:35 P.M., "SHE (RESIDENT #503) IS VERY DEPRESSED, TEARFUL AT TIMES. SHE EXPERIENCES GUILT FEELINGS RELATED TO SEXUAL ABUSE BY A WORKER. HER SLEEP AND APPETITE ARE POOR. SHE EXPERIENCES DIFFICULTY SWALLOWING DUE TO THE MEMORY OF TRAUMATIC ORAL SEX ABUSE EXPERIENCES. SHE FEELS DIRTY AND ASHAMED OF HERSELF...SHE THREATENED TO HURT HERSELF BY PUTTING A PHONE CORD AROUND HER NECK OR PUTTING HER HEAD THROUGH THE WINDOW..." ON 2/14/13 AT 2:10 P.M., THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON 12/03/2012, WHEN LG #27 REPORTED THE ABUSE TO THE STATE AGENCY, AS A RESULT OF THE FACILITY'S FAILURE TO PREVENT THE SEXUAL ABUSE OF RESIDENT #503. THIS DEFICIENT PRACTICE PLACED ALL RESIDENTS RESIDING IN THE FACILITY AT RISK FOR ABUSE. ON 02/19/2013, THE SURVEYOR CONFIRMED THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: THE ALLEGED PERPETRATOR WAS SUSPENDED PENDING INVESTIGATION ON 02/11/2013. THE RESIDENT (#503) WAS PLACED ON 1:1 SUPERVISION STARTING 02/11/2012 ON ALL SHIFTS AND IS ON-GOING. THE RESIDENT WAS EVALUATED BY THE PHYSICIAN ASSISTANT ON 02/13/2012. FINDINGS INCLUDE "NO PHYSICAL OR EMOTIONAL DISTRESS NOTED." RESIDENT (#503) IS NOT AT THE FACILITY AT THIS TIME. TESTING FOR [MEDICAL CONDITION] WILL BE OFFERED UPON RESIDENT'S RETURN TO THE FACILITY. THE FACILITY'S POLICY AND PROCEDURE ON ABUSE AND SMOKING HAVE BEEN REVIEWED AND UPDATED ON 02/11/2013. STAFF EDUCATION ON THE REVISED SMOKING POLICY WAS INITIATED ON 02/12/2013. AT THIS TIME, ABOUT 90% (188 OUT OF 210) OF EMPLOYEES HAVE BEEN IN-SERVICED. THE IN-SERVICE IS ON-GOING TO CAPTURE 100% OF THE EMPLOYEES. NO STAFF WILL BE ALLOWED TO WORK UNTIL THEY HAVE RECEIVED THE EDUCATION. STAFF IN-SERVICE ON ABUSE POLICY AND PROCEDURE (INITIATED) ON 02/12/2013. THE IN-SERVICE IS ONGOING TO CAPTURE 100% OF EMPLOYEES. THE FOLLOWING TOPICS WERE ALSO DISCUSSED: RESIDENT TO RESIDENT ABUSE, STAFF TO RESIDENT ABUSE, WITH SPECIAL EMPHASIS ON STAFF/MANAGEMENT RESPONSIBILITIES TO REPORT ABUSE. AT THIS TIME, ABOUT 90% (188 OUT OF 210) OF EMPLOYEES HAVE BEEN IN-SERVICED. NO STAFF WILL BE ALLOWED TO WORK UNTIL THEY HAVE RECEIVED THE EDUCATION. THE ABUSE PREVENTION AUDIT TOOL TO MONITOR RESIDENTS FOR STATEMENTS OF ABUSE OR NON-VERBAL SIGNS AND SYMPTOMS OF ABUSE WAS INITIATED BY NURSE MANAGERS ON 02/14/2013. THE AUDIT WILL BE ON-GOING 3 TIMES A WEEK FOR 3 MONTHS OR UNTIL COMPLIANCE IS ACHIEVED. FINDINGS WILL BE REPORTED TO THE QA (QUALITY ASSURANCE) COMMITTEE. ON 02/14/2013, ALL RESIDENTS WERE ASSESSED FOR SIGNS AND SYMPTOMS OF ABUSE. 79 INTERVIEWABLE RESIDENTS WERE ASKED IF THEY FEEL SAFE IN THE NURSING HOME, 100% OF THE RESIDENTS INTERVIEWED FEEL SAFE AT THE FACILITY. 77 NON-INTERVIEWABLE RESIDENTS WERE ASSESSED FOR NON-VERBAL SIGNS AND SYMPTOMS OF ABUSE. NO SIGNS AND SYMPTOMS OF ABUSE WERE OBSERVED OR REPORTED. THE ASSESSMENTS WERE DOCUMENTED IN THE AUDIT TOOLS. STARTING 02/13/13, TWO STAFF MEMBERS WILL BE ASSIGNED TO ACCOMPANY RESIDENT #503 DURING SMOKING HOURS. ALL SMOKERS WILL BE SUPERVISED BY STAFF DURING SMOKING TIMES. THE SHIFT SUPERVISOR WILL DO ROUNDS TO ASSURE THAT NO ABUSE OCCURS TO RESIDENTS WHEN THEY ARE OUT TO SMOKE AND TO ENFORCE STAFF COMPLIANCE WITH SMOKING PROCEDURES. THE IMMEDIATE JEOPARDY (IJ) WHICH BEGAN ON 12/03/2012 WAS REMOVED ON 02/14/2013. THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF "ISOLATED" AND SEVERITY OF "NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY" UNTIL SUSTAINED COMPLIANCE CAN BE VERIFIED. ( )

THIS CITATION PERTAINS TO INTAKE #MI 431 BASED ON OBSERVATIONS, INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO ENSURE THAT 2 OF 4 RESIDENTS REVIEWED FOR FALLS (#101 AND #102) FROM A TOTAL SAMPLE OF 5, RECEIVED ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS RESULTING IN A FALL AND RIGHT HIP FRACTURE FOR RESIDENT #101 AND A FALL WITH ABRASIONS FOR RESIDENT #102. FINDINGS INCLUDE: RESIDENT #101 ACCORDING TO THE FACE SHEET DATED 6/27/2011, RESIDENT #101 WAS AN [AGE] year-old-FEMALE WHO LIVED AT THE FACILITY SINCE 1/26/2011. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #101 HAD SEVERE COGNITIVE IMPAIRMENTS WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. SHE DID NOT WALK, USED A WHEELCHAIR FOR MOBILITY AND REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH ALL TRANSFERS. RESIDENT #101 COULD NOT MAINTAIN STANDING BALANCE WITHOUT HUMAN ASSISTANCE. FALL ASSESSMENTS, COMPLETED ON 1/26/2011 AND 4/15/2011, PLACED RESIDENT #101 AT "HIGH RISK" FOR FALLS DUE TO HER DISORIENTATION, RECENT FALLS, NEED FOR ASSISTANCE WITH ALL TRANSFERS, BALANCE PROBLEMS WITH STANDING AND WALKING, DECREASED MUSCLE COORDINATION, USE OF ASSISTIVE DEVICES, SIDE EFFECTS OF MEDICATIONS AND MULTIPLE [DIAGNOSES REDACTED]. IN A FALL CARE PLAN DATED 1/26/2011, STAFF IDENTIFIED RESIDENT #101 AT RISK FOR FALLS AND IMPLEMENTED THE FOLLOWING INTERVENTIONS: FREQUENT VISUAL CHECKS EVERY SHIFT; ASSISTIVE DEVICES AS NEEDED; A LOW BED; AND ENABLER BARS. A SECOND FALL CARE PLAN DATED 2/8/2011 (UPDATED ON 4/15/2011), CONTINUED TO IDENTIFY RESIDENT #101 AT RISK FOR INJURY AND REQUIRED STAFF TO ADDITIONALLY PROVIDE MINIMALLY ONE PERSON TO ASSIST WITH ALL TRANSFERS AND A TAB ALARM TO HER WHEELCHAIR AND BED. HOSPITAL RECORDS, DATED 1/09/2011, RECEIVED WITH RESIDENT #101 ON ADMISSION 1/26/2011, IDENTIFIED HER AT RISK FOR FALLS WHEN A PHYSICIAN DOCUMENTED A [DIAGNOSES REDACTED]. A HISTORY AND PHYSICAL NOTE DATED 4/18/2011 IDENTIFIED RESIDENT #101 AT RISK FOR FALLS DUE TO AN UNSTEADY GAIT AND RIGHT-SIDED PARALYSIS. PHYSICIAN ORDERS [REDACTED].#101. THERAPY EVALUATED RESIDENT #101 ON 1/27/2011, 2/24/2011, 3/10/2011, 4/12/2011, 4/16/2011 AND DETERMINED SHE REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE PHYSICAL ASSISTANCE WITH ALL TRANSFERS. ON 5/13/2011, OCCUPATIONAL THERAPY DOCUMENTED RESIDENT #101 NEEDED TO CONTINUE WITH STAFF ASSISTANCE FOR ALL TRANSFERS. NURSING NOTES DOCUMENTED AN ASSESSMENT COMPLETED ON 1/26/2011 AT 6:25 P.M., WHICH FOUND RESIDENT #101 TO BE AT RISK FOR FALLS. NURSING APPLIED A "TAB ALARM" AND A "PRESSURE ALARM" TO THE RESIDENT FOR SAFETY. DESPITE SKILLED THERAPY ASSESSMENTS REQUIRING ONE PERSON TO ASSIST WITH ALL TRANSFERS, THE FACILITY FAILED TO PROVIDE RESIDENT #101, THE REQUIRED ASSISTANCE WITH TRANSFERS AND AMBULATION FROM HER BED ON 2/05/2011. SHE fell TO THE FLOOR, WITHOUT INJURY. NO DOCUMENTED EVIDENCE COULD BE FOUND IN THE MEDICAL RECORD TO SUGGEST STAFF IMPLEMENTED ANY ALTERATIVE INTERVENTIONS TO MAINTAIN RESIDENT #101'S SAFETY AFTER THIS FALL. STAFF SIMPLY DOCUMENTED THE APPLICATION OF THE "TAB ALARM," A DEVICE PREVIOUSLY APPLIED FOR HER SAFETY. ON 7/07/2011 AT 7:00 P.M. THE ASSISTANT DIRECTOR OF NURSING SAID THE ALARMS WERE NOT IN PLACE 2/06/2011, WHEN SHE RE-ASSESSED THE RESIDENT'S FALL RISK. SHE SAID THAT SHE REAPPLIED THE TAB ALARM WHICH WAS PREVIOUSLY IMPLEMENTED ON 1/26/2011. ACCORDING TO NURSING NOTES DATED 2/13/2011 AT 9:00 P.M., THE FACILITY FAILED TO PROVIDE RESIDENT #101, THE REQUIRED ASSISTANCE WITH TRANSFERS AND AMBULATION FROM HER BED. RESIDENT #101 fell TO THE FLOOR AND SUSTAINED "RIGHT KNEE REDNESS." ON 3/23/2011, AT 1:00 P.M., A NURSE DOCUMENTED "RESIDENT ATTEMPTS TO STAND AND WALK SPONTANEOUSLY, NUMEROUS TIMES." STAFF MADE NO CHANGES TO THE RESIDENTS CARE PLAN TO ENSURE RESIDENT #101 REMAINED SAFE AFTER WITNESSING THESE BEHAVIORS. ON 4/25/11, STAFF CONTINUED TO DOCUMENT THE RESIDENTS ATTEMPTS TO SELF-TRANSFER AND THE INITIATION OF 30 MINUTE CHECKS. ON 7/07/2011 AT 7:00 P.M., THE SAFETY NURSE SAID THAT THE FACILITY IMPLEMENTED 30 MINUTE CHECKS (AN INTERVENTION TO EVALUATE THE RESIDENT'S LOCATION AND WELL-BEING) ON 4/25/11 IN RESPONSE TO THE RESIDENT'S BEHAVIORS. THE SAFETY NURSE WAS NOT ABLE TO EXPLAIN IF THIS INTERVENTION WAS EFFECTIVE. SHE PROVIDED NO EVIDENCE THAT THE INCREASED LEVEL OF SUPERVISION OCCURRED. WHEN ASKED IF NURSING STAFF CONTINUED TO CHECK ON THE RESIDENT'S WHERE-ABOUTS EVERY 30 MINUTES, SHE (THE SAFETY NURSE) DID NOT KNOW WHEN RESIDENT #101 WAS REMOVED FROM THE THIRTY MINUTE CHECKS OR WHY. ON 5/01/2011, NURSING NOTES CONTINUED TO DOCUMENT RESIDENT #101'S FREQUENT ATTEMPTS TO SELF-TRANSFER. STAFF IMMEDIATELY PLACED RESIDENT #101 AT THE NURSING STATION BUT FAILED TO IMPLEMENT ANY LONG-TERM SAFETY DEVICES OR SUPERVISION TO ENSURE RESIDENT #101 WAS SAFE. ON 6/08/2011 AT 2:55 P.M., NURSES DOCUMENTED THE FACILITY'S FAILURE TO PROVIDE THE REQUIRED LEVEL OF ASSISTANCE NECESSARY FOR RESIDENT #101 TO TRANSFER FROM HER WHEELCHAIR. STAFF FOUND RESIDENT #101 ON THE FLOOR JUST INSIDE THE DOORWAY OF ROOM 109 ON HER RIGHT SIDE. RESIDENT #101 IMMEDIATELY COMPLAINED OF RIGHT HIP AND LEG PAIN. NURSES DOCUMENTED THE PRESENCE OF A FOREHEAD ABRASION SUSTAINED DURING THE FALL. AN X-RAY OF THE RIGHT HIP AND FEMUR DATED 6/08/2011, REVEALED AN "ACUTE COMPLETE FEMORAL NECK FRACTURE" (BROKEN HIP) AND FAMILY SUBSEQUENTLY PLACED RESIDENT #101 IN HOSPICE CARE. ON 7/07/2011, EMPLOYEE "E" (A NURSE) SAID THAT SHE WAS ROUTINELY ASSIGNED TO RESIDENT #101 BEFORE HER FALL ON 6/08/2011. EMPLOYEE "E" SAID AT LEAST EVERY OTHER DAY RESIDENT #101 ATTEMPTED TO SELF-TRANSFER AND/OR AMBULATE FROM HER WHEELCHAIR OR BED. EMPLOYEE "E" SAID THAT RESIDENT #101 WAS NOT EASILY REDIRECTED DUE TO HER LEVEL OF CONFUSION. SHE SAID STAFF DID NOT IMPLEMENT ANY OTHER SAFETY DEVICES OR INCREASE THE RESIDENT'S LEVEL OF SUPERVISION. ON 7/07/2011 AT 7:00 P.M., THE DIRECTOR OF NURSING AND THE FACILITY'S SAFETY NURSE REVIEWED RESIDENT #101'S MEDICAL RECORD. NEITHER EXPLAINED NOR PROVIDED ANY DOCUMENTED EVIDENCE WHY THE SAFETY ALARMS PREVIOUSLY APPLIED TO RESIDENT #101 ON 1/26/2011, WERE NOT IN PLACE WHEN SHE fell [DATE]. NEITHER EXPLAINED NOR PROVIDED ANY DOCUMENTED EVIDENCE OF INCREASED SAFETY DEVICES OR SUPERVISION IMPLEMENTED FOR RESIDENT #101 FOLLOWING STAFF WITNESSED, FREQUENT (EVERY OTHER DAY) SELF-AMBULATING AND/OR SELF-TRANSFERRING ATTEMPTS. THE SAFETY NURSE SAID THAT SHE REVIEWS RESIDENTS FOR SELF-TRANSFERS AND SELF-AMBULATION WHEN MADE AWARE OF THESE BEHAVIORS. SHE SAID THAT SHE DID NOT REASSESS RESIDENT #101 BECAUSE STAFF DID NOT NOTIFY HER OF THESE BEHAVIORS. THE DIRECTOR OF NURSING AND SAFETY NURSE COULD NOT EXPLAIN WHY RESIDENT #101 DID NOT RECEIVE THE REQUIRED LEVEL OF SUPERVISION NECESSARY TO ENSURE A SAFE TRANSFER FOR THREE OF THREE FALLS. RESIDENT #102 ACCORDING TO THE FACE SHEET DATED 5/03/2011, RESIDENT #102 WAS A [AGE] year-old-MALE WHO LIVED AT THE FACILITY SINCE 3/17/2011. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #102 REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS AND AMBULATION. A COMPETENCY FORM COMPLETED BY TWO PHYSICIANS ON 4/08/2011, FOUND RESIDENT #102 INCOMPETENT TO UNDERSTAND RESIDENT RIGHTS OR MAKE HEALTH CARE DECISIONS DUE TO HIS DEMENTIA. THE FACILITY'S FALL RISK ASSESSMENTS COMPLETED ON 4/29/2011, 5/06/2011, 5/13/2011 AND 5/20/2011, ALL IDENTIFIED RESIDENT #102 AT "HIGH RISK" FOR FALLS DUE TO HIS INTERMITTENT CONFUSION, HISTORY OF FALLS, REQUIREMENT FOR TRANSFER ASSISTANCE, INABILITY TO BALANCE WHILE STANDING, DECREASED MUSCULAR COORDINATION, UNSTABLE MOVEMENTS, THE NEED FOR ASSISTIVE DEVICES, SIDE EFFECTS FROM MULTIPLE MEDICATIONS AND PREDISPOSING DIAGNOSES. IN A FALL CARE PLAN DATED 3/17/2011, STAFF IDENTIFIED RESIDENT #102 AT RISK FOR FALLS AND IMPLEMENTED THE FOLLOWING INTERVENTIONS: A TAB ALARM (CHANGED ON 5/3/2011 TO A PRESSURE ALARM) TO HIS BED AND WHEELCHAIR; A CALL LIGHT WITHIN REACH; FREQUENT VISUAL CHECKS THROUGHOUT EACH SHIFT; A LOW BED; BILATERAL FLOOR MATS; AND ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS. ON 4/29/2011 AND 5/12/2011 SKILLED THERAPY ASSESSED RESIDENT #102 AND DETERMINED HIM AT RISK FOR FALLS DUE TO A BALANCE DISFUNCTION AND DETERMINED HE NEEDED A STAFF MEMBER TO ASSIST WITH ALL TRANSFERS AND AMBULATION. ACCORDING TO NURSING NOTES DATED 5/4/2011, 5/9/2011, 5/10/2011, 5/11/2011, 5/12/2011, 5/15/2011, 5/16/2011, 5/18/2011, 5/19/2011, 5/22/2011, 5/23/2011 AND 5/26/2011, STAFF WITNESSED RESIDENT #102 REMOVING HIS OWN SAFETY ALARMS. FOLLOWING THESE OBSERVATIONS THE FACILITY FAILED TO IMPLEMENT ANY ADDITIONAL SAFETY DEVICES OR INCREASED SUPERVISION TO ENSURE RESIDENT #102 REMAINED SAFE. ACCORDING TO AN UNUSUAL OCCURRENCE REPORT DATED 6/01/2011 AT 6:05 P.M., STAFF FAILED TO PROVIDE THE REQUIRED STAFF ASSISTANCE FOR RESIDENT #102 AND HE fell TO THE FLOOR IN HIS BATHROOM. AFTER THIS FALL THE FACILITY FAILED TO IMPLEMENT ANY ADDITIONAL SAFETY DEVICES OR INCREASED SUPERVISION TO ENSURE RESIDENT #102 REMAINED SAFE. STAFF SIMPLY DOCUMENTED "RES(IDENT) REMOVES ALARMS,..IS COMBATIVE AND RESISTIVE TO CARE" AND NON COMPLIANT WITH SAFETY MEASURES. ON 6/02/2011, 6/06/2011 AND 6/22/2011, NURSES WITNESSED AND DOCUMENTED AN UNSTEADY GAIT WHEN RESIDENT #102 SELF-AMBULATED IN HIS BEDROOM, AFTER DISABLING HIS PRESSURE ALARM. FOLLOWING THESE OBSERVATIONS THE FACILITY FAILED TO IMPLEMENT ANY ADDITIONAL SAFETY DEVICES OR INCREASED SUPERVISION TO ENSURE RESIDENT #102 REMAINED SAFE. ON 7/07/2011 AT 5:20 P.M., EMPLOYEE "E" (A CERTIFIED NURSING ASSISTANT) SAID SHE WAS OFTEN ASSIGNED TO RESIDENT #102 AND FOUND HE ALWAYS REMOVED HIS OWN SAFETY ALARMS. SHE SAID RESIDENT #102 FREQUENTLY SELF-AMBULATED AND TRANSFERRED WITHOUT STAFF ASSISTANCE EVEN THOUGH HE WAS NOT STEADY ON HIS FEET. EMPLOYEE "E" COULD NOT IDENTIFY ANY INTERVENTIONS IMPLEMENTED BY THE FACILITY TO KEEP RESIDENT SAFE AFTER IT WAS KNOWN THAT HE HAD THE ABILITY TO DISARM THE ALARMS. ON 7/07/2011 AT 6:05 P.M., THE UNIT MANAGER FOR RESIDENT #102 SAID STAFF ATTEMPTED TO KEEP RESIDENT #102 SAFE BY REAPPLYING THE SAFETY DEVICES HE REMOVED. THE UNIT MANAGER COULD NOT EXPLAIN HOW THIS MAINTAINED RESIDENT #102'S SAFETY. SHE COULD NOT IDENTIFY ANY ADDITIONAL DEVICES OR SUPERVISION IMPLEMENTED TO PREVENT FUTURE FALLS/INJURY. ON 7/07/2011 AT 7:00 P.M. THE DIRECTOR OF NURSING AND SAFETY NURSE FAILED TO EXPLAIN HOW ANY ALARMS FUNCTIONED TO MAINTAIN SAFETY AFTER RESIDENTS DEMONSTRATE THE ABILITY TO REMOVE THEM WITHOUT STAFF KNOWLEDGE. NEITHER PROVIDED ANY EVIDENCE OF ADDITIONAL DEVICES OR SUPERVISION IMPLEMENTED TO KEEP RESIDENT #102 SAFE AFTER IT WAS KNOWN THAT HE HAD THE ABILITY TO DISARM THE ALARMS. ON 7/01/2011 AT 11:40 A.M., RESIDENT #102 WAS OBSERVED ALONE IN HIS BEDROOM, LYING ON HIS BED. RESIDENT #102 DID NOT HAVE HIS FLOOR MATS OR PRESSURE ALARM APPLIED. HIS CALL LIGHT WAS NOT WITHIN REACH AS CARE PLANNED FOR HIS SAFETY. ON 7/07/2011 AT 5:45 P.M., RESIDENT #102 WAS IN THE AUTUMN DINING ROOM SITTING IN HIS WHEELCHAIR. RESIDENT #102 DID NOT HAVE HIS PRESSURE ALARM APPLIED TO HIS WHEELCHAIR AS CARE PLANNED FOR HIS SAFETY.