Every finding on record at Hillsdale County Medical Care Facility

Based on observation, interview and record review, the facility failed to ensure staff utilized appropriate personal protective equipment (PPE) for two (R14 and R45) of two reviewed. Findings include: Review of the medical record reflected Resident 14 (R14) was admitted to the facility on [DATE], with diagnoses that included severe sepsis with septic shock and urinary tract infection. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/11/26, reflected R14 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician Orders revealed an active order dated 2/8/26 for Contact Isolation d/t (due to) VRE (vancomycin-resistant enterococcus- a bacteria) and Pseudomonas (a bacteria). On 2/24/2026 at 11:53 AM, R14 was observed in bed. A sign was observed posted outside of R14's door indicated Enhanced Barrier Precautions. No signage was observed indicating that the resident was under Contact Isolation precautions. On 2/25/2026 at 8:31 AM, the same observation was made of the missing Contact Isolation precautions sign posted outside of R14's door. On 2/25/26 at 8:40 am, Registered Nurse C confirmed that R14 was on Contact Isolation Precautions and that the Contact Isolation Precaution sign was not posted outside of R14's door. Registered Nurse C removed the Contact Precaution sign from the top drawer of the isolation cart located in the hallway and hung the sign outside of R14's door. R45: Review of the medical record reflected R45 admitted to the facility on [DATE], with diagnoses that included diabetes and COVID-19 (2/20/26). A Physician's Order, with a revision date of 2/20/26, reflected R45 was placed on droplet precautions due to being positive for COVID-19. On 02/24/2026 at 1:44 PM, R45 was observed seated in a recliner, in their room. A droplet precaution sign was hanging outside the room door. A PPE storage cart was in the hallway and noted to include gloves, gowns, face shields and KN95 masks. On 02/24/2026 at 2:11 PM, a staff member was observed to enter R45's room, wearing a gown, gloves and KN95 mask. Eye protection was not observed to be used. On 02/24/2026 at 2:28 PM, a staff member was observed in R45's room, obtaining vital signs. The staff member was wearing a gown, gloves and KN95 mask. Eye protection was not observed to be used. In an interview on 02/26/2026 at 10:32 AM, Infection Preventionist (IP) C conveyed R45 was on droplet precautions, and the expectation for PPE use included wearing a mask, gown and gloves when going into the room. IP C stated there was not a requirement to wear eye protection for droplet precautions, and they no longer used eye protection for COVID-19 positive residents. When asked about the type of mask used, IP C showed a box of KN95 masks. On 02/26/2026 at 11:10 AM, Director of Nursing (DON) B reported the expectation for PPE use for a COVID-19 positive resident included the use of a gown, gloves, N95 mask and eye protection. According to the Centers for Disease Control and Prevention (CDC), Infection Control Guidance: SARS-CoV-2, updated 6/24/24, .Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment .HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . (https://www.cdc.gov/covid/hcp/infection-control/index.html)

Based on observation, interview and record review the facility failed to maintain accurate medical records for minimum data set data for 1 (R15) of 23 residents. Findings include: Resident #15 (R15)Review of the medial record demonstrated that R15 was admitted [DATE] with diagnoses that included abdominal pain, pressure ulcer of right buttock, cellulitis (bacterial skin infection), peripheral vascular disease (PVD), obstructive sleep apnea, edema (swelling), enlarged prostate, vitamin D deficiency, anemia (low red blood cells), hypothyroidism (low thyroid hormone), hypertension, osteoarthritis (degenerative joint disease) of left shoulder, gastro-esophageal reflux disease, muscle weakness, dysphagia (difficulty swallowing), type 2 diabetes, and depression. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/15/2025, revealed a Brief Interview for Mental Status (BIMS) of 12 (mild cognitive impairment) out of 15.On 02/24/2026 at 02:40 p.m. during observation and attempted interview R15 was observed lying down in bed. R15 verbalized that he did not want to be interviewed.Review of R15's Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 12/15/2025, demonstrated section O-Special Treatments, Procedures, and Programs -F1- Invasive Mechanical Ventilation B(while a resident) was documented as yes.On 02/25/2026 at 11:49 a.m. Minimum Data Set (MDS) Nurse Assistant M explained that the facility does not service residents that would require mechanical ventilation for breathing. MDS Nurse Assistant M reviewed R15's MDS, with an Assessment Reference Date (ARD) of 12/15/2025, section O-Special Treatments, Procedures, and Programs F1-Invasive Mechanical Ventilation B and confirmed that it was documented as yes. MDS Nurse Assistant M confirmed that she had completed that section of R15's MDS. MDS Nurse Assistant M explained that it was documented yes in error.

Based on observation, interview and record review the facility failed to implement interventions to prevent decrease in range of motion for 1 (R50) of 1 resident reviewed for range of motion. Findings include: Resident #50 (R50)Review of the medical record demonstrated that R50 was admitted [DATE] with diagnoses that included seizures, rheumatoid arthritis (auto immune disease that attacks joints), type 2 diabetes, dementia, paralysis (unable to move) left side, hypertension, hyperlipidemia (high fat content in blood), depression, restless leg syndrome, gastro-esophageal reflux, vitamin D deficiency, dysphagia (difficulty swallowing), stroke, low back pain, assistance with personal care, and dependence on wheelchair. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/08/2026, revealed a Brief Interview for Mental Status (BIMS) of 09 (moderate cognitive impairment) out of 15.During observation and interview on 02/24/2026 at 09:52 a.m. R50 was observed sitting up in her reclining chair at bedside. R50 was also observed to have contracted left hand. R50 was asked if staff had been performing Range of Motion with her hand. R50 explained that staff had not been performing ROM with her left hand or with her left arm. R50 demonstrated that she could not lift her left arm past the height of her left shoulder. R50 demonstrated that she could lift her right arm above her shoulder.Review of R50's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/08/2026, section GG- Functional Abilities- subsection GG01115-A Upper Extremity- revealed impairment on one side. Review of R50s task, in the point of care documentation, revealed a task that stated RNU (Restorative Nursing) AAROM (Active Assisted Range of Motion) for BUE (Bilateral Upper Extremity) gravity eliminated slides 10 reps (repetitions) x 2 daily routine as necessary. The record revealed the preceding task was initiated 10/20/2023. Review of documentation for preceding thirty days did not demonstrate that the task had been completed.Review of R50's Kardex (document used to inform direct care staff of resident needs0 revealed RNU (Restorative Nursing) exercise upper.During an interview on 02/26/2026 at 07:30 a.m. Assistant Director of Nursing (ADON) R explained that the facility did have a Restorative Nursing Program. ADON R explained that the program was overseen by Rehabilitation Director (RD) N. ADON R reviewed R50's task RNU exercise upper and confirmed that no documentation was present for the preceding days.During an interview on 02/26/2026 at 07:34 a.m. Rehabilitation Director (RD) N explained that she monitored the facility Restorative Nursing (RNU) Program. RD N explained that after resident finished skilled therapy services, the therapy staff would complete a referral to the RNU Program. RD N explained that a Restorative Nursing Program could include Range of Motion for resident with contractures. RD N explained that R50 was not receiving RNU. After reviewing R50's medical record RD N confirmed that task for RNU. RD N could not explain what ROM had not been completed as required in the task. RD N could not explain if R50 need Range of Motion and explain that a new evaluation would have to be conducted to determine the requirement.

Based on observation, interview and record review, the facility failed to accurately complete a Do-Not-Resuscitate (DNR) document for one (R45) of two reviewed. Findings include:Review of the medical record reflected R45 admitted to the facility on [DATE], with diagnoses that included diabetes and COVID-19 (2/20/26). On 02/24/2026 at 1:44 PM, R45 was observed seated in a recliner, in their room.R45's DNR form, for 9/8/25, reflected signatures by R45, a Durable Power of Attorney (POA), the Physician and one witness. In an interview on 02/26/2026 at 12:21 PM, Social Services Director (SSD) D reviewed R45's DNR form and noted there to be one witness signature. SSD D reported DNR forms needed two witness signatures.

Based on observation, interview and record review the facility failed to maintain baseline care plans for 1 (R119) of 23 residents. Findings include: Resident #119 (R119)Review of the medical record demonstrated R119 was admitted [DATE] with diagnoses that included paralysis (loss of movement) of the left side, congestive heart disease (CHF), atrial fibrillation, atherosclerotic heart disease (build up of plaque on artery walls), type 2 diabetes, asthma, hypertension, hyperlipidemia (high fat content in blood), peripheral vascular disease (PVD), insomnia, anxiety, depression, migraine, gastro-esophageal reflux disease, muscle spasm, and stroke. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/2026, revealed a Brief Interview for Mental Status (BIMS) of 11(moderate cognitive impairment) out of 15.On 02/24/2026 at 10:27 a.m. during observation and interview R119 was observed lying down in bed. R119 requested that her husband I answer the questions that were being asked. R119's husband I explained that she had a history of pain and muscle spasms prior to her admission to the facility. R119's husband I explained that he had explained this to R119's attending physician and that the physician was ordering appropriate medication for pain and R119's muscle spasms. R119's husband I could not identify any other interventions besides medication that had been attempted.Review of R119's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/2026, demonstrated section J- Health Conditions- sub section J0410-Pain Frequency revealed that R119 had pain almost constantly.Review of R119's plan of care did not list any problem areas for her pain and did not list any interventions for the treatment of her pain.During an interview on 02/25/2026 at 02:19 a.m. Director of Nursing (DON) B explained that it was her expectation and facility policy that residents would have a base line care plan initiated within 48 hours of admission. DON B explained that it was her expectation that a resident's baseline plan of care would include necessary information for the treatment of pain (if appropriate). DON B confirmed that R119's plan of care did not have a problem statement related to pain and did not include any interventions for the treatment of that pain. DON B confirmed that R119s Minimum Data Set (MDS), with and Assessment Reference Date (ARD) of 02/11/2026, identified that R119 had pain almost constantly. DON B explained that it was her expectation that R119 would have a care plan, upon admission, that would have identified R119's pain and the interventions that staff could have taken to treat R119's pain. DON B could not explain why R119's medical record did not have a baseline plan of care for the treatment of her pain.

Based on observations, interviews and record review, the facility failed to protect the residents' right to be free from sexual and physical abuse by other resident's. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included dementia, anxiety and depression. The MDS reflected that R101s had a BIM (assessment tool) score which indicated his ability to make daily decisions was severely impaired. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, falls, unsteady on feet, and depression. The MDS reflected that R102s had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired. Review of the complaint received by the State Agency on 9/24/25 alleged the facility failed to prevent and report abuse allegations to the State Agency. During a telephone interview on 9/25/25 at 11:59 a.m., Complainant “Y” verified complaint and reported often worked in basement of facility on dementia unit. Complainant “Y” reported on 8/23/25 R101 walked up to R102 and started shoving R102 and hitting R102 on the shoulder and staff separated residents and incident was reported to supervisor who was told incident needed to be reported to Director of Nursing (DON) “B” and Nursing Home Administrator (NHA) A” because abuse allegation. Complainant “Y” believes Nurse Supervisor notified DON “B” and was told did not need to be reported because both residents had dementia and NHA “A” followed up and told Complainant Y the same. Complainant “Y” reported on 9/6/25 R101 was ramming wheelchair into R102 while she was eating and staff separated residents, assessments were completed. Complainant “Y” reported R101 behaviors increased and at one-point R101 placed hands on R102 shoulders and started shaking R102 violently making R102s entire body move. Residents were again separated and assessments completed, and same nurse supervisor was notified along with physician who ordered intramuscular Ativan. Complainant “Y” reported R101 was a strong male and R102 was frail [AGE] year-old women. Complainant “Y” reported Certified Nurse Assistant (CNA) “R” got to R102 first and separated residents and R102 was taken to her private room and event was also reported to DON “B” and NHA “A” and physician via secure conversation/text. Complainant “Y” reported was questioned after event by NHA “A” who reported not to use word, “violent” in documentation and Complainant “Y” reported there was no other word to describe the event. Complainant “Y” reported NHA “A” reported intervention would be to remove wheelchair but Complainant Y reported was unsure how that would even help because R101 was not in wheelchair when he approached R102 and started shaking her. Complainant “Y” reported was told neither resident to resident incident was reported to the State of Michigan because both residents had dementia. During an observation on 9/29/25 at 9:55 a.m., R101 and R102 was observed in dementia unit, located in the facility basement. R101 and R102 were in the common area sitting in recliners that were lined up around the television four chairs apart from each other. R101 had a brace on right knee and observed staff assisted R101 to the bathroom via a wheelchair. The unit had two certified nurse aids and one nurse and about 10 residents present. During an interview on 9/29/25 at 1:00 p.m., Nursing Home Administrator (NHA) “A” reported was the facility Abuse Coordinator. NHA “A” reported had two reported allegations of abuse in past 10 months. The two abuse allegations did not include R101 or R102. Requested all Incident/Accident reports with complete investigations for R101 and R102 on 9/29/25 at 2:37 p.m. Received all R101 and R102 Incident/Accident reports for last six months with no resident-to-resident incidents on 9/29/25 at 3:23 p.m. Review of R101 Nurse Progress Note, dated 6/20/25 at 9:35 p.m., reflected, “CNA [certified nurse aid] came up to writer and reports that she has seen resident put his finger in another patients face [R102] and shouldn't sit next to her because he tried to control her and calls her his wife. States she doesn't think they should sit together anymore.” Review of R101 Nurse Progress Note, dated 8/23/25 at 8:31 p.m., reflected, “Reported to supervisor at 2024[8:24 p.m.] that this resident was seen by CENA [Competency Evaluated Nursing Assistant] striking a female resident multiple times on shoulder and chest earlier this shift. Writer was not made aware of this until approximately 2000.” Review of R101 Nurse Progress Note, dated 8/23/25 at 9:50 p.m., reflected, “DON notified of CN [charge nurse] report of incident.” Review of R101 Behavior Progress Note, dated 9/6/25 at 3:00 p.m., reflected, “Resident being very aggressive to staff. Trying to run into CNAs with WC [wheelchair]. Trying to approach a female resident thinking she is his wife. Tried to go into female resident room. Phone call placed to [named Medical Director “X”] and one time order given for 1mg Ativan IM. POA [power of attorney] aware.” Review of R101 Nursing Progress Note, dated 9/6/25 at 3:04 p.m., reflected, “At approximately 1420 [2:20 p.m.], resident ambulated to female pt. [patient] who was sitting in recliner chair in great room and placed his hands on her shoulders and began violently shaking her. Staff intervened and ended this behavior and female pt. was taken to her room to eliminate stimulus. This resident continued to try to locate female pt. whom he thought was his wife and ran his w/c into all staff members intentionally on multiple occasions. Was yelling throughout demanding to know where his wife was. Attempted to provide food, fluids and offered a walk outside all new order for Ativan 1mg IM obtained and given at approximately 1435 [2:35 p.m.].” Review of R101 Nurse Progress Note, dated 9/6/25 at 8:58 p.m., reflected, “At approx 1810 [6:10 p.m.], as most residents had eaten supper, this resident began ramming his w/c into a female resident's w/c. This resident believes this female is his wife and unable to convince him otherwise or distract him. Female resident was still eating when this occurred and residents were separated at this time. This resident went back two additional times and rammed his w/c into hers. Resident was asked why he was doing this and he stated, how else am I supposed to get her attention? Review of R101 Nurse Progress Note, dated 9/7/25 at 3:43 p.m., reflected, “Per report, pt. was fine all first shift. As soon as second shift began, pt. started to ramp up again. Has been yelling about wanting to see his wife, referring to specific female pt. Female was removed from great room prior so that pt would not become fixated on her again. So far this shift he has rammed his w/c into staff X1 [times one] and tried to ram into a visitor that staff was speaking with but staff intervened. Has been yelling quite a bit this shift about specific female pt. and that staff is liars…Since all this tends to happen on second shift, question if this is a circadian cycle for this pt. and if he needs a routine medication to control it. Currently gets Buspar 5mg tid[three times daily] but it is not helping. The 1mg Ativan yesterday did seem to help. Not asking for anything right now but will text you if situation worsens.” Review of R101 Behavior Progress Note, dated 9/12/25, reflected, “At 10:05 am, [named R101] was sitting in a PC[personal chair] chair up at the TV area and began to express, Where is [named wife], I want to see my wife, [named wife]! Staff sat with him explaining that his wife lived at another facility. [named R101] expressed, No she's not, where is she, I just seen her. During an interview on 9/29/25 at 3:46 p.m., Licensed Practical Nurse Risk Manager (RM) “N” reported had been in that role about five months and had worked at the facility for 12 years. RM “N” reported R101 was non-complaint who had no safety awareness with diagnosis of dementia who lives in dementia unit in the basement of the facility. RM “N” reported R101 thinks R102 was his wife and often require one on one care because he becomes fixated on R102. RM “N” reported worked on R101s unit 9/25/25 second shift and reported was not aware prior to that day R101 was fixated on R102 and reported R101 had increased behaviors and had to call DON “B” for additional assistance even with one-on-one care for R101. RM “N” verified she documented the following Nurse Progress Note, dated 9/25/25 at 4:02 p.m., “Elder was sitting in personal chair in dayroom upon my arrival to the unit at 1400[2:00 p.m.]. Noticed he was picking at his arm protectors and wanted to walk. He [R101] stood up without assistance X2[times two]. First time CNA [certified nurse aid] took him to the bathroom with AX2[assist time two], gait belt and w/c[wheelchair]. 2nd time they went for a stroll in his w/c outside for a bit. He was then placed back in his personal chair with CNA sitting beside him. Writer asked CNA what usually helps him stay distracted, and she replied someone sitting with him at all times giving him attention. CNA left the unit to go to lunch. Writer sat beside Elder and conversated with him. He kept directing the topic back to who he thinks is his wife which is truly just another Resident who was sitting within his sight. The other assigned CNA was doing bed checks and toileting Elders. Family members to another Elder came in to visit which intensified his[R101] behaviors. He was so worried who was talking to his wife, I don't know those people, I need to make sure my wife is okay. AX2 [assist time two] with gait belt stood him up to reposition him to his w/c to diffuse the situation by bringing him outside. DON was paged to the unit and Social Work accompanied her. They talked with Elder and wheeled him around the facility prior to bringing him back and doing puzzles together. All was well upon my departure at 4pm.” RM “N” reported reviews and completes resident fall investigations and reported R101 has had several recent falls with recent fracture because of poor safety awareness and again reported had no prior knowledge of R101 behaviors towards R102. (Evidence that thorough investigation had not been completed for frequent falls and resident to resident events to determine root cause related to ongoing behaviors.) During an interview and record review on 10/1/25 at 1:34 p.m., NHA “A” reported facility had additional information that had not yet been provided related to R101 and R102 that facility felt was an issue with staff performance of Registered Nurse (RN) “P”. NHA “A” provided file for R101 and R102 resident to resident events on 8/23/25 and 9/6/25 on facility letterhead of typed events. NHA “A” reported RN “P” no longer worked at facility. Review of the file reflected handwritten statement from CNA “R”, dated 8/23/25, that reflected, “On 8/23 [named R101] became agitated at [named R102] and open hand smacked her on her shoulder/chest area. This happened approximately around 3:30 p.m.” The statement was signed by CNA “R”. Continued review of the file reflected a second timeline of events on facility letter head for R101 and R102, dated 9/6/25, reflected two, “Hey Social Work” documents, dated 9/6/25. Review of R101's first, Hey Social Work documents reflected, “Resident is being aggressive with other residents, shaking them, in their face, yelling at them accusing them.” The form included R101 had the following behavior: yelling, abusive language, grabbing, accusing, pushing, and expressing anger and unable to redirect. The document was signed by CNA “R”. Review of the second Hey Social Work document, dated 9/6/25, reflected, “resident is being aggressive towards other residents especially [named R102] he thinks she is his wife. He is running into nurse and aides with wc[wheelchair].” The form included R101 had the same marked behaviors as the first document. During a telephone interview on 10/1/25 at 3:11 p.m., CNA “R” reported usually worked on the dementia unit in the basement on second shift with both R101 and R102. CNA “R” reported R101 frequently gets very fixated on R102 and yells at her, grabs her and has shaken R102 in the past. CNA “R” reported staff attempt to keep R101 and R102 separated, and staff try to intervene to reduce risk of altercation. CNA “R” reported R102 was[AGE] years old with dementia and is unsure if she knows what is happening and R101 is convinced R102 is his wife. CNA “R” reported recalled incident in August 2025 when R101 was patting R102 and shoulder and shouting hay, hay. CNA “R” reported on 9/6/25 R101 approached R102 and grabbed R102 shoulders and started shaking R102 back and forth and both CNA staff separated residents. CNA “R” reported told R101 he was not allowed to put his hands on other residents, and he became upset and incident was reported to RN “P” and completed, “Hey Social Worker” document. CNA “R” reported incident was reported to nurse because potential allegation of abuse that was required to be reported immediately. CNA “R” reported after 9/6/25 incident there were no changes in interventions but to continue to attempt to keep R101 and R102 separate. CNA “R” reported R101 does get mad and R102 and had called her an old hag and reported residents do not deserve to be treated that way or called names and should be reported. During a telephone interview on 10/2/25 at 10:26 a.m., CNA “V” reported often worked second shift with both R101 and R102. CNA “V” reported R101 was obsessed with R102 and staff constantly have to separate them and R101starts to escalate behavior to be right next to her with attempt to even try to push her wheelchair. CNA “V” reported R101 aggressive behaviors toward R102 have increase over past four to six weeks and staff have expressed concerns to several management staff including DON “B”. CNA “V” reported R101 has also had several falls because he is so determined to get to R102 including recent fall with fracture. CNA “V” reported staff attempt to redirect but often not effective and R101 requires one on one supervision that is not always possible to properly care for other residents. CNA “V” stated R101 is often, “Locked on that thought and nothing else matters to him.” CNA “V” reported R101 has called R102 a bitch and other residents as well. CNA “V” reported R101 resident to resident altercations to second shift supervisor “AA”. CNA “V” reported R101 behaviors have been progressively getting worse and occur at least 3 times per week minimum and are reported to charge nurse because potential allegations of abuse. CNA “V” reported last week DON “B” had to take R101 off the unit because R102 had family that was visiting and R101 was agitated that he did not know who they were and did not want them with R102 and reported R102 appeared frustrated with situation. During an interview on 10/2/25 at 10:48 p.m., Social Worker (SW) “K” reported R101 had behaviors that included he had history of being combative with staff and thinks a female resident is his wife and gets focused and agitation often increases in afternoon. SW “K” reported the, “Hey Social Worker” was a tool that staff use to communicate behaviors residents might be having with Social Worker and reported had not received any for R101. SW “K” reported was not aware of any resident-to-resident altercations with R101 and R102 other than when R101 taps R102 on shoulder to get her attention. SW “K” reviewed, “Hey Social Worker” forms provided by NHA “A”, dated 9/6/25, and verified had never seen either one. SW “K” reported if she had received the documents would have reported to NHA “A” immediately because allegations of physical abuse that needed to be reported and investigated and need to follow up with all parties involved because facility SW. During an interview on 10/2/25 at 11:26 a.m., NHA “A” reported had been in position for five years and was also the abuse coordinator. NHA “A” reported staff are expected to report all allegations of abuse to nurse supervisor, DON “B”, or NHA “A” immediately. NHA “A” reported did not reported R101 and R102 allegations of abuse to the State of Michigan (SOM) because they delt with it as personal issue not allegation of abuse and stated, “in hindsight that was incorrect.” NHA “A” reported should have reported R101 and R102 incidents on 8/23/25 and 9/6/25 to the SOM as allegations of abuse and verified that was wrong. During an interview on 10/2/25 at 11:56 a.m., DON “B” reported received a call from supervisor that RN “P” had reported an incident that occurred at the beginning of the shift that CNA staff reported R101 was going after R102 related to both incidents on 8/23/25 and 9/6/25. DON “B” reported did not believe RN “P” but should have believed CNA staff that included written witness statements, should have reported to the NHA “A”, State of Michigan, and completed thorough investigation. Review of the medical record reflected R104 was admitted to the facility on [DATE], with diagnoses that included dementia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/2/25, reflected R104 scored 7 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R105 was admitted to the facility on [DATE], with diagnoses that included dementia, need for assistance for personal care, mild cognitive impairment, and Alzheimer's disease. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/6/25, reflected R105 was unable to have a Brief Interview for Mental Status (BIMS-a cognitive screening tool) conducted due to severe cognitive impairment. On 9/25/25 at 2:57 PM, R104 was observed in his room seated in his wheelchair. R104 was talking out loud said “ehhhh” and “ohhh.” After entry into his room, R104 was welcoming to conversation and stated that he had a bird that he loves to talk with. On 9/25/25 at 3:12 PM, R105 was observed in bed resting. Review of R104's Care plan reflected an added intervention on 3/27/23 and revised on 3/21/25 which stated “…He is also inappropriate at times. If [R104] is participating in a group setting such as eating in the dining room or an activity, wait to bring the resident down until at least one staff member is present to monitor. [R104] also sits by male residents during activities and in the dining room…”. Review of R105's Electronic Medical Record reflected that R105 was nonverbal and used nonverbal cues and sounds/cries in an attempt to make needs known. Review of a Behavior Note on 2/21/25 revealed R104 had to be corrected many times during the 6-2 shift about being inappropriate with other residents and with the CNA's. He tried to grab a CNA's bottom while they were walking by. He kept whistling at another resident until it made her upset and she had to propel away. He heckled the CNA'S whenever he was in the halls and not in bed. Review of a Behavior Note dated 3/7/25 revealed R104 stated to a female resident while in dining room, Hey baby, let me feel your tits. Writer did not know about this until several hours post incident but did speak to resident about it and told him how inappropriate it was. In an interview on 9/25/25 at 12:53 pm, Registered Nurse (RN) P stated that she received information during shift report during a shift in late March 2025 that R104 was observed groping R104's breasts in the activity room. LPN P was advised to ensure that R104 and R105 were not seated near each other to maintain R105's safety. In an interview on 9/29/25 at 9:59 am, Certified Nursing Assistant (CNA) J reported that she was working the day, back in March 2025, that R104 was observed fondling R105's breasts. CNA J stated that both residents were in the activity room and CNA J overheard a commotion. When CNA J responded, R104 was observed handling R105's breasts. Moving forward, staff was instructed to ensure that R104 and R105 were not placed near each other. CNA J reported this to the nurse. In an interview on 9/29/25 at 4:04 pm, CNA L stated that he overheard R105 yelling and immediately identified that R105 was upset about something. CNA L entered the activity room to observe R104 grabbing R105's breasts. R105 was visibly disturbed about the actions of R104. CNA L stated he separated the residents immediately and was asked to fill out an incident report. On 10/2/25 at 11:26 AM, Nursing Home Administrator (NHA) A verified that he was the abuse coordinator and explained the process of reporting abuse allegations. When asked if he had any awareness of this incident, NHA A denied knowing about R104 incident with R105, however, did state that the incident should have been reported to him and that he would have reported it to the State of Michigan and completed an investigation. NHA A and Director of Nursing B both reported that there were no incident reports or investigations for this incident. Review of the Abuse, Neglect and Exploitation Policy implemented 9/2021 and reviewed 9/2024 defined sexual abuse as non-consensual sexual contact of any type. The same policy stated, an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . reporting of all alleged violations to the Administrator, state agency .immediately, but no later than 2 hours after the allegation is made . Applying the reasonable person standard, it can be expected that R105 would have experienced emotional distress as a result of the abuse, as such a reaction aligns with how an average person would respond under similar circumstances.

Based on interview and record review, the facility failed to provide the necessary standards of care and services for wound and skin care management in one (Resident #106) of three reviewed for quality of care. This deficient practice resulted in R106's hospitalization for septic shock, cellulitis, increased pain, and the need for intravenous antibiotic therapy, and implementation of hospice(end of life services) and death. This citation pertains to intake 2626820 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R106 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included congestive heart failure (CHF), diabetes mellitus, hypertension (high blood pressure), legally blind, cellulitis, and lymphedema. The MDS reflected that R106s had a BIM (assessment tool) score of 14 which indicated her ability to make daily decisions was cognitively intact, and she required staff supervision with locomotion on unit, dressing, hygiene, bathing, and transfers. Continued review of the MDS reflected no history of refusal of care. Review of the complaint received by the State Agency alleged the facility failed to provide wound treatments as ordered resulting in sepsis and death. During a telephone interview on 9/25/25 at 11:59 a.m., Complainant Y verified complaint and reported R106 passed away after returning from hospital on hospice services. Complainant Y reported R106 was treated in the hospital for septic shock and cellulitis after a Licensed Practical Nurse (LPN) F did not follow physician orders and placed black plastic trash bags over R106's lower legs for over two days that caused infection. Complainant Y reported R106 required frequent as need dressing changes related to increase bilateral lower leg swelling and weeping around 6/20/25 and was told nurse placed trash bags on 6/21/25 and remained in place until 6/23/25 when found by the facility wound nurse who informed the Director of Nursing (DON) B. Complainant Y reported when the bags were removed from R106s legs on 6/23/25 the skin just slid off R106 legs and the wounds were significantly worse than prior week. Complainant Y reported was told R106 wanted to go to activity on 6/21/25 but legs were weeping so much the plastic bags were placed and the next shift was not informed and remained in place until found on 6/23/25 (two days later). Complainant Y reported R106 reported increased pain and was treated in the facility for cellulitis initially then transferred to the hospital after being found unresponsive on 7/10/25. Complainant Y reported had spoke with Medical Director X after R106 hospital admission and discussed black trash bags used as treatment and reported Medical Director X was shocked and unaware of situation. Complainant Y' reported facility risk manager was one of R106's nurses that weekend and stated, Common sense tells you it will cause a problem. What the h*ll were they thinking? Complainant Y reported R106 was alert and oriented who often went out with friends and had good quality of life prior to worsening of bilateral lower leg wound cellulitis on 6/23/25. Review of the Wound Evaluations, dated 6/20/25, reflected R106 had three new in-house acquired venous wounds (ruptured blisters) to bilateral lower legs with 0/10 on pain scale that included:-#4 venous, Left Medial Malleolus - Middle-- measurement 3.3x3x0.1, cluster of 2, moderate serious drainage with no signs of infection.-#5 venous, Right Medial Calf - Middle-- measurement: 4x2x0.1, moderate serious drainage with no signs of infection.-#6 venous, Front Right Lateral Lower Leg-- measurement: 11x14x0.1, cluster of 11, moderate serious drainage with no signs of infection. Review of R106 Nurse Progress Note, dated 6/21/25 at 7:57 p.m., reflected, Wound Treatment Charting - The patient has had to have her bilateral leg dressings completed 4 times today 6 am - 8 pm. When the patient stands up the urine just runs all over her legs and the dressings are saturated with urine. The patient receives 2 Bumex 1 mg every am. The bilateral legs were washed with warm soap and water each time and new dressings applied. Supervisor notified. Review of R106's Treatment Administration Record (TAR), dated 6/21/25 through 6/23/25, reflected R106 had physician ordered treatments that included the following: Left distal medial low leg: Cleanse with normal saline, apply skin prep to periwound, cover wound with calcium alginate (2x2), cover with 4x4 bordered dressing every day shift.Left distal pretib: Cleanse with normal saline, apply skin prep to periwound, cover wound with calcium alginate (2x2), cover with 4x4 bordered dressing every day shift.Left Superior Pretib: Cleanse with normal saline, apply skin prep to periwound, cover wound with calcium alginate (2x2), cover with 4x4 bordered Dressing every day shift.Right Medial calf: Cleanse with normal saline, apply skin prep to periwound, cover wound with calcium alginate (2x2), cover with 4x4 bordered dressing every day shift.Right Pretib: Cleanse with normal saline, apply skin prep to area. Cover with ABD pads x 2, secure with kerlex and secure with tape every day shift.Continued Review of R106 TAR, dated 6/17/25, reflected whole (no documentation) for, Bilateral lower legs: 2 layer compression every day shift every Tue. Continued Review of R106 TAR revealed one documented treatment completed on 6/21/25 for each of the listed areas and documentation that R106 refused all the above listed treatment on 6/22/25. Review of R106 Secure Conversations Progress Note, sent by facility Wound Nurse M, dated 6/23/25 at 11:03 a.m., reflected, Resident's legs have detoriated since friday and is now open on both shins circumferential. Will have [named facility wound provider U] see on Wednesday. In the meantime her legs are seeping copious amounts of fluid. Okay to change treatments to opilocks and kerlex changed q [every] shift? Continued review of Progress Note revealed Medical Director X responded, Yes, thanks. at 11:16 a.m. (According to Nurse Progress Note dated 6/21/25 at 7:57 p.m. R106 had a change in condition with increased bilateral lower extremity drainage that required dressing changes four times instead of one time daily as ordered with no evidence that Physician had been notified prior to 6/23/25.) Review of R106 Psychosocial Progress Note, dated 6/24/25 at 2:41 p.m., reflected, SW [Social Work] met with [named R106] today. She did not have any concerns at this time. She is a little annoyed/frustrated about her current health condition. SW provided support, encouragement and validation of her feelings. Review of R106 Nurse Progress Note, dated 6/25/25 at 6:44 p.m., reflected, Resident will begin Doxycycline for bilat.[bilateral] lower leg cellulitis tomorrow morning. Review of the Wound Evaluations, dated 6/25/25, reflected R106 had deteriorating bilateral lower leg wounds with increased pain 7/10 on pain scale that included the following:-#4 transitioned to #7 venous, front Left Lateral Lower Leg-measurements 10.5x17.5x0.1, heavy serious drainage, angry red color with signs of infection.-#5 transitioned to #6 venous, front Right Lateral Lower Leg-measurements 13.5x25x0.1, heavy serious drainage, redness, inflammation, signs of infection and documented cellulitis. Review of R106 Nurse Progress Note, dated 6/27/25 at 8:34 p.m., reflected, Treatment to right lower leg redone d/t dressing extremely wet. Pt. was painful throughout this drsg. [dressing] change. Review of R106 Nurse Progress Note, dated 6/28/25 at 9:56 p.m., reflected, Treatments to bilateral lower legs redone. Right was saturated with drng [drainage], left was around ankle. Areas remain red with several open areas. Right leg is painful. Continues to take Doxycycline for cellulitis BLE [bilateral lower extremities]. Review of R106 Nurse Progress Note, dated 6/30/25, reflected, Late entry for 6/29/25 day shift Infection note: [named R106] is on an oral antibiotic for tx [treatment] of cellulitis of her lower extremities. [named R106] has open wounds on bilateral lower extremities that are weeping fluids. [Named R106] expressed pain in her right lower extremity is more prevalent than the minimal pain felt in her left lower extremity. [Named R106] rates her right lower extremity pain to be varied between minimal and 7/10 depending on the position and if treatments are being completed. [Named R106] was sleepy the first part of the morning stating she did not sleep well r/t discomfort of her lower extremities.Review of R106 Nurse Progress Note, dated 7/3/25 at 12:12 p.m., reflected, Elder stayed in her room all shift thus far. Ate both meals in her room. Uses her call light appropriately for assistance and to voice needs. Complained of headache and requested PRN Tylenol. Review of R106 Nurse Progress Note, dated 7/5/25, reflected, The patient is on Doxycycline Hyclate oral tab 100 mg by mouth am and bedtime for BLE Cellulitis. x 10 days. The patient has one more dose this evening and she will complete her ABT[antibiotic] regime.The patient's treatment was completed at 9 am and again at 2 pm for urine saturated dressings. Review of R106 Nurse Progress Note, dated 7/10/25 at 6:45 a.m., reflected, Took resident's blood pressure via wrist cuff measures 63/30 with a heart rate of 100. Resident in and out of consciousness. 22g IV [intravenous line] started x1 attempt in right hand. IV fluids started. Resident came up to 120/60. Fluids turned down to 75 cc/hr as resident has dx [diagnosis] of CHF. Resident more alert after blood pressure came up and started she feels dizzy and she is having chest pain. Continued review of Progress Notes revealed no notes between 7/5/25 and 7/10/25 at 6:45 a.m. when R106 found unresponsive. Review of R106 Nurse Progress Note, dated 7/10/25 at 6:46 a.m, reflected, Sending elder to [named local emergency room] for evaluation She is a full code and BP[blood pressure] dropped from 99/65 to 69/30. Elder very pale with an irregular heart rate usually alert but slow to respond at this time. Review of R106 Secure Conversations Progress Note (sent to Medical Director X), dated 7/15/25 at 1:13 p.m., reflected, [Named R106] arrived to the unit at 1245. Son at side. Option for End of life Comfort care per [named facility] policy was chose, as well as DNR[do no resuscitate]. Review of R106 Nurse Progress Note, dated 7/15/25 at 1:35 p.m., reflected, [named R106] arrived on the Unit for readmission at 1245 via stretcher with [named] transport service. [Named R106] is on oxygen at 4-5 L via nasal cannula upon arrival. A 4 person slide transfer to her bed completed. Audible negative vocalization heard. EMS [emergency medical service] staff reported [named R106] last pain medication was at 1055 when she left the Hospital. [named R106] expressed verbally Just give me a Shot. Pain medication discharge orders reviewed with [named physician] with orders for Morphine sulfate concentrate 20mg/ml, give 0.25 ml every 4 hours scheduled and 0.25 ml every 2 hours as needed for pain and dyspnea. Review of the Hospital records, dated 7/10/25, reflected R106 was treated at local hospital for cellulitis, septic shock and non STEMI (non ST elevation myocardial infarction) and was transferred to a level 2 trauma center. Continued review of R106 hospital records revealed elevated while blood count (WBC) and no evidence of urinary tract infection. Continued review of R106 History and Physical, dated 7/10/25, reflected, Usually is alert and orientedx3.Found decreased level of responsiveness today and hypotension. Started an IV and IV fluids. When EMS arrived she was still hypotensive and was still decreased level of responsiveness. When became more aroused and awake she started complaining of chest pain. Upon arrival to the ER [emergency room] she is more alert she states she has a little bit of chest pain but mostly pain in her knees which she always has. Additionally she states she has edema and weeping from both legs. They are both wrapped and she has noticed some increased redness to the left leg recently. Review of R106 Hospital Cardiology Consult, dated 7/11/25, reflected, [AGE] year-old female history of HFpEF [diastolic heart failure], lymphedema, CKD [chronic kidney disease] who presents from nursing home with altered mental status, lower extremity swelling/redness, hypotension, concern for infection. Upon arrival, she was given IV antibiotics, BP [blood pressure] stabilized. She is now more awake and alert. She does state intermittent chest discomfort though she states it is more so constant pain in the middle of her back which somewhat radiates to the center of her chest. States she is acutely short of breath, feels like she is wheezing and it is difficult to take a deep breath. She has not had significant palpations-dizziness. She is aware that her LE edema is chronic but states it has much worsened lately as well as redness, tenderness and some drainage.WBC H 28.5 [white blood cell count indicator of infection with normal range less than 11].Diagnosis NSTEMI-troponin down trending.Acute HFpEF.Sepsis-likely secondary to cellulitis. Review of R106 Hospital Wound Ostomy Continence Note, dated 7/11/25, reflected, Bilateal [bilateral] lower leg cellulitis, legs are bright red, swollen, tender, moist satellite wound beds. Venelex ordered to be applied when it comes from pharmacy. Review of R106 Hospital Care Management Team Note, dated 7/15/25, reflected, IP [in patient] day 5, admitted with Nstemi and septic shock Palliative consult, and was decided that patient will return to [named facility] with hospice services.Clinical Formulation.admitted with Nstemi and septic shock likely caused from cellulitis of leg wounds. Review of R106 Hospital Discharge summary, dated [DATE], reflected, Discharge diagnosis Septic shock, Cellulitis. Review of the Death Certificate, dated 7/18/25, reflected R106's cause of death included NSTEMI with contributing causes that included kidney disease, diabetes, hypertension and CHF. Review of the facility staffing schedules, dated 6/20/25 through 6/23/25, reflected Licensed Practical Nurse (LPN) F was R106's nurse on 6/21/25 and 6/22/25 day shift and LPN D was R106 nurse on 6/23/25 (when complainant alleged black plastic bags were found on R106's bilateral lower legs). During an interview on 9/29/25 at 1:47 p.m. Licensed Practical Nurse (LPN) D reported R106 was alert and oriented, legally blind and had wounds on lower legs and slept in recliner with legs elevated. LPN D reported was R106's nurse on 6/23/25 day shift when she found R106 with black trash bags over bilateral lower legs at start of shift and notified the facility wound nurse M immediately. LPN D reported the wound nurse removed the dressings and contacted the Director of Nursing DON B. LPN D reported was also working when R106 was transferred to the hospital on 7/10/25 when staff reported to her that R106 was confused, had low blood pressure and R106 reported she felt like she was going to faint around 6:15 a.m. LPN D reported 911 was called and R106 was transferred to local hospital. During a telephone interview on 9/29/25 at 2:14 p.m., Wound Nurse (WN) M reported R106 had bilateral venous ulcers that were healing well in early June. WN M reported R106 refused to take physician ordered diuretic few days prior to 6/20/25, when she had seen R106 for wound assessments, related to increased drainage after restarting diuretics. WN M reported were unable to order needed compression supplies mid-June and had to make adjustments in treatments but orders to change bilateral lower leg dressings daily. WN M reported assessed wound weekly and documented in Electronic Medical Record and reported was unsure why R106 did not have wound assessments for 7/8/25 (two days prior to being admitted to the hospital for sepsis and cellulitis). WN M reported was alerted by LPN D on 6/23/25 that R106 had black plastic trash bags on bilateral lower legs and black trash bags were removed and R106's old dressings under bags were heavily saturated with wound drainage and complained of increased leg pain. WN M reported was unsure how to describe R106 leg wound but reported they had significantly worsened since 6/20/25 and stated, legs were weeping so bed they did not know what to do. WN M reported that is when she contacted the facility Wound Nurse Practitioner U and DON B who completed an investigation and staff teaching. WN M reported was unsure why R106 had black plastic trash bags on legs or how long they had been in place and verified was not physician ordered. During an interview on 10/2/25 at 8:55 a.m., WN M reported had been the facility wound nurse for over one year. WN M reported saw R106 on 6/20/25 for wound assessment and thought had changed order to three times daily, however, after reviewing Physician Orders and Treatment Administration Record reported R106 wound treatments were daily but thinks she left extra supplies in zip lock bags for weekend. WN M reported supervisor always has keys that can access her office where supplies are stored. WN M reported R106 had increased drainage over the weekend, and nurse placed black trash bags over R106 legs and verified were removed on 6/23/25 after breakfast. WN M again reported when R106 old dressing were removed on 6/23/25 they were heavily saturated, and wounds were significantly worse from 6/20/25 with right leg worse than left and reported R106 wounds went from small blister area to full leg wounds with R106 complaints of 7 out of 10 pain on scale. WN M stated she was, shocked. WN M reported placing black plastic trash bags over R106 legs was not acceptable nurse practice. WN M reported was informed by the DON B that two nurses received education after the event. WN M stated, reported to DON B because [named R106] wounds were significantly worse and placing black plastic trash bags over dressings was not an acceptable practice and that is not what I want in my building. WN M reported R106 did not have history of refusing treatment and if resident refused treatment would expect to see Nurse Progress Note and verified was unable to locate for 6/22/25. WN M verified R106 supplies were not available on 6/17/25 and waited until 6/20/25 to notify physician because supplies were expected to arrive. WN M reported R106 was started on antibiotics for cellulitis on 6/26/25 after being assessed by facility Wound Nurse Practitioner on 6/25/25. WN M reported was present when R106 was sent to the hospital on 7/10/25 after being alerted R106 was not acting right assessed R106. WN M reported knew R106 was a full code and was non-responsive at time and obtained crash cart and wrist cuff. WN M reported R106 blood pressure was 63 over something and was showing signs of, tanking. WN M reported started IV fluids and after about 100 cc R106 reported chest pain. WN M reported fluids were slowed related to history of CHF and 911 was called and R106 was transferred to local hospital. During a telephone interview on 10/2/25 at 9:42 a.m., LPN F reported was R106 nurse on 6/21/25 and 6/22/25 and reported R106 had copious amounts of drainage from bilateral legs that required several dressing changes on 6/21/25 related to saturated dressings. LPN F reported R106 had compression dressings that were not available. LPN F reported R106 never refused treatments and stated, in fact, [named R106] wanted to heal wounds. LPN F reported was unsure why she would have documented R106 refused treatment on 6/22/25 unless she documented on wrong resident and verified R106 definitely did not refuse treatment. LPN F reported placed black plastic bags on R106 bilateral legs around 1:15 p.m. and reported was unsure what day, because of copious amount of drainage and did not remove prior to end of shift. LPN M reported informed next shift nurse but could not recall name. LPN F reported plastic bags were not ordered by physician and was unsure if R106 change of condition on 6/21/25 had been reported to the physician, but if so, documented would be in Progress Notes. (Verified no mention of physician notification of change). LPN F reported received verbal education from DON B because physician orders were no followed. During a telephone interview on 10/2/25 at 10:09 a.m., the facility Wound Nurse Practitioner U reported LPN D and WN M asked her to see R106 related to wounds that went from cluster wounds to entire lower legs. Practitioner U reported R106 first observed on 6/25/25 and determined to have cellulitis and antibiotics were ordered. Practitioner U reported was informed by WN M that R106 was found to have plastic bags over dressings prior to consult. Practitioner stated, not appropriate treatment, definitely not. During an interview on 10/2/25 at 11:56 a.m., DON B reported was informed that R106 was found to have black plastic bags over dressings on bilateral lower legs on 6/23/25. DON B' reported that was not appropriate and/or physician ordered treatment because keeps heat in. DON B reported R106 legs were twice as bad after removing bags and saturated dressing on 6/23/25 when observed with WN M with copious amounts of drainage. DON B reported R106 was alert and oriented times three and her own responsible party. DON B reported she questioned LPN F about placing plastic bags on R106 legs and LPN F reported, yes, she had done that. DON B reported was unsure when the bags were placed on R106 legs. DON B reported placing plastic bags over dressings was not an acceptable practice and would expect the nurse to follow physician orders and contact physician with change of condition. DON B verified LPN M did not follow the physician orders or contact physician with change of condition on 6/21/25 and was given education after the incident. DON B reported R106 was started on antibiotic treatment for cellulitis on 6/26/25 and investigation was completed, however, did not complete Incident/Accident report related to event. DON B verified R106 was admitted to the hospital for NSTEMI, sepsis and cellulitis and returned to facility on hospice services and passed 7/18/25. During an interview on 10/2/25 at 1:10 p.m., DON B provided file for R106 skin investigation with no evidence of Incident/Accident report and revealed DON B had also provided education to another staff member nurse supervisor Z. DON B verified nurse supervisor Z responded to written education and was not present at time of event and DON B verified after review of nurse schedules. (Evidence that investigation was not through or complete). Review of the provided file for R106 included written statement by DON B, dated 6/23/25. The statement included, [named LPN D] mentioned that [named LPN F] had applied a plastic bag because it was seeping continuously. The file included, Counseling Notification, oral warning, dated 6/23/25, that reflected, Subject: Improper Treatment in Place.Education Provided: Follow treatment exactly as ordered. Notify Doctor with change of Condition.

Based on observation, interview, and record review the facility failed to investigate an allegation of abuse in one (Resident #105) out of 7 reviewed for abuse. Findings include:Review of the medical record reflected R104 was admitted to the facility on [DATE], with diagnoses that included dementia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/2/25, reflected R104 scored 7 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R105 was admitted to the facility on [DATE], with diagnoses that included dementia, need for assistance for personal care, mild cognitive impairment, and Alzheimer's disease. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/6/25, reflected R105 was unable to have a Brief Interview for Mental Status (BIMS-a cognitive screening tool) conducted due to severe cognitive impairment. On 9/25/25 at 2:57 PM, R104 was observed in his room seated in his wheelchair. R104 was talking out loud said ehhhh and ohhh. After entry into his room, R104 was welcoming to conversation and stated that he had a bird that he loves to talk with. On 9/25/25 at 3:12 PM, R105 was observed in bed resting. Review of R104's Care plan reflected an added intervention on 3/27/23 and revised on 3/21/25 which stated .He is also inappropriate at times. If [R104] is participating in a group setting such as eating in the dining room or an activity, wait to bring the resident down until at least one staff member is present to monitor. [R104] also sits by male residents during activities and in the dining room.Review of R105's Electronic Medical Record reflected that R105 was nonverbal and used nonverbal cues and sounds/cries in an attempt to make needs known. Review of a Behavior Note on 2/21/25 revealed R104 had to be corrected many times during the 6-2 shift about being inappropriate with other residents and with the CNA's. He tried to grab a CNA's bottom while they were walking by. He kept whistling at another resident until it made her upset and she had to propel away. He heckled the CNA'S whenever he was in the halls and not in bed.Review of a Behavior Note dated 3/7/25 revealed R104 stated to a female resident while in dining room, Hey baby, let me feel your tits. Writer did not know about this until several hours post incident but did speak to resident about it and told him how inappropriate it was.In an interview on 9/25/25 at 12:53 pm, Registered Nurse (RN) P stated that she received information during shift report during a shift in late March 2025 that R104 was observed groping R104's breasts in the activity room. LPN P was advised to ensure that R104 and R105 were not seated near each other to maintain R105's safety. In an interview on 9/29/25 at 9:59 am, Certified Nursing Assistant (CNA) J reported that she was working the day, back in March 2025, that R104 was observed fondling R105's breasts. CNA J stated that both residents were in the activity room and CNA J overheard a commotion. When CNA J responded, R104 was observed handling R105's breasts. Moving forward, staff was instructed to ensure that R104 and R105 were not placed near each other. CNA J reported this to the nurse.In an interview on 9/29/25 at 4:04 pm, CNA L stated that he overheard R105 yelling and immediately identified that R105 was upset about something. CNA L entered the activity room to observe R104 grabbing R105's breasts. R105 was visibly disturbed about the actions of R104. CNA L stated he separated the residents immediately and was asked to fill out an incident report. On 10/2/25 at 11:26 AM, Nursing Home Administrator (NHA) A verified that he was the abuse coordinator and explained the process of reporting abuse allegations. When asked if he had any awareness of this incident, NHA A denied knowing about R104 incident with R105, however, did stated that the incident should have been reported to him and that he would have reported it to the State of Michigan and completed an investigation. NHA A and Director of Nursing B both reported that there were no incident reports or investigations for this incident. Review of the Abuse, Neglect and Exploitation Policy implemented 9/2021 and reviewed 9/2024 defined sexual abuse as non-consensual sexual contact of any type. The same policy stated, an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . reporting of all alleged violations to the Administrator, state agency .immediately, but no later than 2 hours after the allegation is made .Applying the reasonable person standard, it can be expected that R105 would have experienced emotional distress as a result of the abuse, as such a reaction aligns with how an average person would respond under similar circumstances.

Based on observations, interviews, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Findings include:Review of the medical record reflected R104 was admitted to the facility on [DATE], with diagnoses that included dementia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/2/25, reflected R104 scored 7 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R105 was admitted to the facility on [DATE], with diagnoses that included dementia, need for assistance for personal care, mild cognitive impairment, and Alzheimer's disease. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/6/25, reflected R105 was unable to have a Brief Interview for Mental Status (BIMS-a cognitive screening tool) conducted due to severe cognitive impairment. On 9/25/25 at 2:57 PM, R104 was observed in his room seated in his wheelchair. R104 was talking out loud said “ehhhh” and “ohhh.” After entry into his room, R104 was welcoming to conversation and stated that he had a bird that he loves to talk with. On 9/25/25 at 3:12 PM, R105 was observed in bed resting. Review of R104's Care plan reflected an added intervention on 3/27/23 and revised on 3/21/25 which stated “…He is also inappropriate at times. If [R104] is participating in a group setting such as eating in the dining room or an activity, wait to bring the resident down until at least one staff member is present to monitor. [R104] also sits by male residents during activities and in the dining room…”. Review of R105's Electronic Medical Record reflected that R105 was nonverbal and used nonverbal cues and sounds/cries in an attempt to make needs known. Review of a Behavior Note on 2/21/25 revealed R104 had to be corrected many times during the 6-2 shift about being inappropriate with other residents and with the CNA's. He tried to grab a CNA's bottom while they were walking by. He kept whistling at another resident until it made her upset and she had to propel away. He heckled the CNA'S whenever he was in the halls and not in bed. Review of a Behavior Note dated 3/7/25 revealed R104 stated to a female resident while in dining room, Hey baby, let me feel your tits. Writer did not know about this until several hours post incident but did speak to resident about it and told him how inappropriate it was. In an interview on 9/25/25 at 12:53 pm, Registered Nurse (RN) P stated that she received information during shift report during a shift in late March 2025 that R104 was observed groping R104's breasts in the activity room. LPN P was advised to ensure that R104 and R105 were not seated near each other to maintain R105's safety. In an interview on 9/29/25 at 9:59 am, Certified Nursing Assistant (CNA) J reported that she was working the day, back in March 2025, that R104 was observed fondling R105's breasts. CNA J stated that both residents were in the activity room and CNA J overheard a commotion. When CNA J responded, R104 was observed handling R105's breasts. Moving forward, staff was instructed to ensure that R104 and R105 were not placed near each other. CNA J reported this to the nurse. In an interview on 9/29/25 at 4:04 pm, CNA L stated that he overheard R105 yelling and immediately identified that R105 was upset about something. CNA L entered the activity room to observe R104 grabbing R105's breasts. R105 was visibly disturbed about the actions of R104. CNA L stated he separated the residents immediately and was asked to fill out an incident report. On 10/2/25 at 11:26 AM, Nursing Home Administrator (NHA) A verified that he was the abuse coordinator and explained the process of reporting abuse allegations. When asked if he had any awareness of this incident, NHA A denied knowing about R104 incident with R105, however, did stated that the incident should have been reported to him and that he would have reported it to the State of Michigan and completed an investigation. NHA A and Director of Nursing B both reported that there were no incident reports or investigations for this incident. Review of the Abuse, Neglect and Exploitation Policy implemented 9/2021 and reviewed 9/2024 defined sexual abuse as non-consensual sexual contact of any type. The same policy stated, an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . reporting of all alleged violations to the Administrator, state agency .immediately, but no later than 2 hours after the allegation is made . Applying the reasonable person standard, it can be expected that R105 would have experienced emotional distress as a result of the abuse, as such a reaction aligns with how an average person would respond under similar circumstances. A review of the State Operations Manual (SOM), revised 4/25/25, revealed, The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment: Thoroughly investigate the alleged violation . For all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, exploitation, and mistreatment, including injuries of unknown source . the facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary (if any) for the protection of residents. Depending upon the type of allegation received, it is expected that the investigation would include, but is not limited to . Conducting interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witnesses . Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included dementia, anxiety and depression. The MDS reflected that R101s had a BIM (assessment tool) score which indicated his ability to make daily decisions was severely impaired. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, falls, unsteady on feet, and depression. The MDS reflected that R102s had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired. Review of the complaint received by the State Agency on 9/24/25 alleged the facility failed to prevent and report abuse allegations to the State Agency. During a telephone interview on 9/25/25 at 11:59 a.m., Complainant “Y” verified complaint and reported often worked in basement of facility on dementia unit. Complainant “Y” reported on 8/23/25 R101 walked up to R102 and started shoving R102 and hitting R102 on the shoulder and staff separated residents and incident was reported to supervisor who was told incident needed to be reported to Director of Nursing (DON) “B” and Nursing Home Administrator (NHA) A” because abuse allegation. Complainant “Y” believes Nurse Supervisor notified DON “B” and was told did not need to be reported because both residents had dementia and NHA “A” followed up and told Complainant Y the same. Complainant “Y” reported on 9/6/25 R101 was ramming wheelchair into R102 while she was eating and staff separated residents, assessments were completed. Complainant “Y” reported R101 behaviors increased and at one-point R101 placed hands on R102 shoulders and started shaking R102 violently making R102s entire body move. Residents were again separated and assessments completed, and same nurse supervisor was notified along with physician who ordered intramuscular Ativan. Complainant “Y” reported R101 was a strong male and R102 was frail [AGE] year-old women. Complainant “Y” reported Certified Nurse Assistant (CNA) “R” got to R102 first and separated residents and R102 was taken to her private room and event was also reported to DON “B” and NHA “A” and physician via secure conversation/text. Complainant “Y” reported was questioned after event by NHA “A” who reported not to use word, “violent” in documentation and Complainant “Y” reported there was no other word to describe the event. Complainant “Y” reported NHA “A” reported intervention would be to remove wheelchair but Complainant Y reported was unsure how that would even help because R101 was not in wheelchair when he approached R102 and started shaking her. Complainant “Y” reported was told neither resident to resident incident was reported to the State of Michigan because both residents had dementia. During an observation on 9/29/25 at 9:55 a.m., R101 and R102 was observed in dementia unit, located in the facility basement. R101 and R102 were in the common area sitting in recliners that were lined up around the television four chairs apart from each other. R101 had a brace on right knee and observed staff assisted R101 to the bathroom via a wheelchair. The unit had two certified nurse aids and one nurse and about 10 residents present. During an interview on 9/29/25 at 1:00 p.m., Nursing Home Administrator (NHA) “A” reported was the facility Abuse Coordinator. NHA “A” reported had two reported allegations of abuse in past 10 months. The two abuse allegations did not include R101 or R102. Requested all Incident/Accident reports with complete investigations for R101 and R102 on 9/29/25 at 2:37 p.m. Received all R101 and R102 Incident/Accident reports for last six months with no resident-to-resident incidents on 9/29/25 at 3:23 p.m. Review of R101 Nurse Progress Note, dated 6/20/25 at 9:35 p.m., reflected, “CNA [certified nurse aid] came up to writer and reports that she has seen resident put his finger in another patients face [R102] and shouldn't sit next to her because he tried to control her and calls her his wife. States she doesn't think they should sit together anymore.” Review of R101 Nurse Progress Note, dated 8/23/25 at 8:31 p.m., reflected, “Reported to supervisor at 2024[8:24 p.m.] that this resident was seen by CENA [Competency Evaluated Nursing Assistant] striking a female resident multiple times on shoulder and chest earlier this shift. Writer was not made aware of this until approximately 2000.” Review of R101 Nurse Progress Note, dated 8/23/25 at 9:50 p.m., reflected, “DON notified of CN [charge nurse] report of incident.” Review of R101 Behavior Progress Note, dated 9/6/25 at 3:00 p.m., reflected, “Resident being very aggressive to staff. Trying to run into CNAs with WC [wheelchair]. Trying to approach a female resident thinking she is his wife. Tried to go into female resident room. Phone call placed to [named Medical Director “X”] and one time order given for 1mg Ativan IM. POA [power of attorney] aware.” Review of R101 Nursing Progress Note, dated 9/6/25 at 3:04 p.m., reflected, “At approximately 1420 [2:20 p.m.], resident ambulated to female pt. [patient] who was sitting in recliner chair in great room and placed his hands on her shoulders and began violently shaking her. Staff intervened and ended this behavior and female pt. was taken to her room to eliminate stimulus. This resident continued to try to locate female pt. whom he thought was his wife and ran his w/c into all staff members intentionally on multiple occasions. Was yelling throughout demanding to know where his wife was. Attempted to provide food, fluids and offered a walk outside all new order for Ativan 1mg IM obtained and given at approximately 1435 [2:35 p.m.].” Review of R101 Nurse Progress Note, dated 9/6/25 at 8:58 p.m., reflected, “At approx 1810 [6:10 p.m.], as most residents had eaten supper, this resident began ramming his w/c into a female resident's w/c. This resident believes this female is his wife and unable to convince him otherwise or distract him. Female resident was still eating when this occurred and residents were separated at this time. This resident went back two additional times and rammed his w/c into hers. Resident was asked why he was doing this and he stated, how else am I supposed to get her attention? Review of R101 Nurse Progress Note, dated 9/7/25 at 3:43 p.m., reflected, “Per report, pt. was fine all first shift. As soon as second shift began, pt. started to ramp up again. Has been yelling about wanting to see his wife, referring to specific female pt. Female was removed from great room prior so that pt would not become fixated on her again. So far this shift he has rammed his w/c into staff X1 [times one] and tried to ram into a visitor that staff was speaking with but staff intervened. Has been yelling quite a bit this shift about specific female pt. and that staff is liars…Since all this tends to happen on second shift, question if this is a circadian cycle for this pt. and if he needs a routine medication to control it. Currently gets Buspar 5mg tid[three times daily] but it is not helping. The 1mg Ativan yesterday did seem to help. Not asking for anything right now but will text you if situation worsens.” Review of R101 Behavior Progress Note, dated 9/12/25, reflected, “At 10:05 am, [named R101] was sitting in a PC[personal chair] chair up at the TV area and began to express, Where is [named wife], I want to see my wife, [named wife]! Staff sat with him explaining that his wife lived at another facility. [named R101] expressed, No she's not, where is she, I just seen her. During an interview on 9/29/25 at 3:46 p.m., Licensed Practical Nurse Risk Manager (RM) “N” reported had been in that role about five months and had worked at the facility for 12 years. RM “N” reported R101 was non-complaint who had no safety awareness with diagnosis of dementia who lives in dementia unit in the basement of the facility. RM “N” reported R101 thinks R102 was his wife and often require one on one care because he becomes fixated on R102. RM “N” reported worked on R101s unit 9/25/25 second shift and reported was not aware prior to that day R101 was fixated on R102 and reported R101 had increased behaviors and had to call DON “B” for additional assistance even with one-on-one care for R101. RM “N” verified she documented the following Nurse Progress Note, dated 9/25/25 at 4:02 p.m., “Elder was sitting in personal chair in dayroom upon my arrival to the unit at 1400[2:00 p.m.]. Noticed he was picking at his arm protectors and wanted to walk. He [R101] stood up without assistance X2[times two]. First time CNA [certified nurse aid] took him to the bathroom with AX2[assist time two], gait belt and w/c[wheelchair]. 2nd time they went for a stroll in his w/c outside for a bit. He was then placed back in his personal chair with CNA sitting beside him. Writer asked CNA what usually helps him stay distracted, and she replied someone sitting with him at all times giving him attention. CNA left the unit to go to lunch. Writer sat beside Elder and conversated with him. He kept directing the topic back to who he thinks is his wife which is truly just another Resident who was sitting within his sight. The other assigned CNA was doing bed checks and toileting Elders. Family members to another Elder came in to visit which intensified his[R101] behaviors. He was so worried who was talking to his wife, I don't know those people, I need to make sure my wife is okay. AX2 [assist time two] with gait belt stood him up to reposition him to his w/c to diffuse the situation by bringing him outside. DON was paged to the unit and Social Work accompanied her. They talked with Elder and wheeled him around the facility prior to bringing him back and doing puzzles together. All was well upon my departure at 4pm.” RM “N” reported reviews and completes resident fall investigations and reported R101 has had several recent falls with recent fracture because of poor safety awareness and again reported had no prior knowledge of R101 behaviors towards R102. (Evidence that thorough investigation had not been completed for frequent falls and resident to resident events to determine root cause related to ongoing behaviors.) During an interview and record review on 10/1/25 at 1:34 p.m., NHA “A” reported facility had additional information that had not yet been provided related to R101 and R102 that facility felt was an issue with staff performance of Registered Nurse (RN) “P”. NHA “A” provided file for R101 and R102 resident to resident events on 8/23/25 and 9/6/25 on facility letterhead of typed events. NHA “A” reported RN “P” no longer worked at facility. Review of the file reflected handwritten statement from CNA “R”, dated 8/23/25, that reflected, “On 8/23 [named R101] became agitated at [named R102] and open hand smacked her on her shoulder/chest area. This happened approximately around 3:30 p.m.” The statement was signed by CNA “R”. Continued review of the file reflected a second timeline of events on facility letter head for R101 and R102, dated 9/6/25, reflected two, “Hey Social Work” documents, dated 9/6/25. Review of R101's first, Hey Social Work documents reflected, “Resident is being aggressive with other residents, shaking them, in their face, yelling at them accusing them.” The form included R101 had the following behavior: yelling, abusive language, grabbing, accusing, pushing, and expressing anger and unable to redirect. The document was signed by CNA “R”. Review of the second Hey Social Work document, dated 9/6/25, reflected, “resident is being aggressive towards other residents especially [named R102] he thinks she is his wife. He is running into nurse and aides with wc[wheelchair].” The form included R101 had the same marked behaviors as the first document. During a telephone interview on 10/1/25 at 3:11 p.m., CNA “R” reported usually worked on the dementia unit in the basement on second shift with both R101 and R102. CNA “R” reported R101 frequently gets very fixated on R102 and yells at her, grabs her and has shaken R102 in the past. CNA “R” reported staff attempt to keep R101 and R102 separated, and staff try to intervene to reduce risk of altercation. CNA “R” reported R102 was[AGE] years old with dementia and is unsure if she knows what is happening and R101 is convinced R102 is his wife. CNA “R” reported recalled incident in August 2025 when R101 was patting R102 and the shoulder and shouting, hey, hey in R102 face. CNA “R” reported on 9/6/25 R101 approached R102 and grabbed R102 shoulders and started shaking R102 back and forth and both CNA staff separated residents. CNA “R” reported told R101 he was not allowed to put his hands on other residents, and R101 became upset and incident was reported to RN “P” and also completed, “Hey Social Worker” document. CNA “R” reported incident was reported to nurse because potential allegation of abuse that was required to be reported immediately. CNA “R” reported after 9/6/25 incident there were no changes in interventions but to continue to attempt to keep R101 and R102 separated. CNA “R” reported R101 does get mad at R102 and had called her an old hag and stated residents do not deserve to be treated that way or called names and should be reported. During a telephone interview on 10/2/25 at 10:26 a.m., CNA “V” reported often worked second shift with both R101 and R102. CNA “V” reported R101 was obsessed with R102 and staff constantly have to separate them. CNA V reported R101 behaviors escalate when not allowed to be right next to R102 with attempt to even try to push her wheelchair. CNA “V” reported R101 aggressive behaviors toward R102 have increase over past four to six weeks and staff have expressed concerns to several management staff including DON “B”. CNA “V” reported R101 has also had several falls because he is so determined to get to R102 including recent fall with fracture. CNA “V” reported staff attempt to redirect but often not effective and R101 requires one on one supervision that is not always possible to properly care for other residents. CNA “V” stated R101 is often, “Locked on that thought and nothing else matters to him.” CNA “V” reported R101 has called R102 a bitch as well as other residents. CNA “V” reported R101 resident to resident altercations to the second shift supervisor “AA”. CNA “V” reported R101 behaviors have been progressively getting worse and occur at least three times per week at a minimum and are reported to charge nurse because they are potential allegations of abuse. CNA “V” reported last week DON “B” had to take R101 off the unit because R102 had family that was visiting and R101 was agitated that he did not know who they were and did not want them with R102 and reported R102s family appeared frustrated with situation. During an interview on 10/2/25 at 10:48 p.m., Social Worker (SW) “K” reported R101 had behaviors that included history of being combative with staff and thinks a female resident is his wife and gets focused and agitation often increases in the afternoons. SW “K” reported the, “Hey Social Worker” was a tool that staff use to communicate behaviors residents might be having with Social Worker and reported had not received any for R101. SW “K” reported was not aware of any resident-to-resident altercations with R101 and R102 other than when R101 taps R102 on shoulder to get her attention. SW “K” reviewed, “Hey Social Worker” forms provided by NHA “A”, dated 9/6/25, and verified had never seen either one. SW “K” reported if she had received the documents would have reported to NHA “A” immediately because allegations of physical abuse that needed to be reported and investigated and need to follow up with all parties involved because she was the facility SW. During an interview on 10/2/25 at 11:26 a.m., NHA “A” reported had been in position for five years and was also the abuse coordinator. NHA “A” reported staff are expected to report all allegations of abuse to nurse supervisor, DON “B”, or NHA “A” immediately. NHA “A” reported did not reported R101 and R102 resident to resident allegations of abuse to the State of Michigan (SOM) because they delt with it as personal issue not allegation of abuse and stated, “in hindsight that was incorrect.” NHA “A” reported should have reported R101 and R102 incidents on 8/23/25 and 9/6/25 to the SOM as allegations of abuse and verified that was wrong. During an interview on 10/2/25 at 11:56 a.m., DON “B” reported received a call from supervisor that RN “P” had reported an incident that occurred at the beginning of the shift that CNA staff reported R101 was going after R102 related to both incidents on 8/23/25 and 9/6/25. DON “B” reported did not believe RN “P” but should have believed CNA staff that included written witness statements, should have reported to the NHA “A”, State of Michigan, and completed thorough investigation.

Based on observation, interview and record review, the facility failed to implement facility policy and procedure for reporting allegations of abuse for 4 of 7 sampled residents (R101, R102, R104 and R105) reviewed for abuse, resulting in potential allegations of abuse not being reported, thoroughly investigated in a timely manner and continued resident abuse.Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included dementia, anxiety and depression. The MDS reflected that R101s had a BIM (assessment tool) score which indicated his ability to make daily decisions was severely impaired. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R102 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, falls, unsteady on feet, and depression. The MDS reflected that R102s had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired. Review of the complaint received by the State Agency on 9/24/25 alleged the facility failed to prevent and report abuse allegations to the State Agency. During a telephone interview on 9/25/25 at 11:59 a.m., Complainant “Y” verified complaint and reported often worked in basement of facility on dementia unit. Complainant “Y” reported on 8/23/25 R101 walked up to R102 and started shoving R102 and hitting R102 on the shoulder and staff separated residents and incident was reported to supervisor who was told incident needed to be reported to Director of Nursing (DON) “B” and Nursing Home Administrator (NHA) A” because abuse allegation. Complainant “Y” believes Nurse Supervisor notified DON “B” and was told did not need to be reported because both residents had dementia and NHA “A” followed up and told Complainant Y the same. Complainant “Y” reported on 9/6/25 R101 was ramming wheelchair into R102 while she was eating and staff separated residents, assessments were completed. Complainant “Y” reported R101 behaviors increased and at one-point R101 placed hands on R102 shoulders and started shaking R102 violently making R102s entire body move. Residents were again separated and assessments completed, and same nurse supervisor was notified along with physician who ordered intramuscular Ativan. Complainant “Y” reported R101 was a strong male and R102 was frail [AGE] year-old women. Complainant “Y” reported Certified Nurse Assistant (CNA) “R” got to R102 first and separated residents and R102 was taken to her private room and event was also reported to DON “B” and NHA “A” and physician via secure conversation/text. Complainant “Y” reported was questioned after event by NHA “A” who reported not to use word, “violent” in documentation and Complainant “Y” reported there was no other word to describe the event. Complainant “Y” reported NHA “A” reported intervention would be to remove wheelchair but Complainant Y reported was unsure how that would even help because R101 was not in wheelchair when he approached R102 and started shaking her. Complainant “Y” reported was told neither resident to resident incident was reported to the State of Michigan because both residents had dementia. During an observation on 9/29/25 at 9:55 a.m., R101 and R102 was observed in dementia unit, located in the facility basement. R101 and R102 were in the common area sitting in recliners that were lined up around the television four chairs apart from each other. R101 had a brace on right knee and observed staff assisted R101 to the bathroom via a wheelchair. The unit had two certified nurse aids and one nurse and about 10 residents present. During an interview on 9/29/25 at 1:00 p.m., Nursing Home Administrator (NHA) “A” reported was the facility Abuse Coordinator. NHA “A” reported had two reported allegations of abuse in past 10 months. The two abuse allegations did not include R101 or R102. Requested all Incident/Accident reports with complete investigations for R101 and R102 on 9/29/25 at 2:37 p.m. Received all R101 and R102 Incident/Accident reports for last six months with no resident-to-resident incidents on 9/29/25 at 3:23 p.m. Review of R101 Nurse Progress Note, dated 6/20/25 at 9:35 p.m., reflected, “CNA [certified nurse aid] came up to writer and reports that she has seen resident put his finger in another patients face [R102] and shouldn't sit next to her because he tried to control her and calls her his wife. States she doesn't think they should sit together anymore.” Review of R101 Nurse Progress Note, dated 8/23/25 at 8:31 p.m., reflected, “Reported to supervisor at 2024[8:24 p.m.] that this resident was seen by CENA [Competency Evaluated Nursing Assistant] striking a female resident multiple times on shoulder and chest earlier this shift. Writer was not made aware of this until approximately 2000.” Review of R101 Nurse Progress Note, dated 8/23/25 at 9:50 p.m., reflected, “DON notified of CN [charge nurse] report of incident.” Review of R101 Behavior Progress Note, dated 9/6/25 at 3:00 p.m., reflected, “Resident being very aggressive to staff. Trying to run into CNAs with WC [wheelchair]. Trying to approach a female resident thinking she is his wife. Tried to go into female resident room. Phone call placed to [named Medical Director “X”] and one time order given for 1mg Ativan IM. POA [power of attorney] aware.” Review of R101 Nursing Progress Note, dated 9/6/25 at 3:04 p.m., reflected, “At approximately 1420 [2:20 p.m.], resident ambulated to female pt. [patient] who was sitting in recliner chair in great room and placed his hands on her shoulders and began violently shaking her. Staff intervened and ended this behavior and female pt. was taken to her room to eliminate stimulus. This resident continued to try to locate female pt. whom he thought was his wife and ran his w/c into all staff members intentionally on multiple occasions. Was yelling throughout demanding to know where his wife was. Attempted to provide food, fluids and offered a walk outside all new order for Ativan 1mg IM obtained and given at approximately 1435 [2:35 p.m.].” Review of R101 Nurse Progress Note, dated 9/6/25 at 8:58 p.m., reflected, “At approx 1810 [6:10 p.m.], as most residents had eaten supper, this resident began ramming his w/c into a female resident's w/c. This resident believes this female is his wife and unable to convince him otherwise or distract him. Female resident was still eating when this occurred and residents were separated at this time. This resident went back two additional times and rammed his w/c into hers. Resident was asked why he was doing this and he stated, how else am I supposed to get her attention? Review of R101 Nurse Progress Note, dated 9/7/25 at 3:43 p.m., reflected, “Per report, pt. was fine all first shift. As soon as second shift began, pt. started to ramp up again. Has been yelling about wanting to see his wife, referring to specific female pt. Female was removed from great room prior so that pt would not become fixated on her again. So far this shift he has rammed his w/c into staff X1 [times one] and tried to ram into a visitor that staff was speaking with but staff intervened. Has been yelling quite a bit this shift about specific female pt. and that staff is liars…Since all this tends to happen on second shift, question if this is a circadian cycle for this pt. and if he needs a routine medication to control it. Currently gets Buspar 5mg tid[three times daily] but it is not helping. The 1mg Ativan yesterday did seem to help. Not asking for anything right now but will text you if situation worsens.” Review of R101 Behavior Progress Note, dated 9/12/25, reflected, “At 10:05 am, [named R101] was sitting in a PC[personal chair] chair up at the TV area and began to express, Where is [named wife], I want to see my wife, [named wife]! Staff sat with him explaining that his wife lived at another facility. [named R101] expressed, No she's not, where is she, I just seen her. During an interview on 9/29/25 at 3:46 p.m., Licensed Practical Nurse Risk Manager (RM) “N” reported had been in that role about five months and had worked at the facility for 12 years. RM “N” reported R101 was non-complaint who had no safety awareness with diagnosis of dementia who lives in dementia unit in the basement of the facility. RM “N” reported R101 thinks R102 was his wife and often require one on one care because he becomes fixated on R102. RM “N” reported worked on R101s unit 9/25/25 second shift and reported was not aware prior to that day R101 was fixated on R102 and reported R101 had increased behaviors and had to call DON “B” for additional assistance even with one-on-one care for R101. RM “N” verified she documented the following Nurse Progress Note, dated 9/25/25 at 4:02 p.m., “Elder was sitting in personal chair in dayroom upon my arrival to the unit at 1400[2:00 p.m.]. Noticed he was picking at his arm protectors and wanted to walk. He [R101] stood up without assistance X2[times two]. First time CNA [certified nurse aid] took him to the bathroom with AX2[assist time two], gait belt and w/c[wheelchair]. 2nd time they went for a stroll in his w/c outside for a bit. He was then placed back in his personal chair with CNA sitting beside him. Writer asked CNA what usually helps him stay distracted, and she replied someone sitting with him at all times giving him attention. CNA left the unit to go to lunch. Writer sat beside Elder and conversated with him. He kept directing the topic back to who he thinks is his wife which is truly just another Resident who was sitting within his sight. The other assigned CNA was doing bed checks and toileting Elders. Family members to another Elder came in to visit which intensified his[R101] behaviors. He was so worried who was talking to his wife, I don't know those people, I need to make sure my wife is okay. AX2 [assist time two] with gait belt stood him up to reposition him to his w/c to diffuse the situation by bringing him outside. DON was paged to the unit and Social Work accompanied her. They talked with Elder and wheeled him around the facility prior to bringing him back and doing puzzles together. All was well upon my departure at 4pm.” RM “N” reported reviews and completes resident fall investigations and reported R101 has had several recent falls with recent fracture because of poor safety awareness and again reported had no prior knowledge of R101 behaviors towards R102. (Evidence that thorough investigation had not been completed for frequent falls and resident to resident events to determine root cause related to ongoing behaviors.) During an interview and record review on 10/1/25 at 1:34 p.m., NHA “A” reported facility had additional information that had not yet been provided related to R101 and R102 that facility felt was an issue with staff performance of Registered Nurse (RN) “P”. NHA “A” provided file for R101 and R102 resident to resident events on 8/23/25 and 9/6/25 on facility letterhead of typed events. NHA “A” reported RN “P” no longer worked at facility. Review of the file reflected handwritten statement from CNA “R”, dated 8/23/25, that reflected, “On 8/23 [named R101] became agitated at [named R102] and open hand smacked her on her shoulder/chest area. This happened approximately around 3:30 p.m.” The statement was signed by CNA “R”. Continued review of the file reflected a second timeline of events on facility letter head for R101 and R102, dated 9/6/25, reflected two, “Hey Social Work” documents, dated 9/6/25. Review of R101's first, Hey Social Work documents reflected, “Resident is being aggressive with other residents, shaking them, in their face, yelling at them accusing them.” The form included R101 had the following behavior: yelling, abusive language, grabbing, accusing, pushing, and expressing anger and unable to redirect. The document was signed by CNA “R”. Review of the second Hey Social Work document, dated 9/6/25, reflected, “resident is being aggressive towards other residents especially [named R102] he thinks she is his wife. He is running into nurse and aides with wc[wheelchair].” The form included R101 had the same marked behaviors as the first document. During a telephone interview on 10/1/25 at 3:11 p.m., CNA “R” reported usually worked on the dementia unit in the basement on second shift with both R101 and R102. CNA “R” reported R101 frequently gets very fixated on R102 and yells at her, grabs her and has shaken R102 in the past. CNA “R” reported staff attempt to keep R101 and R102 separated, and staff try to intervene to reduce risk of altercation. CNA “R” reported R102 was[AGE] years old with dementia and is unsure if she knows what is happening and R101 is convinced R102 is his wife. CNA “R” reported recalled incident in August 2025 when R101 was patting R102 and the shoulder and shouting, hey, hey in R102 face. CNA “R” reported on 9/6/25 R101 approached R102 and grabbed R102 shoulders and started shaking R102 back and forth and both CNA staff separated residents. CNA “R” reported told R101 he was not allowed to put his hands on other residents, and R101 became upset and incident was reported to RN “P” and also completed, “Hey Social Worker” document. CNA “R” reported incident was reported to nurse because potential allegation of abuse that was required to be reported immediately. CNA “R” reported after 9/6/25 incident there were no changes in interventions but to continue to attempt to keep R101 and R102 separated. CNA “R” reported R101 does get mad at R102 and had called her an old hag and stated residents do not deserve to be treated that way or called names and should be reported. During a telephone interview on 10/2/25 at 10:26 a.m., CNA “V” reported often worked second shift with both R101 and R102. CNA “V” reported R101 was obsessed with R102 and staff constantly have to separate them. CNA V reported R101 behaviors escalate when not allowed to be right next to R102 with attempt to even try to push her wheelchair. CNA “V” reported R101 aggressive behaviors toward R102 have increase over past four to six weeks and staff have expressed concerns to several management staff including DON “B”. CNA “V” reported R101 has also had several falls because he is so determined to get to R102 including recent fall with fracture. CNA “V” reported staff attempt to redirect but often not effective and R101 requires one on one supervision that is not always possible to properly care for other residents. CNA “V” stated R101 is often, “Locked on that thought and nothing else matters to him.” CNA “V” reported R101 has called R102 a bitch as well as other residents. CNA “V” reported R101 resident to resident altercations to the second shift supervisor “AA”. CNA “V” reported R101 behaviors have been progressively getting worse and occur at least three times per week at a minimum and are reported to charge nurse because they are potential allegations of abuse. CNA “V” reported last week DON “B” had to take R101 off the unit because R102 had family that was visiting and R101 was agitated that he did not know who they were and did not want them with R102 and reported R102s family appeared frustrated with situation. During an interview on 10/2/25 at 10:48 p.m., Social Worker (SW) “K” reported R101 had behaviors that included history of being combative with staff and thinks a female resident is his wife and gets focused and agitation often increases in the afternoons. SW “K” reported the, “Hey Social Worker” was a tool that staff use to communicate behaviors residents might be having with Social Worker and reported had not received any for R101. SW “K” reported was not aware of any resident-to-resident altercations with R101 and R102 other than when R101 taps R102 on shoulder to get her attention. SW “K” reviewed, “Hey Social Worker” forms provided by NHA “A”, dated 9/6/25, and verified had never seen either one. SW “K” reported if she had received the documents would have reported to NHA “A” immediately because allegations of physical abuse that needed to be reported and investigated and need to follow up with all parties involved because she was the facility SW. During an interview on 10/2/25 at 11:26 a.m., NHA “A” reported had been in position for five years and was also the abuse coordinator. NHA “A” reported staff are expected to report all allegations of abuse to nurse supervisor, DON “B”, or NHA “A” immediately. NHA “A” reported did not reported R101 and R102 resident to resident allegations of abuse to the State of Michigan (SOM) because they delt with it as personal issue not allegation of abuse and stated, “in hindsight that was incorrect.” NHA “A” reported should have reported R101 and R102 incidents on 8/23/25 and 9/6/25 to the SOM as allegations of abuse and verified that was wrong. During an interview on 10/2/25 at 11:56 a.m., DON “B” reported received a call from supervisor that RN “P” had reported an incident that occurred at the beginning of the shift that CNA staff reported R101 was going after R102 related to both incidents on 8/23/25 and 9/6/25. DON “B” reported did not believe RN “P” but should have believed CNA staff that included written witness statements, should have reported to the NHA “A”, State of Michigan, and completed thorough investigation. Review of the medical record reflected R104 was admitted to the facility on [DATE], with diagnoses that included dementia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/2/25, reflected R104 scored 7 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected R105 was admitted to the facility on [DATE], with diagnoses that included dementia, need for assistance for personal care, mild cognitive impairment, and Alzheimer's disease. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/6/25, reflected R105 was unable to have a Brief Interview for Mental Status (BIMS-a cognitive screening tool) conducted due to severe cognitive impairment. On 9/25/25 at 2:57 PM, R104 was observed in his room seated in his wheelchair. R104 was talking out loud said “ehhhh” and “ohhh.” After entry into his room, R104 was welcoming to conversation and stated that he had a bird that he loves to talk with. On 9/25/25 at 3:12 PM, R105 was observed in bed resting. Review of R104's Care plan reflected an added intervention on 3/27/23 and revised on 3/21/25 which stated “…He is also inappropriate at times. If [R104] is participating in a group setting such as eating in the dining room or an activity, wait to bring the resident down until at least one staff member is present to monitor. [R104] also sits by male residents during activities and in the dining room…”. Review of R105's Electronic Medical Record reflected that R105 was nonverbal and used nonverbal cues and sounds/cries in an attempt to make needs known. Review of a Behavior Note on 2/21/25 revealed R104 had to be corrected many times during the 6-2 shift about being inappropriate with other residents and with the CNA's. He tried to grab a CNA's bottom while they were walking by. He kept whistling at another resident until it made her upset and she had to propel away. He heckled the CNA'S whenever he was in the halls and not in bed. Review of a Behavior Note dated 3/7/25 revealed R104 stated to a female resident while in dining room, Hey baby, let me feel your tits. Writer did not know about this until several hours post incident but did speak to resident about it and told him how inappropriate it was. In an interview on 9/25/25 at 12:53 pm, Registered Nurse (RN) P stated that she received information during shift report during a shift in late March 2025 that R104 was observed groping R104's breasts in the activity room. LPN P was advised to ensure that R104 and R105 were not seated near each other to maintain R105's safety. In an interview on 9/29/25 at 9:59 am, Certified Nursing Assistant (CNA) J reported that she was working the day, back in March 2025, that R104 was observed fondling R105's breasts. CNA J stated that both residents were in the activity room and CNA J overheard a commotion. When CNA J responded, R104 was observed handling R105's breasts. Moving forward, staff was instructed to ensure that R104 and R105 were not placed near each other. CNA J reported this to the nurse. In an interview on 9/29/25 at 4:04 pm, CNA L stated that he overheard R105 yelling and immediately identified that R105 was upset about something. CNA L entered the activity room to observe R104 grabbing R105's breasts. R105 was visibly disturbed about the actions of R104. CNA L stated he separated the residents immediately and was asked to fill out an incident report. On 10/2/25 at 11:26 AM, Nursing Home Administrator (NHA) A verified that he was the abuse coordinator and explained the process of reporting abuse allegations. When asked if he had any awareness of this incident, NHA A denied knowing about R104 incident with R105, however, did stated that the incident should have been reported to him and that he would have reported it to the State of Michigan and completed an investigation. NHA A and Director of Nursing B both reported that there were no incident reports or investigations for this incident. Review of the Abuse, Neglect and Exploitation Policy implemented 9/2021 and reviewed 9/2024 defined sexual abuse as non-consensual sexual contact of any type. The same policy stated, an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . reporting of all alleged violations to the Administrator, state agency .immediately, but no later than 2 hours after the allegation is made . Applying the reasonable person standard, it can be expected that R105 would have experienced emotional distress as a result of the abuse, as such a reaction aligns with how an average person would respond under similar circumstances.

Based on observation, interview, and record review the facility failed to assess for the potential of a restraint in one (Resident #3) out of three reviewed. Findings include:Review of the medical record reflected R3 was admitted to the facility on [DATE], with diagnoses that included dementia and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/13/25, reflected R3 scored 4 out of 15 (severe impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/15/25 at 12:50 pm, R3 was observed consuming lunch on the patio area. Review of a Progress Note dated 6/16/2025 at 1:12 pm reflected Resident (R3) tipped footrest on personal chair tipped out onto the floor hematoma to right forehead .Review of a General Nursing Note dated 6/16/2025 at 12:48 PM stated Post fall and after investigation Elder was sitting in her personal chair with her feet up, sensor pad in place and sounding. Elder is unaware of her limitations and thought she was able to ambulate independently. New orders to not be left unattended in her personal chair with her feet up .In an interview on 9/15/25 at 12:54 PM. Licensed Practical Nurse (LPN) E stated that at the time of the fall, R3 was attempting to get out of her recliner chair and fell out of the front of it. LPN E confirmed that the footrest of the recliner was up, the remote to control the footrest was out of reach, however, LPN E stated that R3 does not have the cognitive ability to effectively operate the remote to the recliner. In an interview on 9/15/25 at 2:00 PM Director of Nursing (DON) B stated that at the time of the fall R3 was in her personal recliner chair with the feet elevated. R3 attempted to climb out of her personal chair and fell forward out of the chair. DON B reported that every resident requires a safety audit of their personal chairs however, R3 had not had a safety audit or a physician restraint audit of her personal chair. As a result of this fall an intervention was added to R3's care plan reminding staff not to leave R3 unattended in her personal chair. Per the State Operations Manual, physical restraint is any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident such as placing a resident in a chair, such as a beanbag or recliner, that prevents a resident from rising independently.

Based on observation, interview and record review the facility failed to prevent a fall during ambulation in one (resident #2) out of three reviewed for falls resulting in a fall during ambulation that caused a clavicle fracture. Findings include: Review of the medical record reflected Resident #2 (R2) was admitted to the facility on [DATE], with diagnoses that included weakness and dementia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/3/25, reflected R2 scored 11 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 9/15/25 at 10:56 am R2 was dressed and seated in her wheelchair. R2 explained that she was wishing she could go home however, had experienced a fall at the facility that resulted in some setbacks. R2 explained that while walking back to her recliner with the assistance of a staff member, she had lost her balance and sustained a fall that resulted in a right clavicle fracture.Review of R2's Care plan revealed that on 6/2/25, R2 required Assist of 1 person for all transfers with use of gait belt and 2WW (two wheeled walker).Review of a General Progress Note dated 6/22/25 at 2:01 PM reflected Res (Resident #2) was with CNA (Certified Nursing Assistant) walking back from the bathroom, states she let go of the gait belt to pull the pc (personal chair) closer. Res (Resident #2) lost her balance fell in the bathroom doorway landing on her right side and hitting her head on the bathroom door R2 was transferred to the local Emergency Department.Review of R2's Hospital Discharge paperwork revealed R2 was diagnosed with a closed nondisplaced right distal clavicle fracture. In an interview on 9/15/25 11:51 AM, CNA D reported that she was transferring R2 from her bathroom to her personal recliner when the fall occurred. CNA D stated that she was using the gait belt and R2 had her walker and CNA D had a lapse in judgement and took her hand off R2's gait belt. R2 fell sideways, landing on her right shoulder which resulted in a fracture. CNA D stated that she received education from the nurse and stated she should never let go of a gait belt while transferring a resident.In an interview on 9/15/25 at1:43 PM, Director of Nursing B stated that the expectation would be to not remove your hand from the gait belt while transferring a resident.

Based on observation, interview and record review the facility failed to: 1.) ensure the safety of resident during staff assisted transfer, and 2.) implement care-planned interventions for 1 of 4 sampled residents (R6) reviewed for accidents, resulting in actual harm for R6's fall during staff assisted transfer with bilateral pelvic fractures, a fractured left elbow, and a non displaced fracture near her left total hip site on 3/10/24 and 10/21/24 that required transfer to the hospital. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R6 was a [AGE] year old female admitted to the facility on [DATE], with re-admission post hospital admission 3/12/24 following left pelvic fractures, a fractured left elbow, and a non displaced fracture near her left total hip site, and 10/23/24 post fall with a left lesser trochanter fracture which is non-operable with other diagnoses that included history left hip replacement, heart failure, hypertension(high blood pressure), diabetic, Osteoarthritis, heart disease, chronic lung disease, anxiety and depression. The MDS reflected R6 had a BIM (assessment tool) score of 13 which indicated her ability to make daily decisions was cognitively intact with no behaviors including rejection of care. Continued review of the significant change MDS, dated [DATE], reflected R6 was now bed bound and was dependant on staff for all activities of daily living. During an observation and interview on 12/03/24 at 9:14 AM, R6 door was closed. R6 was laying in bed wearing a hospital gown, call light out of reach resting on oxygen concentrator about three feet from bed. R6's fitted sheet was under R6 but not over edges of air mattress with odor of BM(bowel movement) in room. R6 appeared able to answer questions without difficulty and reported would use call light to get staff assistance if needed. During an observation on 12/03/24 at 10:20 AM, R6 door closed and call light continued to be out of reach, now on the floor under resident bed. R6 eyes closed laying in bed. During an observation and interview on 12/03/24 at 12:15 PM, R6 door was open and family was R6's daughter DD was present with call light on and within reach. R6 daughter DD reported call light was on because R6 needed assistance with bowel incontinence care. R6 daughter DD reported R6 had foley catheter in place related to since most recent fall with left hip fracture related to Orthopedic order for bed rest and stage 3 pressure wound to sacral area. R6 reported had fall about 6 months ago with several fractures during a staff assisted transfer then an additional fall about two months ago during staff assisted transfer with fracture of left hip. R6 reported pressure wound started at the facility. During an observation on 12/04/24 at 8:45 AM, R6 door was open, resident was sitting upright in bed eating independently dressed in hospital gown with call light out of each under the bed. Review of the Nursing Progress note, dated 3/10/2024 at 8:00p.m., reflected, Secure Conversations Messages: Subject: FALL[2024-03-10 19:37:24 EDT] .Resident fell outside bathroom door, witnessed as CNA[Certified Nursing Assistance] was assisting resident. Complains of left hip pain including with ROM[range of motion]. Dr phoned and order to send out to ER for further eval and tx[treatment]. Small hematoma to left side of forehead and bruise to left top of hand . Review of the Nursing Progress note, dated 3/11/2024 at 4:54a.m., reflected, Telephoned [named] Hospital ER[emergency room ] and was notified that resident was admitted with hip fracture . Review of the Nursing Progress note, dated 6/22/202 at 2:27 p.m., reflected, Resident observed sitting on the floor in front of her dresser beside her PC[personal chair] leaning back on the dresser, Code 99 called. Assessed resident, no injuries noted. Resident did state,My butt hurts from sitting on the floor. Resident's oxygen was off spo2[oxygen saturation] was 83% on RA[room air], re-applied oxygen immediately before assessing her and spo2 increased to 91% on 2.5 LPM[liters per minute] o2via NC[nasal canula]. Resident assisted in PC via maxi-lift. CNA stated, I was walking resident back from the bathroom and she was off balance so I lowered her to the floor. Resident did not hit her head. CNA did not have F/U[follow up] w/c[wheelchair]behind resident as ordered when ambulating. CNA was given a written verbal warning for resident not having o2[oxygen] on and for not using F/U w/c while ambulating as ordered . Review of the Nursing Progress note, dated 10/21/2024 at 6:39 p.m., reflected, At 1450p[2:50 p.m.] Resident was being transferred from her motor-chair to her personal chair with gait belt on and 2ww[two wheel walker], by this writer, resident lost her balance, and resident fell backwards to the floor. Code 99 called. Upon assessment resident complained of left hip pain, resident not moved and 911 called, resident left by ambulance at 1515pm[3:15 p.m.]. Review of the Nursing Progress note, dated 10/23/2024 at 2:51 p.m., reflected, Admission Summary Note Text: Resident arrived back at facility at 1323[1:23 p.m.] via stretcher accompanied by 2 EMTs[emergency medical technicians] after a fall. Resident has a Left lessor trochanter FX[fracture]. Resident is non-wt bearing, has a 16 Fr Foley catheter. Resident's pain level now is a #7 of 10, Percocet 7.5/325mg tab given at 1357[1:57 p.m.]. Resident has a stage 3 pressure wound to coccyx that is covered by border foam . Review of the Incident/Accident(I/A) reports provided 12/04/24 at 1:10 PM, revealed R6 had fall with several fractures on 3/10/24 during staff assisted transfer without following interventions including the use of a gait belt. Fall on 6/22/24 during staff assisted transfer without following ordered interventions. Fall on 10/21/24 during staff assisted transfer with left lessor trochanter fracture. Continued review of the I/A reports reflected no witness statements. Director of Nursing (DON) B reported would provided complete investigations. Review of the Fall Assessment, dated 1/21/24, reflected R6 was at high risk for falls with score of 55. Continued review of the Fall Assessment, dated 9/12/24, reflected R6 was at high risk for falls with score of 70. Review of R6 Care Plan, dated 10/8/2019 to current 12/10/24, reflected, The resident is high risk for falls r/t cardiac issues/anxiety/COPD/muscle weakness/prior history of falls, Macular Degeneration. The Care Plan had interventions that included, Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 12/08/2019 . During a telephone interview on 12/05/24 at 10:37 AM, Certified Nurse Aid (CNA) EE reported was transferring R6 on 3/10/24 when she fell in bathroom. CNA EE reported R6 used walker with one person assist for transfers with gait belt. CNA EE reported R6 did not have gait belt on at the time of the fall because R6 did not like it. CNA EE reported R6 fell hard on left hip and left elbow the hit left side of face on floor just inside bathroom door when R6 insisted CNA EE pick up personal item from the floor. CNA EE reported R6 was in visual pain as evidenced by wincing and guarding and reported pain in left hip and told EMS left elbow. CNA EE reported called for nurse who was just outside R6 door and reported remained with R6 on the floor until EMS arrived 30 minutes to one hour later. CNA EE reported received education after fall to always use gait belt during transfers and if residents refuse to notify nurse prior to transfer. CNA EE reported after 3/10/24 fall R6 transfer status was maxi lift(hoyer) with 2 assist, then to 1 assist with 4ww and gait belt. CNA EE reported R6 was making good recovery after fall and had additional fall with nurse assist about 2 months ago. During a telephone interview on 12/05/24 at 2:39 PM, Licensed Practical Nurse (LPN) FF reported was transferring R6 on 10/21/24 from motorchair to personal chair in room when R6 lost balance and fell backwards on floor. LPN FF reported she was standing beside R6 with gait belt in place and walker in front of R6 when R6 lost balance fell on back on floor. LPN FF reported was unsure if she was holding R6 gait belt by side of the back. LPN FF reported R6 reported severe pain to left leg and could not even stand for left leg to be touched. During a telephone interview on 12/06/24 at 5:06 PM, CNA GG reported was working 3/10/24 when R6 fell . CNA GG reported was the first extra staff to respond to the code 99(fall code). CNA GG reported R6 was laying in doorway of bathroom in room and did not have a gait belt on. CNA GG reported gait belt should always be used during staff assisted transfer and reported had informed nurse manager was not in place. CNA GG reported CNA EE received education after R6 fall related to use of gait belt at all times. During an interview on 12/06/24 at 9:25 AM, Therapy staff HH verified R6 transfer status was one assist with use of walker and gait belt at the time of the 3/10/24 and 10/21/24 fall. During an interview on 12/06/24 at 11:39 AM, LPN II reported was R6 nurse on 3/10/24 and reported had medication cart just outside R6 when she heard crash in R6's room and heard CNA FF say R6 was on the floor. LPN II reported R6 was on the floor, in the bathroom doorway, laying on her back and called code 99. LPN II reported R6 complained on 10/10 pain left hip with externally rotated ankle. LPN II reported CNA EE remained with R6 on floor until EMR arrived after about 20 minutes. LPN II reported R6 transfer status prior to fall was staff assist of 1 with use of gait belt and walker and verified gait belt was no in place. During an interview on 12/10/24 at 12:30 PM, DON B reported would expect staff to use gait belt with all resident transfers and follow care plans. DON B reported R6 had history of refusing gait belt. DON B reported staff was re-educated on use of gait belt with resident transfers. Review of the provided education reflected staff sign in with no topic of education or date. Review of the facility, Transfer with a Gait Belt policy, undated, reflected, The resident will be assessed by professional therapies for the safest transfer option to provide the resident and staff with the utmost safety .Put on the resident's stockings/socks, shoes and gait belt .Face the resident .Grasp the gait belt on each side of the waist-with your fingers inserted up through eh bottom of the belt. Flex your knees and hips deeply, supporting the resident's knees with yours. Straighten your knees and hips, lifting the resident to a standing position at the same time. Pivot the resident so that the back of their legs are close to the chair, your hands still in position in the gait belt. Tell the resident that the chair is behind them and that you are going to lower them into the chair seat .

Based on interview and record review the facility failed to, investigate allegations of abuse for four out of four residents (Residents #31, 55, 326, & 478). Findings Included: Resident #31 (R31): Record review of R31's Minimum Data Set (MDS) dated [DATE], revealed R31 had a Brief Assessment for Mental Status (BIMS) score of 12 out of 15 which revealed moderate cognitive impairment. Review of R31's care plans revealed R31 had the potential to be verbally, sexually inappropriate during care. The care plan was initiated on 3/2/2021, and revised on 11/18/2024. The interventions listed on the care plan included, When doing personal cares, redirect when resident makes comments that are sexual in nature and document., dated 10/9/2024. Another intervention in place was to redirect R31 when inappropriate comments were made by R31 that were sexual in nature. The intervention was dated 11/18/2024. Review of R31's electronic medical record (EMR) dated 11/19/2024, revealed, .when in her room checking her catheter and drain bag resident was on the phone telling the other person (male voice) I am on Levaquin (antibiotic) because they were molesting me, they do other stuff to me also but because they are molesting me now I have a UTI (urinary tract infection). social work and supervisor notified. Further review of R31's EMR progress notes dated 11/19/2024 at 12:38 PM, revealed R31's son was notified of R31's statement. It was documented that R31's son stated She's (R31) on and off her rocker. It was documented in the progress note, Administrator was immediately notified of resident statement . Administrator A was requested to provide all incident reports for R31 for the last year. One incident report was received which was not related to R31's statement of being molested. In an interview on 12/10/2024 at 11:52 AM, Administrator A stated yes he recalled the allegation of R31 stating she was molested. Administrator A stated he was made aware of R31's statement that she had been molested at 12:28 PM on 11/19/2024. Administrator A stated that he did not investigate R31's allegation, because R31's son was on the phone with R31 when R31 made the statement. Administrator A stated R31's son was able to witness/collaborate that none of what R31 stated had occurred. Administrator A was asked how he knew the date and time the allegation occurred, Administrator S stated it would be documented in the progress notes. However, upon review of R31's progress notes, during Administrator A's interview, the notes revealed R31 did not state a date and time she allegedly was molested. Administrator A stated he did not investigate the allegation because he felt the son collaborated the allegation did not occur. 34705 Resident #55(R55) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R55 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included right below the knee amputation, difficulty walking, anxiety disorder, diabetic and legally blind. The MDS reflected R55 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. The MDS reflected R55 had no behaviors. During an asseveration and interview on 12/04/24 at 9:45 AM, R55 was laying in bed and appeared able to answer questions without difficulty. R55 reported concern that male resident(named R326) entered her room uninvited several months ago who lived in room [ROOM NUMBER]. R55 reported she was legally blind but could see shadows and hear well. R55 reported after R326 entered her room he went in bathroom then exited bathroom and closed R55 door to hall and approached her and kept getting closer and she started screaming for help and R326 responded, shhhh. R55 reported R326 left room and she informed Licensed Practical Nurse (LPN) JJ of what happened. R55 reported LPN JJ informed her R326 would not hurt her. R55 reported she was scared of R326 and when he entered her room she felt intimidated and uncomfortable by R326. R55 reported Nursing Home Administrator (NHA) A apologized to R55 about incident and reported should have read R326 history prior to admission. R55 reported R326 was discharged 2 days later. Resident #326(R326) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R326 was a [AGE] year old male admitted to the facility on [DATE] through 2/7/24 with diagnoses that included Alzheimer with behavior disturbances, bladder cancer, urinary incontinence, dysphasia, weakness and depression. The MDS reflected R326 had a BIM (assessment tool) score of 00 which indicated his ability to make daily decisions was severely impaired. Review of R326 Psychosocial Notes, dated 1/29/2024 at 12:55 p.m., reflected, SW[social work] Met [named R326] and his guardian [named guardian] in his room in Morning [NAME]. [named R326] was per [named guardian] living on the streets 5 years ago in [NAME] and went to the Martha's house and the last 6 months was at [named guardian] adult foster care home. [Named R326] had a large construction company and a nursery, little else is known at this time. He likes TV, westerns and baseball. He does not follow a routine. He needs assistance showering, wears briefs, does not sleep well at night, loves cupcakes and candy bars. He has not wandered per [named guardian]. SW completed a BIMS, PHQ2-9, Wandering Risk and Trauma assessments. [named R326] was unable to answer most questions and information was given by [NAME] when applicable. [named R326] has a diagnosis of Dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, Alzheimer's disease, unspecified and Insomnia. He is prescribed Remeron, Cymbalta and Melatonin. He is a full code and has no plans to discharge. Review of R326 Psychosocial Note, dated 1/29/2024 at 4:51 p.m., reflected, Call with [named guardian], guardian regarding medication consent and also behaviors. SW informed that he seemed agitated when she went in to do a BIMS. [named guardian] informed that R326 had no behaviors. If agitated he would go to his room and watch TV. She noted that little kids like him. She informed that she thinks he may be a bit stir crazy as she likes to go out and about with two others that lived in the home on the golf cart. She approved for [NAME] to see psychiatric services. Review of R326 Psychosocial Note, dated 1/30/2024 at 8:05 a.m., reflected, Stopped to check on [named R326] at breakfast. He was getting cup of coffee and food was being served. Staff informed he likes to walk around and they are 1:1 today to ensure he does not wander or go in other's rooms . Review of R326 Alert Note, dated 1/30/2024 at 1:46 p.m., reflected, Resident pulled gait belt off in the bathroom and was making marks to the cna about peeing on her while grabbing the cna. Nurse aware. Review of R326 Nursing Progress Note, dated 2/3/2024 06:08 a.m., reflected, CENA[nurse aid] reported to this writer at approx 0440 this A.M., resident was observed leaving another resident's room. CENA noted that this resident had urinated on the foot pedals of that resident's WC while in her room. Just prior to this happening this resident's was relaxed, lying in his bed with his eyes closed. Resident was toileted throughout the night. Review of R326 Nursing Progress Notes, dated 2/4/2024 at 2:08 a.m., reflected, Shortly after shift change resident was observed coming out of another residents room from across the hall unassisted. Resident was redirected back to his room, toileted et placed in his P.C. A little while later as CNA was attempting to get his duties started, again observed resident in another residents room standing at residents bedside leaning over her. As resident was redirected back to his room he hit CNA in the arm, not hurting CNA but did state, He had quite a hit. Resident again was toileted and resident agreed to lay down. (0000). Call light was given et explained to resident. Resident across the hall was startled by his presence but stated, I'm okay. Supervisor is aware of residents behavior. Review of R326 Nursing Progress Note, dated 2/4/2024 at 1:49 p.m., reflected, Resident has been great on 1st shift cooperative, but resident had a 1:1 which could follow him around and keep him out of other resident's rooms. Great appetite and drinks very well. Review of R326 Nursing Progress Note, dated 2/6/2024 at 5:29 a.m., reflected, Resident is resting in bed quietly. Resident ate a snack prior to going to bed at beginning of shift. Resident was cooperative and pleasant with staff at that time. A couple of hours later resident was observed in resident's room across the hall. Resident redirected and assisted to his personal bathroom, and then back to bed. Resident has been incontinent of bladder since previous void. Resident will not allow staff to wash him, and change pull up at this time. Resident shaking his head no, and lifting legs back onto bed with each attempt. Review of R326 Nursing Progress Note, dated 2/6/2024 at 6:04 a.m., reflected, At approx 0550 this writer observed resident walk quickly across hall to room [ROOM NUMBER] and close the door behind him. This writer immediately went to room [ROOM NUMBER] to redirect this resident out of the other resident's room. Resident was attempting to pull his pants down to urinate on the floor. Resident stated I'm not going anywhere. Resident eventually allowed staff to assist him back to his room. Resident then urinated on his bathroom floor. Review of R326 Psychosocial Note, dated 2/7/2024 at 11:50 a.m., reflected, Call with [named case worker], (current county) APS[adult protective services] to gain background information. She informed that neighboring county and current county Lifeways served [named R326] in the past along with information about his previous residence. She informed he was a chain smoker as well. Review of R326 Psychosocial Note, dated, 2/7/2024 at 1:04 p.m., reflected, Notified that [named R326] was quite agitated; CNA[certified nurse aid] with him and needed assistance. [named R326] was making remarks he was getting out of here, others are trying to kill him, he won't let that happen along with him continually blowing air out of his mouth, with a very agitated look on his face. Was not able to redirect his agitation but walked with him as he quickly wheeled himself all over first floor a few times. He attempted to go toward front door with 2 SW[social worker] and Administrator redirecting him back toward his neighborhood. SW and CNA took to room, offered lunch and eventually [named R326] came to nurses station and CNA brought another lunch and he ate having eventually calming down. Therapy took to bathroom and then to walk. Review of R326 Nursing Progress Note, dated, 2/7/2024 at 1:32 p.m., reflected, This am supervisor was walking by resident's room and he was standing at the end of his bed urinating on the floor. Resident redirected and reminded we use the restroom (Showed him the bathroom sign and the bathroom) we do not pee on the floor. After breakfast CNA tried to toilet resident but he did not go, he then set in his PC[personal chair] watching television as the daughter of the neighbor across the hall came out in the hall and said this gentleman had his penis out. Nurse went in to check on resident and he was master baiting with the door open. Nurse made sure he was safe and shut his door for privacy, CNA went in to check on him and clean him up. Resident was in his w/c just before lunch propelling himself around with staff walking with him keeping him out of others rooms, when trying to redirect resident out of rooms he started to swing his fist at staff. Supervisor, Social Worker notified and helped with resident. Review of R326 Nursing Progress Note, dated 2/7/2024 at 5:20 p.m., reflected, Guardian [named] here for transfer of care. Med list gone over, discharge paperwork signed. Wander guard removed from right ankle. Staff assisted to car. During a telephone interview on 12/05/24 at 2:50 PM, Licensed Practical Nurse(LPN) FF reported if resident exposed self to others would notify nurse manager and/or Social Worker because could be behavior. LPN FF reported could be allegation of abuse and would report to nurse manager and Nursing Home Administrator(NHA) immediately. During an interview on 12/10/24 at 8:55 AM, LPN JJ reported had worked at the facility for several years. LPN JJ reported R55 did report male resident in her room and verified R326 used to wander and urinate in other resident rooms. LPN JJ reported R55 appeared upset after male resident entered her room uninvited by the way R55 was acting. LPN JJ reported contacted the supervisor, director of nursing(DON), and NHA. LPN JJ reported R326 was not resident for long and staff had to keep close eye on R326 related to frequent wandering in other resident rooms. LPN JJ reported R326 had prior history of being demented. LPN JJ reported if resident exposed self to others could be allegation of sexual abuse, after first stating, if not touched, no. LPN JJ was then asked, do they need to be touched to be allegation of sexual abuse, no. LPN JJ reported if unwanted exposure would be allegation of sexual abuse and would contact supervisor, DON and NHA immediately who determine if investigation was needed. During an interview on 12/10/24 at 10:14 AM, Social Worker KK reported had worked at facility over a year. SW KK reported was responsible for residents on [NAME] Lane and Morning [NAME] units including R55. SW KK reported would follow up with residents after allegation of abuse to assess psychosocial well being and verify residents feel safe. SW KK reported described R326 as gentle giant with possible history of traumatic brain injury. SW KK reported R326 behaviors(wander in other resident rooms, and urinating in public exposing self) caused several female residents anxiety and felt intimidated by R326 size. SW KK stated, [named R326] being at facility was traumatic for several women, he had the look like he was looking through you. SW KK reported R326 was not a good fit for the facility. SW KK reported R326 was discussed in morning meeting on 2/5/24 through 2/7/24 and verified was on vacation 2/1/24 through 2/4/24. SW KK verified was unable to locate follow up documentation in R55 chart post incident, when R326 entered resident room uninvited, but recalls speaking with resident and reported should have documented. No Facility Reported Incidents related to R326 were located in the reporting system. A request for Incident reports revealed no incidents related to the abuse allegations. During an interview on 12/10/24 at 11:20 AM, Nursing Home Administrator(NHA) A reported had worked at the facility for [AGE] years and had been the abuse coordinator for the past five years. NHA A reported staff expected to report allegations of abuse immediately to direct supervisor or NHA. NHA A reported facility policy to report allegations of abuse within 2 hours if physical injury and 24 hours if no injury and SW staff involved investigations. NHA A reported R326 did not have any reported allegations of abuse. NHA A was queried if he had any knowledge of residents who felt intimidated or uncomfortable with R326 or and incidents of R326 exposing private areas to other residents. NHA A reported did not think R326 was willful with his actions. NHA A reported would expect staff to report if resident felt threatened or fearful of another resident including when R326 entered R55 room uninvited. NHA A reported incident was not reported to the state of Michigan and was unable to day why. During an interview on 10/10/24 at 1:40 p.m., NHA A reported after review of R326 medical record verified R326 entered R55 private room several times uninvited and verified should have been reported and investigated and SW should have followed up with both residents involved. 46954 Resident 478 (R478) Review of the medical record revealed R478 admitted to the facility on [DATE] with diagnoses that included dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/24 revealed R478 scored 7 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/03/24 at 11:38 AM, R478 was observed at the dining room table. R478 did not respond to an interview attempt. Review of a Behavior Note dated 5/31/2024 reflected R478 refused weekly shower; bed bath given by male cena [certified nursing assistant] much to res's [residents] dismay. Res [resident] hollering during care, this writer went in to assist cena [certified nursing assistant] in finishing the bed bath, res [resident] threatening to slap cena [certified nursing assistant] in the face for molesting her. Res [resident] kept protesting and calling for nurse despite this writer standing at the side of the bed helping. After cena [certified nursing assistant] and this writer left res's [residents'] room she continued to holler out for a few minutes . The author of the note was identified as Registered Nurse (RN) K. In an interview on 12/05/24 at 3:53 PM, Registered Nurse (RN) K was very defensive and uncooperative with questioning regarding the documented allegation. RN K stated that if that allegation was something that she would have had reported to her, she would have notified the abuse coordinator as soon as possible. Review of a Behavior note dated 9/7/2024 revealed Resident (R478) was delusional and paranoid this shift. Wanted staff with her at all times because she was frightened. When asked what she was frightened of pt. (R478) responded that first shift staff was mean to her .Begged this nurse to stay with her because she needed protection. Then begged male CENA [certified nursing assistant] to stay with her. Each time that staff left her side, she then stated that each person was mean to her, that this nurse called her names, that male CENA [certified nursing assistant] and his gangsters (referring to staff) were going to hurt her and that she was going to beat him with her beating stick. Repeated several times that staff was going to try to kill her and every resident here .When put to bed, resident was a bit calmer but still paranoid. The author of this note was identified as Registered Nurse (RN) L. In an interview on 12/05/24 at 3:15 PM, RN L reported that it was a common occurrence that R478 displayed feelings of paranoia and made accusations that staff were mean to her or performed care in a matter that was sexual. In an interview on 12/05/24 at 2:47 PM, Licensed Practical Nurse (LPN) F reported that R478 occasionally makes comments about staff being mean to her or hurting her while providing care, which LPN K passes along to management for follow up. No Facility Reported Incidents related to R478 were located in the reporting system. A request for Incident reports revealed no incidents related to the abuse allegations. In an interview on 12/10/24 at 11:21 AM, Nursing Home Administrator (NHA) A stated that the expectation for allegations of any kind of abuse would be reported immediately to him so that he could conduct an investigation. NHA A denied any knowledge of R478's allegations and stated that the allegations would have required to be reported to the State Agency and perform an investigation.

Based on observations/interviews/record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for four out of four residents (Residents #31, 55, 326, & 478). Findings Included: Resident #31 (R31): Record review of R31's Minimum Data Set (MDS) dated [DATE], revealed R31 had a Brief Assessment for Mental Status (BIMS) score of 12 out of 15 which revealed moderate cognitive impairment. Review of R31's care plans revealed R31 had the potential to be verbally, sexually inappropriate during care. The care plan was initiated on 3/2/2021, and revised on 11/18/2024. The interventions listed on the care plan included, When doing personal cares, redirect when resident makes comments that are sexual in nature and document., dated 10/9/2024. Another intervention in place was to redirect R31 when inappropriate comments were made by R31 that were sexual in nature. The intervention was dated 11/18/2024. Review of R31's electronic medical record (EMR) dated 11/19/2024, revealed, .when in her room checking her catheter and drain bag resident was on the phone telling the other person (male voice) I am on Levaquin (antibiotic) because they were molesting me, they do other stuff to me also but because they are molesting me now I have a UTI (urinary tract infection). social work and supervisor notified. Further review of R31's EMR progress notes dated 11/19/2024 at 12:38 PM, revealed R31's son was notified of R31's statement. It was documented that R31's son stated She's (R31) on and off her rocker. It was documented in the progress note, Administrator was immediately notified of resident statement . Administrator A was requested to provide all incident reports for R31 for the last year. One incident report was received which was not related to R31's statement of being molested. In an interview on 12/10/2024 at 11:52 AM, Administrator A stated yes he recalled the allegation of R31 stating she was molested. Administrator A stated he was made aware of R31's statement that she had been molested at 12:28 PM on 11/19/2024. Administrator A stated that he did not report R31's allegation, because R31's son was on the phone with R31 when R31 made the statement. Administrator A stated R31's son was able to witness/collaborate that none of what R31 stated had occurred. Administrator A was asked how he knew the date and time the allegation occurred, Administrator S stated it would be documented in the progress notes. However, upon review of R31's progress notes, during Administrator A's interview, the notes revealed R31 did not state a date and time she allegedly was molested. Administrator A stated he did not report the allegation because he felt the son collaborated the allegation did not occur. 34705 Resident #55(R55) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R55 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included right below the knee amputation, difficulty walking, anxiety disorder, diabetic and legally blind. The MDS reflected R55 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact. The MDS reflected R55 had no behaviors. During an asseveration and interview on 12/04/24 at 9:45 AM, R55 was laying in bed and appeared able to answer questions without difficulty. R55 reported concern that male resident(named R326) entered her room uninvited several months ago who lived in room [ROOM NUMBER]. R55 reported she was legally blind but could see shadows and hear well. R55 reported after R326 entered her room he went in bathroom then exited bathroom and closed R55 door to hall and approached her and kept getting closer and she started screaming for help and R326 responded, shhhh. R55 reported R326 left room and she informed Licensed Practical Nurse (LPN) JJ of what happened. R55 reported LPN JJ informed her R326 would not hurt her. R55 reported she was scared of R326 and when he entered her room she felt intimidated and uncomfortable by R326. R55 reported Nursing Home Administrator (NHA) A apologized to R55 about incident and reported should have read R326 history prior to admission. R55 reported R326 was discharged 2 days later. Resident #326(R326) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R326 was a [AGE] year old male admitted to the facility on [DATE] through 2/7/24 with diagnoses that included Alzheimer with behavior disturbances, bladder cancer, urinary incontinence, dysphasia, weakness and depression. The MDS reflected R326 had a BIM (assessment tool) score of 00 which indicated his ability to make daily decisions was severely impaired. Review of R326 Psychosocial Notes, dated 1/29/2024 at 12:55 p.m., reflected, SW[social work] Met [named R326] and his guardian [named guardian] in his room in Morning [NAME]. [named R326] was per [named guardian] living on the streets 5 years ago in [NAME] and went to the Martha's house and the last 6 months was at [named guardian] adult foster care home. [Named R326] had a large construction company and a nursery, little else is known at this time. He likes TV, westerns and baseball. He does not follow a routine. He needs assistance showering, wears briefs, does not sleep well at night, loves cupcakes and candy bars. He has not wandered per [named guardian]. SW completed a BIMS, PHQ2-9, Wandering Risk and Trauma assessments. [named R326] was unable to answer most questions and information was given by [NAME] when applicable. [named R326] has a diagnosis of Dementia in other disease classified elsewhere, unspecified severity, with other behavioral disturbance, Alzheimer's disease, unspecified and Insomnia. He is prescribed Remeron, Cymbalta and Melatonin. He is a full code and has no plans to discharge. Review of R326's Psychosocial Note, dated 1/29/2024 at 4:51 p.m., reflected, Call with [named guardian], guardian regarding medication consent and also behaviors. SW informed that he seemed agitated when she went in to do a BIMS. [named guardian] informed that R326 had no behaviors. If agitated he would go to his room and watch TV. She noted that little kids like him. She informed that she thinks he may be a bit stir crazy as she likes to go out and about with two others that lived in the home on the golf cart. She approved for [NAME] to see psychiatric services. Review of R326 Psychosocial Note, dated 1/30/2024 at 8:05 a.m., reflected, Stopped to check on [named R326] at breakfast. He was getting cup of coffee and food was being served. Staff informed he likes to walk around and they are 1:1 today to ensure he does not wander or go in other's rooms . Review of R326 Alert Note, dated 1/30/2024 at 1:46 p.m., reflected, Resident pulled gait belt off in the bathroom and was making marks to the cna about peeing on her while grabbing the cna. Nurse aware. Review of R326 Nursing Progress Note, dated 2/3/2024 06:08 a.m., reflected, CENA[nurse aid] reported to this writer at approx 0440 this A.M., resident was observed leaving another resident's room. CENA noted that this resident had urinated on the foot pedals of that resident's WC while in her room. Just prior to this happening this resident's was relaxed, lying in his bed with his eyes closed. Resident was toileted throughout the night. Review of R326 Nursing Progress Notes, dated 2/4/2024 at 2:08 a.m., reflected, Shortly after shift change resident was observed coming out of another residents room from across the hall unassisted. Resident was redirected back to his room, toileted et placed in his P.C. A little while later as CNA was attempting to get his duties started, again observed resident in another residents room standing at residents bedside leaning over her. As resident was redirected back to his room he hit CNA in the arm, not hurting CNA but did state, He had quite a hit. Resident again was toileted and resident agreed to lay down. (0000). Call light was given et explained to resident. Resident across the hall was startled by his presence but stated, I'm okay. Supervisor is aware of residents behavior. Review of R326 Nursing Progress Note, dated 2/4/2024 at 1:49 p.m., reflected, Resident has been great on 1st shift cooperative, but resident had a 1:1 which could follow him around and keep him out of other resident's rooms. Great appetite and drinks very well. Review of R326 Nursing Progress Note, dated 2/6/2024 at 5:29 a.m., reflected, Resident is resting in bed quietly. Resident ate a snack prior to going to bed at beginning of shift. Resident was cooperative and pleasant with staff at that time. A couple of hours later resident was observed in resident's room across the hall. Resident redirected and assisted to his personal bathroom, and then back to bed. Resident has been incontinent of bladder since previous void. Resident will not allow staff to wash him, and change pull up at this time. Resident shaking his head no, and lifting legs back onto bed with each attempt. Review of R326 Nursing Progress Note, dated 2/6/2024 at 6:04 a.m., reflected, At approx 0550 this writer observed resident walk quickly across hall to room [ROOM NUMBER] and close the door behind him. This writer immediately went to room [ROOM NUMBER] to redirect this resident out of the other resident's room. Resident was attempting to pull his pants down to urinate on the floor. Resident stated I'm not going anywhere. Resident eventually allowed staff to assist him back to his room. Resident then urinated on his bathroom floor. Review of R326 Psychosocial Note, dated 2/7/2024 at 11:50 a.m., reflected, Call with [named case worker], (name of county) APS[adult protective services] to gain background information. She informed that neighboring county and current county Lifeways served [named R326] in the past along with information about his previous residence. She informed he was a chain smoker as well. Review of R326 Psychosocial Note, dated, 2/7/2024 at 1:04 p.m., reflected, Notified that [named R326] was quite agitated; CNA[certified nurse aid] with him and needed assistance. [named R326] was making remarks he was getting out of here, others are trying to kill him, he won't let that happen along with him continually blowing air out of his mouth, with a very agitated look on his face. Was not able to redirect his agitation but walked with him as he quickly wheeled himself all over first floor a few times. He attempted to go toward front door with 2 SW[social worker] and Administrator redirecting him back toward his neighborhood. SW and CNA took to room, offered lunch and eventually [named R326] came to nurses station and CNA brought another lunch and he ate having eventually calming down. Therapy took to bathroom and then to walk. Review of R326 Nursing Progress Note, dated, 2/7/2024 at 1:32 p.m., reflected, This am supervisor was walking by resident's room and he was standing at the end of his bed urinating on the floor. Resident redirected and reminded we use the restroom (Showed him the bathroom sign and the bathroom) we do not pee on the floor. After breakfast CNA tried to toilet resident but he did not go, he then set in his PC[personal chair] watching television as the daughter of the neighbor across the hall came out in the hall and said this gentleman had his penis out. Nurse went in to check on resident and he was master baiting with the door open. Nurse made sure he was safe and shut his door for privacy, CNA went in to check on him and clean him up. Resident was in his w/c just before lunch propelling himself around with staff walking with him keeping him out of others rooms, when trying to redirect resident out of rooms he started to swing his fist at staff. Supervisor, Social Worker notified and helped with resident. Review of R326 Nursing Progress Note, dated 2/7/2024 at 5:20 p.m., reflected, Guardian [named] here for transfer of care. Med list gone over, discharge paperwork signed. Wander guard removed from right ankle. Staff assisted to car. During a telephone interview on 12/05/24 at 2:50 PM, Licensed Practical Nurse(LPN) FF reported if resident exposed self to others would notify nurse manager and/or Social Worker because could be behavior. LPN FF reported could be allegation of abuse and would report to nurse manager and Nursing Home Administrator(NHA) immediately. During an interview on 12/10/24 at 8:55 AM, LPN JJ reported had worked at the facility for several years. LPN JJ reported R55 did report male resident in her room and verified R326 used to wander and urinate in other resident rooms. LPN JJ reported R55 appeared upset after male resident entered her room uninvited by the way R55 was acting. LPN JJ reported contacted the supervisor, director of nursing(DON), and NHA. LPN JJ reported R326 was not resident for long and staff had to keep close eye on R326 related to frequent wandering in other resident rooms. LPN JJ reported R326 had prior history of being demented. LPN JJ reported if resident exposed self to others could be allegation of sexual abuse, after first stating, if not touched, no. LPN JJ was then asked, do they need to be touched to be allegation of sexual abuse, no. LPN JJ reported if unwanted exposure would be allegation of sexual abuse and would contact supervisor, DON and NHA immediately who determine if investigation was needed. During an interview on 12/10/24 at 10:14 AM, Social Worker KK reported had worked at facility over a year. SW KK reported was responsible for residents on [NAME] Lane and Morning [NAME] units including R55. SW KK reported would follow up with residents after allegation of abuse to assess psychosocial well being and verify residents feel safe. SW KK reported described R326 as gentle giant with possible history of traumatic brain injury. SW KK reported R326 behaviors(wander in other resident rooms, and urinating in public exposing self) caused several female residents anxiety and felt intimidated by R326 size. SW KK stated, [named R326] being at facility was traumatic for several women, he had the look like he was looking through you. SW KK reported R326 was not a good fit for the facility. SW KK reported R326 was discussed in morning meeting on 2/5/24 through 2/7/24 and verified was on vacation 2/1/24 through 2/4/24. SW KK verified was unable to locate follow up documentation in R55 chart post incident, when R326 entered resident room uninvited, but recalls speaking with resident and reported should have documented. No Facility Reported Incidents related to R326 were located in the reporting system. A request for Incident reports revealed no incidents related to the abuse allegations. During an interview on 12/10/24 at 11:20 AM, Nursing Home Administrator(NHA) A reported had worked at the facility for [AGE] years and had been the abuse coordinator for the past five years. NHA A reported staff expected to report allegations of abuse immediately to direct supervisor or NHA. NHA A reported facility policy to report allegations of abuse within 2 hours if physical injury and 24 hours if no injury and SW staff involved investigations. NHA A reported R326 did not have any reported allegations of abuse. NHA A was queried if he had any knowledge of residents who felt intimidated or uncomfortable with R326 or and incidents of R326 exposing private areas to other residents. NHA A reported did not think R326 was willful with his actions. NHA A reported would expect staff to report if resident felt threatened or fearful of another resident including when R326 entered R55 room uninvited. NHA A reported incident was not reported to the state of Michigan and was unable to day why. During an interview on 10/10/24 at 1:40 p.m., NHA A reported after review of R326 medical record verified R326 entered R55 several times uninvited and verified should have been reported and SW should have followed up with both residents involved. 46954 Resident 478 (R478) Review of the medical record revealed R478 admitted to the facility on [DATE] with diagnoses that included dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/24 revealed R478 scored 7 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/03/24 at 11:38 AM, R478 was observed at the dining room table. R478 did not respond to an interview attempt. Review of a Behavior Note dated 5/31/2024 reflected R478 refused weekly shower; bed bath given by male cena [certified nursing assistant] much to res's [residents] dismay. Res [resident] hollering during care, this writer went in to assist cena [certified nursing assistant] in finishing the bed bath, res [resident] threatening to slap cena [certified nursing assistant] in the face for molesting her. Res [resident] kept protesting and calling for nurse despite this writer standing at the side of the bed helping. After cena [certified nursing assistant] and this writer left res's [residents'] room she continued to holler out for a few minutes . The author of the note was identified as Registered Nurse (RN) K. In an interview on 12/05/24 at 3:53 PM, Registered Nurse (RN) K was very defensive and uncooperative with questioning regarding the documented allegation. RN K stated that if that allegation was something that she would have had reported to her, she would have notified the abuse coordinator as soon as possible. Review of a Behavior note dated 9/7/2024 revealed Resident (R478) was delusional and paranoid this shift. Wanted staff with her at all times because she was frightened. When asked what she was frightened of pt. (R478) responded that first shift staff was mean to her .Begged this nurse to stay with her because she needed protection. Then begged male CENA [certified nursing assistant] to stay with her. Each time that staff left her side, she then stated that each person was mean to her, that this nurse called her names, that male CENA [certified nursing assistant] and his gangsters (referring to staff) were going to hurt her and that she was going to beat him with her beating stick. Repeated several times that staff was going to try to kill her and every resident here .When put to bed, resident was a bit calmer but still paranoid. The author of this note was identified as Registered Nurse (RN) L. In an interview on 12/05/24 at 3:15 PM, RN L reported that it was a common occurrence that R478 displayed feelings of paranoia and made accusations that staff were mean to her or performed care in a matter that was sexual. In an interview on 12/05/24 at 2:47 PM, Licensed Practical Nurse (LPN) F reported that R478 occasionally makes comments about staff being mean to her or hurting her while providing care, which LPN K passes along to management for follow up. No Facility Reported Incidents related to R478 were located in the reporting system. A request for Incident reports revealed no incidents related to the abuse allegations. In an interview on 12/10/24 at 11:21 AM, Nursing Home Administrator (NHA) A stated that the expectation for allegations of any kind of abuse would be reported immediately to him so that he could conduct an investigation. NHA A denied any knowledge of R478's allegations and stated that the allegations would have required to be reported to the State Agency and perform an investigation.

Based on interview and record review the facility failed to ensure catheter care/perineal care was provided for one (#124) of three reviewed for urinary catheters. Findings include: Review of the medical record revealed R124 admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/24 revealed R124 scored 3 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Additionally, R124's MDS indicated that he had a urinary catheter. R124 no longer resided in the facility. Review of a General Nursing Note dated 6/13/2024 7:09 PM revealed CNA [certified nursing assistant] states resident is c/o [complaining of] of burning to peri [perineal] area and penis at this time. Resident has indwelling catheter. Straw yellow urine draining from tubing and into bag with small amount of sediment. insertion site inspected and noted to have large amount of purulent drainage. Penis also reddened and slightly swollen. Review of a General Nursing Note dated 6/21/2024 4:47 PM revealed [resident family member] requests resident be sent to [local emergency department] for eval [evaluation] and tx [treatment] of uncontrolled pain from foley catheter, difficulty swallowing and penile discharge. Review of the Hospital Paperwork dated 6/21/24 revealed R124 the nurses at the hospital pulled back the foreskin and observed yeast and redness on R124's penis. R124 was discharged back from the hospital with an antifungal cream. Review of a secure conversation dated 6/22/24 revealed a request for the Physician to assess R124's foreskin. Additionally, the message stated Staff reminded of importance of pulling foreskin back when doing care and applying ointment. Review of a Urology consultation dated 7/5/24 revealed instructions to provide BID twice a day cleaning to penis. Review of the Care Plan revealed no instructions for ensuring catheter care was completed. Review of the Physician Orders revealed no instructions for ensuring catheter care was completed. Reveal of the Kardex revealed no instruction for ensuring catheter care was completed. Review of the Task section on the electronic medical record revealed no instructions for ensuring catheter care was completed. Review of the Medical Record revealed no documentation that catheter care was consistently being completed on R124. On 12/10/24 at 3:10 PM, Registered Nurse V confirmed the absence of catheter care orders and the absence of any catheter care being performed on R124.

Based on observation, interview and record review, the facility failed to implement care planned interventions for one (Resident #13) and develop a comprehensive care plan for one (Resident #478) of two reviewed. Findings include: Resident #13 (R13): Review of the medical record reflected R13 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included stage two pressure ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) of the sacral region (7/5/24) and Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/6/24, reflected R13 scored eight out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had a facility-acquired stage two pressure ulcer. R13's Care Plan reflected they had an air mattress to assist with pressure reduction. On 12/03/24 at 10:55 AM, R13 was observed lying in bed, on their back. An air mattress pump was observed hanging on the foot board of the bed. The power switch was in the on position, however, the lights on the pump were not illuminated, indicating the air mattress pump was not on and/or functioning. R13 reported they had a wound on their buttocks that was being treated. On 12/06/24 at 10:13 AM, R13 was observed lying in bed. The air mattress pump, hanging on the foot of the bed, was observed with the power switch in the on position. There were no lights illuminated on the pump, indicating the air mattress was not on and/or functioning. The power cord from the mattress pump was observed partially unplugged from the wall outlet. During an interview on 12/05/24 at 10:43 AM, Licensed Practical Nurse (LPN) M reported R13's interventions to facilitate wound healing included an air mattress. Regarding how they would determine if the air mattress was on and functioning, LPN M reported they looked at the mattress when they went into the room and could tell if it was on. LPN M reported they also listened for alarms, stating the mattress would alarm if there was low pressure or if it was not plugged in. During an interview on 12/06/24 at 10:15 AM, when asked how staff knew if an air mattress was functioning, Certified Nurse Aide (CNA) S stated that was a good question. CNA S reported CNAs did not do anything with air mattresses, but sometimes, they could hear the mattresses functioning. During an interview and observation that began on 12/06/24 at 10:39 AM, Wound Care Nurse Practitioner (NP) T and Wound Care Registered Nurse (RN) O reported R13 had an air mattress. Upon inspection of R13's air mattress and pump, RN O stated someone had turned the air mattress off. They then noted the air mattress pump was partially unplugged from the wall. RN O felt R13's air mattress and reported it had lost some air since they had been in R13's room around 5:00 AM that morning. NP T and RN O were uncertain who was responsible for ensuring the air mattress was on/functioning. 46954 Resident 478 (R478) Review of the medical record revealed R478 admitted to the facility on [DATE] with diagnoses that included dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/24 revealed R478 scored 7 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/03/24 at 11:38 AM, R478 was observed at the dining room table. R478 did not respond to an interview attempt. Review of a Secure message dated 8/9/2024 reflected R478 was experiencing paranoia and was attempting to exit the facility. Review of a Behavior Note dated 9/21/at 7:56 PM revealed R478 was actively exit seeking to patio door trying to get out of the building did propel self up to the front of the building wanting to go home refused to lay down states she is worried something happened to her husband attempted to redirect several times. Review of a Behavior Note dated 9/25/2024 at 8:22 PM revealed R478 was exit seeking this shift . Review of a Secure Conversation dated 9/28/2024 at 8:20 PM revealed R478 was once again, exit seeking. Review of a Behavior Note dated 11/24/2024 at 1:39 PM revealed R478 propelled self from the dining room table calling out help for staff sitting in front of egress door to the porch trying to open the door and asking for staff to push her outside her son is out there in his car unable to redirect left alone able to redirect laid down for a rest period on 2-10 pm shift exit seeking lasted 40 minutes. In an interview on 12/05/24 at 3:15 PM, RN L reported that it was a common occurrence that R478 displayed feelings of paranoia and would exit seek. RN L stated that the facility was not outfitted with a wanderguard alarm system so the staff would try and catch the behavior so that they could lock the front door of the facility to prevent R478 from exiting. In an interview on 12/05/24 at 2:47 PM, Licensed Practical Nurse (LPN) F reported that R478 occasionally exit seeks however, the exit seeking had increased in the past few months. LPN F confirmed that there was no wanderguard system in the facility where R478 resided, so staff did their best to maintain R478's safety by locking the front doors to the facility. In an interview on 12/06/24 at 9:49 AM, Registered Nurse (RN) R stated that she has observed R478 exit seeking on several occasions. In an interview on 12/06/24 at 10:15 AM, Social Work (SW) Z stated that she had just recently learned that R478 had been exit seeking so she added it to the care plan yesterday. Review of R478's care plan revealed that an exit seeking care plan was developed on 12/2/24, despite displaying exit seeking behavior for months prior. In an interview on 12/10/24 at 12:13 PM , Director of Nursing (DON) B stated that if a resident was displaying exit seeking behavior, she would expect to see that care planned.

Based on observation, interview and record review, the facility failed to assess for the use of a possible physical restraint for two (Resident #96 and #118) of two reviewed. Findings include: Resident #96 (R96): Review of the medical record reflected R96 admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, neurocognitive disorder with Lewy Bodies and diabetes. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/15/24, reflected R96 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/03/24 at 10:08 AM, R96 was observed seated in a recliner, in their room. Both of R96's legs were elevated on the recliner leg rest. R96 reported they were unable to control the leg rest of the recliner chair due to the remote control being located behind the back of the chair. R96 reported they were placed in the recliner after breakfast that morning, between 8:00 AM to 8:30 AM. On 12/05/24 at 10:36 AM, R96 was observed seated in a recliner, in their room. Both of R96's legs were elevated on the recliner leg rest. The recliner remote control was hanging behind the back of the chair. On 12/06/24 at 9:46 AM, R96 was observed seated in their recliner, with the leg rest elevated. The remote control for the recliner was hanging behind the back of the recliner. During an interview on 12/06/24 at 9:26 AM, Certified Nurse Aide (CNA) Q reported R96 transferred with the assistance of two people and used a mechanical lift as needed. CNA Q reported R96 was unable to control the leg rest of their recliner, as the remote control was kept behind the chair. CNA Q reported R96 could operate the recliner chair, but staff did not give R96 the remote control because they did not want R96 to stand and fall. During an interview on 12/06/24 at 9:48 AM, Registered Nurse (RN) R reported R96 could probably control the leg rest of their recliner, if they wanted to. RN R believed the remote control for R96's recliner was kept on the back of the recliner. RN R reported if R96 had the remote control for their recliner, they may get up and self-transfer. A Physician's Order, with a revision date of 10/24/24, reflected R96's bed and recliner controls were to be kept out of reach for safety. During an interview on 12/06/24 at 11:06 AM, Director of Nursing (DON) B reported keeping the controls out of reach was for fall prevention. DON B reported they did not want the recliner chair raised to a lifting position and potentially having the resident fall forward and hit their head. When asked if there was an assessment to determine if keeping the controls out of reach could be considered a restraint, DON B reported therapy did an assessment. A verbal request for the assessment was made by the State Agency. During an interview on 12/06/24 at approximately 11:20 AM, Risk Manager (RM) U reported they had therapy evaluate to determine if the resident could use the controls safely. If they could not, an order was written to keep the controls out of reach. If a resident could reach around and get in the side pocket of their chair, the remote control was placed behind the chair. RM U reported the rationale for keeping R96's recliner remote behind the chair was because R96 had raised the chair and slid out of it. On 12/10/24 at 11:01 AM, and email request was sent to Nursing Home Administrator (NHA) A for any restraint assessments and therapy notes/assessments pertaining to restraints or the use of a recliner for R96 in the past 12 months. The documentation provided did not reflect that R96 had been assessed for safe use of the recliner remote control or to determine whether keeping the recliner remote control out of reach was a possible restraint. 46954 Resident #118 Review of the medical record revealed R118 admitted to the facility on [DATE] with diagnoses that included history of falling and dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/24 revealed R118 scored 3 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 12/05/24 09:54 AM R118 was observed sleeping in recliner. R118 was dressed and nicely groomed. Review of a General Nursing Note dated 4/26/2024 at 7:50 PM revealed .was speaking with nurse in hallway, heard a loud thumping noise, entered room to see resident (R118) sitting on floor attempting to return PC (personal chair) to upright position by pushing the foot section closed. Asked resident what happened and she laughed stating I couldn't put this down so I climbed out so I could push it . Manual PC removed. electric lift chair placed in room with controls out of reach. Review of a Secure Conversation dated 4/26/2024 at 8:06 PM revealed Resident (R118) fell at 1945 (7:45 PM), unwitnessed resident states she did not fall she climbed out of PC (personal chair) and was trying to shut the footstool . PC to be removed and replaced with electric PC . The author of the note was identified as Licensed Practical Nurse (LPN) AA. In an interview on 12/5/24 at 4:27 PM, LPN AA stated that she remembered R118 and that R118 fell a lot. Regarding the fall out of the recliner chair, LPN AA stated that R118 climbed out of the recliner chair because she could not get out due to the footrest being elevated. LPN AA confirmed that the chair was a personal reclining chair with a manual handle to raise and lower the footrest portion of the recliner chair. LPN AA stated that the intervention for that fall was to replace her manual recliner chair with an electric reclining chair and hid the remote (remote to control the footrest portion of the chair) to keep her in the chair and maintain her safety. LPN AA stated that it was common practice to hide the chair controls behind the chair. Review of a Physician Order revealed an active order which stated PC (personal recliner chair) controls out of reach re: safety. The order was initiated on 5/2/24. In an interview on 12/05/24 at 1:47 PM Licensed Practical Nurse (LPN) BB stated that she was familiar with R118. LPN AA recalled when R118 had a fall out of her personal recliner chair back in August 2024 after R118 stood from her personal reclining chair. R118 will attempt to stand and walk however, does not realize that she cannot ambulate independently anymore. LPN BB reported that the footrest of the recliner chair was down at the time. LPN AA stated that she does not like the footrest of the chairs being up because it creates extra hazards if the residents try to climb out of their personal chair. In an interview on 12/05/24 at 4:20 PM, Licensed Practical Nurse (LPN) CC stated that he was familiar with R118. At the time of her original fall, LPN CC verified that R118 made several attempts to independently ambulate and would often self transfer or attempt to ambulate without staff assistance or assistive devices. In an interview on 12/06/24 at 11:23 AM Licensed Practical Nurse (LPN) U stated that she was familiar with R118's fall out of the recliner and verified R118 crawled out of the recliner. LPN U was unsure if the footrest was up, but she stated she would assume so. LPN U stated that the manual recliner chair was replaced with an electric recliner chair with a remote to control the footrest portion, and a therapy evaluation was requested to determine if R118 was able to safely control the recliner chair footrest. If the resident cannot safely control the chair, an order is placed to keep the chair controls out of reach. LPN U stated that if any resident is not able to control the footrest of the recliner chair, the footrest of the recliner chair should not be up because it can create a safety risk. During an interview on 12/06/24 at 11:06 AM, Director of Nursing (DON) B reported keeping the controls out of reach was for fall prevention. DON B reported they did not want the recliner chair raised to a lifting position and potentially having the resident fall forward and hit their head. When asked if there was an assessment to determine if keeping the controls out of reach could be considered a restraint, DON B reported therapy did an assessment. A verbal request for the assessment was made by the State Agency. On 12/10/24 at 11:01 AM, and email request was sent to Nursing Home Administrator (NHA) A for any restraint assessments and therapy notes/assessments pertaining to restraints or the use of a recliner for R118 in the past 12 months. The documentation provided did not reflect that R118 had been assessed for safe use of the recliner remote control or to determine whether keeping the recliner remote control out of reach was a possible restraint.

This citation pertains to intake number MI00143720. Based on observation, interview, and record review the facility failed to ensure that five out of seven residents (Resident #1, 2, 3, 5 & 7) received appropriate care and treatment for facility acquired pressure ulcers. Findings Included: Resident #1 (R1): Per the facility face sheet, R1 was admitted to the facility on [DATE]. R1's diagnosis list revealed she had a stage 4 (a deep ulcer that can involve bone, muscle, tendons, with a high chance of infection) pressure ulcer to her sacrum (bone at the base of the spine), which had developed at the facility. R1's wound was not observed due to R1's hospitalization on [DATE]. Review of a Skin & Wound Evaluation V7.0 dated 12/18/2023, revealed R1 had moisture associated skin damage (MASD-skin irritation from prolonged moisture to the skin) from IAD Incontinence Associated Dermatitis (swelling and irritation of the skin). The evaluation revealed the MASD was In-House Acquired, meaning it occurred at the facility and was not present on admission. The evaluation revealed the wound was new. The evaluation had no further documentation. There was no documentation that the physician was made aware. Review of a picture taken on 12/18/2023, for a WOUND EVALUATION of R1's sacral MASD revealed R1 had facility acquired sacral and coccyx (tail bone) areas that had reddened skin with approximately four areas with the top layer of skin missing. There were no wound measurements, description, treatment, nor signature documented on the WOUND EVALUATION. Review of R1's progress notes dated 12/20/2023, revealed R1's bilateral buttocks and peri area had increased redness over the past few days. The note revealed that R1 was noted to have an open area on her left buttock, and the wound care nurse was notified. Record review of a SKIN OBSERVATION TOOL dated 12/21/2023, revealed the assessment was blank having no documentation on the assessment. No Wound Evaluation, or Skin & Wound Evaluation was completed again until 1/2/2024. Review of a picture dated 1/2/2024, taken for a wound evaluation revealed an increase in open wounds that were on both sides of R1's sacral area including R1's coccyx area. There were no wound measurements, was described as MASD, IAD, in house acquired that were new, with pink or red open areas. The treatment documented was to cleanse with water, apply Viscopaste (cream that can be used for chronic dermatitis), and place a wedge pillow under R1. The evaluation revealed R1's wound was deteriorating, and the treatment was changed as a result. However, no previous treatment was noted to have been ordered for R1's wounds dated 12/18/2023, per review of December 2023 Physician's orders, and R1's medication administration record (MAR) and treatment administration record (TAR). Review of R1's Physician orders dated 12/1/2023 through 4/17/2024 revealed no Physician's order was written for a wound treatment of Viscopaste and cleanse with water. However, the treatment was on R1's Treatment Administration Record (TAR) from 1/2/2024 through 1/12/2024 and was documented to have been provided by nursing staff. Review of a wound evaluation dated 1/12/2024, revealed no wound measurements, the wound was improving, no odor was present, the treatment was changed to Medihoney (dressing or gel medication) however, did not indicate why the dressing treatment was changed from Viscopaste to Medihoney. The wound was documented to be MASD. Review of R1's Physician's orders dated 12/1/2023 through 4/17/2024 revealed no order for Medihoney. However, the TAR for January 2024 revealed the Medihoney treatment was documented as provided on 1/13 and 1/14/2024. Review of a wound evaluation dated 1/23/2024 revealed R1's sacral and coccyx wound covered a larger area and had merged into all one wound. The wound evaluation revealed the wound continued to be documented as MASD, was pink or red, excoriated (irritated) skin, and the treatment was changed to Aquacel dressing (used as a sterile dressing to cover wounds that are draining pus or other fluids), and covered with a foam dressing. Review of Physician's order dated 21/1/2023 through 4/17/2024 revealed no Physician's order for Aquacel. Review of a Skin & Wound Evaluation dated 1/31/2023 revealed R1's sacral/coccyx wound was documented as MASD, and there were no measurements. Review of a Skin & Wound Evaluation dated 2/8/2024 revealed R1's sacral/coccyx wound was documented as MASD, and measurements of 27.1 cm (centimeters) area X 5.8 cm length X 7.8 cm width. The evaluation revealed R1's wound was slow to heal, and the current treatment (Aquacel) would continue. Review of a WOUND EVALUATION dated 2/13/2024, revealed a picture of R1's wound on her sacral and coccyx area. The wound was noted to be one wound that was open with some slough (dead tissue) in a small portion of the wound bed, which also had a blackened area, with full thickness tissue loss in R1's coccyx area. The wound evaluation had no measurements, was documented to be MASD, slow to heal, and was improving. The assessment was not signed. Per the Resident Assessment Instrument (RAI) manual (manual used to assist with resident Minimum Data Assessment or MDS) dated [DATE], Version 1.18.11, a stage 3 pressure ulcer was defined as, Full thickness tissue loss. Subcutaneous (the first layer under the layer of skin) fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss . Review of a Skin & Wound Evaluation V7.0 dated 2/13/2024, revealed R1's sacral/coccyx wound was documented to be MASD, no wound description, treatment, nor measurements were documented. It was documented that R1's wound was improving. Additionally, on R1's right sacrum a separate wound was present. Review of a WOUND EVALUATION dated 2/21/2024, revealed R1's wound measured 13.82 cm X 4.35 cm X 8.52 cm, however observation of the picture revealed R1 had a stage 3 wound on her right sacrum that was separate from the larger wound, and did not have any measurements documented. The evaluation revealed the wound remained documented as MASD, was slow to heal, and improving. Review of a Skin & Wound Evaluation V7.0 dated 2/21/2024, revealed no documentation under, C. Wound Bed which described the bed of the wound, evidence of infection, and other. Under D. Exudate (drainage), there was no documentation whether there was any exudate present or not. Under E. Periwound (the skin edge around the wound) there was no documentation. There was no documentation of whether R1 had any pain from the wound area. Under G. Orders it was documented that R1's wound was slow to heal. No treatment was documented under H. Treatment. The evaluation under 1. Progress revealed improving. The wound was documented to be MASD. Review of a Skin & Wound Evaluation V7.0 dated 2/28/2024, revealed R1's sacral wound was now documented as a stage 4 (full-thickness skin and tissue loss) pressure ulcer (ulcer that develops from constant pressure). The measurements were 13.8 cm X 4.4 cm X 3.7 cm, with no depth of the wound documented. The description of the wound bed, drainage, and periwound was not documented. There was no documentation of whether R1 had pain, no treatment, nor interventions were documented. Under Progress it was documented that the wound was improving. (pressure ulcer staging is stage 1 to stage 4 with stage 4 being the worst). Under Notifications: there was no check mark that the Physician was notified of the worsening of R1's sacral/coccyx wound. Review of a Monthly Physician's Progress Note dated 3/2/2024, revealed the only documentation regarding R1's pressure ulcer was under Summary of Findings and stated Sacral pressure ulcer. Review of a Monthly Physician Progress Note dated 3/6/2024, revealed the only documentation of R1's pressure ulcer was under SUMMARY OF FINDINGS which stated, .Sacral pressure ulcer . There was no documentation that the Physician had observed R1's pressure ulcer. Review of a Skin & Wound Evaluation V7.0 dated 3/6/2024, revealed wound measurements of 9.1 cm X 3.7 cm X 3.7 CM, and was slow to heal. There was no other documentation. Review of a Skin & Wound Evaluation V7.0 dated 3/13/2024, revealed stage 4 sacral pressure ulcer, in-house acquired, no measurements, the wound had slough in 70% of the wound bed, was having some seropurulent drainage with a faint odor (drainage and odor can be signs of infection), and was documented to be slow to heal. Under Notifications: there was no check mark that the Physician was notified of the drainage and faint odor of R1's sacral/coccyx wound. Review of a Skin & Wound Evaluation V7.0 dated 3/26/2024, revealed R1's sacral/coccyx wound had 100% slough in it, no measurements were documented, now had a Foul odor, with moderate drainage, and was deteriorating. Under, 3. Notes: Resident has appointment for debridement (removes dead or infected tissue) on Thursday (3/7/2024) at Wound Clinic at (name redacted) Hospital. The evaluation had no documentation that the Physician was made aware of the foul odor. Review of a Skin & Wound Evaluation V7.0 dated 4/2/2024 revealed R1's pressure ulcer measurements were 27.7 cm X 5.3 cm X 6.9 cm with no depth documented. There was no documentation of the description of the wound, the treatment, drainage, or pain. Review of a WOUND EVALUATION dated 4/10/2024 revealed a picture of R1's pressure ulcer. The pressure ulcer was a stage 4 with dark slough, dark periwound skin, measured 18.46 cm X 5.29 cm X 4.32 cm, was slow to heal, and was improving. Review of a Skin & Wound Evaluation V7.0 dated 4/10/2024, revealed no documentation of the description of R1's sacral/coccyx wound, no documentation of drainage nor odor, and no documentation of the treatment for R1's pressure ulcer. Review of R1's wound clinic notes dated 2/29/2024 revealed, R1 had an unstageable (cannot stage due to slough obscuring the wound bed) sacral pressure ulcer with full-thickness skin and tissue loss. Measurements were 5.7 cm X 5.9 cm, and an area of 33.63 square cm. The notes revealed there was a copious (abundant) amount of drainage. The wound clinic notes revealed a Physician's order to cleanse R1's left buttocks (sacral), cut to fit collagen (helps build healthy tissue) sheet to wound bed and then cover both wounds (coccyx and sacral) with border superabsorbent sacral dressing. Review of R1's Physician orders dated 12/1/2023 through 4/17/2024, revealed the wound clinic's order from R1's visit on 2/29/2024 was not transcribed on to R1's facility Physician's orders. Upon review of R1's MAR for the month of February 2024 revealed no orders for treatment to R1's coccyx pressure ulcer but only treatment for R1's sacral ulcer. Review of a wound consult documentation dated 3/28/2024, revealed a culture of R1's sacral pressure ulcer was taken, and the pressure ulcer was unstageable, would need additional debridement, and a wound vac (vacuum placed on wound that drains fluids and promotes blood flow to the wound) was the future plan. Review of Physician's orders revealed that on 4/1/2024 R1 had a PICC (peripherally inserted central catheter-IV line that goes into a vein in the upper arm and into a large vein above the right side of the heart) inserted on 4/1/2024 for IV antibiotics. Further review of R1's Physician orders revealed that on 4/1/2024 Vancomycin (high spectrum antibiotic used for serious infections) was ordered to be administered one time a day for 14 days via R1's PICC line for wound infection. Review of an MRI (magnetic resonance imaging-scan of the body that provides detailed images) of R1's sacrum and coccyx dated 4/12/2024, revealed R1's coccyx wound had early signs of osteomyelitis (inflammation of the bone caused by infection). Review of R1's progress notes revealed that on 4/15/2024, R1 was transferred to the emergency room due to confusion and not feeling well. Review of a wound clinic assessment dated [DATE], revealed a, 7.6 cm X 6.1 cm X 4.7 cm sacral pressure ulcer with exposed necrotic (dead tissue) adipose (fat) and muscle. Moderate brown .drainage present in the wound. Reddened periwound . Review of hospital records dated 4/17/2024 revealed, .Patient (R1) with large, baseball size wound to her coccyx that is foul-smelling. Visible muscle .sloughing skin. Wound bed is unable to be fully assessed due to the sloughing . Under ASSESSMENT/PLAN it was documented R1 had coccygeal osteomyelitis with surrounding cellulitis (inflammation). Review of R1's progress notes revealed that on 4/18/2024 R1 returned to the facility on hospice services, her PICC line was removed, and R1 was place on comfort care. Review of R1's care plans revealed a care plan was put into place on 12/7/2023, because R1 was at risk for skin breakdown. The care plan was last updated on 3/8/2024 with no further updates made to R1's plan of care. Resident #5 (R5): Per the facility face sheet R1 was admitted to the facility on [DATE]. Diagnosis included METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS (MRSA-a staph infection) INFECTION . The diagnosis was dated 1/16/2024, and was acquired during R5's stay at the facility. Per the RAI (resident assessment instrument) manual, under section M0300G, a DTI is purple or maroon area of discolored intact skin due to damage of underlying soft tissue. Review of R5's progress notes dated 11/29/2023 revealed R5's weekly skin assessment was completed, and no skin issues were found. Review of progress notes dated 12/6/2023 revealed, Skin assessment was completed by wound care manager (RN E) today. New issue is 2.16 X 1.58 cm red area right heel. Treatment is in place. Review of a WOUND EVALUATION dated 12/6/2024, revealed R5 was identified to have a deep tissue injury (DTI) pressure ulcer. The wound was measured 2.24 cm X 2.16 cm X 1.58 cm. The picture taken along with the assessment revealed R5's right heel was red and was not purple or maroon as defined by the RAI manual. Unable to conclude if the skin was intact per the picture. Per the RAI manual, under section M0300A, a stage 1 pressure ulcer was defined as an observable, pressure related alteration of intact skin that had a defined area of persistent redness. On 12/8/2023 the notes revealed R5 had an appointment with his vascular surgeon. Record review of progress notes dated on or around 12/6/2023 revealed no documentation that R5's Physician was made aware of his right heel redness. A Physician's order to place comfort foam to R5's right heel, and change every Monday, Wednesday, and Friday was placed on 12/6/2023, however the order was discontinued on 12/7/2023. Another Physician's order was put into place on 12/7/2023 for a Duoderm (dressing) to be place on R5's right heel and changed three time a week on Monday, Wednesday, and Friday. The order was discontinued on 12/8/2023 and re-written on 12/8/2023 to only change the Duoderm on Mondays. Review of a nursing progress note dated 12/13/2023 revealed R5 had been seen by the vascular surgeon on 12/13/2023 and was found to have venous ulcerations (ulcers cased by lack off or no blood flow). Review of progress notes dated 12/15/2024, revealed R5 was moaning and crying out that his right foot was painful. There was no WOUND EVALUATION done again for two weeks which was on 12/20/2023. The evaluation revealed that R5's right heel was 14 days old and was deteriorating. There were no wound measurements, the picture revealed an open wound with black tissue present in the wound. Registered Nurse RN E who was the wound nurse, had documented the wound to be a DTI pressure ulcer that was acquired at the facility. Review of a Skin & Wound Evaluation V7.0 dated 12/20/2023, revealed RN E had documented R5's right heel wound as a pressure ulcer that was a DTI, and was acquired at the facility. No wound measurements were documented, and had no treatment documented other than a foot buddy which was a boot worn on the foot for pressure relief. There was no documentation that the Physician was made aware. Review of Skin & Wound Evaluation V7.0 dated 1/15/2024, revealed R5's right heel wound was documented as a pressure ulcer, DTI, treatment was Santyl (used to remove damaged tissue), a moist sterile 4 X 4 dressing with a dry 4 X 4 dressing on top, and then wrapped with an ACE (elastic/compression bandage). Review of a radiology consultation dated 1/16/2024, revealed R5 had a PICC line put in. Review of Physician's orders revealed R5 was started on Vancomycin IV to be administered one time a day for MRSA (Methicillin-Resistant Staphylococcus aureus-a staph bacterial infection) in his wound. A Skin & Wound Evaluation V7.0 dated 1/22/2024, revealed the evaluation was performed by RN E. RN E continued to document R5's right heel wound as a pressure ulcer that was a DTI. No measurements were documented, no wound description, and no treatment was documented on the evaluation. There was no documentation that the Physician was made aware. Review of progress notes dated 1/25/2024, revealed R5's right heel was documented to be necrotic gangrenous (death of body tissue due to lack of blood flow or a serious bacterial infection) ulcer right heal, with MRSA in right foot. A diagnosis of diabetic foot ulcer with infection in right heel with possible Osteomyelitis (bone infection) was documented. Another progress note dated 1/25/2024 revealed, R5's vascular surgeon wanted to discuss with R5's family that R5 will eventually need an inevitable amputation (right foot). Review of a vascular surgeon note dated 1/31/2024, revealed R5's right heel was debrided (removal of dead tissue), the size of the wound was larger with necrotic tissue present. Review of a Skin & Wound Evaluation V7.0 dated 2/8/2024 revealed, RN E documented R5's right heel to be a pressure ulcer that was a DTI, and measured 19.7 cm X 5.9 cm X 4.3 cm. The evaluation also revealed R5's wound had drainage and a strong foul odor. Review of progress notes dated 2/13/2024 revealed, necrotic area spreading up heel and foot. Foul smell noted. Review of progress notes dated 2/17/2024, revealed R5 signed on to Hospice, had a significant wound on his heel that was no longer being treated, and R5 did not want to amputate his foot/leg. Review of a Skin & Wound Evaluation V7.0 dated 2/15/2024 revealed RN E documented R5's right heel to be a vascular wound that measured 3.8 cm X 2.5 cm X 2.1 cm, with an increase in pain, light drainage, and a faint odor. The evaluation had no documentation that the Physician was made aware of the odor or drainage. Review of a 2/20/2024 picture of R5's right heel revealed the wound to have necrotic tissue and small amount of slough in the bed of the wound, measurements were 20.74 cm X 5.38 cm X 5.49 cm. Review of a Wound Evaluation dated 3/5/2024, revealed only a picture was taken. No measurements or description of the wound was documented. Review of a Physician's monthly progress note dated 2/20/2024, revealed R5 was being treated with Vancomycin IV for 14 days due to MRSA in R5's right heel wound. Furthermore, the note revealed that the Physician spoke with R5's vascular surgeon who state that R5's wound (right heel) was too far gone, and he recommended Hospice care. Review of a picture of R5's right heel dated 2/28/2024 revealed the wound bed was completely necrotic, and measured 17.5 cm X 4.03 cm X 5.36 cm. Review of a Physician's monthly progress note dated 3/5/2024, revealed under HISTORY, SUMMARY OF FINDINGS, AND PLAN no documentation regarding R5's right foot ulcer. Review of a Physician's monthly progress note dated 4/2/2024 revealed no documentation of R5's right heel wound. Review of R5' progress notes revealed on 4/11/2024 R5 was complaining of being in extreme pain and was witnessed to be in tears from pain in his right foot. In an observation and interview on 4/18/2024 at 10:10 AM, Registered Nurse (RN) C and RN D stated that diabetic/vascular ulcers were not staged but rather were given a grade for severity. RN C said R5 had a cap of slough when she first saw him on 4/8/2024 which fell off. A strong odor present upon removal of the dressing from R5's right heel. RN C stated that she noted the odor yesterday 4/17/2024, and said she alerted the Physician right away, and R5 was placed on an antibiotic for 7 days. RN C said with the first noted odor of a wound the Physician was to be notified due to a suspected infection. R5's right heel wound was observed to be filled with slough, and painful for R5 to raise his leg up off the bed. In a continued interview RN C and RN D stated that no Physician nor Nurse Practitioner (NP) had ever accompanied them while doing wound rounds and treatments and said there was no Physician or NP oversite for wound care and treatments. No Physician or NP was observed to be present during wound treatments with RN C and RN D on 4/18/2024. In an interview on 4/18/2024 at 11:14 AM, RN C and D stated they both had identified concerns with wound care which included lack of documentation, skin/wound assessments not being done, facility acquired pressure ulcers that had progressed to stage 4 pressure ulcers. RN C said that her and RN D told the Director of Nursing (DON) B about their concerns. RN C and D both stated that they had changed wound treatment orders and dressings for many residents, because the RN Es wound treatments were incorrect. RN C and D both restated that they had identified the lack of wound care and treatments and the several stage 4 pressure ulcers that were all infected. RN C reiterated that the wound program did not have any oversight, and needed to be put back in order, because everything (wound treatments, assessments,) was not being done. RN C stated that her and RN D began an all-resident skin assessment starting 4/5/2024. In an interview on 4/19/2024 at 9:30 AM, RN E, who was the wound nurse, stated that R1's wound started as red skin which opened fast, and said R1 then had a stage 1 pressure ulcer on her coccyx. RN E said she did not know if R1's wound was MASD but said she had the staff put a cream on it. RN E said the following Monday when she returned to work R1's coccyx wound was open and had become one wound which she stated was a stage 2 pressure ulcer. RN E said the Physician wanted her to make treatment suggestions which he would then approve of. RN E said she knew the treatment to use for each type of wound, because she had worked in home care. RN E said a stage 3 pressure ulcer was identified when there was tissue involved. RN E just repeatedly stated there was tissue involved but was not able to state the characteristics of a stage 3 pressure ulcer. RN E, upon asking what where the immediate interventions she put into place to stop the worsening of R1's wound, RN E was not able to answer the question. RN E said she did not report to DON B any concerns with the identified facility acquire pressure ulcers or worsening of them. RN E said it was because DON B had no wound background or experience. RN E said she received wound education from a sales representative (for wound treatments) that would visit the facility one time a month. RN E said R1's wound became infected, so R1 had a PICC line put in and was started on IV Vancomycin. RN E said she had no wound education from the facility on hire. RN E said she did not have any oversite for wound care, no Physician or NP would go to the facility and do wound rounds and treatments with her, said it would have been nice to have someone for oversite to make sure she was doing the correct treatment for wounds. RN E was not able to answer why several of R1 and R5's wound assessments did not have measurements, she could not answer why the wound evaluations were not completed, but rather stated there were to many residents and she could not complete wound evaluations and treatments on all the residents. RN E said the wound evaluations that were not completed were because she never went back to finish them. RN E then said she did not complete them because she had other residents to do wound evaluations on. RN E said that she did not make DON B aware that she could not complete all the resident's wound evaluations, because it was her responsibility and felt she should be able to complete all of them. RN E was asked where she would get the diagnosis for the type of wound, she said she could not recall what she did to get the correct diagnosis of a wound. Regarding the wound clinic orders RN E said she did not always agree with the wound clinic Nurse Practitioner (NP), and would 'get into it with her, because she did not agree with the NP's treatments that she ordered. RN E said she would call the wound clinic NP about her orders and ask her, are you sure?, and said the NP would tell her yes. RN E said she would not use the NP's wound clinic treatment orders and would change the orders to what she knew to be the right orders. RN E further stated that she questioned the wound clinic NP's background and wound education. RN E said she talked to DON B about the wound clinic but not about all the wounds in the facility that were deteriorating. RN E said she would send the Physician a text message for a wound treatment order, and he would just agree with her. Regarding R5, RN E stated that the sales representative told her to treat R5's right heel wound it like it was a pressure ulcer. RN E said the wound clinic did not debride R5's right heel wound on either of his two visits, so she did it herself and scrubbed his wound clean. Review of R5's electronic medical record (EMR) revealed R5 never went to the wound clinic, only the vascular surgeon. Review of RN E education file revealed she received Wound Care Orientation Packet & instruction on 10/18/2022 per her signature that included, Admission Skin Assessment, Weekly Skin Assessment, Preventative Skin Care ,Skin Protection Guidelines, Application of Ointments, Ice Bag Treatments, Arm & Leg Protectors, Ostomy Care Policy, Orientation to Wound Care General Information. In an interview on 4/19/2024 at 1:11 PM, DON B stated that she started looking into the facility acquired wounds in January 2024 because a concern with resident's wound care and treatments were identified. DON B said she wanted to start over and assess all residents skin, and make sure all the wound treatments matched the treatment orders. DON B said she did find wound care orders that were discontinued, but not discontinued on the resident's treatment administration record (TAR). DON B said she did have concerns form the previous last week regarding RN E's wound treatment orders. DON B said she could not be certain that the Physician had ever seen any of the resident's wounds. DON B said the wound assessments were not being done, and wound prevention interventions were not in place, including at the time a resident wound was initially identified. In an interview on 4/23/2024 at 11:30 AM, (this interview took place after the exit on 4/19/2024) with NP H, who was the wound clinic NP, stated she had been employed at the wound clinic since October 2022. NP H said that R5 had never been a patient at the wound clinic before. NP H said R1 was not referred to the wound clinic until 3/28/24, and said she questioned why the facility waited that long to send her to the clinic. NP H said she debrided R1's wound, and that the last time she debrided it he was into the muscle and felt bone. Review of facility policy and procedure titled, Pressure Ulcer Protocol dated 11/2022, revealed that on page 1 all the stages of a pressure ulcer were listed along with their descriptions. The policy under Pressure Ulcer Assessment Procedure revealed that wounds were to have the location, measurements, staging, wound description, appearance, and status documented. The policy also revealed that the wound care nurse was to notify the DON of any changes to a pressure ulcer such as a stage 1 that had declined to a stage 2, and such forth. The policy was not signed by the facility Medical Director. 45135 Resident #3 (R3) Review of the medical record revealed Resident #3 (R3) was initially admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation, peripheral vascular disease, atherosclerosis of native arteries of extremities, with rest pain, right leg, chronic obstructive pulmonary disease, and diabetes 2. According to Resident #3 (R3)'s Minimum Data Set (MDS) dated [DATE], revealed R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R#3's Braden scale results were a score of 13, showing R3 was at moderate risk for skin breakdown. Record review revealed the admission assessment of the wounds on R3. Coccyx pressure ulcer 0.5cm x0.3cm x0.1cm, Stage 2. Right heel pressure ulcer 5.0cm x5.0cmx0.0cm suspected deep tissue injury (Record review revealed the admission assessment of the wounds on R3. Coccyx pressure ulcer 0.5cm x0.3cm x0.1cm, Stage 2. Right heel pressure ulcer 5.0cm x5.0cmx0.0cm suspected deep tissue injury (Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue). A second skin assessment dated [DATE] describes the heel pressure ulcer with no measurements and wound bed is filled with 100% eschar. Right toe pressure ulcer 0.5cm x0.5cm x0.0cm suspected deep tissue injury. Right dorsum foot pressure ulcer stage 1, no measurements. Left elbow other type of wound 1.0cm x1.0cm x0.0cm. Left knee, surgical incision, 19cm. Minimum Data Set (MDS) for admission assessment documented R3 had 1 stage 1 pressure ulcer, 1 stage 2 pressure ulcer, and 2 unstageable pressure ulcers under section MO300 current number unhealed pressure ulcers/injuries at each stage. Record review of 11/01/23 revealed a skin/wound assessment. Left lower leg amputation surgical site with 21 staples, was stable with a small amount of blood on the dressing covering it. Coccyx pressure ulcer 0.5x0.3x0.1. Right heel pressure ulcer 5.0x5.0x0.0 suspected deep tissue injury. Right toe pressure ulcer is unstageable due to eschar. Marked as deteriorating. Right dorsum foot pressure ulcer stage 1, no measurements. Left elbow other type of wound 1.0cm x1.0cm x0.0cm. Left knee, surgical incision, 19cm. No documentation to support a provider oversight of the wound/pressure ulcer program. Record review revealed no weekly skin/wound assessment on 11/08/23 was completed on the right heel, right dorsal foot, right anterior foot, coccyx, left elbow or surgical site for the left lower leg amputation site. Record review revealed on 11/10/23 in the nursing progress notes that the nurse called the vascular surgeons office with concerning areas on the right foot. New order received to not wrap the right foot. Record review revealed on 11/13/23 in the nursing progress notes that the nurse identified the right heel with a dark unstageable area on the heel, removed protective dressing and heel is soft and looks like it a blood blister about the size of a half a dollar, left message for wound care to assess. Record review revealed on 11/14/23 at 10:41 in the nursing progress notes documented the wound care nurse assessed areas. Right heel with dark area and dark unstageable area also on middle toe have become soft and developed what looks like a blister. Record review of 11/14/23 revealed a skin/wound assessment. Left lower amputation surgical site with 21 sta[TRUNCATED]

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls in one of three residents reviewed for falls (Resident #4), resulting in a fracture. Findings Include: Resident #4 (R4) On 10/02/23 at 1:16 PM R4 was observed sitting in her wheelchair with an alarm on the back of her chair. R4's Minimum Data Set (MDS) dated [DATE] revealed she was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS) score of 03 (00-07 Severely Impaired); her transfer status at that time was extensive assist and used a wheelchair and walker for mobility. R4 had the diagnoses of Alzheimer's, Multiple Sclerosis, and Chronic Obstructive Pulmonary Disease (COPD, lung disease). Incident Report dated 3/17/23 at 11:20 AM revealed the nurse was in the hallway and hear a thud like sound, R4 was observed on her right knee and lowered herself to her left side. The same report indicated the alarm was not sounding and R4 reported she was trying to pick up her pen that she had dropped on the floor. R4 was transferred to the hospital. Operative Report dated 3/20/23 revealed R4 had a fractured right femur (thigh bone of leg articulating at the hip and knee) and underwent surgery. The same report indicated R4 would be non-weight bearing for six weeks. Nurses note dated 3/22/23 at 6:29 AM revealed the post fall investigation was completed and R4 had orders to not be left unattended in her wheelchair in her room, foot pedal be on her wheelchair, and therapy evaluation. The same note indicated questioning if R4's alarm was on at the time of the incident, when checked after the incident it was functioning appropriately. R4's electronic medical record revealed she returned to the facility on [DATE] at 8:30 PM. R4's Significant Change MDS assessment dated [DATE] revealed she was totally dependent on staff for transfers and used a wheelchair only for mobility. Fall risk assessment dated [DATE] at 12:54 PM revealed R4 was at high risk of falling, had previous falls, and overestimated or forgets limits. Risk Manager/Licensed Practical Nurse (LPN) H was interviewed on 10/04/23 at 11:39 AM and stated she investigated R4's fall on 3/17/23 and was not able to confirm the alarm had been turned on prior to R4's fall. LPN H stated she did not know what time R4's alarm was last checked for proper functioning, or how long R4 had been sitting in her wheelchair prior to the fall. LPN H stated staff should have checked the functioning of R4's alarm every two hours. LPN H stated she had only had a couple days of training in the risk management role. LPN H stated following R4's fall she educated all staff on making sure alarms were turned on and functioning correctly. Registered Nurse (RN) I was interviewed on 10/04/23 at 12:36 PM and stated she was near R4's room in the hallway and was passing medications when she heard a boom noise. RN I stated R4's alarm did not sound. RN I stated a nurse had sat on the alarm pad, stood up and it functioned correctly in alarming. RN I stated she did not recall how long she had been sitting in her wheelchair prior to her fall. Certified Nurse Assistant (CNA) J was interviewed on 10/04/23 at 1:45 PM and stated she was assigned to R4 on 3/17/23 and did not recall what time she got up and into her wheelchair. CNA J stated she had not had a chance to check on her prior to the incident, that she had just started working that day. CNA J stated R4 had tried to pick up a pen on the floor prior to her fall and had reached for things on the floor prior to the incident on 3/17/23. CNA J stated she was not sure if R4 had a reacher/grabber pick up tool to assist her in picking up items. R4's Fall Risk care plan dated 11/03/19 indicated she was at high risk of falls due to altered gait, balance, safety judgement, muscle weakness and history of falls. R4's goal was to be free of injury of falls. The same care plan indicated she had a pressure sensor alarm in her bed and wheelchair, initiated on 11/03/19. There was no intervention for a reacher/grabber pick up tool on R4's fall risk care plan. DON B was interviewed on 10/04/23 at 1:56 AM and stated a reacher/grabber pick up tool would be a good intervention for R4, since she was reaching for something when she fell .

This citation pertains to intake MI 092. Based on observation, interview and record review, the facility failed to ensure the mechanical lift sling was secured prior to a transfer for one (Resident #2) of three reviewed for falls, resulting in a fall with injury during a mechanical lift transfer. Findings include: Review of the medical record reflected R2 was admitted to the facility on [DATE], with diagnoses that included non-toxic single [CONDITION(S)] nodule, diabetes, unspecified dementia without behavioral disturbance, need for assistance with personal care and dependence on wheelchair. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/8/22, reflected R2 had short-term and long-term memory problems. The same MDS reflected R2 did not walk and transferred with total assistance of two or more people. On 6/23/22 at 1:04 PM, R2 was observed in a recliner, in the common area, with the leg rest elevated. R2 was wearing gripper socks on both feet and had a blanket over her. A mechanical lift sling was observed beneath R2. Non-skid strips were observed on the floor in front of the recliner. An Incident Report for 6/1/22 at 12:30 PM reflected staff were transferring R2 from the wheelchair to the recliner when the top clips of the maxi-lift (mechanical lift) came unsnapped. The wheelchair tipped back, and R2 hit the back of her head on the floor. An injury to the back of the head was documented. The facility's investigation summary reflected that during a maxi-lift transfer from the wheelchair to a personal chair, R2 and her wheelchair tipped backwards, causing R2 to strike the back of her head on the floor. R2 was transported to the hospital for evaluation and treatment. Further review of the facility's investigation file reflected that on 6/1/22 at 12:30 PM, a Code 99 (facility fall code) was called. Upon Registered Nurse (RN) Supervisor arrival, R2 was lying on the floor, still in her wheelchair, with an RN attending to a posterior (back) scalp wound. At 12:50 PM, EMS was called, and the Physician and Responsible Party were notified. R2's posterior scalp wound was treated with two ABD pads and Kerlix. Report was called to the hospital, notifying of R2's blood thinner use and current condition. R2 left the facility with EMS at 1:15 PM, according to the investigation. The mechanical lift and sling being used during the transfer were removed from service, pending inspection. At 5:00 PM, the facility received notification from the hospital that R2 was returning to the facility without stitches or staples, and there was no skull fracture or bleed. There was an abrasion over a hematoma that was cleaned and bandaged. R2 returned to the facility at 5:50 PM with a diagnosis of superficial abrasion to back of head and fall. The investigation further reflected, Back of head with half dollar size abrasion and no drainage noted, but slight [CONDITION(S)] noted. According to the investigation, the maxi-lift was returned to service following inspection finding, the lift is in good working order, free of any defects and preforming [sic] to all manufacturer specifications. The facility's investigation determined that at least one clip from the sling to the lift became dislodged upon upward motion, prior to being put under weight load. The staff failed to observe the clip was not fully engaged prior to putting the sling under weight load, causing R2 and the chair to tip backwards. Upon reenactment, it was determined the clip was not fully engaged prior to being under load. A visual inspection of the sling clips showed no wear or damage. During an interview on 6/23/22 at 1:04 PM, CNA H reported she and CNA F were transferring R2 from her wheelchair to a recliner, in the units common area, when the fall occurred on 6/1/22. CNA H reported she personally hooked the sling to the maxi-lift, and CNA F was operating the controller. CNA H saw R2 being elevated, then she went to adjust the non-skid material in the recliner, due to it being twisted. When CNA H turned back around, R2's wheelchair was tipped over. CNA H reported she did not see the fall, but when she turned, she saw R2 on the floor with the wheelchair tipped backwards. CNA H reported R2 was still in her wheelchair and hit her head on the floor. The mechanical lift sling was still hooked to the lift between R2's legs, but the top hooks (upper body area) were not hooked to the lift. CNA H was unsure of how the fall occurred, as she reported she made sure the lift hooks were snapped in place at the time she connected the sling to the lift. CNA H reported the sling just came off and may not have been pulled down all the way. During an interview on 6/23/22 at 1:50 PM, CNA E reported staff knew to keep their eyes on the residents at all times (during mechanical lift transfers), especially when the resident was being lifted. They had one person controlling the lift, and the second person was supposed to be watching the resident. CNA E reported she had observed mechanical slings fall when there was not much tension, if it wasn't put on correctly. During an interview on 6/23/22 at 2:12 PM, CNA F reported CNA H asked for assistance transferring R2 from the wheelchair to a personal chair. CNA F described that they hooked R2 up to the lift, then she began raising R2. R2's buttocks was off the wheelchair a little bit when both top hooks detached from the lift. When those came undone, R2's back came down and hit the wheelchair. The wheelchair tipped over, and R2 hit the back of her head on the floor. During the same interview, CNA F reported that CNA H connected the top hooks to the lift, and she connected the bottom (leg) hooks. CNA F reported she did not watch CNA H connect the straps/hooks, but she personally checked all four straps to make sure they were secure. She reported CNA H had told her they had been having trouble with some of the lifts. When queried about the trouble, CNA F stated the charge nurse had been made aware. CNA F reported the hooks came off, usually on one side, when putting a resident in bed. During an interview on 6/23/22 at 2:54 PM, Director of Nursing (DON) B reported code 99 was called, and she and another nurse responded. When she responded, R2 was still in her wheelchair with the mechanical sling around her but completely detached from the lift. DON B acknowledged that R2 struck her head. She described that R2 had an abrasion and was bleeding from the back of her head. DON B and the other nurse applied pressure with a bandage. When asked what they determined happened, DON B described that CNA H hooked the sling on, but she did not think CNA H pushed the hooks all the way down to secure them. With R2's weight, it flipped the wheelchair completely up. DON B reported sitting in a wheelchair to reenact the incident, and the same thing happened. She described that when the sling was hooked on the bottom and not the top, the wheels of the wheelchair moved quickly when raising the lift. During an interview on 6/23/22 at 3:24 PM, Nursing Home Administrator (NHA) A reported that ultimately, the CNA did not secure the latch (mechanical sling hook/strap). He stated that their photos showed three areas for the black clasp (hook mechanism for the sling to attach to the mechanical lift). He described that if those were not all the way down, the turgor of the nylon strap pushes it back up. According to NHA A, that was the only thing that could have happened. Record review reflected R2 had a prior incident that involved the use of the mechanical lift. An Incident Report for 4/11/22 at 7:15 PM reflected while transferring with the maxi-lift, the wheelchair tilted, and R2 slid down the nurse's legs. The report reflected staff were educated on double checking to be certain the maxi-lift was correctly positioned and connected. There were no injuries indicated on the report. A Progress Note for 4/11/22 at 7:57 PM reflected, .On 4/11/22 at 1915 [7:15 PM] was asked by staff to help spot a transfer with lift, stepped into room, staff began lifting resident, chair began tipping backwards while liftIng [sic] up, stepped forward to grab resident and have staff stop lift, resident lowered to floor down writers legs, residents head did not hit floor, asked resident if hurt and resident denied being injured. Wheelchair removed from under resident, sling attached correctly to lift, resident assisted to bed via lift after determined was safe to move resident. Resident again assessed for pain or injury, again denied pain . A Communication with Physician Progress Note for 4/11/22 at 8:55 PM reflected, . Good evening, just had to lower [R2] to the floor, sadly the lift was not completely hooked up before elevating the resident, the chair started tipping backward and I grabbed the sling, resident slid down my legs and landed gently on the floor, head remained elevated off the floor didn't even touch my feet. Resident denies pain or discomfort. Staff has been educated on making certain the lift is properly secure before beginning to lift resident . A Progress Note for 4/25/22 at 1:54 PM reflected, .Post fall and after investigation no new orders are warranted at this time spoke with staff on importance of two people observing proper hook up of lift before proceeding with transfer. Please continue to follow all safety measures.

This citation pertains to Intake MI 306 and MI 141. Based on interview and record review, the facility failed to identify and provide care in accordance with professional standards of practice that were patient centered, in accordance with the residents' preferences, and goals for care for one of three reviewed for Quality of Care (Resident #2), resulting in (using the reasonable person standard) prolonged physical, mental, and psychosocial suffering and death. Findings include: According to an anonymous Complaint, filed 7/15/20, Resident was made to walk many times around unit to 'calm him down'. He was made to drink 4 glasses of prune juice, 2 doses of milk of magnesium, and then was given 2 enemas back to back, while being held down by staff. The resident has severe anal bruising, enlarged scrotum, and rectal bleeding. This was reported to higher ups next day and was blown off. They did get a CT scan do to bleeding but telling staff it showed a cyst and that's why the bleeding. According to the Significant Change Minimum Data Set (MDS), dated [DATE], Resident #2 (R2) was severely, cognitively impaired, needed extensive assistance of two or more staff with bed mobility, was always incontinent of bowel, had one unstageable Stage I pressure ulcer over a bony prominence and one skin tear, and [DIAGNOSES REDACTED]., winces, wrinkled forehead, furrowed brow, clenched teeth or jaw), protective body movements or postures (bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement). According to R2's previous MDS, dated [DATE], he was occassionally incontinent of bowel, had no indications of pain or [MEDICAL CONDITION]. Review of R2's MDS dated [DATE] revealed no [MEDICAL CONDITION]. R2's MDS, dated [DATE] revealed Death in facility. Review of R2's Certificate of Death revealed the cause of his death was Perianal (in or in the tissues near the anus) abcess (full of puss). According to a hospital History and Physical, dated 7/23/20, R2's #1 [DIAGNOSES REDACTED]. Nursing Progress Notes, dated 7/14/20 at 3:51 AM, revealed, (R2's) scrotum is enlarged. A small amount of bright red blood from his rectum. He is biting his gums probably from pain . Nursing Progress Notes, dated 7/14/20 at 10:37 AM, revealed, .new orders for [MEDICATION NAME] and treatment orders . to skin tear near rectum . R2's Medication Administration Records revealed he wore a 72 hour [MEDICATION NAME] Patch 12 MCG/HR patch every day between 7/14/20 - 8/04/20. R2's Medication Administration Records revealed he received [MEDICATION NAME] almost every two hours beginning 7/27/20. Review of R2's Wound Records revealed no mention of a skin tear. Review of R2's Wound Records, dated 7/20/20 at 9:37 AM, revealed, Wound measurements 1. Area 21.4 cm2; 2. Length 7.3 cm; 3. Width 4.2 cm; 4. Depth 0.1 cm; 5. Undermining Not applicable; 6. Tunneling Not applicable. Weekly assessment completed to what originated as a bruise at the rectum. Wound is now with thick slough, with dark/black edges. Wound has a foul odor. Difficult to keep a dressing in place d/t (due to) the location and d/t (R2) stools often and is (incontinent) . Review of R2's Wound Records, dated 7/23/20 at 10:50 AM, revealed, Wound measurements 1. Area 26.3 cm2; 2. Length 8.1 cm; Width 4.1 cm; 4. Depth 0.2 cm; Undermining Not applicable; 6. Tunneling 0.7 cm. Assessment of wound, changed since last assessment. Wound bed it black necrotic tissue. The edges are pink. Tunneling noted at about 9:00: 0. cm and at about 11:00 0.5 cm. Periwound is dark pink in color . Wound with foul odor. (R2) moved slightly with signs of discomfort with light palpation . On 7/31/20 R2's wound was labeled pressure . unstageable with slough or eschar . in-house acquired. CNA (Certified Nurse Aide) H worked Snap Dragon Alley on 7/12/20 between 2:00 PM - 10:00 PM. CNA G worked Snap Dragon Alley on 7/12/20 between 2:00 PM - 10:00 PM. CNA W worked Snap Dragon Alley on 7/12/20 - 7/13/20 between 2:00 PM - 2:00 AM. CNA T worked Snap Dragon Alley on 7/12/20 - 7/13/20 between 10:00 PM - 6:00 AM. CNA GG worked Snap Dragon Alley on 7/13/20 between 2:00 AM - 6:00 AM. LPN (Licensed Practical Nurse) O worked Snap Dragon Alley on 7/12/20 between 6:00 AM - 2:00 PM. LPN DD worked Snap Dragon Alley on 7/12/20 between 2:00 PM - 6:00 PM. RN (Registered Nurse) J (the third shift supervisor) worked Snap Dragon Alley as a charge nurse on 7/12/20 between 6:00 PM - 10:00 PM. RN L worked Snap Dragon Alley 7/12/2 - 7/13/20 between 10:00 PM - 6:00 AM According to a Witness Statement, dated 7/14/20 (not timed), I (CNA G) witnessed an unsettling enema procedure performed by my floor nurse in Snap Dragon Valley, (RN J). (RN J) asked (CNA H) and myself to assist her in an enema orchestrated on an Alzheimer patient (R2) The nurse instructed me to hold the residents' legs and instructed (CNA H) to hold his arms and torso . the nurse then proceeded to jam the tip into the resident's rectum. The resident instantly started to shout, scream and cry. I felt really upset but continued to do what I was instructed because I trusted my nurse and figured the patient was having a behavior with the discomfort of the enema. We then cleaned up the resident and put a clean brief on him. Moments later I assisted (CNA W) in the bathroom as she helped toilet (R2) and we discovered blood in the brief and blood coming out of (R2's) rectum. I went to (RN J) and instantly reported the blood. She said that's normal and it could be because he's so impacted. Several minutes later we (CNA H and I) were asked to do another enema with the nurse. This time it was very unsettling as I watched the nurse now lubricate her gloves and shove her fingers inside the rectum to help 'break up the compacted stool'. (R2) screamed and cried and shouted, 'please make it stop . oh, fuc* I'm going to die, get out of there' and much more as tears fell from his eyes. Stool and blood was on the glove once the nurse pulled her hand out. The next enema was given, and the resident was washed up and changed into a new brief and pants. (RN J) then instructed to walk (R2) around to move his bowels. I walked him around the rest of the shift and he was so tired he was falling asleep and then told the nurse I felt he was unsafe to continue to walk around and I was told to keep him moving . (R2) showed signs of pain and discomfort and couldn't even sit down . According to a Witness Statement, (not dated/timed), CNA H documented, On Sunday, 7/12/20, I worked with (CNA G) and (RN J) was the nurse. (R2) received an enema on first shift around (1:30 PM) according to one of the CNAs. We toileted (R2) at about (2:15 PM) with no stool produced. Later that night, (CNA G) and I helped hold (R2) for another enema. While I'm unsure whether he was clenching, impacted, etc., perhaps a combination of the two, the enema was not fully instilled. (R2) gripped me hard and would not let go but appeared more pained than angry. He screamed profanities and screamed for help and we did our best to comfort him. Later, he received about 3 ounces prune juice w/MOM (with Milk of Magnesia) and 4 ounces plain prune juice and we pushed water. (RN J) attempted digital stimulation using the first three fingers and thumb of her hand with little success, though he began passing trace amounts of liquid stool A second enemas was delivered successfully, although after the dig with an unlubricated glove, there was significant bleeding and pain. In an interview, on 8/12/20 at 2:19 PM, CNA H reported, They told me (R2) received an enema around 1:30 PM on first shift (R2's Medication Administration Record [REDACTED]. We moved his bed his bed out from the wall I held his hands and upper body and (CNA G) held his legs. (R2) was holding me more than I was holding him; he seemed scared. We tried to talk to him . (RN J) pulled the enema out of his rectum, only about 1/3 had been given. I saw her. She started and looked the same for the insertion but when he got upset, she used more force on it for a minute or two minutes, doing a twisting-pushing motion. At first (R2) just acted normal shouting profanities and cussing us out. Towards the end, he was calling for his mother and screaming, 'Oh help me, oh god, it hurts, Mom help me.' Afterwards, he could not get up out of bed by himself. He did not want to get out of bed at all which was very unusual for him. We could not sit him at the side of the bed because he would scream in pain that his bottom hurt. Me and (CNA G) got him to roll over to lean on one side, placed his feet on the floor and arm under arm walked him to the bathroom to see if he would produce stool. There was frank bleeding, bright red, soaked into the brief enough to change the brief two or three times before the next enema. I heard (CAN G) tell (RN J), '(R2) is bleeding and it's kind of a lot.' (RN J) said that's normal and never went in to check him. Maybe 30-40 minutes later (RN J) called us in to help her again and we did the same thing as before. This time, (R2) was shaking and went, 'Oh God, not again!' The enema was more successfully installed but as soon as she removed it dribbled out and was mostly clear. Then a little stool brown and chunky stool on the tip of the enema. (RN J) tried digital stimulation - used four fingers without lubrication and he screamed in pain and said, 'NO, get it out!' There were small crumbles of BM (bowel movement) on the glove. No results on my shift. On third shift, I heard he produced a medium stool. She didn't order us to hold him down but (CNA G) really had to hold his leg so he couldn't bring his leg back to make the nurse stop. A little blood on the glove, but when we put his brief on there was stark red blood on the brief a few ounces. There was blood in the toilet. The water was tinged red. 30 minutes later, (RN/Registered Nurse F) said we had to get him up and walk him around. We walked him. He had a funny look in his eyes, he was shaking, unstable, drifting back and forth and leaning back and forth. He seemed too tired and shaken to be walking. (CNA G) told (RN F) and she said, 'Keep walking him.' RN J told CNA W) to get water and force fluids. She said, 'Pump him full of fluids and keep him walking'. Total walking was from 8:30 PM -10:00 PM and (RN J) wanted him to keep walking. (RN J) was upset with (CNA T) and me for laying him down. He just couldn't keep doing it anymore. It just didn't feel right. I told her I understand why you want him to keep walking, but this doesn't seem safe and she got hostile. She said in a nasty tone, Well nurse Megan, if you know everything, you just do it. I asked her a lot of questions that night. Is he supposed to be bleeding that much? She said, 'He's fine'. I believe he has a right to refuse and during the first enema he made it very clear he didn't want interventions to be applied, and we kept going. He drank prune juice cup full, 4 ounces, then half of the second one mixed with MOM. I think (RN J) was physically rougher than she should have been.; she had blinders on to get him to have stool and did everything she could to make that happen without considering his safety or comfort or his right to refuse. DON (Director of Nursing B) called me into her office on Wednesday (7/15/20) and said it was an epididymal cyst that ruptured. No thorough investigation. (DON B) kind of said, 'I don't know what really happened so we kept him here longer than we should have. We brought him back here to die.' She contacted his son and said, 'If he were my Dad, I would make him a DNR (do not resuscitate). I wasn't educated at all, but she told me, 'We don't do digital stimulation here' . I don't know if physical trauma can cause epididymal cyst to rupture. I was not told anything further. DON (B) showed me the picture the wound nurse took three 3 days after the incident. It may have been there that night, but he was up walking the rest of the night and we didn't bother looking at his bottom. This may be an administrative thing that issues or mistakes that nurses have made get covered up and glossed over. In a telephone interview, on 8/12/20 at 10:00 PM, CNA T stated, (CNA W) I took (R2) to the restroom around 11:15. (R2) had blood in the toilet, brief and on his legs. It was dripping down his legs and, on the floor, - droplets falling. Told (RN L) as soon as we came out of his room. (RN L) told us she was told there would be blood and not to worry about it. Same amount in the next two briefs. Every couple of hours. Second time around 1:00 AM and (CNA W) left at 2:00 AM and (CNA GG) came in at 2:00 AM. The next brief change was around 5:00 AM; at that time, it was the same as before. Then we washed him, and we made (RN L) go in and look because she wouldn't look before. She was playing Candy Crush on her phone and she usually leave doesn't leave the nurses' station. We asked (RN L) to give (R2) pain medication a few different times through the night, then at 5:00 AM we said, 'At least give him Tylenol', and she said he didn't have an order and we needed to wait until the first shift nurse came in. You could tell he was painful when I came in. He wouldn't sit down, and his bottom was painful when he sat down on the bed. He could only lay on his right side. He would holler and push away if we tried to prop him on his left side. It was unusual for him. I was extremely pissed-off that she wouldn't get him some pain medication. At 6:00 AM, in the parking lot we called (DON B) about what had happened. We told her what we had walked into at 10:00 PM and that he had been bleeding all night, that he was in pain and wasn't given anything all night . I believe it was done when (RN F) was with him. (RN L) - I believe she didn't do anything to help him all night; (CNA GG) and I said, 'You need to get up and go look at him.' I have concerns about her. She doesn't give pain meds when they are needed . They think someone didn't chart a BM . they were discussing that at report. If we forget to chart, you can go back in and chart. No one has ever called to ask if I missed charting. (Quality Assurance CC) used to check the books to make sure they were filled in, but I don't know of anyone checking now. According to a Witness Statement, dated 7/13/20 (not timed), CNA (Certified Nursing Assistant) GG documented, On Saturday, July 11, 2020 . was informed, in report, that (R2) was given a suppository on the prior shift . on this day showed no unusual behaviors . (no) signs of needing to use the toilet .did not any of his usual signs of needing to have a bowel movement . At approximately 13:30 (1:30 PM) . (R2) had yet to have a bowel movement. The charge nurse determined that, at this point, an enema would be required . The charge nurse and a fell ow CNA administered the enema . (R2) had not had a bowel movement upon first shift departure . On Sunday, July 12, 2020, I reported to work at 2:00 AM . (The CNA that gave me report said) (R2) hadn't had a solid bowel movement .the movement that he had was extremely 'watery' . There were no unusual occurrences on this shift . (R2) showed no signs of needing to have a bowel movement. He did regularly urinate . On July 13, 2020, I arrived to work at 2:00 AM . (CNA T) appeared extremely upset. (CNA T) said that she would explain when she came back (from break) . (at 2:00 AM), the charge nurse (L) was sitting behind the desk. I noticed that (R2) was in bed, which was unusual for him . (CNA T) report that (R2) was given two enemas within half an hour, milk of magnesia and approximately seven glasses of prune juice. She state (sic) that he had one solid formed stool and some loose stool. She also state he appeared to be passing blood . stated that she reported this to the nurse .(R2) was showing signs of discomfort. MULTIPLE, FREQUENT attempts throughout the next 2-3 hours, by both us CNAs were made to reposition (R2) and make him comfortable . 5:10 (AM) I undid (R2's) brief so that we could begin washing him. (R2) was extremely agitated . Once resident was on his side, there was a clear view of his peri-rectal area. There was evidence of blood near his rectum. There was blood in his brief. His scrotum was abnormally swollen. I immediately went to get the charge nurse . The charge nurse came in . stated that she didn't see any 'active' bleeding, so there wasn't much that she could do. We tried to point out that the size of his scrotum was not normal. We tried to point out that he was painful. We were told again that she couldn't do anything . We left him without a brief for his comfort. Several blue pads were laid under him. As he was gently rolled, fresh blood spots were noted on the clean blue pads. I immediately went to the charge nurse and informed her that there was active bleeding. She stated that it was 20 (minutes) till 6:00, 'I am not going to do anything. I will let the day shift nurse know and she can do it' . In a telephone interview, on 8/13/20 11:50 AM, CNA GG reported, (R2) tended to have days and nights backwards. He is usually up at 2:00 AM. (On 7/13/20) prior to 5:10 AM, when we rolled him he seemed uncomfortable and agitated when we changed him. Between 2:00 AM - 5:00 AM, (RN L) was gone for an hour for lunch . We asked her to come at 5:10 AM when we saw there was potentially an issue . There was no active bleeding when the nurse was in there but when we rolled him there was blood on the pad and we told her at 5:40 AM. (RN L) told me she wasn't going to do anything even though I told her there was active bleeding. I feel we pointed out that something was wrong, we tried to get help for our resident and felt we were not listened to. Our job is to notice behavior changes, and physical changes and we were disregarded. We told (RN L), something is wrong. In an interview, on 8/13/20 at 10:54 AM, third shift House Supervisor/Registered Nurse/RN J reported, It came up on the computer that (R2) was due (for an enema) and it said how many shifts and that is what I went by. No, I was not told he was on bowel protocol by (Licensed Practical Nurse/LPN DD) or that she gave a suppository (earlier that day). (Former Quality Assurance CC) would not have found it because she didn't work weekends. I can't tell what the system does. We learned to use the computer to decide two years ago when we learned how to use the EMR (electronic medical record). (Resident #3) was on bowel program Friday (7/10/20/Review of R2's Medication Administration Record [REDACTED]. Regarding R2, RN J said, I was trying to get him to go (have a bowel movement), so I gave him prune juice and MOM (milk of magnesia laxative) and he was straining so hard his face was red. Yes, I gave him prune juice 60 cc and 15 cc of MOM mixed together. Later, I tried 60 cc prune juice. I did not call the doctor; I just used my nursing judgement. I pulled up the aides' tasks and he was 4 days, rolling into 5 days with no bowel movement. If you assume he had a BM on the shift that no one charted, he was on the 9th day on second shift. If he did have a BM on the day it wasn't charted, then it would only have been the 5th shift . (R2) kicked out at me when I gave the first enema. (R2) walked into the general area and screamed, 'I got to[***]' He had 5-6 pea sized pellets in the toilet. I don't know how you count that as a BM. He laid back down, that's when I gave him, about 40 minutes later prune juice and MOM. He came back out yelling that he had to[***] In the bathroom yelling and not cooperative at all, straining and red face, I felt like I needed to check him, first one he didn't cooperate at all, I checked him and there was hard stool and rectal vault was full. I felt we needed to give him an enema. (R2) took ½ of it and squirmed a lot, so I stopped. They walked him in the merry walker . (CNA G) walked him. He was up at 10:00 PM and I gave report to (RN L). (RN L) said nothing about the bowel protocol. At 10:00 PM, I was supervisor and went to the COVID unit and counted off. Around 11:00 PM, (R2) was still walking around with (CNA T). No one said anything about his condition not being okay. I called each unit and spoke with (RN L) and she said (R2) was sleeping and he had no BM. As I was getting ready to leave 6:15 AM (LPN K) called and spoke with (Unit Manager/RN AA) and said there was a lot of bruising and (Unit Manager AA) said she would go look at it and I should go home. Ultrasound showed a cyst at the head of the epididymis. On Tuesday, I went to see what was going on. (RN II) was his nurse Monday night. There was a long bruise. I measured it 13.5 cm long. (Wound Nurse/ RN Q) documented everything before I did. I was just floored as to where this bruise came from. Hospital report - I was shocked - perforation, abscess. I did not speak with (Medical Director R) about it. (Medical Director R) was on vacation for two weeks. I don't know why (Physician Assistant Y) wasn't called in. (Unit Manager/RN EE) is the Unit Manager. Perforation is a potential with enemas or suppositories. I spoke with (Director of Nursing DON B) about that on 7/21/20. If a resident resists an enema . I stopped. (CNA H's) hands, (CNA G) supported his back and held is legs up. (R2's) rectal vault full of stool . didn't come out for us . He was lying on his left side in bed, I checked him with one finger. He yelled. I then attempted another enema. I didn't even think about notifying the doctor. I did not receive discipline and was only educated on enemas . We need to look at the bowel protocol no one mentioned the problem until you brought it to my attention. RN J reported she did not call Son FF or a physician regarding R2 to get an order to administer repeated enemas, give prune juice with unscheduled MOM, to perform digital removal of stool, the inability to instill the first eneam, about the presence of blood, or R2 screaming in pain during the instillation of the enemas. RN J reported she did not check R2's BM record or the MAR indicated [REDACTED]. In an interview, on 8/12/20 at 1:11 PM, RN O reported, I count a hole as no BM. You have nothing else to tell you otherwise. If I know who worked prior, I might message them but if I don't know and it's been days prior, I wouldn't know. That's the way we've always done it, count it as a no BM. I gave (R2) MOM on 7/06/20 at 1333. Our computer generates an alert that tells us how many shifts without a BM. If you don't read the date of the alert, you can make a mistake. I clear out alerts after 24 hours makes it clearer communication. Not everyone clears them out. RN O continued, When I saw (R2) on Wednesday 14th, . I walked into a night mere his testes were huge, he had a big bruise and skin tears. I was off for a couple days and when I came back it was necrotic. I heard from supervisor that he had a rectal perforation and it was really horrible. He was very, very painful, I couldn't get him out of bed he would cry out and cling to you. Even when turned side to side. The ice packs were applied, it was shiny; it was so tight - scrotum. We gave pain meds, but he was thrashing around because of the pain. He wanted up but he couldn't. When he came back from the hospital, he was on [MEDICATION NAME] (liquid narcotic medication). He had declined a lot and I knew I would never be able to heal that. I feel definitely at the end he was very comfortable the [MEDICATION NAME] once it got increased. During care he was in discomfort. In an interview, on 8/13/20 at 9:17 AM, CNA E reported, On Sunday (7/12/20 first shift), my immediate help is what can we do comfort-wise? (R2's) scrotum was engorged. What can we do to help him? It was uncomfortable for him to walk. What could we put on him that wouldn't bind or pinch? You could tell by his face and grimacing he was in pain . We applied cold compresses - that seemed to help some . (R2) was in pain when scooting. (CAN GG) sat with him on her breaks to talk to him and we put country music. He used to sing with music. I don't do a lot of the charting. It is done on the computer. It gives an alert if it's been seven shifts. I'm not tech savvy. I don't know if you can go back to fill it in. It will go in the red if we haven't charted. In an interview, on 8/12/20 at 10:10 AM, LPN K (who worked first shift 7/13/20) reported, In report from (RN L) and she told me about (R2's) rectum and wanted me to look at it with her. After she left, I took measurements. The skin tear was hard to see because it blended in with the bruising. She said he had an enema and she wasn't sure what happened. (R2) had very soft stool so the bleeding wasn't from that. I called (Unit manager AA) supervisor and told her about it. I asked her to come down to see it. I said, This is concerning. I told her about the rectal bleeding, bruising and skin tear. (RN J) was still in the supervisor's office and I heard her saying the bruising was possibly from him plopping down and the bleeding could be from a hard stool and she said nothing about the skin tear. (Unit manager AA) came down and saw it she seemed shocked when she saw it. It wasn't as the notes described it. This did not just appear. His scrotum was not swollen the day before. I've never seen anything like that from an enema. I know him well enough and seen him a few days before. He just appeared painful and not getting up he didn't want to sit up. He laid on his side and seemed different, looked very tired, he looked out of it - there was a look in his eyes. He wasn't himself. He never got better, never walked again, or used a urinal again. His stools were soft almost, liquid and a couple times blood tinged. The blood on the pad, I thought was coming from his rectum. When I was there, the doc or (physician extender) did not visit him. The Bowel protocol says after 7 shifts MOM, after 8 shifts a suppository, after 9 shifts it would be an enema. Does not say give 2 enemas. (RN L) told me that (RN F) gave 2 enemas and that they walked him and that he had prune juice and milk of magnesia on her shift second; she comes in at 6:00 PM - 10:00 PM). I think he was on the Bowel Program and already had an enema. Sometimes it doesn't get cleared on the dashboard (computer). That's why we look at their actual tasks bowel records and what the aides wrote. I didn't look back to see if the shift before her gave MOM. No, she didn't follow the protocol. I did not receive education after this happened. I heard he had 240 or 360 prune juice. That is not part of the bowel protocol. I heard she gave MOM in the prune juice. I feel that he should not have 2 enemas. I asked (RN L) and did (RN J) to come down and see this they said no. Not sure where the bruising came from or how that would have happened. The CNAs said that he was walked laps and given a lot prune juice and MOM and I was told the first one (enema) didn't all go in. I think maybe the enema caused the bruising. Maybe (R2) was poked with the enema roughly. He's had plenty of enemas and we've never held him down. If I knew that they had 2 aides holding him down, I would say he was refusing and that was abuse. Walking him if he was tired? He shouldn't have been walked a lot like they said. He should have been left alone . (RN J) didn't follow protocols. Review of the education RN J received revealed, Education on Policy and Procedure of disposable enemas . 1. Enema procedure - policy provided; 2. Impacted (stool), dis-impaction, scope of practice; 3. Manual removal of fecal impaction; 4. Assessment . Complete an abdominal assessment (bowel sounds, abdominal extension, pain or discomfort with our without touch to abdomen); 4. Options other than digital dis-impaction: Abdominal flat plate (x-ray), Monitor/assess resident; 5. Communication with physician .In the future, I will assess the resident and the need for initiating or continuing the Bowel Program, to prevent the potential of trauma during procedure . The document was signed and dated by DON B and RN J on 7/21/20 (not timed). Review of R2's Medication Administration Record [REDACTED] 1. Linzess Capsule 72 MCG. Give 1 capsule by mouth in the morning related to constipation (start date 5/08/20 - end date 7/28/20). 2. Polyethylene [MEDICATION NAME] Powder (also known as [MEDICATION NAME]) give 17 gram by mouth in the morning for constipation (start date 4/30/20 - end date 7/28/20). 3. Senna-[MEDICATION NAME] Sodium Tablet 8/6-50 mg. Give 1 tablet by mouth at bedtime for constipation (start date 4/28/20 - 7/28/20). 4. Bowel Program per facility protocol every 8 hours as needed for Constipation: no bowel movement on the 7th shift Give 30 ml of Milk of Magnesium; no bowel movement on the 8th shift Give [MEDICATION NAME] suppository; no bowel movement on the 9th shift Give [MEDICATION NAME] enema. If no bowel movement on the 10th shift contact physician (start date 4/29/20 - end date 8/02/20). Review of R2's Care Plans revealed he did not have a plan of care for bowel function/dysfunction. Review of R2's Bowel Elimination Record (documented by CNAs) revealed the 2:00 PM - 10:00 PM shift on 7/08/20 was blank, indicating that R2's bowel elimination had not been documented on that shift and therefore, it could not be determined whether he had had a BM during that timeframe. If R2 had a BM on that shift, it would mean, according to the Bowel Protocol, it should not have been initiated/medication should not have been administered on 7/11/12 at all. The Professional Standard of Quality for documentation of the residents health care in a medical record is the information must be true and complete. (Fundamentals of Nursing, Concepts, and Practice. Mosby. Potter, P.A., Perry, A.G., 1985) R2's Medication Administration Record [REDACTED]. There was documentation on the MAR indicated [REDACTED]. Review of Nursing Progress Notes revealed the above nurses did not notify the physician regarding their decisions to administer these medications/procedures. In it's entirety, the facility Bowel Program, dated 2/28/19, read as follows: Policy Statement: Nursing department will pursue and provide such care as will refresh and provide comfort to the resident and assure that elimination is occurring appropriately Purpose: To aid in evaluation of resident's bowel habits, to establish regular routines, and to decrease or prevent the incidence of constipation. Forms used: Bowel program is monitored in PCC (Point Click Care Electronic Medical Record); Procedure: Residents are assessed upon admission by nursing department in regard to the resident's bowel pattern and bowel regularity. All CNA's must address bowel movements in PCC. Alerts will be sent to the nurse in appropriate time frames rt (sic). If no BM (bowel movement) in six shifts, beginning on the seventh shift, the nurse will give 30 cc's of MOM (Mild of Magnesia) p.o. (orally). If no results, at the beginning of the eight shift, a [MEDICATION NAME] suppository is given rectally. If no results, at the beginning of the ninth shift, give [MEDICATION NAME] Enema. If no results are recorded, consult physician. *May given 30cc's MOM with physician's orders [REDACTED]. Review of the facility Disposable Enemas Policy and Procedure, (not dated) revealed, no instruction to administer a second enema if only a partial enema is administered, did not instruct(TRUNCATED)

This citation pertains to Intake Number MI 461 Based on interview and record review, the facility failed to ensure adequate monitoring for [MEDICATION NAME] and [MEDICATION NAME] use in one (Resident #2) of two reviewed for medications, resulting in an elevated [MEDICAL CONDITION] Stimulating Hormone (TSH) level and hospitalization with a [DIAGNOSES REDACTED]. Findings include: Review of the medical record revealed Resident #2 (R2) admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed R2 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of R2's Physician order [REDACTED]. When giving Dig monitor pulse if< than 60, hold Dig and notify the physician. Another physician's orders [REDACTED]. Review of R2's labwork dated 8/3019 revealed a [MEDICATION NAME] level was never performed. The TSH level was 5.09. A normal level was 0.36-3.74. Review of R2's Physician order [REDACTED]. The physician's orders [REDACTED]. The medical record revealed the recheck in 2 months was never performed. R2's TSH was rechecked on 12/11/19, after she returned from the hospital, and was 8.79. Review of the Medication Administration Records (MARs) and the Progress Notes revealed [MEDICATION NAME] was held by Licensed Practical Nurse (LPN) G on the following dates due to a pulse of less than 60 and the physician was not notified, per orders: 9/16/19, 9/17/19, 9/21/19, 9/22/19, 10/1/19, 10/21/19, 11/3/19. LPN E administered [MEDICATION NAME] to R2 when the pulse was documented as less than 60 on the following dates: 11/19/19, 11/23/19, 11/28/19. There was no pulse documented with administration of [MEDICATION NAME] on the following dates: 8/31/19, 8/31/19, 9/1/19, 9/2/19, 9/3/19, 9/4/19, 9/5/19, 9/6/19, 9/7/19, 9/8/19, 9/9/19, 9/10/91, 9/11/19. 9/12/19, 9/13/19, 9/14/19, and 9/24/19. In an interview on 3/4/20 at 9:22 AM, LPN E reported she gave the [MEDICATION NAME] on 11/19/19, 11/23/19, and 11/28/19 when R2's pulse was below 60 because R2's daughter/responsible party wanted her to. When asked about the pulse not being documented in August and September, LPN E reported it must not have popped up on the MAR indicated [REDACTED]. In an interview on 3/4/20 at 10:20 AM, LPN G reported she held R2's [MEDICATION NAME] when her pulse was less than 60. When asked about notifying the physician, LPN G reported that would only be done if the [MEDICATION NAME] was held for three to four days in a row. LPN G reported she never notified the physician when the [MEDICATION NAME] was held and was not aware there was an order to do so. When asked about the pulse being documented with the administration of the [MEDICATION NAME], LPN G reported the pulse should be on the MAR. In an interview on 3/4/20 at 9:45 AM, Registered Nurse (RN) Supervisor D reported the physician should be notified if a pulse was less than 60 and [MEDICATION NAME] was held. RN Supervisor D reported the notification should be documented in the progress notes. RN Supervisor D reported she did recall that R2's daughter/responsible party wanted the [MEDICATION NAME] administered even if the pulse was less than 60, but reported there should have been documentation that the physician was notified of that. When asked about R2's [MEDICATION NAME] level not being done on admission and the TSH level not being rechecked in October 2019, RN Supervisor D reported that at that time, the clerk was new to the facility. RN Supervisor D reported she was not sure how the labwork was missed. When asked if anyone verified that the clerk entered the orders correctly or that the order was completed as ordered, RN Supervisor D stated No, not really. I just ask if admit labs have been done. I don't go back in and research what has been done. In an interview on 3/4/20 at 11:00 AM, Director of Nursing (DON) B reported R2 did not have an admission [MEDICATION NAME] level done as ordered. DON B reported the missing labwork was discovered when R2 was transferred to the hospital and diagnosed with [REDACTED]. When asked if there was any double check system done after the ward clerk entered laboratory orders, DON B reported the facility had a nurse to nurse double check system in place for medications. When asked if it was done for labwork, DON B stated not necessarily, probably not. DON B reported she was not aware that R2's TSH level was not repeated in October, as ordered and was not aware there was no pulse documented with the administration of multiple [MEDICATION NAME] doses. DON B reported she was not surprised nurses administered the Digxoin if R2's pulse was under 60 because R2's daughter ran the show. When asked what staff should have done, DON B reported the nurses should have held the [MEDICATION NAME] and notified the physician. DON B reported she thought holding [MEDICATION NAME] and notifying the physician of a pulse under 60 was a standing order. Review of the Nursing Note dated 12/3/19, revealed resident sitting at desk in wheelchair. resident slouched over and became unresponsive. resident has right side facial droop. right pupil unresponsive. unable to move arm on right side did not know own name. R2 was transferred to the hospital. Review of the hospital History and Physical dated 12/4/19, for the admission date of [DATE], revealed When the patient presented to the ER she was found to have elevated [MEDICATION NAME] level and complained of chest pain, and had unusual changes on her EKG. R2's [MEDICATION NAME] level was 2.89 ng/mL, which was a critically high level. A normal [MEDICATION NAME] level should be between 0.5-2 ng/mL. R2's [DIAGNOSES REDACTED]. R2 readmitted to the facility on [DATE]. She transferred to the hospital again on 1/10/20 and was not in the facility at the time of the survey. [MEDICATION NAME] is a medicine that is used to treat certain heart conditions. [MEDICATION NAME] toxicity can be a side effect of [MEDICATION NAME] therapy. It may occur when you take too much of the drug at one time. It can also occur when levels of the drug build up for other reasons such as other medical problems you have. The most common prescription form of this medicine is called [MEDICATION NAME] .If you take [MEDICATION NAME] medicine, you should have your blood level checked regularly. Blood tests should also be done to check for conditions that make this toxicity more common. (https://medlineplus.gov/ency/article/ 5.htm)

Based on observation, interview and record review the facility failed to ensure that emergency care which includes staff training and competency for implementation of emergency interventions for, at a minimum, cardiac/respiratory complications, and included provision of appropriate equipment at the resident's bedside for immediate access, such as during an unplanned extubation (trach tube falls out) for 1 of 1 sampled residents (#118) evaluated for [MEDICAL CONDITION] care resulting in the likelihood of failure to maintain the airway in case of obstruction or accidental dislodgement of the [MEDICAL CONDITION] and death. Findings include: A review of the (facility name) Facility Assessment reflected the following: We take each admission on a case by case basis with examinations of the medications ordered, supplies the resident needs as well as equipment .It is extremely important to us that we accept people that we have the clinical knowledge and expertise to take of (sic) along with the equipment to provide care .We review to assure that we can meet all the residents (sic) needs to maintain or improve their level of wellness and functioning .Supplies and equipment are easily obtained for needs of the resident. We are able to assess needs for our residents in advance of admission and obtain the equipment needed and any training required . Resident #118 (R118) A review of the undated facility policy with no physician's signature, titled, Trach([MEDICAL CONDITION])/Stoma (surgical opening) Cleaning and Suctioning, reflected no procedures or mention of what emergency equipment and supplies should be kept at bedside for a resident with a trach. There were no emergency procedures for choking,[MEDICAL CONDITION] (from the stoma) or mucous plugs. A review of the facility's document titled Admit/Readmit Screener, dated 10/22/18, reflected that R118 was admitted to the facility on [DATE]. A review of the care plans for R118 reflected [DIAGNOSES REDACTED]. The care plan indicated R118 was totally dependent on one to two staff for all activities of daily living. A review of the respiratory plan of care, last revised on 1/29/19, for R118 reflected a goal of Airway will remain patent. Interventions included,[MEDICAL CONDITION] as ordered. [MEDICAL CONDITION] as needed. Humidify with saline bullets as needed. Maintain/apply oxygen as ordered/needed. NMT (nebulizer) treatments as ordered checking pulse oximetry (measure oxygen in the blood without a blood test) and lung sounds pre- and post-treatments. The care plan failed to state the size [MEDICAL CONDITION] and the type of inner cannula (disposable or cleanable) R118 had, and how [MEDICAL CONDITION] was to be done. According to the facility's document titled, Code Status R118's responsible person had determined he would not be resuscitated if his breathing or heart stopped, and he was receiving comfort care services from the facility. On 4/15/19 at approximately 10:10 a.m., R118 was observed in his bed in his room on his left side with a blue bolster (support pillow) at his back. The joints of his elbows and wrists were contracted (frozen in a bent position). His eyes were open, as was his mouth. When spoken to gently, there was no response with eye movement or position. A humidifier and suction set-up were observed in the room. The suction set-up was on a stand and did not have a suction cannula attached, but there were some packages of suction cannulas in the drawer of the stand. The humidifier was turned off, and R118 was breathing room air (no oxygen used). A search of drawers and the closet in the room reflected no Ambu bag (manual breathing assist device, used with or without oxygen), [MEDICAL CONDITION] nor extra inner cannulas (trach tubes have an outer cannula that remains in the resident and an inner cannula that is either replaced or cleaned according to physician's orders [REDACTED]. On 4/15/19 at approximately 10:15 a.m., Licensed Practical Nurse (LPN) Q was asked to show this surveyor an ambu bag and an extra [MEDICAL CONDITION] kit in R118's room. LPN Q could not find the equipment in his room. In the extra med room, located near R118's room and the nurse's station, LPN Q was unable to locate the requested equipment. When asked to identify if there were extra [MEDICAL CONDITION], LPN Q could not say, but this Surveyor observed a box of Shiley size six, individually packaged, disposable inner cannulas, in a box on the table in the extra med room. LPN Q called Registered Nurse (RN), Unit Manager R and she pointed to the inner cannulas in the extra med room. She also suggested that a physician had come in during the night, and [MEDICAL CONDITION] might have been changed due to a build-up of secretions ([MEDICAL CONDITION]). This physician also prescribed steroids for R118 to keep the secretions down. RN R showed this Surveyor where the Ambu bag was kept in a locked room on the crash cart, down and around 2 hallways to the other nurse's station. RN R said that [MEDICAL CONDITION] supplies were kept in the central supply room in the basement. When asked if the Ambu bag would connect to R118's trach, RN R didn't know. On 4/15/19 at approximately 10:20 a.m., RN R and this Surveyor visited the supply room in the basement. When asked, Central Supply (CS) Clerk V was unable to locate any size 6 [MEDICAL CONDITION], but there were split gauzes, inner cannulas [MEDICAL CONDITION] kits available. RN R asked CS Clerk V to order an Ambu bag that will connect with a trach. When asked who had keys to the locked central supply area, this Surveyor was told management (Director of Nurses (DON), Nursing Home Administer (NHA), Assistant NHA, unit managers, central supply staff and maintenance had keys. Staff nurses and aides did not. On 4/15/19 at 10:37 a.m., LPN Q was observed as she [MEDICAL CONDITION] to R118 in his room. The care provided held to current standards [MEDICAL CONDITION] and infection control. Again, there was no Ambu bag or [MEDICAL CONDITION] kits observed in the resident's room. On 4/16/19 at 11:05 a.m., NHA A and DON B were presented with an Immediate Jeopardy Notification due to the facility's failure to have emergency and [MEDICAL CONDITION] and supplies at the bedside. A corrective action plan was requested from the facility to remove the immediate jeopardy. NHA A commented that R118 was a no-code, on comfort care and did not need an Ambu bag in his room. On 4/16/19 at 1:00 p.m., DON B suggested that they had worked so hard to prepare for R118's admission to the facility since there had been no residents with trachs for many years. We did so much training, DON B said, and emergency equipment was readily available in the crash cart. When asked, DON B said nurses had been trained on suctioning and cleaning of trachs, and provided sign-in sheets that showed training was done on (MONTH) 2nd and 3rd, 2019. DON B was encouraged to review the regulatory language at F695. DON B suggested that she knew R118 when the injury occurred. He was [AGE] years old, sustained injuries during football practice, was cleared in the emergency department but developed severe symptoms a few days later. R118 had [MEDICAL CONDITION] then, approximately [AGE] years. Immediate Jeopardy was removed on 4/16/19 when the facility had the following in place: One resident was identified that may have been effected by the alleged noncompliance. A physical assessment was performed on the identified resident (4-17-19 at 1015) and he was found to have suffered no ill effects from the alleged noncompliance. On 4-16-19 at 1300 (1:00 p.m.) a supply cart/three drawer containing the following equipment: 5 Shiley Inner Cannulas, 2 [MEDICAL CONDITION] Care Trays With Vinyl Gloves, 2 AirLife Nebulizer Caps, 5 AirLife [MEDICAL CONDITION] Holders, 3 Suction Catheter Trays with Chimney valve, 2 AirLife Adult [MEDICAL CONDITION] Masks, 2 Aerosol Drainage Systems, 2 AirLife Corrugated Flexible Polyethylene and EVA Tubing, 1 Adult Spur Il Ambu bag compatible with resident'[MEDICAL CONDITION] placed in the resident's room and will be recreated for subsequent [MEDICAL CONDITION] residents. In addition, on (MONTH) 15 at 1300 the facility ordered two #6 Shiley [MEDICATION NAME] trachs and they arrived on (MONTH) 17, 2019. On (MONTH) 16 at 1720 the facility took receipt of one #6 Shiley [MEDICATION NAME] trac(h) and it was placed in the resident room supply cart/ 3 drawer. Nursing staff (23 RNs and 23 LPNs) education began on 4-16-19 and is ongoing to ensure recognition of correct and appropriate equipment and it's proper use. Education will be completed no later than Monday (MONTH) 22, 2019. No nurses will be allowed to care for the identified resident until they have received proper demonstration of suctioning, cleaning and return demonstration of Ambu bag [MEDICAL CONDITION]. The facility completed nursing department education on (MONTH) 3, 2019 regarding demonstration and return demonstration of [MEDICAL CONDITION] cleaning and suctioning. Necessary [MEDICAL CONDITION] equipment to be maintained in a resident's room has been added to the facility's [MEDICAL CONDITION] care policy and procedure. Included in the identified necessary equipment is an Ambu-bag, additional inner cannulas, [MEDICAL CONDITION] and [MEDICAL CONDITION] kit. The equipment in the [MEDICAL CONDITION] cart will be maintained daily by the Purchasing Director/facility stocking clerk. Facility supervisors have 24hour access to central supply and are responsible for maintaining par levels when the Purchasing Director/facility stocking clerk are unavailable The item name and quantity of supplies removed are to be placed on the outgoing supply list located in Central Storage. The facility policy and procedure regarding [MEDICAL CONDITION] care (including par levels) is posted on the [MEDICAL CONDITION] supply cart/ 3 drawer to ensure proper par levels are known and adhered to. In addition to [MEDICAL CONDITION] supplies to be kept in resident's rooms, general supply has and will maintain additional backup supplies at a minimum par level of two. Central supply tracks and reorders supplies via incoming and outgoing supply list. A review of the facility's policy and procedure, updated on 4/16/19, [MEDICAL CONDITION] Care Policy and Procedure included the following additions at the end, Equipment: Suction machine and suction catheter, Distilled or sterile water, Normal saline, [MEDICAL CONDITION] cleaning kit, Extra inner cannula tube if necessary, Ambu bag, Trach/Obturator (used to [MEDICAL CONDITION] stiff enough to reinsert). A review of Nursing Education Attendance sheets reflected that 33 nurses had been educated as stated in the removal plan. On 4/17/19 at approximately 10:00 a.m., a #6 [MEDICAL CONDITION] observed in the drawer of the plastic supply cart. The Ambu bag and extra inner cannulas were also present in the room. On 4/17/19 at 2:20 p.m., Staff Educator X was interviewed. When asked what education she had provided [MEDICAL CONDITION], Staff X said she first looked at the policy and procedure in (MONTH) (YEAR), when she first came to work at the facility. I went over suctioning, cleaning,[MEDICAL CONDITION] changes with all the nurses to find out what they knew and to gauge where they were, she said. This was not hands-on training. There had been [MEDICAL CONDITION] training that Staff X knew of. On 4/17/19 at 2:44 p.m., Infection Control Nurse S was interviewed. When asked, IC Nurse S said she covered changing the inner cannula, cleaning the inner cannula, dressing change, tie change and suctioning on a mannequin during our skills event on (MONTH) 2nd and 3rd of this year. After R118 was admitted , we had to pull some old policies and one was redone. Nurses [MEDICAL CONDITION], Nurse S said, The former DON may have done training, but I'm not aware of it if she did. Nurses asked questions [MEDICAL CONDITION], and I answered them. Only a few nurses weren't trained at the skills event in early April, and they haven't yet returned to work. They will have to [MEDICAL CONDITION] before they work with R118. There was no [MEDICAL CONDITION] for nurses that Staff X knew of. On 4/18/19 at approximately 10:15 a.m., Purchasing Manager (PM) U was interviewed on the process to [MEDICAL CONDITION] in central supply and rooms as follows, CS Clerk V will inventory the supplies in the resident's room and replace them daily Monday through Friday. The supervisors will fill in on the weekends. CS Clerk V will replace supplies weekly in central supply. When supervisors remove supplies from central supply, they write it on a clip board, including where they took the supply. There were actually 2-#6 Shiley trachs on a shelf in central supply the whole time, but no one knew it. CS Clerk V fills out a list of supplies to order, we have levels to keep on hand for everything. Two [MEDICAL CONDITION] were ordered. When asked, PM U said, As far as I know, R118 has the [MEDICAL CONDITION] was admitted with. The [MEDICAL CONDITION] ordered arrived late Tuesday and the second arrived Wednesday. On 4/18/19 at 10:27 a.m., LPN Z was interviewed. When asked what she would do if she found R118'[MEDICAL CONDITION] his pillow said she would replace it and give him oxygen. If his heart was not stopped, I would use the Ambu bag to his stoma. On 4/18/19 at 10:35 a.m., LPN Aa was interviewed. When asked what she would do if R118'[MEDICAL CONDITION] out, LPN Aa said, Ideally, I would would call for help. R118 was a no resuscitation, but it would still be an emergency. I would check for blockage, stay with him and give him oxygen through [MEDICAL CONDITION] in the hole in his throat. On 4/18/19 at approximately 9:00 a.m., DON B was interviewed. When asked, DON B said if R118'[MEDICAL CONDITION] out, she would expect the nurse to pop it back in and administer oxygen. A [MEDICAL CONDITION] not the first choice but better than going without. DON B said she would do this via the Ambu bag and oxygen to assist with breathing until the ambulance arrived. I'm meeting with every nurse for them to demonstrate how to attach the ambu bag to [MEDICAL CONDITION] making them aware that supplies are now in his room. DON B said. When asked, DON B said she had not trained/educated nurses about what to do if [MEDICAL CONDITION] out. We used a [MEDICAL CONDITION] from the hospital for our skills fair in early April, DON B said. On 4/18/19 at 9:10 a.m., RN T was observed as he prepared [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 20 milligrams daily for R118. When asked, RN T said that R118 was prescribed the medication in the hospital, and had taken it since returning to the facility on [DATE].When asked what he would do if he discovered R118'[MEDICAL CONDITION] on his pillow, RN T said he would call 911, set R118 up some and put oxygen on him by putting [MEDICAL CONDITION] over the stoma. He would not attempt to replace [MEDICAL CONDITION]. On 4/18/19 during the morning, a confidential staff interview was conducted. This staff person reported that there had been [MEDICAL CONDITION] kits in central supply for months, but that the clerk didn't realize what they were. On 4/18/19 at 10:55 a.m., an email was sent to NHA A requesting to speak with Physician/Medical Director Y. At 11:32 a.m., the following email response was received from NHA A, I contacted (Physician Y) and he is swamped. He will not be over to the facility. He was here all day yesterday. Although the Immediate Jeopardy was removed on 4/16/19, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

Based on observation, interview and record review the facility failed to prevent the development of an unstageable pressure ulcer for 1 (Resident #22) of 5 residents reviewed with pressure ulcers, resulting in surgical debridement and upon opening a stage 4 pressure ulcer. Findings Include Resident #22: Resident (R) #22 was interviewed on 05/23/18 at 10:36 AM. During the interview R22 was asked to inform the writer about the pressure ulcer on her bottom. R22 revealed, I go once a week to a wound clinic in (name of nearby city) , they measure it and take care of it . Also, that she had the pressure ulcer last year. R22 was observed sitting up in her recliner on her bottom tilted back, no padding was noted under her bottom other than a blue colored bed pad, and her feet were elevated. An air mattress and a heels up device was noted on top of her bed. R22 stated, In the bed they are supposed to turn you every 2 hours. I get my medication around 03:00 AM and bath, you have to take your turn. They did not like for me to wear a brief, when I'm in the bed. I don't like sitting in my pee, so I told my doctor I wanted to wear a brief. Review of R22's hard chart and Electronic Medical Record (EMR) on 05/24/18 at 01:14 PM, both reflected R22 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The admission MDS (MDS: resident assessment tool) for R22 with a target date of 6/14/17 reflected: R22 was cognitively intact, required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, and bathing, extensive assistance of 1 person for hygiene, and that R22 was negative for pressure ulcers. The quarterly MDS for R22 with a target date of 11/26/17 reflected: R22 was cognitively intact, required limited assistance of one person for bed mobility, transfers, hygiene, extensive assistance of 1 person for dressing, bathing and that R22 had 1 unstageable suspected deep tissue injury. The facility's Multi-Disciplinary Progress Notes (MDPN) with a start date of 6/9/17, reflected Wound Care hand written above MDPN. On 6/9/17 the note reflected R22 had been admitted , her admission skin assessment was completed, and R22 was rated a 6 moderate risk. Also that R22 was in overall good condition. On 6/15/17 the MDPN note reflected that R22's 5-day MDS et pressure sore risk assessment was completed, and had no skin issues. On 6/22/17 the MDPN note reflected that R22's 14 day MDS et pressure sore risk assessment was completed, and had no new skin issues. On 9/4/17 the MDPN note reflected that R22's quarterly MDS et pressure sore risk assessment was completed, and had no skin issues. On 11/12/17 the MDPN note reflected that R22's had a deep dark red area, and the directly center was noted a red/purplish color, and that R22 expressed tenderness. The location of the area was not documented. On 11/28/17 the MDPN note reflected that R22's quarterly MDS et pressure sore risk assessment was completed and reflected: Area Right upper buttock is now open with yellow slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) base-perimeter dark pink et bleachable-Area is now unstageable . On 12/13/17 the MDPN note reflected that the weekly assessment was completed, and R22's wound base was with thick yellow slough-edges were pink and the periwound base of the wound was a dark purple color. On 12/18/17 the MDPN note reflected that the weekly assessment was completed, slough remained thick and the Santyl treatment was not effective due to large amount of slough. On 12/27/17 the MDPN note reflected that the weekly assessment was completed, and R22's wound bed was with grey/white/yellow slough thick filling the wound, edges dark pink, periwound dark pink, wound with foul/musty odor, R22 expressed discomfort at wound area, and treatment was changed to Dakins solution. On 1/11/18 the MDPN note reflected further debridement (To remove dead, contaminated, or adherent tissue and/or foreign material. To debride a wound is to remove all materials that may promote infection and impede healing) was necessary. On 1/17/18 the MDPN note reflected R22 had an initial appointment at (name of wound clinic, in nearby city). On 2/15/18 the MDPN note reflected R22 was ordered for wound vac placement (Negative-pressure Wound Therapy (NPWT) is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds). On 2/23/18 the MDPN note reflected R22 wound as a stage four pressure injury. Weekly Skin Report/CNA (Certified Nursing Assistant) sheets usually completed by CNA's and signed by a nurse during the acceptance and/or refusal on bath/shower days were negative for any marked area on her bottom until 11/14/17. On that date a circle was drawn on a body of a person near the buttocks area, and the word TX (presumably treatment) was written. The wound clinic doctor consultation notes dated 1/17/18 reflected: Reason for visit: wounds first visit. Findings: wound measurement Left gluteus 0.9 x 1.1 x 2 undermined circumferential 3 centimeters (cm). [DIAGNOSES REDACTED]. The wound clinic doctor consultation notes dated 1/26/18 reflected: Reason for visit: wound. Findings: Pre-debridement measurements: 1.9 x 1.2 x 2.3 with undermining 12-12 = 2.8 cm. Post debridement measurements: 1.9 x 1.2 cm 3.2 with undermining 12-12 = 4 cm, and reflected a new order for a surgical consult. [DIAGNOSES REDACTED]. A Physicians Progress Note was noted completed for R22 dated 11/15/17. There were no checks/notes next to the Skin section or under the Assessment/Plan section that reflected concerns. A Physicians Progress Note, was noted completed for R22 dated 12/20/17. Near the top of the sheet reflected, .Tx in place for sore on bottom . There were no checks/notes next to the Skin section. Under the Assessment/Plan section, 1. Apprec. wound care, was the only thing written related to R22's pressure ulcer. On 05/24/18 at 11:44 AM wound care LPN (EE) revealed R22 had treatments for a stage 4 pressure ulcer to her right buttock, R22 developed the pressure ulcer at the facility, a treatment nurse or floor nurse normally did dressing changes, and measurements were done at the wound clinic in a nearby city. LPN EE revealed R22 opened area started off as reddened areas, then an unstageable pressure ulcer, and then a stage 4 pressure ulcer. R22's dressing was change on 05/24/18 at 01:36 PM, by LPN (PP). When R22's old dressing was removed from the right buttock, an odor and a small amount of yellow colored drainage was observed on the dressing. The opened area appeared to be about 1 inch in circumference with tunneling. R22 complained of mild pain/discomfort during the dressing change. On 05/24/18 02:08 PM R22 revealed, she liked to sit up in her chair before she got the pressure ulcer and would tell staff her butt was sore. On 05/24/18 at 02:35 PM hard chart review continued reflected R22's pressure sore risk assessment had a hand written entry that reflected: Right (arrow up) buttock/sacral = SDTI 11/12/17. The (YEAR) HealthComMedia online reference reflected: The National Pressure Ulcer Advisory Panel (NPUAP) defines an SDTI as a Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The Pressure sore risk assessment dated [DATE] reflected a line written through unstageable and hand written- Rt. upper buttock change (arrow) stage 4 and the #1 in the quarterly column as (1) by S/P Pressure Ulcers. R22's thin chart requested and provided on 5/24/18 at 14:57 AM, had an physicians' order dated 1/11/18 for an initial appointment at the wound clinic, and reflected an appointment date of 1/17/18 at 08:00 AM. On 05/25/18 at 09:52 AM LPN EE and Registered Nurse (RN T) were interviewed about how the facility failed to prevent the development of an unstageable / stage 4 pressure ulcer. RN T revealed she initially saw R22 on 11/12/17, and the area was considered a suspected deep tissue injury because it was non-blanchable at the center. When RN T was asked what may have caused the pressure ulcer RN T stated, She previously had been independent with toileting and at wheelchair level and was changed to assist x 1 on 11/9/17. She had a specialty mattress, pressure relieving mattress and pad on her wheelchair. Everyone was a 2 hour turn, and pillows were to be put under her legs. RN T revealed that R22's skin issue was not brought to her attention until 11/12/18 by a charge nurse. Both nurses looked at the chart and revealed they could not find documentation related to any description and/or monitoring of the unstageable area prior to 11/12/17. Prior to RN T being summoned to view the area, neither nurse had been informed of any skin irregularities related to R22.

These citations pertain to intake numbers MI 394 & MI 480. Based on observation, interview, and record review, the facility failed to: 1.) provide adequate supervision to prevent the elopement, and ensure the safety in 1 of 3 sampled residents (Resident #500) reviewed for elopement, from a total sample of 4 residents, resulting in Immediate Jeopardy for Resident #500 who was at risk for elopement and had a history of [REDACTED].#500 climbed a 5 foot courtyard fence and eloped from the facility, unbeknownst to the facility staff, then was found approximately 1/4 of a mile walking down the road by an off duty employee. This deficient practice places all 8 residents, who wore "Code Alert" bracelets, at a high risk for serious harm, injury, and/or death, and 2.) transfer a resident per facility policy in 1 of 4 sampled residents (Resident #501) reviewed for falls, from a total sample of 4 residents, resulting in Resident #501 sustaining a L4 (lumbar/lower spine) fracture after an inadequate transfer. Findings include: Per the Face Sheet Resident #500 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Court Order dated 8/20/2014 revealed that Resident #500's spouse was appointed as his guardian, due to Resident #500's inability to totally not care for his self. Review of the "Minimum Data Set" ((MDS) dated [DATE] revealed Resident #500 had a "Brief Interview for Mental Status" (BIMS) score of 15 out of 15 which indicated he was cognitively intact. The MDS revealed that Resident #500 required limited assistance with transferring, ambulating, and locomotion. In an interview on 4/30/2015 at 9:17 AM, Visitor #5 reported that on 4/16/2015 as she was walking across the parking lot, she saw Resident #500 at the courtyard fence, standing on his walker, and going over the fence. Visitor #5 reported Resident #500 was pretty much over the fence and she yelled "no!" and Resident #500 got down. Visitor #5 said staff must have heard her yell, because a lot of staff came out to get Resident #500 back into the building. Visitor #5 said she could not remember if other staff, visitors, or residents were out in the courtyard at the time Resident #500 was climbing over the fence. In an interview on 4/29/2015 at 11:45 AM and 3:05 PM, and again on 4/30/2015 at 10:30 AM, Director of Nursing (DON) #6 and Administrator #7 said Resident #500 had made an attempt to climbed the fence on 4/16/2015. DON #6 and Administrator #7 said they did not observe or see Resident #500 on the courtyard fence. DON #6 and Administrator #7 said they heard Licensed Practical Nurse (LPN) #5 yelling, and went out to the courtyard, but Resident #500 was walking back towards the building, and was very sweaty. DON #6 said that on 4/26/2015, when Resident #500 climbed over the courtyard fence he had left the dining room and that no other staff member or resident was in the courtyard at the time Resident #500 climbed over the fence because it was meal time and all residents were in the dining room eating. DON #6 said Resident #500 had told her that he could leave if he wanted too. DON #6 said Resident #500 always talked about getting out of the facility, and stated that Resident #500 said he felt like he was in a prison. DON #6 said Resident #500 walked everywhere around the facility and that was why he had a WanderGuard bracelet on (a bracelet put on and alarms a WanderGuard protected door when the resident gets to close to the door). DON #6 said Resident #500 was placed on 1:1 supervision after his elopement on 4/26/2015, but no other increase in supervision was put into place after 4/20/2015 when Resident #500's every 1 hour checks were discontinued. DON #6 stated, "How could we have known he (Resident #500) could climb the fence. In an interview on 4/29/2015 at 12:50 PM, Resident #500 stated that he wanted out of here (the facility). Resident #500 said he went over the fence a couple of nights ago. Resident #500 said he used his walker to get over the fence. He said when he got to the top of the fence he rolled his body over the top and landed on the other side. Resident #500 said he walked down the road where a girl picked him up and brought him back to the facility. Resident #500 said he was going to his house that was about 2 blocks away from the facility. Resident #500 said he had houses that needed to be worked on. Resident #500 said he "jumped" the fence, should not have, but he did. In an observation on 4/29/2015 at 12:50 PM this surveyor noted Resident #500 as he ambulated in his room. Resident #500 had a very unsteady gait. Resident #500 was observed to not use his walker. Review of a care plan titled, "Behavioral Symptoms" dated 4/16/2015 revealed an intervention for every 1 hour checks for 24 hours. The care plan revealed an intervention dated 4/20/2015 to discontinue the every 1 hour checks on Resident #500. The care plan did not indicated Resident #500 had a WanderGuard bracelet on, or that Resident #500 voiced that he wanted to leave the facility and could if he wanted to. After 4/20/2015 no other interventions were noted to have been put in place for Resident #500's behaviors and verbalization of wanting to leave the facility. Upon review of all care plans in the medical record for Resident #500 no care plan was noted in regards to Resident #500 wandering, that he wore a WanderGuard bracelet, or that he verbalized he wanted to leave the facility, and could if he wanted to. Review of the facility Incident Report dated 4/27/2015, revealed that Resident #500's wife was visiting him and that they had an argument on 4/27/2015 at approximately 4:30 PM. The report revealed that Resident #500 told his wife that he wanted a divorce. The report revealed that Resident #500's wife had left the facility shortly after the argument. The incident report revealed that Resident #500 was upset and went outside to the courtyard, climbed the fence that enclosed the courtyard, and walked down the road where the speed limit was 35 Mph, towards the bowling ally. The report revealed that Resident #500 was not visualized (by staff, visitors, or other residents) when he climbed the fence and left the facility. The report revealed that Resident #500 was picked up by an off duty staff member and brought back to the facility. In an interview on 4/30/2015 at 9:30 AM, LPN #1 said on 4/26/2015 at approximately 5:30 PM, she was driving down the road the facility was on, when she saw Resident #500 walking down the same road. LPN #1 said initially when she saw Resident #500 she was not able to stop where he was standing due to traffic behind her. LPN #1 said she called every phone number she could think of at the facility, but stated that she could not get anyone to answer the phone. LPN #1 said she went around the block (loosing site of Resident #500) and when she arrived back to where Resident #500 was, he was further down the road. LPN #1 said she was able to get Resident #500 into her car. LPN #1 said Resident #500 was very sweaty. LPN #1 said Resident #500 was walking in the grass. LPN #1 said Resident #500 asked her to not take him back to the facility. LPN #1 said she took Resident #500 back to the facility and reported the incident to the second shift supervisor. In an interview on 4/30/2015 at 10:00 AM, Certified Nurse Aid (CNA) #4, who had been employed with the facility for one month, said during dinner time on 4/26/15 around 5:00-5:30 PM Resident #500 was in the dining room with his wife. CNA #4 said Resident #500 and his wife argued, and Resident #500's wife left. CNA #4 stated that Resident #500 left the dining room approximately 10-15 minutes after his wife left. CNA #4 said she did not know where Resident #500 went when he left the dining room. CNA #4 said she saw Resident #500 when he arrived back into the building, and he was out of breath. CNA #4 said Resident #500 was on every 1 hour visual checks, but stated that the checks had been discontinued on 4/20/2015. CNA #4 stated that she worked on Resident #500's hall on 4/25/2015, and she was told Resident #500 was still on every 1 hour checks, although CNA #4 said she did not document any 1 hour checks because no other staff member showed her how too. During an observation of the courtyard fence on 4/30/2015 at 1:25 PM with Maintenance Director #5, revealed that the fence Resident #500 climbed was 5 feet in height. On 5/1/2015 at 3:00 PM, Administrator #7 was notified of the Immediate Jeopardy that was identified on 4/29/2015, and began on 4/26/2015 when Resident #500 eloped from the facility, unbeknownst to the facility staff. On 5/1/2015, the surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1). A complete head to toe assessment was completed on 4/26/2015 at 5:40 PM. No adverse effects were noted. 2). On 4/26/2015, Resident #500 was placed under 1 on 1 observation at 5:45 PM, and will remain so until further notice. 3). On 4/26/2015, physician and Resident #500's wife were notified of the elopement at 5:55 PM. 4). On 4/27/2015, the fence was examined in front courtyard (where elopement took place) at 10:30 AM the fence was found to be sturdy and solid, a staff member used walker identical to Resident #500's to attempt to climb over fence, and was successful. 5). On 4/27/2015, two local fencing companies were contacted at 11:30 AM to determine what type of fence could provide us more security for the residents. 6). On 4/27/2015, the Social Worker, Clinical Manager, and Physician Assistant met with Resident #500 to discuss his elopement as well as his state of mind. He reiterated that he was upset with his wife for telling him he will never leave here and wanted to prove to her that he could. He also said he would never do it again. 7). On 4/27/2015, the DON met with Resident #500 to discuss his elopement. 8). On 4/28/2015, a meeting was held to discuss all residents in danger of elopement and wearing WanderGuard's. There are 8 residents on the Code Alert equipment and all 8 were re-assessed for possible Elopement. All 8 residents at risk for elopement have been assessed and the care plans were updated. 9). On 4/28/2015, a meeting was held with the resident's guardian, the Social Worker, DON, and the clinical manager. Discussion was held on the importance of not taunting Resident #500 with his situation, if an argument ensues it would be better if she left. She was also asked to let staff know if they argue so the staff can be on high alert for behaviors. Staff and wife will try to offer more options to Resident #500 so that he has some modicum of control. 10). On 4/29/15, the new alarm switch was installed in the dementia unit. This alarm will sound any time the door to the patio is open and the alarm can only be turned off with a key. 11). On 4/28/2015, the magnetic lock for the exit door out of the unit was ordered from. This works in tandem with our WanderGuard system and will lock the door if Resident #500 approaches. 12). Beginning 5/4/2015, monthly audits will be conducted by the maintenance department on all Wander guard door locks, recorded, and presented to the administrator and then to QI. 13). Resident #500 will remain a 1 on 1 until all the elements of safety are installed. 14.) On 4/29/15, staff began education on Elopement. Anyone who does not attend will be personally in serviced prior to starting his or her shift by one of the nursing management staff. Thus far 105 staff out of 302 have been educated . Resident #501 Review of the Policy and Procedure titled, "Transfers/Ambulation with a Gait Belt" on page #1 under "Procedure" #5, the policy revealed, "Put on resident's stockings/socks, shoes, and gait belt. The gait belt may be put on when the resident is sitting up, if their balance allows it." Per the Face Sheet Resident #501 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed that Resident #501 scored a 6 on her Brief Interview for Mental Status (BIMS) which indicated she had severe cognitive impairment. The MDS revealed that Resident #501 required extensive assistance with bed mobility, transfers, and ambulation. Review of the Incident Report dated 4/25/2015 at 2:20 AM revealed Resident #501 had turned on her call light and Certified Nurse Aid (CNA) #3 went into Resident #501's room to assist. The report revealed that CNA #3 walked with Resident #501 to the bathroom while Resident #501 used her 4 wheeled walker. The report revealed that CNA #3 had her hand on Resident #501 and when CNA #3 went to turn off an alarm Resident #501 fell to the floor. The report revealed CNA #3 was not able to hold Resident #501 up. The incident report also revealed Resident #501 did not have any shoes or slippers on. Review of Nurses' Note dated 4/25/2015 2:20 AM revealed that Resident #501 was standing at her bedside unassisted, with bare feet, and no gait belt around her waist. The note revealed Resident #501 fell next to her bed onto her bottom with her legs out in front of her. The note revealed that CNA #3 had opened the bathroom door and then turned off the alarm, and when CNA #3 turned around Resident #501 was falling to the floor. The note revealed that an assessment was performed and Resident #501 complained of lower back pain. In an interview on 5/1/2015 at 1:35 PM, CNA #3 stated that it was her first time working on the unit Resident #501 was on (on 4/25/15). CNA #3 said Resident #501 put her call light on and she went to assist her. CNA #3 said she checked Resident #501's care card and proceeded to assist her to the bathroom. CNA #3 said there was an alarm at the top of the bathroom door which would sound if passed through. CNA #3 said she entered the bathroom door first and sounded the alarm. CNA #3 stated she was to the side of Resident #501 and Resident #501 did not ever enter the door. CNA #3 then indicated that she used her left hand to turn off the alarm while her right hand was on Resident #501's walker, and therefore Resident #501 did not get any support from CNA #3 while she reached to shut the alarm off. CNA #3 said when she turned around she could see Resident #501 was falling, but CNA #3 was not able to stop the fall. CNA #3 said she tried to grab Resident #501's arm and hand but was not successful in stopping the fall, although she was able to prevent Resident #501 from hitting her head on the bedside table. CNA #3 then proceeded to get assistance. CNA #3 stated that she did not have a gait belt on Resident #501 during the transfer. Review of a written statement by CNA #3 dated 4/27/2015 revealed, "The one thing I did wrong was not having my gait belt on. I just came back from break and forgot to put it back on." Review of a "Counseling Slip" dated 4/28/2015 revealed CNA #3 received disciplinary action as a result of, (per the counseling slip) "On 4/25/2015 it was noted you had not followed facility policy for safety." Review of a CT scan dated 4/26/2015 revealed Resident #501 had a, "Mild acute L4 vertebral body compression fracture." Observation of Resident #501 being transferred from wheelchair to bed was conducted on 5/1/2015 at 1:30 PM. It was observed that Resident #501 was very unsteady on her feet, even when assisted by two other staff members. A gait belt was on Resident #501 and was utilized for assisting Resident #501 to stand up. Resident #501 was observed to not be able to complete the task of transferring from her wheelchair to her bed without assistance of staff. Although the Immediate Jeopardy was removed on 4/29/2015, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to Resident #503 had a fall with fracture, all facility staff had not received education and sustained compliance had not yet been verified by the State Agency. ( )

Based on interview and observation the facility failed to prevent neglect after the facility delayed treatment for 12 hours after a fall with a [MEDICAL CONDITION] in 1 of 14 sampled residents (#24), reviewed for falls, from a total sample of 24 residents, resulting in unnecessary pain. Findings included: Review of the Facility Abuse Policy and Procedure (no date) reflected "Neglect- means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Review of the Facility Immediate Incident Assessment/Evaluation (no date), reflected that the "Procedure: 2. unless the Resident is in eminent danger - do not move them until after the Neighborhood Nurse has done the needed assessment and has given approval...4. Residents should not be moved until it has been determined by the Neighborhood Nurse that there is not injury (the resident has ROM (range of motion) as before) or that the injured Resident warrants being moved. The Neighborhood Nurse will also determine how the Resident is to be moved and if a maxi lift should be used, based on transfer orders, weight bearing status, and if staff is able to lift the Resident's weight." Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #24 was a [AGE] year old male admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS reflected that Resident #24's ability to make daily decisions was moderately impaired, and he required supervision with setup to walk in his room and limited assistance of one staff member to transfer from the bed or chair. Review of the Incident Report dated 2/26/15 at 6:20 a.m., reflected that "resident (Resident #24) was found lying on left side in front of (PC) personal chair on floor. Denies pain this time. Stated he tried to ambulate to bathroom and fell . When standing resident up, resident unable to bare weight to right leg. Complained right behind the knee pain. Unable to describe or rate pain at this time. No swelling noted. Bilateral knees are slightly pink. External rotation noted to right leg, bulging noted at 7:30 a.m. ...Facial grimacing and moaning." Review of the Multi-Disciplinary Progress Notes dated 2/26/15 at 6:20 a.m., reflected Resident #24 "was found lying on left side in front of (PC) personal chair on floor. Restated he was trying to use the bathroom. Denied pain until standing with assistance x 2 with gait belt. Unable to bare weight on right leg. Lowered to PC. Complained pain in right leg behind knee. No swelling noted, bilateral knees slightly red. Assisted x 3 with gait bed transferred to bed (7:00)....Facial grimacing and moaning noted upon assessment behind right knee. 7:00 - assessment concluded external rotation of right foot, bulging behind right knee, x-ray ordered..." In interviews on 3/2/15 at 6:30 p.m., and 3/3/15 at 12:40 p.m., Licensed Practical Nurse (LPN) "JJ" reported that on 2/26/15 at 6:20 a.m. Certified Nursing Assistant (CNA) "MM" found Resident #24 on the floor and came to get her. LPN "JJ" reported that she found Resident #24 on his left side in front of his personal chair, but that he was unable to state how long he had be laying on the floor. LPN "JJ" reported that Resident #24 did not complain of any pain so CNA "MM" and she raised him to a sitting position on the floor and noted that when he was sitting he was showing facial grimacing. LPN "JJ" reported that she and CNA "MM" then stood Resident #24 and noted that he complained of pain in his right knee and that he could not bear weight on his right side, so they sat him in his personal chair. LPN "JJ" stated that she "did not check range of motion (ROM)" prior to moving Resident #24 from the floor. LPN "JJ" reported that she left the room and had (3) CNA's come back in to move Resident #24 from his personal chair to his bed. LPN "JJ" reported that she did not notice external rotation until Resident #24 was laid down in bed. LPN "JJ" reported that at the 7:00 a.m. assessment in bed Resident #24 was painful, moaning, facial grimacing, unable to comprehend the pain scale, but clearly he was in a lot of pain when being assess or moved/repositioned. In an interview on 3/4/15 at 9:00 a.m., CNA "II" reported that LPN "JJ" ask her and CNA "QQ" to transfer Resident #24 from his personal chair to a wheelchair to his bed. In an interview on 3/4/15 at 11:10 a.m., CNA "QQ" reported that between 7:00 - 7:30 a.m. on 2/26/15 Resident #24 was in his personal recliner and he was wet and needed changed. CNA "QQ" reported that when she and CNA "II" stood Resident #24 from the personal chair he was not able to bear any weight on his right leg and they placed him in his wheelchair and informed LPN "JJ" that he was unable to bear any weight she told them to continue with the transfer and put him in bed, but she did not come and assist. CNA "QQ" reported that Resident #24 was putting all his weight on her during the transfer and complained about pain in the right leg when they were lifting his legs up in the bed. CNA "QQ" reported that the right foot did not lay straight. CNA "QQ" reported that Resident #24 appeared painful (facial grimacing), moaning when change and moved. In an interview on 3/3/15 at 12:05 p.m., CNA "MM" reported that on 2/26/15 she found Resident #24's door closed which was not normal, knocked and entered and found him on the floor. CNA "MM" then went and got LPN "JJ" who asked if Resident #24 was hurting looked for swelling, bruising, got vital signs, then sat him up where he appeared painful (facial grimacing). CNA "MM" reported that she and LPN "JJ" then stood Resident #24 who could not bear weight on his right side and put him in his personal chair. CNA "MM" reported that Resident #24 was painful with care the remainder of her shift whenever he was turned and repositioned. Review of the Multi-Disciplinary Progress Notes dated 2/26/15 at 7-3 shift, reflected Resident #24 "continued to be painful with any movement - laying on right side with knee bent unable to sit up very much as he complained of severe pain - Tylenol 1000 mg given with no change in pain with movement - 2:04 p.m. notified doctor of x-ray not yet taken - his physician assistant (PA) to see him (Resident #24) - text sent to her (PA). Unable to sit up enough to eat gave protein shake breakfast and lunch." In an interview on 3/3/15 at 8:20 a.m., LPN "W" reported that Resident #24 had a fall and was in pain. LPN "W" reported that she was in the room when LPN "JJ" was doing her assessment saw the external rotation of the right leg and the ball behind the back of right knee which made her think he had a [MEDICAL CONDITION]. LPN "W" reported that Unit Manager (UM)/Registered Nurse (RN) "EE" was notified of the fall and participated in part of the assessment. LPN "W" reported that he had Tylenol for pain, but she had not called for anything stronger because she thought he might go to surgery. LPN "W" reported that at approximately 2:00 p.m. she texted the physician to tell him that the x-ray had not been completed and the Tylenol was not helping. Review of Text to Physician from Nurse dated 2/26/15 2:04 p.m. revealed, "has still not had his x-ray and we can not move him with out pain, Tylenol not working." Review of Text to Nurse from Physician dated 2/26/15 2:19 p.m., revealed "PA to see. Need to send to ER?" Review of Text to Physician Nurse dated 2/26/15 at 2:24 p.m., "I think so but (RN "EE") not so much." Review of Text to Physician from Nurse dated 2/26/15 at 2:26 p.m., revealed "PA not here." According to "Medical-Surgical Nursing" (4th Edition, 2002), "Evaluation of the hip joint relies primarily on determination of its degree of mobility, because the joint is deep, and difficult to inspect or palpate. The client with hip pain usually experiences pain in the groin area, or the pain may radiate to the knee ... "(pg. 1087). The text continues (pg. 1130) "clients often complain of moderate to severe pain at the site of the fracture or in an adjacent or distal area. For example, clients with a [MEDICAL CONDITION] may have groin pain or pain referred to the back of the knee. Pain is usually due to muscle spasm and [MEDICAL CONDITION], which result from the fracture...". In an interview on 3/3/15 at 9:00 a.m., RN "EE" reported that Resident #24 was laying in his bed when she did her assessment and that he did not have any pain until she lifted his right knee. RN "EE reported that she knew Resident #24 had a fracture because his right leg was shortened and external rotation. RN "EE" left the physician a message, he called her back, and ordered x-rays. RN "EE" reported that she had Unit Clerk (UC) "YY" call for the x-rays, but did not recall if she had ask her to order them STAT (now). RN "EE" reported that at 11:00 a.m. she ask LPN "W" and UC "YY" to find out where the x-ray's for Resident #24 were and they came at 3:00 p.m. RN "EE" reported that if a person was not painful and had a leg that was shortened and rotated that the facility would normally get the x-ray at the facility. RN "EE" reported that she checked on Resident #24 during the day by peeking in from the doorway and he did not appear in pain, but she had not provided any care for him. In an interview on 3/4/15 at 5:10 p.m., CNA "TT" reported that Resident #24 could not even pick up his head to eat on 2/26/15 without being in pain "you could see agony in his face when he sipped his shake." CNA "TT" reported that Resident #24 was given a shake because he was in too much pain to sit up to eat at breakfast and lunch but could drink. Review of the Multi-Disciplinary Progress Notes dated 2/26/15 at 10:45 p.m., reflected Resident #24 was assessed, "right leg turned out, very painful when trying to assist with move. Stated he was haven (DIC) pain mostly near knee area. X-ray arrived at 3:15 p.m., nurse assisted with positioning for x-ray, resident yelling out when moved. Physician notified of pain and gave new order....ambulance called by 5:35 p.m....". (Approximately 11 hours after Resident #24 had the fall with obvious injury) In interviews on 3/3/15 at 9:25 a.m. and 3/4/15 4:45 p.m., RN "KK" reported that when she assessed Resident #24 at 3:00 p.m. he was painful and she could not understand why they were waiting for the x-ray to ship him to the hospital. RN "KK" reported that upon assessment she noted the right leg was turned out and that normally if it was consider a fracture they would send him out, she would have sent him out. RN "KK" reported that x-ray arrived at 3:15 p.m. and Resident #24 was painful during the assessment, called for a stronger pain medication, followed protocol and waited for the x-ray results before sending Resident #24 out to the hospital. Review of Text to Physician from Nurse dated 2/26/15 at 5:29 p.m., reflected "sending (Resident #24) to hospital." Review of Text to Nurse from Physician dated 2/26/15 at 6:06 p.m., reflected "OK." Review of the Radiology Report dated 2/26/15 at 4:19 p.m., reflected Resident #24 had an order for [REDACTED]." The Radiology Report reflected that the examination results were "There is a fracture involving the right femoral neck with lateral displacement." In interviews on 3/3/15 at 2:55 p.m. and 3/5/15 at 3:30 p.m., Administrator "A" reported that she became aware of Resident #24's fall at about 7:30 a.m., and was told he was in bed in his room his right leg was externally rotated, he was having knee pain, and the physician had ordered x-rays. Administrator "A" reported that the facility tries to get the x-rays at the facility rather than have the residents spend all day in the emergency room . Administrator "A" reported that UM/RN "EE" stated "as long as no one fussed with his leg he had no pain." Administrator "A" reported that the Facility Policy and Procedure was not followed if Resident #24 was moved from the floor before he was assessed. Administrator "A" reported that the x-ray should have been completed by noon. In an interview on 3/4/15 at 2:40 p.m., Emergency Medical Unit Personal "SS" reported that they received the call from the facility at 5:38 p.m., arrived at the facility at 5:58 p.m., and arrived at the hospital at 6:39 p.m.. Emergency Medical Unit Personal "SS" reported that from experience, even if the emergency room was busy they would make sure a person who had a fall got an x-ray's and pain control fairly soon after they arrived in the emergency room . Review of the Hospital Emergency Clinical Report - Physicians dated 2/26/15 at 6:57 p.m., reflected "...Physical Exam... Extremities: Right hip. The right leg is shortened, externally rotated and flexed... Gait: Gait not tested due to pain." Review of the Hospital Emergency Clinical Report - Nurses dated 2/26/15 at 6:57 p.m., reflected "Disposition 8:45 p.m. admitted to the joint replacement unit." Review of the Hospital history and physical examination [REDACTED]. It is also noted that his right lower extremity was shortened and externally rotated. X-ray was done, and it showed a right femoral neck fracture. The patient was referred to the ER where imaging study did confirm the presence of a right [MEDICAL CONDITION]." In an interview on 3/5/15 at 2:28 p.m., Unit Clerk (UC) "YY" reported that UM/RN "EE" said to get the x-ray for Resident #24 as soon as we can get it. UC "YY" reported that she ordered the x-ray at 7:05 a.m. ASAP (as soon as possible), which usually was within an hour but it does vary. UC "YY" reported that at about 9:20 a.m. LPN "W" called and ask where x-ray people were and said that the x-ray was needed STAT (now), so she called and changed the order. UC "YY" reported that at 2:20 p.m. LPN "W" called again to see why the x-ray people had not come and she left them a message, but went home before they returned her call. #

This citation has 2 deficiency practice statements, A and B. Deficiency Practice Statement A. Based on interview and record review the facility failed to follow the professional standards of practice after a fall with a fracture for 1 of 14 Sampled Residents (#24), reviewed for falls, from a total of 24 residents, resulting in increased pain and delay in treatment. Findings include: "General Trauma Interventions: Keep the victim lying down or in the position in which he or she is found..." (Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby.). "Secondary injury results from the body's response to the initial trauma ..." Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003) Medical-Surgical Nursing Health and Illness Perspectives (7th ed.). St. Louis: Mosby. Review of the Facility Immediate Incident Assessment/Evaluation (no date), reflected that the "Procedure: 2. unless the Resident is in eminent danger - do not move them until after the Neighborhood Nurse has done the needed assessment and has given approval...4. Residents should not be moved until it has been determined b the Neighborhood Nurse that there is not injury (the resident has ROM (range of motion) as before) or that the injured Resident warrants being moved. The Neighborhood Nurse will also determine how the Resident is to be moved and if a maxi lift should be used, based on transfer orders, weight bearing status, and if staff is able to lift the Resident's weight." Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #24 was a [AGE] year old male admitted to the facility on [DATE], whose [DIAGNOSES REDACTED]. The MDS reflected that Resident #24's ability to make daily decisions was moderately impaired, and he required supervision with setup to walk in his room and limited assistance of one staff member to transfer from the bed or chair. In an interview on 3/3/15 at 12:05 p.m., CNA "MM" reported that on 2/26/15 she found Resident #24's door closed which was not normal, knocked and entered and found him on the floor. CNA "MM" then went and got LPN "JJ" who asked if Resident #24 was hurting looked for swelling, bruising, got vital signs, then sat him up which was painful (facial grimacing). CNA "MM" reported that she and LPN "JJ" then stood Resident #24 who could not bear weight on his right side and put him in his personal chair. CNA "MM" reported that Resident #24 was painful with care the remainder of her shift whenever he was turned and repositioned. In interviews on 3/2/15 at 6:30 p.m., and 3/3/15 at 12:40 p.m., Licensed Practical Nurse (LPN) "JJ" reported that on 2/26/15 at 6:20 a.m. Certified Nursing Assistant (CNA) "MM" found Resident #24 on the floor and came to get her. LPN "JJ" reported that she found Resident #24 on his left side in front of his personal chair, but that he was unable to state how long he had be laying on the floor. LPN "JJ" reported that Resident #24 did not complain of any pain so CNA "MM" and she raised him to a sitting position on the floor and noted that when he was sitting he was showing facial grimacing. LPN "JJ" reported that she and CNA "MM" then stood Resident #24 and noted that he complained of pain in his right knee and that he could not bear weight on his right side, so they sat him in his personal chair. LPN "JJ" stated that she "did not check range of motion (ROM)" prior to moving Resident #24 from the floor. LPN "JJ" reported that she left the room and had (3) CNA's come back in to move Resident #24 from his personal chair to his bed. LPN "JJ" reported that she did not notice external rotation until Resident #24 was laid down in bed. LPN "JJ" reported that at the 7:00 a.m. assessment in bed Resident #24 was painful, moaning, facial grimacing, unable to comprehend the pain scale, but clearly he was in a lot of pain when being assess or moved/repositioned. In an interview on 3/4/15 at 9:00 a.m., CNA "II" reported that LPN "JJ" ask her and CNA "QQ" to transfer Resident #24 from his personal chair to a wheelchair to his bed. In an interview on 3/4/15 at 11:10 a.m., CNA "QQ" reported that between 7:00 - 7:30 a.m. on 2/26/15 Resident #24 was in his personal recliner and he was wet and needed changed. CNA "QQ" reported that when she and CNA "II" stood Resident #24 from the personal chair he was not able to bear any weight on his right leg and they placed him in his wheelchair and informed LPN "JJ" that he was unable to bear any weight she told them to continue with the transfer and put him in bed, but she did not come and assist. CNA "QQ" reported that Resident #24 was putting all his weight on her during the transfer and complained about pain in the right leg when they were lifting his legs up in the bed. CNA "QQ" reported that the right foot did not lay straight. CNA "QQ" reported that Resident #24 appeared painful (facial grimacing), moaning when change and moved. In an interview on 3/3/15 at 8:20 a.m., LPN "W" reported that Resident #24 had a fall and was in pain. LPN "W" reported that she was in the room when LPN "JJ" was doing her assessment saw the external rotation of the right leg and the ball behind the back of right knee which made her think he had a [MEDICAL CONDITION]. LPN "W" reported that Unit Manager (UM) Registered Nurse (RN) "EE" was notified of the fall and participated in part of the assessment. LPN "W" reported that he had Tylenol for pain, but she had not called for anything stronger because she thought he might go to surgery. LPN "W" reported that at approximately 2:00 p.m. she texted the physician to tell him that the x-ray had not been completed and the Tylenol was not helping. Review of Text to Physician from Nurse dated 2/26/15 2:04 p.m. has still not had his x-ray and we can not move him with out pain, Tylenol not working. Review of Text to Nurse from Physician dated 2/26/15 2:19 p.m., PA to see. Need to send to ER? Review of Text to Physician Nurse dated 2/26/15 at 2:24 p.m., I think so but RN "EE" not so much. Review of Text to Physician from Nurse dated 2/26/15 at 2:26 p.m., PA not here. In an interview on 3/3/15 at 9:00 a.m., RN "EE" reported that Resident #24 was laying in his bed when she did her assessment and that he did not have any pain until she lifted his right knee. RN "EE reported that she knew Resident #24 had a fracture because his right leg was shortened and external rotation. RN "EE" left the physician a message, he called her back, and ordered x-rays. RN "EE" reported that she had Unit Clerk (UC) "YY" call for the x-rays, but did not recall if she had ask her to order them STAT (now). RN "EE" reported that at 11:00 a.m. she ask LPN "W" and UC "YY" to find out where the x-ray's for Resident #24 were and they came at 3:00 p.m. RN "EE" reported that if a person was not painful and had a leg that was shortened and rotated that the facility would normally get the x-ray at the facility. RN "EE" reported that she checked on Resident #24 during the day by peeking in from the doorway and he did not appear in pain, but she had not provided any care for him. In interviews on 3/3/15 at 9:25 a.m. and 3/4/15 4:45 p.m., RN "KK" reported that when she assessed Resident #24 at 3:00 p.m. he was painful and she could not understand why they were waiting for the x-ray to ship him to the hospital. RN "KK" reported that upon assessment she noted the right leg was turned out and normally if it was consider a fracture they would send him out, she would have sent him out. RN "KK" reported that x-ray arrived at 3:15 p.m. and Resident #24 was painful during the assessment, she called for a stronger pain medication, followed protocol and waited for the x-ray results before sending Resident #24 out to the hospital. Review of Text to Physician from Nurse dated 2/26/15 at 5:29 p.m., reflected sending Resident #24 to hospital. Review of Text to Nurse from Physician dated 2/26/15 at 6:06 p.m., reflected OK. In interviews on 3/3/15 at 2:55 p.m. and 3/5/15 at 3:30 p.m., Administrator "A" reported that she became aware of Resident #24's fall at about 7:30 a.m., and was told he was in bed in his room his right leg was externally rotated, he was having knee pain, and the physician had ordered x-rays. Administrator "A" reported that the facility tries to get the x-rays at the facility rather than have the residents spend all day in the emergency room . Administrator "A" reported that UM RN "EE" stated "as long as no one fussed with his leg he had no pain." Administrator "A" reported that the Facility Policy and Procedure was not followed if Resident #24 was moved from the floor before he was assessed. Administrator "A" reported that the x-ray should have been completed by noon. In an interview on 3/4/15 at 5:10 p.m., CNA "TT" reported that Resident #24 could not even pick up his head to eat on 2/26/15 without being in pain "you could see agony in his face when he sipped his shake." CNA "TT" reported that Resident #24 was given a shake because he was in too much pain to sit up to eat at breakfast and lunch, but could drink. In an interview on 3/5/15 at 2:28 p.m., Unit Clerk (UC) "YY" reported that UM RN "EE" said to get the x-ray for Resident #24 as soon as we can get it. UC "YY" reported that she ordered the x-ray at 7:05 a.m. ASAP (as soon as possible), which usually was within an hour but it does vary. UC "YY" reported that at about 9:20 a.m. LPN "W" called and ask where x-ray people were and said that the x-ray was needed STAT (now), so she called and changed the order. UC "YY" reported that at 2:20 p.m. LPN "W" called again to see why the x-ray people had not come and she left them a message, but went home before they returned her call. In an interview on 3/4/15 at 2:40 p.m., Emergency Medical Unit Personal "SS" reported that they received the call from the facility at 5:38 p.m., arrived at the facility at 5:58 p.m., arrived at the hospital at 6:39 p.m., and notified the hospital Resident #24 was there at 6:57 p.m. Emergency Medical Unit Personal "SS" reported that from experience, even if the emergency room was busy they would make sure a person who had a fall got x-ray's and pain control fairly soon after they arrived in the emergency room . # Deficiency Practice Statement B. Based on interview and record review the facility failed to follow professional standards of nursing practice of not following physician orders [REDACTED].#9, #3, #12, #5, #7) reviewed for physician's orders [REDACTED]. Findings include: According to Creighton in Law Every Nurse Should Know, 5 th Edition, page 98 "Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out". Resident #9 Resident #9 was admitted to the facility 9/11 with a medical history according to the facility face sheet which included Dementia, depression, [MEDICAL CONDITIONS], dysphagia (difficulty swallowing) [MEDICAL CONDITION] and chronic urinary tract infections. Review of the facility MDS (minimum data set) dated 11/14 revealed Resident #9 was usually able to understand others and able to make herself understood, was severely impaired for daily decision making skills, displayed no behaviors, was totally dependent on two persons for transfers, toileting, bathing , bed mobility and was incontinent of bowel and bladder. Review of the Facility Physician Standing Orders dated 11/14 revealed "Vitals: Weekly unless otherwise ordered by physician". Review of the monthly Physician orders [REDACTED]. Review of Physician orders [REDACTED]. Review of facility Multi-Disciplinary Progress Notes dated 3/14 to 3/1/15 revealed no documented vital signs recorded. Review of the facility document "Vital Signs" the last documented vital signs were recorded on 1/25/15. During an interview on 3/3/15 at 10:20 AM, Staff Nurse "V" reported Resident #9 "is on comfort care so we don't do vitals". Review of the facility document (undated) titled "Comfort Care at the End of Life" "the following criteria is considered to be Comfort Care" pain, oral medications, IV fluids, IV antibiotics, Labs, X-rays, weights, Mobility and Skin, Anxiety, Pastoral Counseling, Social Work Services, Food and Drink, Nausea and Vomiting, Hygiene, Oral Care. Vital Signs was not addressed. During an interview/record review on 3/3/15 at 2:00 PM, DON (Director of Nurses) "B" acknowledged the facilities current Policy and Procedure regarding comfort care. DON "B" reported "I never realized that wasn't addressed guess we'll have to fix it". ( ) Resident #3 According to the facility's Resident Admission Record, Resident #3 was a [AGE] year old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated 11/30/14, Resident #3 was moderately cognitively impaired, usually understood what was said to her, and required assist of 1 staff for bed mobility, transfers, ambulation with a walker, pushing her wheel chair, hygiene, bathing and toileting. Resident #3 could feed herself with set up, was frequently incontinent of bowel and had a urinary catheter. Resident #3 admitted to difficulty breathing with exertion. According to the textbook, Law Every Nurse Should Know, 5th edition, page 98 "Nurses must obey the orders of the physician in charge of a patient, unless an order would lead a reasonable person to anticipate injury if it were carried out". According to the facility's undated policy titled, Comfort Care at the End of Life, whether or not vital signs were continued would be determined by the physician. According to Physician's Phone Orders, dated 9/30/14, comfort care was requested by the family and ordered for Resident #3. Orders were written to discontinue routine lab tests, weights, Xrays and intravenous treatments medications and fluids. According to the facility's Vitals Chart Sheet, starting on 8/27/14, Resident #3's vital signs were documented for the following dates: 9/25/14 through 9/30/14, all 3 shifts; 5 times through 12/27/14, once on 2/9/15 and once on 2/17/15. Of note, "Comfort Care" was hand written and dated 9/30/14 on the sheet. Bi-ox, sats or pulse oximetry refer to a noninvasive test that measures the oxygen level in the blood, and, therefore, the delivery of oxygen to the tissues. It is done by clipping a pulse oximeter on a finger, and a reading appears. (Johns Hopkins Medicine Health Library). According to the facility's undated policy and procedure titled, Pulse Oximetry Procedure, the purpose was, "...to determine need for oxygen and/or adjustment of oxygen based on need". Under, "Procedure: 1. Residents receiving oxygen must have their pulse oximetry done one time per shift - and PRN (as needed) when they are symptomatic. According to the Geriatric Dosage Handbook, 16th edition, page 1021 listed low blood pressure as a potential side effect of [MEDICATION NAME] and recommends routine blood pressure monitoring. Manufacturer's recommendations are the same for [MEDICATION NAME]. According to the March 2015 physician's orders [REDACTED]. A 2nd order, started on 10/29/14 for over night use and as needed, dated 2/23/15. Another order, started on 10/29/14 was, "check pulse ox as needed". A 3rd order, started on 2/23/15, was "Oxygen Apply at bedtime for overnight use and as needed". According to the facility's Physician Standing Orders, under, "Routine Orders: Vitals: Weekly unless otherwise ordered by physician". There were no routine standing orders to check oxygen saturation for those on oxygen. According to the facility's Care Guide (for aides to use) for Resident #3, dated 6/16/14, hand-written was, "Apply O2 (oxygen) at bedtime for overnight use and PRN". According to the nursing care plan for activities of daily living functional/rehabilitation potential, dated 11/30/14, the problem was, "There are times when (Resident #3's) P.O. (pulse oximetry) drops below 88%, especially during the night, that she uses oxygen". The long term goal was, "...will be comfortable & eased of respiratory distress. P.O. will be 88% or greater". The approach (or interventions) included, "oxygen as ordered", without mention of monitoring pulse oximetry. On Resident #3's Vitals Chart Sheet, the following pulse oximetries were documented: twice on 9/26/14; once each on 9/27, 28, 29; once on 12/25; twice on 12/26; twice on 12/30; once each on 1/2/15 and 3; once on 2/17/15. It was unclear how oxygen therapy could be titrated to keep Resident #3's saturation greater than 88% if the pulse oximetry was not checked each time? On 3/4/15 at 1:30 p.m. Registered Nurse (RN) "AE" as interviewed. When asked how routine pulse oximetry was monitored, RN "AE"said that it was done as needed. When asked when pulse oximetry was needed, RN "AE" answered that if the resident doesn't look good, was sweaty or in distress or complained of difficulty breathing whether or not receiving oxygen therapy. When asked about checking pulse oximetry for residents who received oxygen therapy and comfort care, RN "AE" said it would be the same. On 3/4/15 at approximately 4:00 p.m., Resident #3 was interviewed in her room. Resident #3 was observed in her bed with several covers over her. She was not wearing oxygen. When asked if she ever had difficulty breathing, Resident #3 answered that she got winded just moving from her bed to her personal chair or the bathroom. On 3/5/15 at approximately 4:00 p.m., Director of Nurse's "B" was reviewing the pulse oximetry policy and procedure. DON "B" said that the policy was not currently being used, but she would soon change that. ( ) Resident #12 According to the facility's Resident admission Record, Resident #12 was a [AGE] year old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated 12/7/14, Resident #12 was usually understood and usually understood others, was cognitively intact, and was required supervision for eating, ambulation with a walker, propelling her wheel chair and activities of daily living. Resident #12 admitted to difficultly breathing with exertion and lying flat. According to the facility's Care Guide (for aides to use) for Resident #12, dated 6/16/14, hand-written was, "Apply O2 to maintain POX (pulse oximetry reading) 88% or (above)". According to the facility's Vitals Chart Sheet, there was no documentation of pulse oximetry for Resident #12 after 9/19/14. It was unclear how oxygen therapy could be titrated to keep Resident #3's saturation greater than 88% if the pulse oximetry was not checked each time? According to nurse's notes written on the facility's Multi-Disciplinary Progress Notes, no pulse oximetry measurements were documented for Resident #12 from 9/18/14 through 2/27/15 ( ) Resident #5 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #5 was a [AGE] year old male with [DIAGNOSES REDACTED]. The MDS reflected Resident #5 ability to make daily decisions was severely impaired, and he required two person extensive physical assist with transfers, ambulation, dressing, toileting, hygiene and bathing. Review of Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. # Resident #7 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #7 was a [AGE] year old male with [DIAGNOSES REDACTED]. The MDS reflected Resident #7 ability to make daily decisions was moderately impaired, and Resident #7 is independent with transfers, ambulation, dressing, toileting, hygiene and bathing. Review of MAR indicated [REDACTED]. Review of facility Multi-Disciplinary Progress Notes for dates between 2/14/15 through 2/23/15 revealed no entry related to bowels. #

This citation pertains to MI 046. Based on observation, interview and record review, the facility failed to ensure facility staff provided care per the expected guidelines to maintain safety in 3 sampled residents (#50, #51, #52) of 3 evaluated for injuries, from a total sample of 3, resulting in a fracture for Resident #50, a head laceration for Residsent #51, and head lacerations, skin tears and bruising for Resident #52. Findings include: Resident #50 According to the Resident Admission Record, Resident #50 was a [AGE] year old female admitted to the facility on [DATE] for [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated 11/23/14, Resident #50 was severely cognitively impaired, had no speech, sometimes was believed to understand others and was totally dependent on 2 staff for repositioning in bed, transfers with a mechanical lift, dressing, hygiene, bathing, and toileting, was incontinent of bowel and bladder and required assist of 1 staff to push the geri chair. According to the nursing care plan for falls, dated 9/7/14 and updated on 11/23/14, Resident #50 was non-ambulatory and required 2 staff assist with mechanical lift device to and from her wheelchair. Under activities of daily living, dated 9/7/14, staff were to turn/reposition Resident #50 every 2 hours in bed, but failed to indicate if 1 or 2 staff were required to accomplish this. According to the Aide care guide, dated 10/8/14, Resident #50 was to be turned every 2 hours while in bed, but failed to indicated if 1 or 2 staff were required to accomplish this. The care guide had a sticky note attached, by Administrator (ADM) "A", that read, "1. Pt (patient) assist of 2 to position at time of incident". According to the Aide Notes, dated 1/24/15, "Res (Resident #50) crying when being turned for bed check at 11:00 (p.m.) continued to cry. We thought she was crying because she was (illegible word) BM (bowel movement). Second bed check yelling crying (illegible word(s)) right leg. Reported to Nurse check something is wrong. Right knee area very painful and to (sic) much free movement". The note was initialed by Certified Nurse Assistant (CNA) "C". According to an article by the American Academy of Orthopedic Surgeons found online at http://orthoinfo.aaos.org/topic.cfm?topic=A , "Spiral fracture. The fracture line encircles the shaft like the stripes on a candy cane. A strong twisting force to the thigh causes this type of fracture". According to radiology reports, dated 1/24/15 at approximately 6:30 am, Resident #50 had an acute right proximal (close to the hip) linear (or spiral) fracture with medical displacement (the bone ends lean towards the center of the body). Resident #50 was transported to the emergency room , evaluated, determined to not be a surgical candidate and returned to the facility. Further X-rays showed the following: left knee and left lower leg - deformity from old fracture of the knee and diffuse osteopenia (softening of the bone); right ankle - chronic deformity and osteopenia; pelvis and right hip - osteopenia. According to the undated facility document titled, Root Cause Analysis Femur Fracture (Resident #50), it was determined that during first rounds at approximately 22:30 (10:30 p.m.), CNA "C" repositioned Resident #50 without assistance and Resident #50 became tearful, crying, in a manner unusual for her. The expected process was, "Two aides reposition and clean the resident and meet any needs she may have. A review of the care guide reflected that there was some confusion regarding number of staff for positioning, and the care guide was not clear". According to a Physician's Progress Note for Resident #50, dated 2/4/16, "Pt. (patient) okay - (no) outward signs of pain. Pt. recently found to have fx (fracture) of femur, Pt. is bed bound & osteoporotic - this pt. has been found to have non-traumatic fx in the past..." According to a Physician's Progress Note for Resident #50, dated 2/10/16, "Her recent fx is most likely due to the usual procedures involved (with) transfers. Likely occurred as a result of turning pt. (patient) prior to lift transfer, i.e.. torque forces. Not unexpected (with) osteoporotic bones". On 2/24/15 at 2:15 p.m., CNA "D" was interviewed. When asked how Resident #50 communicated with staff, CNA "D" said that with big smiles, eye contact and her cries, related to having a bowel movement or discomfort. On 2/24/15 at 1:00 p.m., Durable Power of Attorney (DPOA) "E" was interviewed. When asked what the family was told about the fractured leg, DPOA "E" said that the break was due to her fragile arthritis condition. When this surveyor mentioned osteopenia, DPOA "E" said that, yes, he recognized that term. On 2/24/15 at 3:40 p.m., Administrator (ADM) "A" was interviewed. When asked, ADM "A" reported that an aide was sure Resident #50's fracture occurred when she repositioned Resident #50 during first rounds on the night shift. On 2/26/15 at 10:17 a.m., CNA "G" was interviewed via telephone. When asked, how many staff were to assist Resident #50 with repositioning in bed, CNA "G" said, "Two". On 2/26/15 at 11:30 a.m., CNA "I" was interviewed via telephone. When asked about the night Resident #50 might have sustained a fractured femur, CNA "I" said that she was working, but had had no physical contact with the resident that Friday night. CNA "I" said that she had assisted other CNAs with Resident #50's care, but the resident was rarely on her assignment. On 2/26/15 at 12:00 p.m., CNA "C" was interviewed via telephone. When asked to describe the Friday night that Resident #50 may have sustained a fractured femur, CNA "C" said the following: At the first bed check, Resident #50 was "fussy", with no tears after she was repositioned. When asked, CNA "C" said that either CNA "K" or "L" assisted her to reposition Resident #50. When asked if she had repositioned Resident #50 by herself that first time, CNA "C" said, "I did not". During 2nd rounds, about 2 hours later, CNA "C" said that Resident #50 exhibited more when repositioned. At around 3 - 3:30 a.m., CNA "C" found Resident #50 to be whimpering before being touched. CNA "C" said, "(Resident #50) was not herself". Again, CNA "C" was asked if she repositioned Resident #50 without assistance, and said, "No". CNA "L" no longer works at the facility, and did not return this surveyor's phone call. On 2/26/15 at 2:00 p.m., ADM "A" was, again, interviewed. When told that CNA "C" denied that she did not reposition Resident #50 by herself on 1/24/15, ADM "A" said, "Well, that's not what she told me". ( ) Resident #51 According to the Resident Admission Record, Resident #51 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set, dated dated [DATE], Resident #51 had significant memory impairment, sometimes understood others and was rarely understood, inattention, disorganized thinking and psychomotor retardation (very slow to respond). Resident #51 required assist of 2 staff for bed mobility, transfers, walking with her walker, dressing, bathing and toileting, assist of 1 staff for eating and hygiene and was always incontinent of bowel and bladder. According to the Fall care plan, dated 8/23/14, Resident #51 was to have an alarm clipped to her clothing wherever she was; in bed, personal chair or wheelchair. (The alarm would sound if Resident #51 attempted to get up to alert staff to check on her right away.) According to a facility procedure titled, "Bed and Chair Alarm Placement Procedure", dated 10/4/07 with a reviewed/revised date of 10/28/08, the purpose was, "To assist staff to keep residents free from falls that may or may not cause an injury...Alarms will be placed on residents who are at risk. In bold print, "Procedure: 16. Do not leave any resident with alarms in the bathroom unattended. According to the Incident Report dated 1/1/15 at 4:10 a.m., Resident #51 fell forward from her toilet and sustained a large laceration to her forehead. Resident #51 was initially unresponsive with snoring respirations, but was observed with facial grimacing, some jerky movements of her arms and an unfocused gaze within minutes. Resident #51 was transported to the emergency room . The risk management recommendation read, "Staff error". On 2/25/15 at 3:50 p.m., CNA "M" was interviewed. When asked what happened on 1/1/15, CNA "M" said that she came to Resident #51's room because her alarm was sounding. CNA "M" observed Resident #51 had gotten up and was standing beside her bed, and became combative when CNA "M" tried to assist her back to bed. CNA "M" noticed that Resident #51 was moving her bowels, assisted Resident #51 to the bathroom and sat her on the toilet. CNA "M" said that she turned away from Resident #51 just long enough to get some wash cloths from the closet, a few steps away, when she heard a loud noise. When she turned back, CNA "M" observed Resident #51 on the bathroom floor. On 2/26/15 at 2:00 p.m., ADM "A" was interviewed. When asked what was the root cause of Resident #51's fall, ADM "A" said it was staff error. It was the facility's policy not to leave a resident with alarms unattended on the toilet. ( ) Resident #52 According to the facility's Resident Admission Record, Resident #52 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (resident assessment), dated 10/19/14, Resident #52 had good long and short term memory, required supervision of 1 staff for eating and hygiene, assist of 1 staff for bed mobility, transfers, walking with his walker, bathing and toileting and had a urinary catheter. According to the Resident #52's Annual Falls Risk Assessment, dated 8/11/14, the following items were checked under the section titled, conditions Representing risk Factors for Falls (check all that apply): previous falls and arthritis". Not checked, but pertaining to Resident #52 were weakness, problems with mobility/gait, history of fractures, visual impairment and acute and sub acute medical illness. Resident #52 was deemed, "At risk for falls r/t (related to) poor transfer balance/history of falls". According to an undated facility document titled "Gait Belt Requirements", "It is the policy of (the facility) that all residents needing assistance with ambulation or transfers will receive assistance and that a gait belt must be used to aide in the transfer or ambulation of these residents..." The employee was to sign and date the document to indicate that they understood and would follow this policy. According to a facility Incident Report, on 12/5/14 at 9:00 p.m., Resident #52 was assisted from his personal chair to his wheelchair by Certified Nurse Aide (CNA) "J". Resident #52 was quoted as saying that he reached for his wheelchair before sitting down, but, "did not get there" and fell to the floor with his left arm under his body. Resident #52 sustained 3 lacerations to his forehead, a large skin tear on his left hand, "encompassing entire hand" and a large bruise and skin tear to his left shoulder. He was transported to the hospital for evaluation and treatment. According to the facility's Falls/Falls Risk Evaluation for the fall on 12/5/14, the risk management recommendation was: "At the time of the fall the CENA (certified nurse assistant) was not using a gait belt per policy". On 2/24/15 at 2:30 p.m., Resident #52 was interviewed. Resident #52 was observed sitting in his personal chair, neatly groomed and dressed with shoes on. When asked about his fall in early December 2014, Resident #52 said, "I'm not sure what happened". On 2/25/15 at 4:20 p.m., CNA "J" was interviewed. When asked what she recalled about Resident #52's fall on 12/5/14, CNA "J" said that Resident #52 was going to bed, and she was assisting him to his wheelchair from his personal chair. CNA "J" said that Resident #52 had just turned and was ready to sit down in the wheelchair when he fell , "Flat on his face". When asked why the fall happened, CNA "J" said that not using a gait belt was the reason. On 2/25/14 at 5:00 p.m., Licensed Practical Nurse (LPN) "N" was interviewed. When asked what she recalled about Resident #52's fall on 12/5/14 and gait belt use, LPN "N" said that any transfers required a gait belt, and this intervention should be on the CNA care guide posted on the inside of each resident's closet door. It is unclear whether use of the gait belt was written on the CNA Care Guide for Resident #52 at the time of the incident, but it was on the Care Guide dated 1/14/2015. On 2/26/15 at 2:00 p.m., ADM "A" was interviewed. When asked about use of gait belts being on care plans and CNA Care Guides , ADM "A" said that staff sign an agreement that they understand the gait belt was part of their uniform, and must be used on residents requiring contact assistance with mobility. The use of gait belts was not typically included in care plan/guide interventions. ( )

Based on interview and record review, the facility failed to notify the physician of a change in condition for 1 (#10) of 25 sampled residents reviewed for physician notification, of a total sample of 25 residents, resulting in Resident #10 to be hospitalized for [REDACTED]. Findings include: In "Legal and Ethical Issues in Nursing" by G. Guido (2001), it documents that "Documentation must show continuity of care, interventions that were used, and patient responses to the therapies implemented. Nurse's notes are to be concise, clear, timely, and complete." (pg. 171) It states that "A jury can infer that no observation of the patient was conducted if there is no mention of a change in condition of the patient." (pg. 171) "A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient." (McMahon & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved May 19, 2011, from http://www.hgexperts.com/article. ) The signs and symptoms of fluid volume deficit and dehydration include: 1) from 2%-20% loss body weight, 2) headaches and dizziness, lethargy, confusion, and disorientation, 3) sunken dry eyes, 4) sticky, dry mucous membranes, 5) low blood pressure, 6) hyperactive bowel sounds with diarrhea, 7) decreased body temperature, 8) dry, flushed, cold, clammy, decreased elasticity of the skin, and 9) dark colored urine with an increase in concentration. (Fundamentals in Nursing, Potter & Perry, 2005, pgs. 1150-1151). According to the facility policy titled "Change of Condition Notification" it reads, "Purpose: ...consult with elder's (resident) physician...Procedure: The facility is to notify...physician...when...the following occur...#3 Change of Status...". According to the Resident Admission Record, Resident #10 was a [AGE] year old female originally admitted to the facility 7/31/08 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. According to the Annual Minimum Data Set (MDS), an assessment tool, dated 12/18/13, Resident #10 demonstrated short and long term memory loss, moderately impaired decision making skills. Resident #10 required extensive assist of one staff member for bathing, dressing, eating, and toilet use. Review of the Nurses Progress Notes dated 12/14/13 reflected "Resident threw breakfast this am on to floor...ate (a zero with a line through, for not taken) for lunch". Review of the Nurses Progress Notes dated 12/15/13 reflected "Resident threw breakfast on floor again this am. Did take med's (medications) off spoon then spit it at nurse. (a zero with a line through, for not taken) med's taken...ate (zero with a line through, for not taken)no lunch...Supervisor aware of refusal to eat meals this shift". Review of the Nurses Progress Notes dated 12/16/13 reflected "...refused to eat breakfast, kept leaving the table...Supervisor aware...12:00-12:30 place in DR (dining room) x (times) 3 for lunch, resident left DR each time. Refused to eat...Dietary aware of refusals to eat". Review of the facilities Nurses Progress Notes dated 12/19/13 reflected "...assisted with meals x's 2 this shift. Resident would only set and look at food". Review of the Nurses Progress Notes dated 12/20/13 reflected "...assisted with meals x 2 this shift. not feeding self Review of the Nurses Progress Notes dated 12/24/13 1650 (2:50 p.m.) reflected "Resident went to hospital for severe dehydration/abnormal lab values...". Review of Resident #10's laboratory tests dated 12/23/13 reflected a high BUN 92 mg/dL (milligrams/deciliter - normal range 7-22 mg/dL). High Creatinine 2.4 mg/dL (normal range 0.6-1.4 mg/dL). High Sodium 172 mEq/L (milliequivilants/liter - normal range 134-145 mEq/L). Osmolality 367 mOsm/K (normal range 269-298 mOsm/K). Review of Resident #10's Weight Log, Resident #10's weight 12/2/13 was 154.4 pounds. On 12/23/13 Resident #10's weight was 148.9. Reflecting a 3.6% loss in 22 days. In an interview on 1/22/14 at 2:00 p.m.with Registered Nurse (RN) #4 and Unit Manager Registered Nurse (RN) #,. RN #4 stated that she had first noticed a change with Resident #10 on 12/14/13. On 12/15/13 Resident #10 still wasn't eating and RN #4 notified her supervisor RN #3. RN #4 stated that on 12/18/13 due to Resident #10 continuing not to eat she began Resident #10 on food acceptance and I & O (intake and output). RN #4 stated that she did not notify Resident #10's Physician or assess Resident #10 for signs or symptoms of dehydration. During the same interview, RN #3 stated that she was aware of Resident #10 not eating but did not feel it was necessary to notify the physician as food acceptance and I&O had been started on 12/18/13. RN #3 stated that she contacted Resident #10's doctor 12/23/13 to request labs and IV for hydration. Both RN #3 and RN #4 stated that on 12/20/13 when Resident #10's doctor was in for to see Resident #10 they did not notify the doctor of Resident #10's refusal to eat or that Resident #10 was placed on food acceptance and I&O. Both RN #3 and RN #4 stated that neither of them had reviewed Resident #10's food acceptance or I&O once it was started. RN #3 and #4 agreed that Resident #10's doctor should have been alerted to Resident #10's change in condition. Review of the Nurses Progress Notes did not reflect any documentation of Resident #10's condition or that food acceptance, I&O was started, dietary notified or that the Resident #10's Physician was notified. Review of the facility Nurses Progress Notes dated 12/24/13 "Resident went to hospital for sever dehydration/abnormal lab values...to (hospital name) at 1650 (4:50 p.m.)".

Based on observation, interview and record review, the facility failed to meet hydration needs for 1 (#10) of 25 sampled residents reviewed for hydration in a total sample of 25 residents, resulting in Resident #10 to be hospitalized for [REDACTED]. Findings include: "A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient." (McMahon & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved May 19, 2011, from http://www.hgexperts.com/article. ) The signs and symptoms of fluid volume deficit and dehydration include: 1) from 2%-20% loss body weight, 2) headaches and dizziness, lethargy, confusion, and disorientation, 3) sunken dry eyes, 4) sticky, dry mucous membranes, 5) low blood pressure, 6) hyperactive bowel sounds with diarrhea, 7) decreased body temperature, 8) dry, flushed, cold, clammy, decreased elasticity of the skin, and 9) dark colored urine with an increase in concentration. (Fundamentals in Nursing, Potter & Perry, 2005, pgs. 1150-1151). According to the Resident Admission Record, Resident #10 was a [AGE] year old female originally admitted to the facility 7/31/08 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. According to the Annual Minimum Data Set (MDS), an assessment tool, dated 12/18/13, Resident #10 demonstrated short and long term memory loss, moderately impaired decision making. Resident #10 required extensive assist of one staff member for bathing, dressing, eating, and toilet use. An observation on 1/22/14 at 8:45 a.m. during the breakfast meal in the Tiger Lily dining room, Resident #10 was observed to be in a wheelchair with a lap tray attached over the arms of the wheelchair and across Resident #10's lap. Resident #10 had her hands resting on the top of the tray. Resident #10 was sitting just outside the dining room. Resident #10 was observed to have a dry mouth. No food or fluids were available to Resident #10. Observation of Resident #10's breakfast meal that was sitting on the table where Resident #10 sat had not been eaten. fluids had not been drank. At 9:05 a.m., Certified Nurse Aide (CNA) #16 removed Resident #10's breakfast from the table. Resident #10 was not offered food or drink before the food was removed. An observation on 1/22/14 between 12:10 p.m. and 12:35 p.m. of the lunch meal in the Tiger Lily dining room, Resident #10 was observed to be sitting at the table with the lap tray in place. Resident #10 was bumping the front of the lap tray up to the table in attempt to get closer to the table. Resident #10 could not get up to table and began wheeling away from the table. Activity Aide #15 offered Resident #10 some chocolate milk Resident #10 stated that she would like some milk. Activity Aide #15 brought back a lidded Styrofoam cup and placed it on Resident #10's table out of Resident #10's line of vision. Activity Aide #15 did not tell or give Resident #10 her chocolate milk. An interview with CNA #16 at 12:20 p.m. in the Tiger Lily dining room on 1/22/14, CNA #16 stated that Resident #10 had not ate or drank that day for breakfast. An observation on 1/23/14 at 12:20 p.m.of the lunch meal in the Tiger Lily dining room, Resident #10 was observed with lap tray on wheelchair with her arms resting on top of the tray mouth and lips dry. CNA #10 brought Resident #10's lunch tray to her table. The food and drinks were placed on the table. CNA #10 attempted to assist Resident #10 up to the table but Resident #10 said "No". CNA #10 then removed Resident #10's clothing protector, threw up her hands and said "I don't know what to do". CNA #10 did not attempt to offer food, fluid or sit down to assist Resident #10 with eating or drinking. CNA #10 went to talk to CNA #5 who went over and sat down next to Resident #10 and was able to get Resident #10 to eat and drink about 25-50% of meal. Review of the facilities Nurses Progress Notes dated 12/14/13 reflected "Resident threw breakfast this am on to floor...ate (a zero with a line through, for not taken) for lunch". Review of the facilitates Nurses Progress Notes dated 12/15/13 reflected "Resident threw breakfast on floor again this am. Did take med's (medications) off spoon then spit it at nurse. (a zero with a line through, for not taken) med's taken...ate (zero with a line through, for not taken)no lunch...Supervisor aware of refusal to eat meals this shift". Review of the facilities Nurses Progress Notes dated 12/16/13 reflected "...refused to eat breakfast, kept leaving the table...Supervisor aware...12:00-12:30 place in DR (dining room) x (times) 3 for lunch, resident left DR each time. Refused to eat...Dietary aware of refusals to eat". Review of the facilities Nurses Progress Notes dated 12/19/13 reflected "...assisted with meals x's 2 this shift. Resident would only set and look at food". Review of the facilities Nurses Progress Notes dated 12/20/13 reflected "...assisted with meals x 2 this shift. not feeding self Review of the facilities Nurses Progress Notes dated 12/24/13 1650 (2:50 p.m.) reflected "Resident went to hospital for severe dehydration/abnormal lab values...". Review of Resident #10's laboratory tests dated 12/23/13 reflected a high BUN 92 mg/dL (milligrams/deciliter), normal range 7-22 mg/dL. High Creatinine 2.4 mg/dL, normal range 0.6-1.4 mg/dL. High Sodium 172 mEq/L (milliequivilants/liter), normal range 134-145 mEq/L. Osmolality 367 mOsm/K, normal range 269-298 mOsm/K. Review of Resident #10's Weight Log, Resident #10's weight 12/2/13 was 154.4 pounds. On 12/23/13 Resident #10's weight was 148.9. Reflecting a 3.6% loss in 22 days. Review of the facilities Food Acceptance Record started 12/18/13 reflected on 12/18/13 Resident #10 had Midnight Shift-100 ml (milliliters) of fluid, Breakfast-240 cc, Lunch- none recorded/section blank, Supper/3-11-360 cc' s'. 12/19/13 nothing was recorded for all 3 shifts/areas blank, 12/20/13 Midnight Shift- 120 cc, Breakfast-120 cc, Lunch- none recorded/section blank, Supper/3-11- 240 cc. 12/21/13 Midnight Shift- 90 cc, Lunch- 240 cc, Supper/3-11- 720 cc. 12/22/13 Midnight Shift- 90 cc, Breakfast- 240 cc, Lunch-240 cc, Supper/3-11- 240 cc. 12/23/13 Midnight Shift- 75 cc, Breakfast- 240 cc, Lunch-120 cc, Supper/3-11- 240 cc. Review of the Nurses Progress Notes did not reflect any documentation of Resident #10's condition or that food acceptance, I&O was started, dietary notified or that the Resident #10's Physician was notified. An interview on 1/22/14 at 2:00 p.m. and interview was conducted with Registered Nurse (RN) #4 and Unit Manager Registered Nurse (RN) #3. RN #4 stated that she had first noticed a change with Resident #10 on 12/14/13. On 12/15/13 Resident #10 still wasn't eating and RN #4 notified her supervisor RN#3. RN #4 stated that on 12/18/13 due to Resident #10 continuing not to eat she began Resident #10 on food acceptance and I & O (intake and output). RN #4 stated that she did not notify Resident #10's Physician or assess Resident #10 for s/s of dehydration. During the same interview with the Unit Manager RN #3 stated that she was aware of Resident #10 not eating but did not feel it was necessary to notify the physician as food acceptance and I&O had been started on 12/18/13. RN #3 stated that she contacted Resident #10's doctor 12/23/13 to request labs and IV for hydration. RN #3 and RN #4 stated that on 12/20/13 when Resident #10's doctor was in for to see Resident #10 they did not notify the doctor of Resident #10's refusal to eat or that Resident #10 was placed on food acceptance and I&O. RN #3 and RN #4 stated that neither of them had reviewed Resident #10's food acceptance or I&O once it was started.RN #3 and #4 agreed that Resident #10's doctor should have been alerted to Resident #10's change in condition between 12/14/13 and 12/23/13. Review of the facility Nurses Progress Notes dated 12/24/13 "Resident went to hospital for sever dehydration/abnormal lab values...to (hospital name) at 1650 (4:50 p.m.)". Review of the hospital History and Physical dated 12/24/13 under the section "HPI:...considerable urinary tract infection with dehydration and [MEDICAL CONDITION] (high sodium level in the blood)". Under "Assessment/Plan: #2...Total water deficit calculated around 4L (liters)." Review of the facilities physician progress notes [REDACTED]. Severe Dehydration, 3. Acute [MEDICAL CONDITION]- Stage 5, and [MEDICAL CONDITION].

This Citation pertains to MI 672 Based on interview and record review the facility failed to notify the family regarding a change in condition, treatments and medications in 1 of 4 sampled resident (#101) reviewed for notification, from a total sample of 4 residents, resulting in the family not being informed to make healthcare decisions and unmet care needs for Resident #101. Findings include: Resident #101 was admitted to the facility on [DATE] and died on [DATE]. According to the Face Sheet, Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (minimum data set) dated [DATE] revealed Resident #101 was severely impaired with daily decision making skills, was sometimes able to make himself understood and sometimes able to understand others, required extensive two person assistance with transfers, was totally dependent on one person with moving about both on and off the unit, totally dependent on two people for dressing, toileting, personal hygiene and one person to feed the resident, had no functional limitations with range of motion to his arms or legs and was incontinent of bowel and had a catheter present in the bladder to drain urine. Review of the Nursing Notes dated [DATE] on the 11 P-7 AM shift revealed "resident (Resident #101) has moist cough, pulse ox (pulse oximetry measures blood oxygen levels) states I am going to die". Review of the Nursing Notes dated [DATE] on the 11 PM-7 AM shift revealed "Resident (Resident #101) refused oral [MEDICATION NAME] (anti-anxiety medication), began shouting for help, PRN (as needed) [MEDICATION NAME] IM at 0300 (3 AM) given". Review of the Nursing Notes dated [DATE] revealed "Family here and signed papers for Risk Management placed in chart". The notes dated [DATE] on the 3 PM-11 PM shift revealed "antibiotic (for Resident #101) continues for urinary tract infection" Nurses Notes dated [DATE] "(urine) culture shows resistance [MEDICATION NAME](antibiotic). Start Bactrim (antibiotic). There was no documentation present in the nursing noted to indicate that the DPOA (Durable Power of Attorney) was notified of [MEDICATION NAME] medication given IM (intramuscularly) or the antibiotic administered to Resident #101. Review of the Nursing Notes dated [DATE] at 12:30 AM "IV (intravenous) started in right hand, infusing at 60 ml/hr" No documentation was present to indicate the DPOA was notified that the IV was started. Review of the Nursing Notes dated [DATE] at 1:30 PM revealed "resident grimacing, guarding ribs with cough complains of pain, when asked if hurting, new order received for [MEDICATION NAME] (pain medication). No documentation was present to indicate the DPOA was notified that the pain medication [MEDICATION NAME] was added to Resident #101's medications or the new information regarding the new onset of pain. In a telephone interview on [DATE] at 11:15 AM, DPOA (durable power of attorney) #1 reported that the facility did not initiate any phone calls to her regarding medications, treatments, or any change in Resident #101's condition. DPOA #1 stated, "My Dad never used oxygen at home, did not use [MEDICATION NAME] and I called about why they were doing what they were doing to him without me knowing about it. The only call I received was one time when he cut his hand during a shower. I absolutely had to call them to find out what was going on. The day before he died , I called them and found out he was being given [MEDICATION NAME] ([MEDICATION NAME]) and I knew then that's given to people who are dying, but I didn't know that he was dying, they didn't tell me. When I saw him on the 15th, I should have insisted he go to the hospital but isn't that their job that should have been automatic? Yes, I had no CPR (cardiopulmonary resuscitation) but I wanted him sent out to the hospital for anything else. He told me that day (15th) to get him out of here and said 'they are going to kill me'. I missed being with my Dad when he died by 40 minutes, why didn't they call me and tell me he was so bad?" Review of the Facility document titled "Advanced Directive Guide" dated [DATE] revealed for CPR, "DNR" (do not resuscitate) was checked, for "hospitalization ", "YES in any situation" was checked. ( )

This Citation pertains to MI 672 Based on interview and record review the facility failed to meet the highest practicable physical well-being by not sending a to the hospital in a timely manner in 1 of 4 sampled residents (Resident #101) reviewed for adequate assessments, from a total sample of 4 residents sampled, resulting in unmet care needs. Findings include: Resident #101 was admitted to the facility on [DATE] and died on [DATE]. Resident #101 according to the facility face sheet was admitted to the facility with a medical history of [REDACTED]. Review of the Facility MDS (minimum data set) dated [DATE] revealed Resident #101 was severely impaired with daily decision making skills, was sometimes able to make himself understood and sometimes able to understand others, required extensive two person assistance with transfers, was totally dependent on one person with moving about both on and off the unit, totally dependent on two people for dressing, toileting, personal hygiene and one person to feed the resident, had no functional limitations with range of motion to his arms or legs and was incontinent of bowel and had a catheter present in the bladder to drain urine. Review of the Facility document titled "Advanced Directive Guide" dated [DATE] revealed CPR "DNR" (do not resuscitate) was checked. "hospitalization ", "YES in any situation was checked. Physician orders [REDACTED].> 88%. Pulse oximetry check every shift". Physician orders [REDACTED]. Review of the Nursing Notes dated [DATE] on the 11 P-7 AM shift revealed "resident (Resident #101) has moist cough, pulse ox low (pulse oximetry measures blood oxygen levels) states "I am going to die". Review of the Nursing Notes dated [DATE] on the 11 PM-7 AM shift revealed Resident #101 "still has moist non-productive cough. Increased bilateral (both) lobes congested, decreased bilateral lobes rubs present. Pulse oximetry 89% - 90% on 4 liters nasal cannula". Review of the chest x-ray (CXR) results dated [DATE] revealed "Conclusion: Mild [MEDICAL CONDITIONS]/pulmonary [MEDICAL CONDITION] vs. pneumonia which should be considered in clinical context of cough, elevated WBC (white blood count) or other signs of lung infection. Follow up CXR as clinically warranted." Review of the Nursing Notes dated [DATE] 12:30 AM "IV (intravenous) started in right hand, infusing at 60 ml/hr". Review of the Intake and output records dated from [DATE] to [DATE] revealed after Resident #101's IV was started on [DATE], Resident #101's intake on the ,[DATE] shift was 1130 cc with only 350 cc urine, ,[DATE] PM intake 240 cc with 300 cc urine output. Review of the Nursing Notes dated [DATE] on the 11 PM - 7 AM shift revealed Resident #101's "Oxygen saturation at 84%. Resident received NMT (nebulized mist treatment inhaled respiratory treatment) before treatment left lower lobe lung sounds absent. Right lobe crackles oxygen 84%. After treatment oxygen level 91%". Review of the Nursing notes dated [DATE] at 1:30 PM revealed "Resident (#101) grimacing, guarding ribs with cough, complains of pain when asked if hurting. Oxygen at 3 L/M. Moist occasional cough noted". Review of the Nursing Notes dated [DATE] at 4:45 AM Resident oxygen sats 70's-mid 80's on 5 L/M per nasal cannula. (Max per nasal cannula is 4 Liters). Lung sounds moist. [MEDICATION NAME] 40 mg (diuretic to get rid of excess body fluids via urine output) IVP (intravenous push). Review of the Nursing Notes dated [DATE] at 6 AM revealed "Resident (#101) oxygen saturation (O2 sats) ,[DATE]% on 02 at 15 L per non-rebreather (oxygen mask fitted with valves exhaled gas vented out, inhaled gas oxygen only comes from bag attached to mask). Doctor notified received orders for [MEDICATION NAME] (antibiotic) 1 GM IM (intramuscular) every 24 hours X 3 days. No documentation was present on the Nursing Notes regarding results of urine output related to the [MEDICATION NAME] given at 4:45 AM. Review of the Nursing Notes dated [DATE] (,[DATE]) revealed Resident #101's "Right hand/arm swollen at 4 PM. O2 continues at 15 liters/min with rebreather mask. pulse ox 86% (ordered to be greater than 88%). Abdominal breathing. Unresponsive to verbal stimuli. IV removed from right hand. Supervisor notified of pain status and family concerns". Nursing Notes dated [DATE] on the 11 PM - 7 AM shift revealed, "Resident (#101) kept trying to climb out of bed, swinging at aides, Pulse ox 98% on 4 L/M. Asleep until 4 AM woke with confusion, combative, very anxious. Pulse ox 69% (normal above 91%) Supervisor here assessing resident until 5:45 AM. Pulse ox 78% on 5 L/M nasal cannula. Pulse ox down to 78%, put on non-rebreather". Nursing Notes dated [DATE] revealed Resident #101 had "Oxygen intact via mask at 15 liters. New order for [MEDICATION NAME] 40 MG IM now given at 23:45 (11:45 PM)." No documentation was present in the Nursing Notes regarding urine output results from [MEDICATION NAME] given at 11:45 PM. Review of the Facility Vitals Chart Sheet dated from [DATE] to [DATE] revealed respirations were ,[DATE] per minute (average is 20 per minute). Review of the Nurses Notes for Resident #101 dated [DATE] (untimed) revealed "Charge nurse called, Unit Manager to room. Resident has no respirations and no apical pulse. Time of death 10:50 AM. POA was notified. Funeral home notified at 14:40 (2:40 PM)." Review of the Facility Physician Standing orders "Emergency Care: #1. Respiratory Distress: Check SaO2 (pulse oximetry) pulse oximetry should be 88% or higher, check for abnormal lung sounds... Contact the Physician and transfer to the hospital." During an interview/record review with Administrator #1, Director of Nurses #2 and Unit Manager #3 on [DATE] at 1:50 PM, when asked to explain during the review of Resident #101's medical record based on the documented evidence why Resident #101 was not sent to the hospital, all three were unable to offer an explanation During a telephone interview on [DATE] at 4 PM, Attending Physician/Medical Director (A) reported that he only saw Resident #101 on [DATE]. Attending Physician/Medical Director (A) stated, "if I see them I write a note. I spoke with the staff (regarding Resident #101's declining condition) but had no sense of urgency and took information verbally over the phone, only the data that was given to me by the staff." When asked if the residents have instructions to go to the hospital do facility staff have to get permission? Attending Physician/Medical Director (A) stated, "They don't have to wait for me to send someone to the hospital if that's their wish they should send them. I knew he had a DNR status, but desired hospitalization ". ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE TO PREVENT FALLS AND FRACTURES FOR 2 OF 17 RESIDENTS REVIEWED FOR FALLS/FRACTURE (#12 AND #13), FAILED TO PROVIDE NECESSARY CARE AND TREATMENT BASED ON COMPREHENSIVE ASSESSMENT IN A TIMELY MANNER FOR 1 RESIDENT (#13) EACH OUT OF A TOTAL SAMPLE OF 25, AND FAILED TO MONITOR HOT WATER TEMPERATURES THAT EXCEEDED 120 DEGREES FARENHEIT, RESULTING IN FACIAL AND FINGER FRACTURES FOR RESIDENT #12, ANKLE FRACTURE WITH A DELAY OF treatment for [REDACTED].#13, AND RESULTING IN THE POTENTIAL TO BURN ALL 10 RESIDENTS IN ROOMS 1 THROUGH 10 WHO LIVED IN CLAUDIA'S COTTAGE. FINDINGS INCLUDE: ON 2/12/13 AT 10:00 AM, BOTH THE ADMINISTRATOR AND NURSE STAFF "KK" WERE PRESENT DURING THE INITIAL TOUR OF THE FACILITY. DURING INITIAL TOUR, RESIDENT #12 WAS OBSERVED IN A LOW BED WITH A BRACE AROUND HER NECK, AND AN ALARM STRING ATTACHED TO HER BLANKET. NURSE "KK" CONFIRMED RESIDENT #12 HAD A FRACTURED NECK, NURSE KK STATED NO FALLS HAVE EVER HAPPENED ON THIS (SNAPDRAGON VALLEY) UNIT. WHEN ASKED HAD THE FALL OCCURRED IN THIS BUILDING, THE ADMINISTRATOR STATED I DON'T KNOW SHE CAME FROM THE MORNING GLORY UNIT, THE ADMINISTRATOR LATER STATED IT COULD HAVE HAPPENED ON THE MORNING GLORY UNIT. THE FEBRUARY 2013 MONTHLY physician's orders [REDACTED]." ACCORDING TO THE NURSES NOTES DATED 7/26/12 ON THE 7AM TO 3PM SHIFT, RESIDENT #12 WAS "admitted AT 1:00 PM, FAMILY ARRIVE WITH HER AND RESIDENT #12 WAS ALERT AND TALKATIVE. SLIGHT CONFUSION NOTED. CODE ALERT BED AND CHAIR ALARM APPLIED." THE ADMISSION MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED THAT RESIDENT #12 HAD A FALL IN THE LAST 2 TO 6 MONTHS PRIOR TO ADMISSION. THERE WAS AN INCIDENT ON 7/28/12 WHERE RESIDENT #12 SLIPPED OUT OF HER WHEELCHAIR IN HER ROOM. HER FAMILY WAS PRESENT AT THAT TIME. ACCORDING TO THE INCIDENT REPORT RESIDENT #12 WAS RACING IN HER WHEELCHAIR WITH HER HUSBAND IN HALL WHEN SHE ENTERED HER ROOM. "SHE FORGOT TO LOCK HER WHEELCHAIR AND SLIPPED OFF LANDING ON HER BUTT NO INJURIES NOTED." THE PREVENTATIVE MEASURES THAT WERE PUT IN PLACE WAS A SENSOR PAD ON WHEEL CHAIR SEAT WITH NON-SKID PAD ON TOP AND BOTTOM. "AS RESIDENT DOES REMOVE BOX AND CARRY IT WITH HER. ANTI-LOCK BRAKES RECOMMENDED." NURSES NOTES DATED 7/26/12 REFLECTED RESIDENT #12 WAS VERY UPSET AND DID NOT KNOW WHY SHE WAS THERE, RESIDENT #12 "HAD CVA (CEREBRALVASCULAR ACCIDENT) SHORT TERM MEMORY LOSS. HAS BEEN ON ONE ON ONE ALL SHIFT." NURSES NOTES DATED 7/27/12 REFLECTED RESIDENT #12 WAS PLEASANT AND CONTINUED TO REPEAT HERSELF "...SHOWN HOW TO USE CALL LIGHT BUT DIDN'T REMEMBER TO USE. NURSES NOTES DATE 7/27/12 REFLECTED RESIDENT #12 WAS "...FREQUENTLY NON-COMPLIANT WITH CALL FOR ASSIST TO AMBULATE..." NURSES NOTES DATED 7/28/12 ON THE 11-7 SHIFT REFLECTED RESIDENT #12 WAS "CALM & COOPERATIVE WITH CARE ... SET OFF ALARM X 3 THIS SHIFT TO USE TOILET, SHOWN HOW TO USE CALL LIGHT BUT FREQUENTLY FORGETS..." THE NURSES NOTES DATED 7/29/12 (11 -7 SHIFT) REFLECTED RESIDENT #12 WAS AWAKE AT SHIFT CHANGE, MADE SEVERAL ATTEMPTS TO GET OUT OF BED, SETTING OFF ALARM, REQUESTING TO CALL HER HUSBAND OR GO DOWNSTAIRS TO FIND HER HUSBAND. STAFF ABLE TO RE-DIRECT AFTER A SHORT WHILE. THEN SLEPT SOUNDLY..." NURSES NOTES DATED 7/30/12 REFLECTED THAT "...AFTER SUPPER WHEN FAMILY GOES HOME ELDER (RESIDENT #12) BECOMES RESTLESS. UP AND DOWN ... SETTING OFF ALARM FREQUENTLY. SHE STATES SHE WANTS TO GO ... CARRYS ALARM IN HAND OR JUST WALKS AROUND WITH MAGNET DANGLING. DOES NOT REMEMBER TO USE CALL LIGHT FOR ASSISTANCE. WE REINFORCE USE OF CALL LIGHT BUT TO NO AVAIL." NURSES NOTES DATED 7/31/12 REFLECT THAT RESIDENT #12 "...CONTINUES TO BE NON-COMPLIANT WITH CALL LIGHT. PERSONAL ALARM ON AT ALL TIMES, CALL LIGHT IN REACH." NURSES NOTES DATED 8/1/12 REFLECT THAT RESIDENT #12 WAS ANXIOUS AT THE BEGINNING OF SHIFT...ALARM SOUNDING - RES INCREASED WALKING IN ROOM. TOOK TO BR (BATHROOM) THEN HELPED TO BED. ALARM SOUNDED AGAIN SHORTLY AFTER - RES (RESIDENT) AGAIN GOT UP AND WAS STANDING BY BED ADJUSTING COVERS..." THE FALL CARE PLAN DATED 8/7/12 REFLECTED THAT RESIDENT #12 WAS AT RISK FOR FALLS RELATED TO A HISTORY OF FALLS AND SEIZURE DISORDERS. THE APPROACHES WERE AS FOLLOWS: THE CHARGE NURSE WAS TO DOCUMENT AND REPORT ANY DECLINE IN ABILITY TO BEAR WT (WEIGHT)/TRANSFERS IN THE NURSES NOTES. NOTIFY THE FAMILY, SUPERVISOR AND PHYSICIAN OF ANY FALLS. CHARGE NURSE TO DOCUMENT IN THE NURSES NOTES. AMBULATE AND TRANSFER WITH ASSIST X 1 STAFF USING A TWO WHEELED WALKER AS ASSISTIVE DEVICE IN ALL AREAS. STAFF TO USE WHEELCHAIR FOLLOW-UP WHEN AMBULATING IN THE HALLS. STANDARD WHEELCHAIR WITH BILATERAL FOOTREST FOR MOBILITY. BED/CHAIR ALARMS WITH SUPER SNAP CLIP/CHECK PER MCF (MEDICAL CARE FACILITY) PROTOCOL, CODE ALERT CHECK PER MCF PROTOCOL, SENSOR ALARM ON BATHROOM DOOR, RESTORATIVE THERAPY AS ORDERED. THE ADMISSION MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED RESIDENT #12 WAS NOT INTERVIEWED FOR THE BRIEF INTERVIEW FOR MENTAL STATUS, HOWEVER THE ADMISSION MDS REFLECTED SHE HAD BOTH LOG AND SHORT TERM MEMORY LOSS WITH MODERATE COGNITIVE IMPAIRMENT. INCIDENT REPORT DATED 8/11/12 REFLECTED RESIDENT #12 "WAS UP AMBULATING IN HALL WITHOUT ASSISTANCE! ALARM SOUNDING. BEFORE STAFF COULD GET TO HER SHE fell , BUT FALL WAS NOT WITNESSED. SUSTAINED 2 LACERATIONS ABOVE LEFT EYE - ONE TO FOREHEAD AND ONE TO BROW LINE. ABRASION UNDER LEFT EYE WITH SWELLING AND BRUISING. NOSE BLEEDING, TOOTH KNOCKED OUT AND CUT ON LEFT CHEEK (INNER WITH BLEEDING. LARGE GOOSE-EGG WITH BRUISE ON POSTERIOR LEFT HAND. SENT TO (NAME OF HOSPITAL)..." ON THIS SAME INCIDENT REPORT DATED 8/11/12 UNDER "SUMMARY OF FINDINGS" "ELDER (RESIDENT #12) HAS BEEN CONFUSED SINCE ADMIT WITH SHORT TERM MEMORY LOSS S/P CVA. BECOMES ANXIOUS/RESTLESS WHEN FAMILY LEAVES FOR THE EVENING IS OFTEN 1:1." THIS SAME FORM ALSO REFLECTED THAT RESIDENT #12 HAD A CHRONIC/ACUTE CONDITION CAUSING RESIDENT TO BE UNSTABLE," HOWEVER THERE WAS NO MENTION OF WHAT THAT CONDITION WAS. THE FACILITY'S POST "FALLS/FALL RISK EVALUATION UNDER "CONDITIONS REPRESENTING RISK FACTORS FOR FALLS THERE WAS NO MENTION OF ANY CHRONIC OR ACUTE CONDITION THAT CAUSED THE FALL. THIS SAME INCIDENT REPORT UNDER "RECOMMENDATIONS AND PREVENTATIVE MEASURES, REFLECTED THAT "RESIDENT HAD BED, CHAIR AND BATHROOM DOOR ALARMS IN PLACE BUT WAS NON-COMPLIANT WITH USE OF CALL LIGHT, VERY FORGETFUL WITH SHORT TERM MEMORY DEFICIT. CHAIR ALARM WAS SOUNDING AT TIME OF FALL, BUT RESIDENT WAS ALREADY UP AMBULATING UNASSISTED IN HALL." THE NURSES NOTES DATED 8/11/12 DID NOT DOCUMENT ANY CHRONIC CONDITION WHICH WOULD CAUSE HER TO FALL. DURING A CONFERENCE MEETING ON 2-14-13 BETWEEN 11AM AND NOON WITH THE ADMINISTRATOR, THE DIRECTOR OF NURSING AND THE RISK MANAGER NURSE "CC", THE RESIDENTS "CHRONIC CONDITION" WRITTEN ON THE BACK OF THE INCIDENT REPORT COULD NOT BE EXPLAINED. ON 2/14/13 BETWEEN 11:00 AM AND 1:00 PM, DURING A MEETING IN THE FIRST CONFERENCE ROOM WITH THE ADMINISTRATOR, THE DIRECTOR OF NURSING (DON) AND NURSE RISK MANAGER "CC", THIS SURVEYOR WAS TOLD THE CARE PLANS THAT WERE IN THE CHART AT THE TIME IT WAS REVIEWED ON 2/13/13 BETWEEN 9:00 AM AND 11:30 AM, WERE NOT THE CURRENT CARE PLANS THAT WERE COPIED 2/13/13, NOR HAD BEEN USED AT THE TIME OF THE FALL. NURSE RISK MANAGER "CC" EXPLAINED ALL THE INTERVENTIONS THAT WERE PUT IN PLACE UPON ADMISSION BECAUSE RESIDENT #12 had a history of [REDACTED]. THE DON GAVE EXAMPLES OF RESIDENT #12 CONSTANTLY GETTING UP AND DOWN AND THE FACILITY HAD NO IDEA OF THIS BEHAVIOR UNTIL AFTER HER FALL ON 8/11/12. HOWEVER, NURSES NOTES FROM 7/26/12 THROUGH 8/1/12 REFLECTED THE SAME BEHAVIOR THE FAMILY EXPLAINED TO THE DIRECTOR OF NURSING. NURSE RISK MANAGER "CC" STATED NURSING HAD NOT INFORMED HER AND SHE WAS UNAWARE OF RESIDENT #12'S BEHAVIOR, RENDERING HER UNABLE TO TAKE PREVENTATIVE MEASURES TO PREVENT THE NEXT FALL. THE THINNED RECORDS WITH THE CARE PLAN THAT WAS IN PLACE AT THE TIME OF THE FALL HAD ALREADY BEEN COPIED. ADDITIONALLY, THERE WAS A LOOSE NURSES NOTE DATED 8-11-12 WITH NO SHIFT OR TIME ON THE NOTATION AND NO SEQUENTIAL NOTES FOLLOWING THE ENTRY. THE LOOSE NURSING NOTE STATED "LATE ENTRY." ON 2-14-13 AT 3:05PM, NURSE "BB" WHO WROTE THE "LATE ENTRY" NURSES NOTE WAS INTERVIEWED AND STATED SHE DID NOT RECALL THE DATE THE LATE ENTRY WAS MADE RELATED TO THE NOTE DATED 8/11/12. NURSE "BB" STATED RESIDENT #12 WAS ALERT AND CONFUSED, RESIDENT #12 WAS ALERT BECAUSE SHE WAS "AWAKE." NURSE "BB" WAS ASKED WHY WAS RESIDENT #12 SAYING "IM SORRY, I'M SORRY." NURSE "BB" SAID I DON'T KNOW, SOMETIMES RESIDENTS FEEL BAD AFTER THEY GET UP UNASSISTED AND FALL. IT WAS EXPLAINED ACCORDING TO THE FACILITY'S DOCUMENTATION, SHE DID NOT SEEM COGNITIVELY ALERT ENOUGH TO KNOW SHE DID ANYTHING WRONG. THEN NURSE "BB" REPLIED SHE WAS ALERT ENOUGH TO TALK AFTER THE FALL. THE RESULTS OF THE HOSPITAL CAT SCAN DATED 8/11/12 REFLECTED RESIDENT #12 HAD "POSTTRAUMATIC CHANGES INVOLVING THE LEFT ORBIT WITH FRACTURES INVOLVING THE MEDIAL WALL AND ORBITAL FLOOR WITH SOME HERNIATION OF THE ORBITAL FAT THROUGH THE FLOOR DEFECT. 2) THERE IS SOME RETROBULBAR HEMORRHAGE AND SUBCUTANEOUS EMPHYSEMA. 30 ALTHOUGH THE GLOBES APPEAR RADIOGRAPHICALLY INTACT THERE IS SOME HEMORRHAGE ABOUT THE LEFT GLOBE AND CLINICAL CORRELATION IS RECOMMEND TO CONFIRM IT THE GLOBE IS INDEED INTACT. 4) NO DEFINITE DISLOCATION OF THE INTRAOCULAR LENSES 50 LEFT FRONTAL SCALP, PERIORBITAL, PRESEPTAL FACIAL SOFT TISSUE SWELLING AND LACERATION. NO RADIODENSE FOREIGN BODY. 6) SUBTLE DEFORMITY LEFT NASION MAY REPRESENT A RECENT FRACTURE." THE HOSPITAL CONSULTATION REPORT DATED 8/12/12 REFLECTED A HISTORY OF PRESENT ILLNESS DESCRIBED AS "A [AGE] year OLD FEMALE WAS admitted TO THE HOSPITAL SECONDARY TO A FALL. SHE SUFFERS C2 FRACTURE AND ORBITAL FRACTURE. THIS SAME CONSULTATION ALSO REFLECTED THAT RESIDENT #12 NEEDED 24-HOUR SUPERVISION ON DISCHARGE, THAT SHE NEEDED "...TO BE IN ECF (EXTENDED CARE FACILITY) FOR WHICH SHE CAN GET SUPERVISION 24 HOURS AS SHE IS AT RISK OF FALL..." THIS SAME REPORT ON PAGE 20 REFLECTED AN "AGE INDETERMINATE COMPRESSION DEFORMITY OF T11... IF THERE IS FOCAL PAIN OR TENDERNESS. THIS SAME REPORT ALSO HAD FINDINGS OF THE LEFT HAND "OBLIQUE, AND LATERAL VIEWS. THERE IS A FRACTURE OF THE BASE OF THE PROXIMAL 5 TH PHALANX WITH OSTEOPENIA AND DEMINERALIZATION..." RESIDENT #12 WAS OBSERVED ON 2/12/13 IN BED AT 10:00 AM. ON 2/13/13 AT 9:00 AM RESIDENT #12 WAS OBSERVED IN BED. BREAKFAST WAS JUST ENDING AND RESIDENT #12 HAD NOT BEEN SEATED AT THE TABLE. ON 2/13/13 AT 9:55 AM NURSE AIDE "OO" CONFIRMED THAT RESIDENT #12 HAD NOT EATEN ANY BREAKFAST BECAUSE SHE WAS ASLEEP. ON 2/13/13 AT 10:40 AM RESIDENT #12 WAS OBSERVED IN A HOYER TRANSFER WHICH WENT WELL. THEN RESIDENT #12 WAS OBSERVED BEING FED AT A TABLE BY HERSELF. SHE RECEIVED TOTAL ASSIST FOR FEEDING. ON 2/14/13 AT 3:30 PM RESIDENT #12 WAS OBSERVED UP IN A RECLINER CHAIR IN A CIRCLE WITH OTHER RESIDENTS. WHEN COMPARING THE ADMISSION MINIMUM DATA SET (MDS) assessment dated [DATE] WITH THE SIGNIFICANT CHANGE assessment dated [DATE] RESIDENT #12 HAD A SIGNIFICANT DECLINE IN HER COGNITIVE ABILITY FROM MODERATE IMPAIRMENT TO SEVERE IMPAIRMENT. SHE WENT FROM ONE PERSON PHYSICAL ASSISTANCE TO AN EXTENSIVE ASSISTANCE, REQUIRING A MECHANICAL LIFT FOR TRANSFERS. DRESSING WENT FROM ONE PERSON ASSISTANCE TO TOTAL ASSISTANCE. EATING WENT FROM INDEPENDENT WITH SET UP TO EXTENSIVE ASSISTANCE. HYGIENE AND BATHING WENT FROM ONE PERSON ASSISTANCE TO TOTAL ASSISTANCE. THE RANGE OF MOTION WENT FROM WALKING WITH ASSISTANCE TO NONE AT ALL. TURNING AROUND WENT FROM ASSISTANCE TO NONE AT ALL. BOWEL INCONTINENCE WENT FROM MOSTLY CONTINENT TO FREQUENTLY INCONTINENT. PAIN WENT FROM ZERO - NO PAIN AND NO PAIN MEDICATIONS TO DAILY COMPLAINTS OF PAIN AND EXPRESSIONS OF PAIN, NOW RESIDENT #12 IS ON A REGULAR AND AS NEEDED PAIN MEDICATIONS. RESIDENT #12'S MOST RECENT QUARTERLY MINIMUM DATA SET (MDS) assessment dated [DATE] REFLECTED RESIDENT #12 HAD SEVERE COGNITIVE IMPAIRMENT, AND WAS NOW TOTALLY DEPENDENT FOR TRANSFERS, DRESSING, EATING HYGIENE AND BATHING. ACCORDING TO THE QUARTERLY MINIMUM DATA SET assessment dated [DATE] RESIDENT #12 HAS ALSO HAD SIGNIFICANT WEIGHT LOSS, WHEN HER ADMISSION ASSESSMENT SHOWS A WEIGHT OF 189 POUNDS AND A HEIGHT OF 65 INCHES, THE QUARTERLY MDS dated [DATE] SHOWS A WEIGHT OF 165 POUNDS. RESIDENT #12'S MOST RECENT WEIGHT RECORDED ON THE WEIGHT LOG WAS 158.7 POUNDS ON 2/14/13. ACCORDING TO NURSES QUARTERLY PROGRESS NOTES DATED 11/7/12 RESIDENT #12 RECEIVED "OXYCODONE 10 MG EVERY EVENING FOR PAIN AND A FENTANYL PATCH 50 MCG REPLACED EVERY 72 HOURS FOR PAIN. ALSO HAS PRN (AS NEEDED) OXYCODONE HCL 10 MG THRE TIMES DAILY FOR PAIN. SHE HAS USED HER PRN OXYCODONE 32 X'S IN OCT (2012) AND 9 X'S IN NOV (2012) THUS FAR..." ACCORDING TO THE FACILITY NURSES' PROGRESS NOTES DATED 1/22/13, 1/25/13, 1/27/13, 1/31/13, 2/5/13 AND 2/10/13 ALL REFLECT THAT RESIDENT #12 WAS IN PAIN AND HAD BEEN GIVEN AS NEEDED PAIN MEDICATIONS IN ADDITION TO REGULARLY SCHEDULED PAIN MEDICATIONS. ( ) ACCORDING TO THE physician's orders [REDACTED]. ON 2/12/13 AT 10:00 A.M., DURING AN INITIAL TOUR, RESIDENT #13 WAS OBSERVED SITTING IN HER WHEELCHAIR WITH HER RIGHT FOOT WRAPPED WITH A BROWN COLOR ACE BANDAGE AT THE THRESHOLD OF HER ROOM. THE REGISTERED NURSE/SUPERVISOR, (STAFF "OO") STATED SHE WAS NOT SURE WHY THE RESIDENT HAD A BANDAGE ON HER RIGHT FOOT. STAFF "OO" LOOKED FOR THE INFORMATION FROM THE RESIDENT'S RECORD AND SAID, THE RESIDENT HAD A SPONTANEOUS HAIR LINE FRACTURE ON HER RIGHT FOOT AND SHE WAS WEARING A FOOT IMMOBILIZER. THE OCCUPATIONAL THERAPY INITIAL EVALUATION DATED 7/24/12 REFLECTED RESIDENT #13 HAD RIGHT DISTAL FEMUR FRACTURE AND HAD IMMOBILIZER (REMOVABLE) ON HER RIGHT LOWER EXTREMITY. PRIOR TO THE FRACTURE THE RESIDENT WAS IDENTIFIED USING A STANDARD WHEELCHAIR WITH BILATERAL FOOTREST AND FOOT BUDDY. THE RESIDENT WAS RECOMMENDED TO USE BODY BOARD TRANSFER, THUS SHE NEEDED A HIGH BACK RECLINER WHEELCHAIR TO ACCOMMODATE THE TRANSFER. THE OCCUPATIONAL THERAPY SERVICE NOTE DATED 8/27/12 REFLECTED RESIDENT #13 WAS TO HAVE A TOTAL ASSIST WITH ACTIVITIES OF DAILY LIVING (ADL) INCLUDING A BODY TRANSFER WITH 3 PERSON ASSIST. ACCORDING TO FACILITY INCIDENT REPORTS RESIDENT #13 HAD 2 INCIDENTS ON 12/12/12. THE FIRST INCIDENT OCCURRED AT 5:00 A.M. THE REPORT STATED RESIDENT #13 WAS FOUND TO HAVE AN "ABRASION TO LEFT LOWER POSTERIOR LEG-ANKLE. AREA 3 CM X 1 CM- SKIN ABRAISED-NOT OPEN. SLIGHT REDNESS. NO DRAINAGE. NO BLOOD AT SITE. ? WILL BRUISE- RES (RESIDENT) RUBS LEFT ANKLE AGAINST RIGHT LEG IMMOBILIZER. THE PREVENTIVE MEASURES INCLUDED PILLOW UNDER LEGS WHEN IN W/C (WHEELCHAIR) TO PREVENT LOWER LEG RUBBING ON FOOT BUDDYS. NO ROUGH EDGES." THE SECOND INCIDENT OCCURRED AT 1:30 P.M. ON 12/12/12. THE REPORT STATED, "DURING A BODY BOARD TRANSFER FROM W/C TO BED, RESIDENT LANDED ON TOP OF CNA (CERTIFIED NURSING ASSISTANT)'S RIGHT LEG. RESIDENT APPEARED TO HAVE NO PAIN, RIGHT SIDE BUMPED INTO CNA." THE PREVENTIVE MEASURES/CORRECTIVE ACTIONS STATED "ASSESSMENT OF SKILLED THERAPY TRANSFER WAS APPROPRIATE, RESIDENT IS A 3 PERSON SLIDEBOARD TRANSFER." THE INVESTIGATIVE INTERVIEW REPORT (UNDATED) WITH 1 OF 3 CENAS (STAFF "PP") STATED CNA (STAFF "Q") ON PULL SIDE AND ANOTHER CNA (STAFF "QQ") AND MYSELF ON PUSH SIDE DURING A 3 PERSON TRANSFER WITH RESIDENT #13. STAFF "Q" WAS ON HER KNEES ON THE BED. AS WE TRANSFERRED RESIDENT SHE LANDED ON STAFF "Q'S" KNEES. STAFF "Q" SLOWLY BACKED HER WAY OFF BED. THE SECOND CENA (STAFF "QQ") ' S INTERVIEW STATEMENT REFLECTED, " ....DURING TRANSFER RESIDENT BUMPED HER RIGHT HIP/LOWER BACK AREA INTO STAFF "Q"' S KNEES ... " THE THIRD CENA (STAFF "Q'S") INTERVIEW STATEMENT REFLECTED, " ...I WAS KNEELING WITH BOTH KNEES ON THE BED, I WENT TO PULL HER TOWARDS ME, I ROLLED ON MY RIGHT SIDE WITH THE MOTION THE RESIDENT ENDED UP ON MY LEFT SIDE ...I GOT MYSELF OUT FROM UNDERNEATH HER ... " RESIDENT #13'S "NURSE'S PROGRESS NOTES" DATED 12/12/12 (3-11 SHIFT) REFLECTED "...RESIDENT UPON MOVING HER RIGHT LEG C/O (COMPLAINS OF) DISCOMFORT...SOME SWELLING OBSERVED TO RESIDENT'S RIGHT LEG. LEG BRACE IN PLACE TO RIGHT LEG..." THE NURSES PROGRESS NOTES DATED 12/13/12 (11-7) REFLECTED, "YELLS OUT IN PAIN WITH ANY MOVEMENT OF RIGHT LEG. RIGHT THIGH DOWN TO KNEE HAS INCREASED EDEMA. SUPERVISOR AWARE..." THE NURSING NOTE DATED 12/13/12 (1:25 P.M.) REFLECTED " RESIDENT #13'S RIGHT LOWER LEG RED AND WARM ABOVE ANKLE, POSITIVE HOMANS'S SIGN, A TEST TO CHECK BLOOD CLOTS OF DEEP VEINS OF THE CALF ( PRESENCE OF PAIN WHEN THE TOE IS PASSIVELY DORSIFLEXED)...WAITING FOR RETURN CALL FROM PRIMARY CARE PHYSICIAN..." THE "ULTRASOUND REPORT" DATED 12/14/12 FOUND NO EVIDENCE OF DEEP VENOUS THROMBOSIS IN THE RIGHT LOWER EXTREMITY. THE NURSING NOTES DATED 12/15/12 REFLECTED RESIDENT #13 "CALLED OUT A FEW TIMES FOR HER CNA (CERTIFIED NURSES AIDE) WITH MOVEMENT OF RIGHT CONTINUES TO YELL OUT, C/O PAIN." THE NURSING NOTE DATED 12/16/12 REFLECTED,"CONTINUES TO YELL OUT IN PAIN WITH ELEVATION OF RIGHT LEG AND WITH PRESSURE TO LEG SUCH AS PUTTING SOCK, BRACE ON OR TURNING. RIGHT LEG FROM THIGH TO ANKLE SWOLLEN. INCREASE ( INCREASE SIGN X 3) REDNESS AND WARMTH TO RIGHT LOWER LEG-SHIN AREA." THE RESIDENT WAS PRESCRIBED CIPRO (ANTIBIOTIC) FOR RIGHT LOWER LEG CELLULITIS. THE NURSING NOTES DATED 12/17/12 REFLECTED RESIDENT #13 "CONTINUES WITH PAIN, WARMTH AND EDEMA TO RIGHT LOWER LEG..." THE NURSING NOTE DATED 12/19/12 REFLECTED RESIDENT #13'S "RIGHT LEG RED-CONTINUES TO YELL OUT WITH TOUCH-PAINFUL..." THE NURSING NOTE DATED 12/20/12 REFLECTED RESIDENT #13'S "RIGHT LOWER LEG CONTINUES TO BE RED AND WARM AND SWOLLEN. C/O PAIN WITH MOVEMENT." THE NURSING NOTE DATED 12/20/12 (7-3 SHIFT) REFLECTED RESIDENT #13 "RIGHT LEG STILL PAINFUL AND RED. X-RAY OF LEG ORDERED CONTINUE ON ANTIBIOTIC FOR CELLULITIS..." THE RADIOLOGY REPORT DATED 12/20/12 (8 DAYS LATER FROM THE INCIDENT) REFLECTED RESIDENT #13 HAD AN ACUTE DISTAL/FIBULA FRACTURE AND RECOMMENDED TO GET ANOTHER X-RAY FOR KNEE AND ANKLE. THE RADIOLOGY REPORT DATED 12/21/12 REFLECTED RESIDENT #13 HAD A "RECENT INCOMPLETELY UNITED RIGHT KNEE FRACTURE IN ADDITION TO A RECENT ANKLE FRACTURE INVOLVING DISTAL TIBIA AND FIBULA. THE NURSING NOTE DATED 12/20/12 REFLECTED, "...PRIMARY CARE PHYSICIAN (PCP) AWARE...ORTHO REFERRAL AS SOON AS POSSIBLE. NO AMBULATION OF ANY KIND. ASKED PCP IF SHOULD SEND PT TO (NAME OF HOSPITAL) DUE TO FRACTURE. "NO. SHE SHOULD BE ALL RIGHT FOR TONOC (TONIGHT)." THE NURSING NOTE ON SAME DAY AT 2245 REFLECTED RESIDENT #13' RIGHT ANKLE AND FOOT SPLINTED WITH A BATH BLANKET AND CLOTH TAPE. THE NURSING NOTE DATED 12/23/12 REFLECTED, RESIDENT #13 " UP IN BED EATING BREAKFAST, IMMOBILIZER AND BATH BLANKET IN PLACE. RESIDENT C/O KNEE PAIN...RIGHT FOOT ROTATED INWARD STILL WITH SENSATION." THE NURSING NOTE DATED 12/26/12 REFLECTED RESIDENT #13'S "RIGHT FOOT REMAINS IMMOBILIZED IN BATH BLANKET...RIGHT FOOT REMAINS TURNED INWARD..." RESIDENT #13 WAS SEEN BY A ORTHOPEDIC SURGEON ON 1/6/13 (18 DAYS LATER SINCE THE ORDER WAS WRITTEN) FOR SPLINT APPLICATION TO HER RIGHT KNEE AND FOOT. THE ORTHOPEDIC CONSULTATION REPORT DATED 1/7/13 DID NOT EXPLAIN WHAT TYPE OF SPLINT THE RESIDENT WAS FITTED OR HOW IT SHOULD BE CARED FOR OR MONITORED. DURING THE WEEK OF SURVEY ON 2/15/13 AT 10:00 A.M., UNIT MANAGER, (STAFF "A") CONTACTED THE PHYSICIAN FOR SPLINT CARE INSTRUCTIONS. ON 2/15/13 AT THE SAME TIME, LICENSED PRACTICAL NURSE, (STAFF "L") STATED THERE WAS NO ORDER TO UNWRAP THE RESIDENT'S RIGHT LEG BANDAGE, THUS NO SKIN CHECKS OR CLEANING HAD BEEN DONE SINCE 1/6/13. THE SOCIAL SERVICE DEPARTMENT NOTE DATED 1/15/13 REFLECTED RESIDENT #13 "DID NOT AMBULATE AND TRANSFERRED VIA A BODYBOARD AND ASSIST OF 3 STAFF. SHE HAS A HIGH BACK RECLINING WHEELCHAIR WITH BILATERAL FOOT RESTS, WITH THE FOOT REST BEING ELEVATED AND A FOOT BOARD IN PLACE...(RESIDENT'S NAME) IS ALERT AND ORIENTED 1-2 WITH VERY POOR SHORT TERM AND FAIR LONG TERM. HER GLOBAL DETERIORATION SCORE IS 5-6 FOR MODERATE DEMENTIA WITH CONFUSION. SHE IS USUALLY PLEASANT, COOPERATIVE AND FRIENDLY WITH CARE...SHE DOES NOT PRESENT WITH MOOD OR BEHAVIORAL ISSUES. ON 12/6/12 SHE WAS STARTED ON CIPRO (ANTIBIOTIC) FOR RIGHT LOWER LEG CELLULITIS AND ON 12/20/12 SHE HAD AN X-RAY FOR RIGHT ANKLE DUE TO A FALL. ON 1/7/13 SHE HAD A ORTHO CONSULT REGARDING THE RIGHT LEG FRACTURE..." THE NURSING NOTES DATED 1/27/13 THROUGH 1/30/13 REFLECTED RESIDENT #13 HAD FEVER ASSOCIATED WITH RESPIRATORY DISTRESS AND SHE WAS PRESCRIBED AN ANTIBIOTIC AS WELL AS INTRAVENOUS FLUID. ALSO THE RESIDENT WAS NOTED TO HAVE A SMALL OPEN AREA OVER HER RIGHT KNEE. THERE WAS A YELLOW DRAINAGE SEEPING OUT OF SMALL OPEN AREA. THE NURSING NOTE DATED 1/30/13 REFLECTED, "...NO DRAINAGE FROM RIGHT KNEE THIS A.M. AREA PINK. WHEN RIGHT KNEE TOUCHED AREA HAS HARD OBJECT (I BELIEVE BONE) THAT POKES UP AND RECEDES. NO FOUL ODOR..." THE NURSING NOTE DATED 1/31/13 REFLECTED RESIDENT #13'S RIGHT KNEE WOUND WAS NOW ACTIVELY DRAINING WITH YELLOW DRAINAGE AND THE OPEN AREA WAS SLIGHTLY WARM. THE RESIDENT WAS PRESCRIBED ANTIBIOTIC. THE NURSING NOTE DATED 2/5/13 REFLECTED RESIDENT #13'S RIGHT KNEE STILL HAD CLEAR LIQUID BUBBLES. THE NURSING NOTE DATED 2/6/13 REFLECTED RESIDENT #13'S RIGHT KNEE HAD A LARGE AMOUNT OF GELATINOUS YELLOW DRAINAGE FROM THE SAME SMALL OPEN AREA. THE AREA WAS VERY TENDER TO TOUCH AND THE RESIDENT WAS MEDICATED WITH ROXANOL (NARCOTIC) FOR PAIN. ON 2/13/13 AT 9:30 A.M. RESIDENT #13 WAS OBSERVED BEING TRANSFERRED FROM HER HIGH BACK WHEELCHAIR TO HER BED VIA BODY BOARD WITH 3 PERSON (CENA "M", "N", AND "O") ASSIST WHILE LICENSED PRACTICAL NURSE/MDS (STAFF " P" ) WAS OBSERVING. THE RESIDENT WAS POSITIONED FLAT IN HER WHEELCHAIR BY LOWERING THE TOP AND RAISING THE BOTTOM TO THE LEVEL OF THE SEAT. THE WHEELCHAIR WAS THEN ALIGNED WITH THE RESIDENT'S TO A SAME HEIGHT. STAFF "M" AND "O" WERE AT BOTH ENDS OF THE WHEELCHAIR WHILE STAFF "N" SLID THE BODY BOARD UNDER THE RESIDENT FROM THE OPPOSITE END OF THE BED. BOTH STAFF "M" AND "O" PUSHED AND ROLLED THE RESIDENT TOWARD THE BED WHILE STAFF "N" PULLED AND ROLLED THE RESIDENT ONTO THE BED. THE RESIDENT YELLED OUT AS SHE WAS MOVED WITH THE BOARD. IMMEDIATELY AFTER THE TRANSFER RESIDENT #13 HAD HER LEG BRACE REMOVED. THERE WAS A WET "ABD" DRESSING OVER HER RIGHT KNEE. STAFF "N"REMOVED THE WET DRESSING AND CLEANED OFF THE LARGE AMOUNT OF SEROUS DRAINAGE WITH TOWEL FROM A SMALL OPENING. THE LICENSED PRACTICAL NURSE (STAFF "L") CAME INTO THE ROOM WITH SUPPLIES OF NEW DRESSING CHANGE. THE RIGHT KNEE WAS OBSERVED TO BE SWOLLEN AND THE AREA SURROUNDING THE SMALL OPENING WAS RED. THE RESIDENT'S RIGHT LOWER LEG HAD BEEN WRAPPED WITH A BROWN COLOR ACE BANDAGE ALL THE WAY DOWN TO HER FOOT WHICH HAD BEEN ROTATED INWARD. STAFF "L" STATED SHE DID NOT HAVE AN ORDER TO REMOVE THE ACE WRAP. ON 2/13/13 AT 11:45 A.M., THE UNIT MANAGER, (STAFF "B") WAS ASKED WHY THE X-RAY WAS NOT INITIALLY CONSIDERED, AND ORDERED 8 DAYS LATER, SINCE THE RESIDENT HAD CLEAR SIGNS AND SYMPTOMS OF FRACTURE SUCH AS SEVERE PAIN, SWELLING, TENDERNESS AND WARMTH TO THE SITE. STAFF "B" STATED SHE THOUGHT THE RESIDENT HAD BLOOD CLOTS INSTEAD. ADDITIONALLY, ON 2/13/13 AT 11:45 A.M., UNIT MANAGER, (STAFF "B") WAS ASKED HOW THE RESIDENT'S LEG COULD BE SPLINTED EFFECTIVELY WITH BATH BLANKET AND TAPE. STAFF "B" STATED THE FACILITY STAFF DID THE BEST THEY COULD WITH WHATEVER THEY HAD TO SPLINT THE RESIDENT'S LEG, BECAUSE THE RESIDENT'S FAMILY REFUSED TO SEND THE RESIDENT TO HOSPITAL. STAFF "B" STATED THE PCP WANTED THE RESIDENT TO SEE AN ORTHOPEDIC SURGEON. HOWEVER THE ORTHOPEDIC OFFICE WAS CLOSED UNTIL 12/27/12 AND THE PCP DID NOT WISH TO SEND THE RESIDENT TO THE emergency room . ( ) THE FACILITY ENVIRONMENTAL TOUR WAS COMPLETED ON 2/14/13 FROM 11:00 A.M. TO 2:30 P.M., WITH MAINTENANCE SUPERVISOR STAFF "D", MAINTENANCE ASSISTANT STAFF "F" AND ENVIRONMENTAL SERVICES SUPERVISOR STAFF "E". THE FOLLOWING WATER TEMPERATURE OBSERVATIONS WERE OBTAINED FROM THE BATHROOM SINKS: 1. ROOM #7 WAS 125.9 DEGREES FAHRENHEIT. 2. ROOM #8'S WAS 122.2 DEGREES FAHRENHEIT. 3. ROOM #9'S WAS 122.2 DEGREES FAHRENHEIT. 4. ROOM #10'S WAS 129.9 DEGREES FAHRENHEIT. MAINTENANCE SUPERVISOR "D" WAS INTERVIEWED IN CLAUDIAS' GLEN COTTAGE BOILER ROOM ON 2/14/13 AT 2:30 P.M. THE FOLLOWING WAS STATED: 1. THE INDIVIDUAL RESIDENT ROOMS HAVE A MIXING VALVE UNIT LOCATED UNDER EACH SINK AND THESE WILL BE REGULATED FOR A LOWER TEMPERATURE. 2. A SPORADIC VISUAL DAILY SPOT CHECK IS COMPLETELY TO DETERMINE IF WATER TEMPERATURES ARE ADEQUATE, UNLESS A WORK ORDER IS RECEIVED. 3. THERE IS NO PAPER COPY OF A WATER TEMPERATURE LOG. 4. WATER TEMPERATURES ON NOTED ON THE COMPUTER WHEN A WORK ORDER IS RECEIVED TO TRACK. 5. THERE IS NOTHING TO BE LOOKED AT UPON THE COMPUTER AS THE COMPUTER CRASHED LAST WEEK AND ALL FILES WERE LOST WHICH DATED BACK TO 2007. THE FOLLOWING WATER TEMPERATURE WAS OBSERVED AND RECORDED WITH MAINTENANCE SUPERVISOR "D" PRESENT ON 2/15/13 AT 8:00 A.M. 1. ROOM #10, 120.2 DEGREES FARENHEIT. MAINTENANCE SUPERVISOR "D" WAS INTERVIEWED IN CLAUDIAS' GLEN COTTAGE BOILER ROOM ON 2/15/13 AT 8:15 A.M. THE FOLLOWING WAS STATED: 1. THE MIXING VALVES WERE CHECKED AND IDENTIFIED AS NOT THE PROBLEM. 2. IT WAS DISCOVERED A TEMPERATURE PROBE WITHIN THE HOT WATER STORAGE TANK WAS DEFECTIVE. 3. A NEW PART HAD TO BE ORDERED. 4. THE PROBLEM HAS BEEN CORRECTED TEMPORARILY UNTIL THE PART ARRIVED AND THE WATER TEMPERATURES ARE BEING ROUTINELY MONITORED TO ENSURE SAFETY. ( )