Every finding on record at Iosco County Medical Care Facility

Based on observation, interview and record review, the facility failed to implement interventions to prevent pressure ulcer development for two residents(R9 and R22) of two residents reviewed, resulting in R9 developing an unstageable DTI and Resident R22 developing a stage II (partial thickness loss of first and second layer of skin) and unstageable DTI, unnecessary pain, and the likelihood for infection and decline in overall health status.Findings include: Resident #9 On 1/6/26 at 10:38 AM, Resident #9 was observed sitting in a wheelchair in the central area of the facility. Resident #9 was unable to provide meaningful responses to questions when asked. A pull tab alarm was observed on the Resident's wheelchair and was connected to the back of their shirt. Licensed Practical Nurse (LPN) I was in the common area of the unit and an interview was completed. When queried, LPN I revealed Resident #9 has a wound on their buttocks. When asked if the wound was a pressure ulcer, LPN I replied, Yes. Resident #9 was observed sitting in their wheelchair in the central area of the unit from 10:38 AM until 11:18 AM on 1/6/26. The Resident was not repositioned by facility staff during this timeframe. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included dementia, depression, anxiety, and left sided hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required total assistance to complete Activities of Daily Living (ADLs) with the exception of eating. The MDS further detailed the Resident was at risk for pressure ulcer development and had developed one unstageable DTI at the facility. Review of the facility provided CMS-802 Resident Matrix form detailed Resident #9 had a Stage 2 facility acquired pressure ulcer. Review of Resident #9's Electronic Medical Record (EMR) revealed a care plan entitled, I have actual for impairment to skin integrity r/t (related to) limited mobility. currently have a pressure ulcer to my left buttock. (Initiated: 4/3/24; Revised: 1/7/26). The care plan included the interventions: - I have a gel/foam cushion in my wheelchair to help offload pressure (Initiated: 11/12/24; Revised: 12/3/25) - I utilize an air mattress for increased pressure reduction (Initiated: 6/3/25) - Staff to lay me down after meals as I allow to help with position changes and offloading pressure. If I do not want to lay down please offer me to sit in a recliner (Initiated: 11/21/24: Revised: 10/2/25) Review of documentation in Resident #9's EMR revealed the Resident had a history of pressure ulcers which had healed and was at risk for pressure ulcer development. Wound documentation revealed the following: - 9/17/25 at 7:43 PM: Health Status Note. CNA called writer to room regarding discolored area on left buttocks, CNA states redness was present yesterday but was worse today, writer observed bluish purple blanchable area to left buttocks, skin is still intact, writer notified wound care nurse this AM, CNA instructed to lay res down after meals and position from left to right, as tolerated by resident. - 9/17/25: Written Weekly Pressure Ulcer Report. Location: L (Left) gluteus. Stage. DTI. Wound measurements in centimeters (cm): 3.9 X 4.4. Care planned interventions: Air Bed, Roho, Lay down after meals. Nutritional Interventions: Milkshake TID (three times a day), Juven BID (twice a day), Boost (TID). - 10/15/25: Written Weekly Pressure Ulcer Report. Location: L (Left) gluteus. Stage. SDTI (Suspected Deep Tissue Injury) . Wound measurements in centimeters (cm): 1.7 X 1.5 . Wound healing. Improving. Care planned interventions: Air Bed, Roho, Reposition q (every) 2 hours, Lay down after meals. Nutritional Interventions: Milkshake TID (three times a day), Juven BID (twice a day), Boost (TID). - 10/22/25: Written Weekly Pressure Ulcer Report. Location: L (Left) gluteus. Stage. SDTI. Wound measurements in centimeters (cm): 2.9 X 4.7 . Wound healing. Deteriorating. Increased slough and eschar. Care planned interventions: Air Bed, Roho, Reposition q (every) 2 hours, Lay down after meals. Nutritional Interventions: Milkshake TID (three times a day), Juven BID (twice a day), Boost (TID). - 12/3/25: Written Weekly Pressure Ulcer Report. Location: L (Left) gluteus. Stage II. Wound measurements in centimeters (cm): 3.9 X 3.6 X 0.2 . Wound healing. Deteriorating. Care planned interventions: Air Bed, Roho, Reposition q (every) 2 hours, Lay down after meals. Nutritional Interventions: Milkshake TID (three times a day), Juven BID (twice a day), Boost (TID). - 12/23/25 at 7:20 AM: Skin & Wound Evaluation. Pressure. Stage II. Left Gluteus. In-House Acquired. Length: 3.2 cm. Width: 3.1 cm. Wound Bed. Slough. 100% . Evidence of Infection. Redness/inflammation. Stalled. Wound continues to show deterioration. Wound bed presents with 100% slough tissue. Peri wound presents as blanchable erythema with induration. Wound order updated today. continues with Milkshake TID, Juven BID and Boost TID for supplements. continues on air bed, gel cushion, and reposition Q 2 hr. - 1/7/26 at 7:05 AM: Skin & Wound Evaluation. Pressure. Unstageable. Left Gluteus. In-House Acquired. Length: 3.4 cm. Width: 4.2 cm. Wound Bed. Slough. 100% . Deteriorating . Review of Resident #9's Health Care Provider (HCP) orders revealed no new nutritional supplements were implemented following the pressure ulcer development. The supplement orders detailed: - Boost three times a day for Supplement. (Ordered and Start: 11/18/24) - Juven Oral Powder (Protein Nutritional Supplement) . every day and evening shift. (Ordered and Start Date: 11/29/24) On 1/7/26 at 3:06 PM, Resident #9 was not present in their room. Certified Nursing Assistant (CNA) II was standing in the central area of the unit and asked where Resident #9 was. CNA II pointed out Resident #9 in the common area of the unit and stated, (Resident #9) is in a bad mood and indicated the Resident was having a rough day. Resident #9 was sitting in a recliner. The recliner chair was in the upright position with the Resident's feet on the floor. The recliner did not have a pressure reduction cushion in place on the seat. When asked what was going on, CNA II revealed Resident #9 has a girlfriend who would come visit them but due to inappropriate sexual behavior/acts, the girlfriend was no longer able to visit per Resident #9's representative. CNA II stated, I think that is part of the reason (Resident #9) is so upset. Upon approaching Resident #9 in the recliner, the Resident began yelling out. When asked questions, Resident #9's responses were unintelligible. A follow up interview was completed with CNA II on 1/7/26 at 3:25 PM. When queried regarding the Resident's pressure ulcer, CNA II revealed they were aware the Resident had a wound dressing in place but had not seen the ulcer. CNA II was asked if Resident #9 was dependent upon staff for repositioning and responded that they were. When queried regarding interventions for pressure prevention, CNA II stated, We put (Resident #9) in the recliner for a couple hours after lunch. When queried if the Resident is supposed to be reclined or sitting upright for pressure reduction, CNA II responded that the Resident is just supposed to sit in the recliner and a seating position was not specified in the care plan. CNA II was then queried how often Resident #9 is repositioned when they are sitting up in their wheelchair and replied, Every couple hours. When queried regarding the frequency Resident #9 is repositioned when they are sitting in the recliner, CNA II replied they do not really reposition Resident #9 when they are in the recliner. When asked how often the Resident was repositioned when in bed, CNA II responded that staff repositioned them every couple of hours. On 1/8/25 at 9:03 AM, Resident #9 was observed in their room in bed with their eyes closed. An interview was completed with LPN JJ on 1/8/26 at 9:08 AM. When queried if they had observed Resident #9's pressure ulcer, LPN JJ replied, No. A request was made to observe wound care at this time and LPN JJ replied, It is not dressing change day. A review of Resident #9's Treatment Administration Record (TAR) revealed the dressing had been changed by the night shift nurse at 2:25 AM. A task on the TAR, Please ensure dressing to L (left) gluteus is clean, dry, and intact. Replace if necessary. Every day and evening shift was documented as completed by LPN JJ on day shift 1/8/26. When queried if they had observed Resident #9's wound dressing that morning, LPN JJ replied, No. When asked why they documented they had observed the Resident's dressing if they had not, LPN JJ responded, I did? I don't know. LPN JJ was then asked to review Resident #9's TAR. LPN JJ confirmed they documented the task as completed but did not observe the dressing. LPN JJ then verbalized they documented the dressing was in place because the Resident's CNA had told them it was there. When asked if documentation of the task indicates they completed the task, LPN JJ did not provide a response. An interview was conducted with Registered Nurse (RN) A and RN F on 1/8/26 at 10:20 AM. When queried what stage Resident #9's pressure ulcer was, both RN A and RN F responded that it was unstageable due to the wound bed being obscured by slough. When asked why the provided CMS-802 form specified the pressure ulcer was a Stage II, RN F responded they thought that it had been corrected. RN F was then asked if a pressure ulcer is able to go from unstageable to a stage II in wound documentation, RN F responded that pressure ulcers can not be downgraded from unstageable to stage II. RN F was then queried why documentation in Resident #9's EMR detailed the pressure ulcer had went from unstageable to a stage II and then back to unstageable, an explanation was not provided. When queried regarding interventions in place related to Resident #9's pressure ulcer, RN F replied, Nutritional (supplements), turn program, different equipment. When asked what different equipment meant, RN F revealed the Resident was to be in their bed, their wheelchair, and a recliner during the day. When queried Resident #9 was supposed to be positioned in a specific position/level of recline in the recliner to minimize pressure and shear, RN F responded, Not ordered. When asked if the position which Resident #9 sits in the recliner and the level of recline may contribute to pressure, RN A responded that it could add pressure and shearing forces. When queried how often Resident #9 is supposed to be repositioned in their wheelchair, RN F replied, Every hour. When asked how often the Resident should be repositioned when sitting in the recliner, RN F responded, Every hour. When queried if the recliner seat cushion was a pressure reduction cushion, both RN A and RN F responded it was not. RN A and RN F were asked why the Resident's care plan specified repositioning every two hours when sitting if they should be repositioned more frequently and responded they had educated staff regarding more frequent repositioning. When queried if repositioning every hour when sitting was best practice for pressure prevention/reduction, RN F indicated frequent repositioning is best. When asked what new interventions were implemented after Resident #9 developed the unstageable pressure ulcer on their left gluteus, RN F indicated wound care treatments were initiated. RN A and RN F were then informed of Resident observations and staff interviews. RN A and RN F both indicated staff had been educated regarding the importance of more frequent repositioning when out of bed. When asked if lack of repositioning may contribute to the pressure ulcer development and deterioration, both RN A and RN F confirmed it could. When queried regarding the status of Resident #9's pressure ulcer during the last assessment completed, RN F stated the wound was a little deteriorated again from last time and that the pressure ulcer had not improved since it had first been identified. Upon request for the facility policy/procedure pertaining to Pressure Ulcers and Skin Management Program, the facility provided a policy/procedure entitled, Wound Treatment Management (Reviewed/Revised: 1/7/26). This policy did not include information pertaining to interventions for pressure prevention and/or reduction. Resident #22: In an interview on 01/06/2026 at 10:34 AM with the Resident #22's family member revealed that Resident 22 got a pressure ulcer here at the facility, they have a bandage on the bottom, and they are changing it every other day. She came from Saginaw hospital after surgery on her left leg fracture and then she got cellulitis. Observation on 01/06/2026 at 10:38 AM the state surveyor observed a heel up device/pad to end of bed, the family member removed the socks and the state surveyor observed the left heel had a large brown/purple deep tissue injury noted. The family member stated that the Registered Nurse W, who stopped working at the facility back in December, before Christmas she stopped working, found the dark spot on the heel and put the foot/leg cushion (Hells-up device) on the bed and said to keep her heels off the bed. Record review on 1/6/2026 of resident #22's medical record/admission assessment and there was no mention of left heel deep tissue injury. No mention of pressure ulcer or deep tissue skin injury in care plans. In an interview and record review in 01/07/2026 at 10:58 AM with Registered Nurse (RN)/wound care (F) management explanation of Resident #22's Pressure ulcer identified on the CMS 802 matrix form. RN F stated that Resident #22 developed a facility acquired stage II pressure ulcer to the right gluteus. RN F stated that she had performed the treatment this morning and that the wound healed the ulcer was resolved. RN F stated that a new order to leave right gluteus covered for 7 days more just to protect the skin area. When we identified the pressure ulcer, we implemented an air bed and Juven (Supplement) twice daily and added gel cushion to Wheelchair. The state surveyor inquired why the pressure ulcer developed? RN F stated Resident #22 was having pain in her leg and did not want to move, post-surgical. Resident #22 was working with therapy to an extent, but would request to get back in bed often, not wanting to move, that's how the pressure ulcer developed. The state surveyor inquired how did the pressure ulcer become stage II before any staff noticed? RN F stated that she did not know how the pressure ulcer went undetected from a red area to an opened wound with drainage. It was stage II when she was first notified. RN F stated that Resident #22 is sometimes incontinent with bowel & bladder. The state surveyor identified that Resident #22 was a 2 assistant from staff for Activities for Daily Living (ADLs), staff should have been aware when redness or changes occur. RN F stated that she was not sure what happened that it went unnoticed till a stage II with open area, with serosanguinous drainage noted. The state surveyor requested to observe the wound today. Observation and interview on 01/07/2026 at 2:01 PM with Registered Nurses A Infection Control and F Wound care entered the room with wound care supplies of wound wash and dry gauze. The Resident #22 was rolled to the right side and observation of the right gluteus revealed an open area pinpoint with slight serosanguinous drainage noted, wound care of wound wash and pat dry, a 2x2 Allevyn foam border dressing applied. The RN's A and F were requested by the state surveyor to remove Resident #22's socks to observe bilateral heels. Observation of Resident #22's left heel was noted with a large dark area, non-blanchable. RN A and F both were surprised and stated that they just found the deep tissue injury with the state surveyor today. The family member was in the room during observation and stated that the left heel sore had been there over 3 weeks, when Registered Nurse W the nurse does not work here anymore she found it and placed the heels-up device/pad to her bed. In an interview and record review on 01/07/2026 at 2:15 PM with Registered Nurse A Registered Nurse/Infection Control Preventionist/In-service director stated Resident #22 has a new left heel has a Deep Tissue Injury (unstageable pressure injury with unknown depth) that is purple/brown in color, that means it been there a while. The DTI is new today. RN A stated that there was nothing on the heels on admission assessment, RN A stated that he had been in the resident's room at least 1 or 2 times to assess her or transfer her. That deep tissue injury to the heel is newfound today during the dressing change. In an interview and Record review on 01/07/2026 at 3:02 PM with Human Resource director X of Registered Nurse W's resignation letter noted her last date of duty was 12/19/2025. In an interview and record review on 01/07/2026 at 3:48 PM with Registered Nurse F RN/Wound Care during an interview related to Resident #22's left heel Deep Tissue Injury. RN F stated that the left heel deep tissue injury she did not know about it. The left heel injury was new to her. RN F stated that she was Resident #22's room doing dressing changes at least once a week and was not aware of the left heel injury. RN F stated that there is a big communication issue between the Certified Nursing Assistance (CNA) and nurses. Each Resident gets two showers or baths weekly, and skin assessments are done once a week by the floor nurses, it is unfortunate to have the state surveyor find a new injury. Deep Tissues Injuries take a very long time to heal, a minimum of a couple of months, if they open it becomes an unstageable or stage II or greater depending on the depth of the wound. It has been there a while; it's dark brown in color. RN F stated that she notified physician/Nurse Practioner on call and the treatment is to keep heels up, while resident is up in Wheelchair to use an Allevyn heel cup to the left heel. RN F stated that she did a photo of the left heel injury it is measured by photo app, length 0.9 x width 2.3, no depth until it opens. Record review of the facility 'Wound Treatment Management' policy, the only policy received for pressure ulcers care, revealed to promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. (8.) The effectiveness of treatments will be monitored through ongoing assessment of the wound In an interview and record review on 01/08/2026 at 7:55 AM with Registered Nurse F RN/Wound care state that there is no mention of the left heel Deep Tissue Injury of any interventions. RN F reviewed the medical record and did not find any deep tissue injury care plan. RN F stated that the care plans are performed by an off-site service provider contracted service and that they recommended that we only identify that a pressure area developed. Not identify the location, stage or treatment. We used to identify all the locations because more than one can develop. In an interview and record review on 01/08/2026 at 8:03 AM with the Director of Nursing related to care plan development. The DON stated that when a resident admits or comes in, we initiate care plans based on diagnosis and needs. record review of Resident #22's care plans pages 1 through 11 revealed no Deep Tissue Injury to left heel. The DON stated that there was no what, where, or when or how to treat. The DON stated that we put in/created a pressure ulcer care plan on the 1/6/2026 and then (stage II) then resolved it on 1/7/2025. I looked in the care plans and there was no pressure ulcer care plan, so I created one on 1/6/2025 and then they said that it resolved so I went back into the care plans on 1/7/2025, that's what I did. We do have an MDS contracted service that does our care plans, and we follow their recommendations.

Based on interview and record review, the facility failed to have policies and procedures for data collection, analysis and feedback procedures for 21 residents sampled of 49 residents, resulting in only one sheet of paper policy for the quality assurance program when the surveyor requested the program to review and the contracted pharmacy services failed to attend the quality assurance quarterly meetings for the last six months. Findings include: Quality assurance Task: Record review of the facility 'Quality Assurance Program' policy dated 12/13/2016 signed by a previous nursing home administrator, revealed that it is the policy of the facility to actively participate in a formalized and written Quality Assurance (QA)/ Quality Assurance Process Improvement (QAPI) program. The program is to be comprehensive (involving all departments) and coordinated, will include monitoring, evaluation, and appropriate follow-up action as needed. (5.) Implementation of an ongoing monitoring system that will provide data about actual care/services provided. (6.) Analysis of data to determine the quality of care/services provided. In an interview and records review on 01/08/2026 at 11:33 AM with the Nursing Home Administrator (NHA)/Quality Assurance coordinator revealed that the facility only has one policy for the QA program from the previous administration signed on 12/13/2016. The NHA stated that there were no other policies for the QA program. The NHA revealed that she had been at the facility for the last year and had not updated the policy. The NHA stated that there were no other policies for data collection/analysis or feedback on QA issues/concerns that could be found. The state surveyor inquired if there were any Process improvement plans (PIPs) in progress? The NHA stated that the facility has one PIP on call lights currently. NHA revealed that last year the facility did one on pressure ulcers, and it improved and we moved it to the back burner and stopped the PIP on that, but I heard that we had an issue yesterday with pressure ulcers. Our identified concerns prior to survey included: Pressure Ulcers, call lights, antibiotic stewardship, infection control, and falls. The state surveyor asked what about survey team concerns of:Certified Nursing Assistances working without pagers- or pagers are not alarming/sounding? The NHA stated that as of yesterday 1/7/25, we will be adding the pagers to the Medication Administration Record (MAR) or assignment sheets and holding the nurses accountable, because staff keep losing them, leaving them at home, not changing the batteries. The state surveyor explained to the NHA that residents are stating that the CNAs come in and shut the call lights off because they are being timed and do not provide the service and state they will come back and do not come back. The NHA stated that she is not aware of situation. Antibiotic stewardship Program- NHA was aware that the program was cited last year at annual survey and will be again at this year's survey. There was no documented antibiotic education given to the physician or nurse practitioners. The QAPI team meets monthly- Committee members list reviewed. Quality Assurance monthly meeting sign-in sheets reviewed from May 2025 through December 2025, revealed that in June 2025 the Pharmacist consultant attended on 6/26/2025 and there was not another pharmacist consultant that attended any QAPI meeting for over 6 months. The state surveyor inquired that the antibiotic stewardship program being discussed at QAPI meetings with pharmacist? Physicians are ordering the antibiotics and not doing any risk vs benefits for prophylactic antibiotics. There are no policies.

Based on observation, interview and record review, the facility failed to sustain a system to ensure corrective measures for 49 of 49 residents residing in the facility, related to prevention and treatment of pressure ulcers/injuries had been monitored, evaluated, and were effective as evidence by repeated deficiencies on pressure ulcers and antibiotic stewardship during the past two annual surveys. Findings include: In an interview and records review on 01/08/2026 at 11:33 AM with the Nursing Home Administrator (NHA)/Quality Assurance coordinator revealed that the facility only has one policy for the QA program from the previous administration signed on 12/13/2016. The NHA stated that there were no other policies for the QA program. The NHA revealed that she had been at the facility for the last year and had not updated the policy. The NHA stated that there were no other policies for data collection/analysis or feedback on QA issues/concerns that could be found. The state surveyor inquired if there were any Process improvement plans (PIPs) in progress? The NHA stated that the facility has one PIP on call lights currently. NHA revealed that last year the facility did one on pressure ulcers, and it improved and we moved it to the back burner and stopped the PIP on that, but I heard that we had an issue yesterday with pressure ulcers. The state surveyor asked what about survey team concerns of:Pressure ulcer/injuries- Observation and interview on 01/07/2026 at 2:01 PM with Registered Nurses A Infection Control and F Wound care entered the room with wound care supplies of wound wash and dry gauze. The Resident #22 was rolled to the right side and observation of the right gluteus revealed an open area pinpoint with slight serosanguinous drainage noted, wound care of wound wash and pat dry, a 2x2 Allevyn foam border dressing applied. The RN's A and F were requested by the state surveyor to remove Resident #22's socks to observe bilateral heels. Observation of Resident #22's left heel was noted with a large dark area, non-blanchable. RN A and F both were surprised and stated that they just found the deep tissue injury with the state surveyor today. The family member was in the room during observation and stated that the left heel sore had been there over 3 weeks, when Registered Nurse W the nurse does not work here anymore she found it and placed the heels-up device/pad to her bed. Certified Nursing Assistances working without pagers- or pagers are not alarming/sounding? The NHA stated that as of yesterday 1/7/25, we will be adding the pagers to the Medication Administration Record (MAR) or assignment sheets and holding the nurses accountable, because staff keep losing them, leaving them at home, not changing the batteries. The state surveyor explained to the NHA that residents are stating that the CNAs come in and shut the call lights off because they are being timed and do not provide the service and state they will come back and do not come back. The NHA stated that she is not aware of situation. In an interview on 01/08/2026 at 10:37 AM with facility Controller W was auditing the call lights. The state surveyor inquired about the silence of the pagers not heard while on the nursing floor. Controller W stated that the aides are not bringing the pagers back to work, yesterday 1/7/26 I was told by Certified Nurse Assistants (CNA's) H and M that there were no working pagers. Controller W stated that she went to the main nursing station and there were 4 pagers on the desk in plain sight. The batteries were dead, so I took the pagers back to my office, changed the batteries, and checked the programing to make sure they were set for CNAs. I walked the pagers back to CNA H and M who were working on the floor with no pagers. The lights above the residents' doors do not light up, that is our old call system and do not work. I am watching CNAs call light times in audits, but I am not aware that they are shutting off the call lights and not coming back. That is not acceptable. Antibiotic stewardship Program- NHA was aware that the program was cited last year at annual survey and will be again at this year's survey. There was no documented antibiotic education given to the physician or nurse practitioners. The QAPI team meets monthly- Committee members list reviewed. Quality Assurance monthly meeting sign-in sheets reviewed from May 2025 through December 2025, revealed that in June 2025 the Pharmacist consultant attended on 6/26/2025 and there was not another pharmacist consultant that attended any QAPI meeting for over 6 months. The state surveyor inquired that the antibiotic stewardship program being discussed at QAPI meetings with pharmacist? Physicians are ordering the antibiotics and not doing any risk vs benefits for prophylactic antibiotics. There are no policies. Record reviews of the facility 'Antibiotic Stewardship Policy' dated 10/26/2024 revealed that improving the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance. An increase in drug-resistant organisms across the country coupled with a decrease in new antimicrobials on the market. The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. The Director of Nursing provides support and oversight and ensures adequate resources for carrying out the program. The Nursing Home Administrator provides adequate resources for carrying out the program and ensures review of the antibiotic use and resistance data at Quality Assurance Performance Improvement meetings.

Deficient Practice Statement (DPS) One:Based on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program, encompassing outcome surveillance, accurate data collection/documentation/analysis and failed to ensure infection control measures during meal service for all residents residing in the Woodland 400 dementia and the Little House units, resulting in lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis, hand hygiene and Personal Protective Equipment (PPE) use during meal service, and the likelihood for cross contamination, spread of microorganisms and illness to all 49 facility residents. Findings include: DPS Two: Based on interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. 2.) Hand hygiene for 7 of 7 residents residing in the Woodland 400 dementia unit with meal service, resulting in the likelihood for the spread of organisms with cross contamination. Findings include: Hand Hygiene with meal service: Observation on 01/07/2026 at 7:51 AM of the woodland dementia 400 dementia unit with breakfast has a meals of scrambled/eggs, meat/ground sausage, Danish, oatmeal with brown sugar, wheat toast, milk/coffee Observed no hand washing by Certified Nurse assistant (CNA) AA between meal tray service set up from green hot box, to resident, and back to hot box and then to the next resident. Passed brown sugar from resident to resident's bowls of oatmeal, touching the bowls and stirring in the brown sugar and then moved on to the next resident. No hand hygiene observed. Record review of the facility 'Handwashing/Hand Hygiene' policy dated 10/3/2023 revealed all employees and volunteers at the facility will practice proper hand washing techniques. In conjunction with standards (universal) Precautions, to provide the best means of preventing and controlling infection. hand Hygiene is practiced at the following times: before touching a resident, after touching a resident, after touching a resident surrounding environment, before assisting a resident with feeding. Dietary is not included in using alcohol-based hand disinfectants, they are to wash their hands using soap and water. Resident #1: Review of the Face Sheet, physician orders dated 12/25, and care plans dated 9/22 to 1/26, revealed Resident #1 was [AGE] years old, admitted to the facility on [DATE] and re-admitted on [DATE], was his own person, and required extensive assistance from staff for all Activities of Daily Living/ADL's. The residents diagnosis included, myocardial infarction, anemia, pneumonia, back pain, malignant neoplasm of kidney, chronic lung and heart failure, acute kidney failure with a urinary catheter in place, shortness of breath, history of falling, and stroke. Review of the residents Urinary Catheter care plan dated 12/10/25, stated Ensure indwelling urinary catheter drainage bag is not touching floor. Observation made on 1/6/26 at 10:54 a.m., revealed the resident sleeping in bed with his catheter bag sitting on the floor next to his bed; no barrier was under the bag. During an interview done on 1/6/26 at approximately 10:00 a.m., Infection Control nurse, RN A stated it (the urinary catheter bag) should not be on the floor, they needed a barrier under it). On 01/06/2026 at 9:16am-9:54am during the initial kitchen tour with Certified Dietary Manager R, observed a spigot near the two-compartment sink that appeared to be unused. When interviewed on whether the spigot is used, CDM R answered no. On 01/06/2026 at 10:38am-11:15am during the housekeeping tour with Housekeeping Supervisor S, observed an out of order hopper located in the main soiled utility room. When interviewed on how long the hopper hasn't been working, Housekeeping Supervisor S stated it has been out of order for over a year. On 01/06/2026 at 10:38am-11:15am observed an out of order hair sink in the barber shop. When interviewed on how long the sink hasn't been working, Housekeeping Supervisor S stated it's been out of order for at least a year. On 01/06/2026 at 10:38am-11:15am observed an out of order hopper located in the soiled utility room in the 400 unit. When interviewed on how long the hopper hasn't been working, Housekeeping Supervisor S stated it's been out of order for a year. On 01/06/2026 at 10:38am-11:15am observed an out of order drinking fountain located in the dining room. When interviewed on how long the drinking fountain hasn't been working, Housekeeping Supervisor S stated it hasn't been working for as long as she's been working there. On 01/06/2026 at 12:26pm during lunch observation with CDM R, observed what appeared to be three unused spigots hanging from pipes in the ceiling, located in the kitchen. When interviewed on whether the spigots are being used for anything, CDM R stated she doesn't know what they were used for. On 01/06/2026 at 1:00pm-1:45pm during the environmental tour with Maintenance T and Maintenance Director U, when interviewed on whether chlorine residual is being monitored, they both answered that chlorine residual is not being tested. On 01/06/2026 at 1:00pm-1:45pm when interviewed on whether the three unused spigots hanging from the ceiling in the kitchen are used or flushed, Maintenance T stated that the spigots have never been turned on. On 01/06/2026 at 1:00pm-1:45pm when interviewed on whether the unused spigot near the two-compartment sink in the kitchen is ever flushed, Maintenance T stated the spigot hasn't been flushed. According to the facility's Water Management Plan on stagnation, dead legs, and abandoned piping, Remove or routinely flush accessible piping that is no longer used. and Conduct survey for abandoned piping yearly and ensure all applicable piping is scheduled for removal or monthly flushing. According to the facility's Water Management Plan on disinfection and chlorine testing, Monitor disinfectant level in the water supply and distal faucets. and Record at least five readings monthly. Take one of the incoming water supply. Take another four from faucets -- hot and cold water at two faucets, one of which is located near the end point of the system. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. and Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Ensure disinfectant residual is detectable throughout the potable water system.

Based on interview and record review, the facility failed to ensure a functional Antibiotic Stewardship program including monitoring to prevent unnecessary and inappropriate antibiotic use for three residents (#'3, #10, and #35) of three residents reviewed for antibiotic use and failed to ensure that antibiotics met criteria for use resulting in the potential for the development of antibiotic-resistant organisms and infections.Findings include:A review of facility Infection Control (IC) Data for December 2025 was completed. The documentation provided did not include documentation revealed two separate line listings titled, CAI (Community Acquired Infection) and HAI (Healthcare Acquired Infection). The CAI line list included five infections including one carry over infection from November 2025 and one prophylactic antibiotic related to a surgical incision infection. The HAI line list included 14 antibiotics including two carry-over infections and four prophylactic antibiotics. Neither line list specified if the infections/antibiotics listed met criteria for use. A review of the provided Infection Control Summary for December 2025 did not include any infection related to antibiotic stewardship including appropriateness of antibiotic use and/or follow-up for any inappropriate antibiotic treatment. An interview was conducted with Infection Control (IC) Registered Nurse (RN) A on 1/8/26 at 11:08 AM. When queried what criteria the facility utilized in their antibiotic stewardship program, RN A replied, McGeer. When queried if the antibiotic meet McGeer Criteria was included on the line list form, RN A replied it was not. RN A was asked how many residents received antibiotics during December 2025 which did not meet criteria and revealed they would need to review each resident's chart to answer. RN A then revealed they had included a comment on two residents listed on the line list that the Provider chose to treat empirically (treat before a specific causative organism is identified). Review of one of the residents with the comment revealed they were treated for Urethral drainage around indwelling catheter with Cipro (antibiotic) for seven days. Signs/Symptoms included on the line list specified, Observed upon assessment. When asked if wound cultures of the drainage were obtained, RN A revealed they were not. When asked if the infection meet criteria for treatment, RN A replied, Did not. With further inquiry, RN A revealed there were several other residents who received antibiotic treatment but did not meet McGeer criteria. When queried regarding follow-up with the Health Care Provider (HCP) when antibiotics do not meet criteria, RN A indicated the HCP is not consistently receptive to feedback. When queried if there was a specific HCP who frequently prescribed antibiotics which do not meet criteria, RN A indicated there was. When asked why antibiotic stewardship information was not included in the Monthly Summary information and how they track antibiotic stewardship data, RN A revealed they had not but would incorporate the information going forward. Review of policy/procedure, Antibiotic Stewardship Policy (Reviewed: 10/9/25) revealed, Policy: Improving the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance. Record review of the facility 'Antibiotic Stewardship Policy' dated 10/26/2024 revealed the that improving the use of antibiotics in healthcare to protect residents and reduce the threat of antibiotic resistance. An increase in drug-resistant organisms across the country coupled with a decrease in new antimicrobials on the market. The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. The Director of Nursing provides support and oversight and ensures adequate resources for carrying out the program. The Nursing Home Administrator provides adequate resources for carrying out the program and ensures review of the antibiotic use and resistance data at Quality Assurance Performance Improvement meetings. Antibiotic use protocols: Laboratory testing shall be in accordance with current standards of practice and CDC guidelines. Resident #3: Record review of Resident #3's Minimum Data Set (MDS) 12/29/2025 revealed an elderly female with Brief Interview of Mental status (BIMs) score of 12 out of 15 cognitive impairments. Medical diagnosis included: anemia, coronary artery disease, heart failure, hypertension, renal insufficiency diabetes, chronic obstructive pulmonary disease, anxiety, and depression. Section H: bladder & bowel noted frequent incontinence. Record review on 01/07/2026 at 12:54 PM of Resident #3's Medication Administration Record (MAR) for October 2025 revealed on 10/29/25 was started on Trimethoprim 100 MG Tablet by mouth one time a day for UTI (Urinary Tract Infection) prevention. Record review of the residents' medical record had no risk vs benefit documentation of the use of prophylactic antibiotic. Record review of the 'Infection Surveillance Monthly Reports' from July 2025 through October 2025 for Resident #3 revealed: May 2025- on 5/6/25 Antibiotic Cefdinir (Omnicef) oral capsule 300mg for 6 days for urinary tract infection. August 2025- on 8/16/25 Antibiotic cephalexin (Keflex) oral tablet 500mg for 9 days for insect bite to left forearm. September 2025- on 8/8/25 through 8/11/25 antibiotic Macrobid oral capsule 100mg by mouth two times daily for urinary tract infection for 10 days then switched 8/11/25 to antibiotic ceftriaxone (Rocephin) 1 gram injection intramuscularly for 7 days for urinary tract infection. On 9/23/2025 Clotrimazole 3 vaginal cream 2% for itching and burning sensation in genitals vaginal symptoms (vaginal yeast infection). October 2025- on 10/2/25 antibiotic Trimethoprim (Bactrim) oral tablet 100mg one-time daily urology recommended prophylactic for chronic urinary tract infection. On 10/6/25 antibiotic Trimethoprim (Bactrim) oral tablet 100mg one-time daily and antibiotic ciprofloxacin (Cipro) 250mg tablet by mouth two times a day for urinary tract infection for 7 days. On 10/28/25 antibiotic Trimethoprim (Bactrim) oral tablet 100mg one-time daily and Antibiotic cephalexin (Keflex) oral tablet 500mg give 1 tablet by mouth 3 times a day for urinary tract infection for 7 days. In an interview and record review on 01/08/2026 at 8:38 AM with Registered Nurse/Infection Control Preventionist/In-service education A was asked about the doubling up on antibiotic use and risk vs benefits documentation. Record review of the 'Infection Surveillance Monthly Reports' from July 2025 through October 2025 for antibiotic usage. Record review of Resident #3's repeated antibiotic usage. Registered Nurse (RN) A was quired about the use of on 9/23/2025 clotrimazole 2% vaginal cream started and why not Diflucan oral? RN A stated it was the physician's choice. Record review of the Trimethoprim Bacterium empirical treatment is an indefinite treatment, with no risk vs benefits found in the medical record. RN A stated that the facility has no policy about the prophylactic use of antibiotics or risk vs benefits, there should be a risk vs benefits as a standard of care. RN A was asked about the development of multi-drug-resistant organisms (MDRO's) created how. RN A stated by treating with multiple antibiotics, resident #3 has had different antibiotics. We do refer to specialist urologists. The residents come back with a script from urology with no culture, and some do come with a culture. Record review of the October 2025 line listing for Resident #3 noted on 10/28/2025 cephalexin oral 500mg tablet by mouth three times daily for 7 days for UTI and at the same time Trimethoprim oral 100mg tablet by mouth one time a day for UTI. RN A stated that it was double antibiotic therapy. Resident #35: Record review of Resident #35's Minimum Data Set (MDS) dated [DATE] revealed an elderly female with Brief Interview of Mental status (BIMs) score of 7 out of 15 cognitive impairments. Medical diagnosis included: anemia, atrial fibrillation, hypertension, gastro-esophageal reflux disease, renal insufficiency, thyroid disorder, hip fracture, chronic obstructive pulmonary disease, non-Alzheimer's dementia and anxiety. Section H: bladder & bowel noted frequent incontinence. Record review of Resident #35's December 2025 Medication Administration Record (MAR) noted that on 12/12/25 antibiotic trimethoprim oral tablet 100mg give 0.5 tablet by mouth in the evening for prophylactic. Did not identify a reason or infection. Record review of the residents' medical record had no risk vs benefit documentation of the use of prophylactic antibiotic. In an interview on 01/08/2026 at 10:54 AM with Registered Nurse/Infection Control Preventionist/In-service education A revealed that there was no risk vs benefit for antibiotic use prophylactic because the facility did not have a policy for that. Resident #35 had Urinary Tract Infections noted on History & Physical when she admitted on [DATE]. Record review of the Dec/Jan MAR TAR noted trimethoprim 100mg antibiotic started 12/12/2025 for infection with no stop date or site of infection. Resident #10: Review of the Face Sheet, minimum Data Set (resident assessment tool dated 2/23, physician orders dated 1/23 through 1/26, and care plans dated 1/17/23, revealed Resident #10 was [AGE] years old, interviewable with confusion, and required total assistance with all ADL's. The residents diagnosis included, heart disease, psychotic disorder, anxiety, anemia, stroke, Crohn's Disease, back pain, right shoulder pain and stage 3 kidney disease. Review of all of Resident #10's facility care plans (dated 10/17/23), revealed no care plan had been developed for antibiotic usage. Review of the residents physician orders dated 3/21/25, revealed two orders for two separate antibiotics (Gentamicin Sulfate Injection Solution 40 MG/ML, inject 4 ml intramuscularly one time a day for UTI for 7 days, and Nitrofurantoin Microcrystal Oral Capsule 100 MG, Give 1 capsule by mouth two times a day for UTI for 3 days), both ordered on 3/21/25, and both discontinued on 3/24/25 (after UA of no growth was sent to the facility). Review of the residents facility laboratory report dated 3/24/25, revealed a urine culture collected on 3/22/25 (a day after antibiotics were ordered), with a result of No growth. Review of the residents lab dated 3/24/25, had hand written note from Nurse Practitioner/NP stating (NP) ordered to discontinue all antibiotics and to review tomorrow during rounds prophylactic antibiotic r/t (related to ) UTI's (urinary tract infections). During an interview done on 1/6/26 at 10:52 a.m., Resident #10 stated I was on an antibiotic and now I have diarrhea. The resident had no idea why she was on an antibiotic, and she said they then they just stopped it. Review of physician progress notes dated 3/21/25 through 3/24/25, revealed no documentation of notes regarding the residents ordered antibiotics or rational for use. During an interview done on 1/7/26 at 2:40 p.m., Infection Control Nurse, RN A stated (Resident #10) shouldn't' have been put on 2 antibiotics, and we should have waited for C&S (culture & sensitivity lab test) prior to antibiotics, there was a care plan for antibiotic usage but 2 days after it was started, and it was discontinued the same day.

Based on Observation, interview and record review, the facility failed to ensure dignity regarding call light response times and accessibility for 4 resident's (Resident's #1, #10, #29, and #49), and 2 confidential Resident's from the Resident Group meeting (held on 1/7/26, at 11:00 a.m.), and 2 residents (Resident #4 and #44) not treated in a dignified manner by staff, resulting in 1 confidential resident being incontinent due to no one answering the call light, embarrassment, anger, fear of being left alone, with the potential for isolation. Findings Include:Review of the facility Call Light Policy dated June 30, 2012, stated A system to provide for the resident when in their rooms and toilet and bathing areas, have a means of directly contacting caregivers. If a call is not answered in a specified length of time (4 minutes), the initial group is re-paged. If the call continues to be unanswered; pages are escalated to back up and supervisory personnel (8 minutes). It is important to see that the resident's needs are met in a timely manner. Resident #1: Review of the Face Sheet, physician orders dated 12/25, and care plans dated 9/22 to 1/26, revealed Resident #1 was [AGE] years old, admitted to the facility on [DATE] and re-admitted on [DATE], was his own person, and required extensive assistance from staff for all Activities of Daily Living/ADL's. The residents diagnosis included, myocardial infarction, anemia, pneumonia, back pain, malignant neoplasm of kidney, chronic lung and heart failure, acute kidney failure with a urinary catheter in place, shortness of breath, history of falling, and stroke. Review of the residents Fall care plan dated 9/27/22, stated Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Observation made on 1/6/26 at 11:54 a.m., revealed the resident in bed sleeping with his call light coiled up and hanging on the wall by the silver plug (not within reach of the resident). During an interview done on 1/6/26 at 12:22 p.m., Nursing Assistant/CNA H stated He likes it (call light) like that, walked out of the room and left his call light hanging on the wall. Resident #10: Review of the Face Sheet, minimum Data Set (resident assessment tool dated 2/23, physician orders dated 1/23 through 1/26, and care plans dated 1/17/23, revealed Resident #10 was [AGE] years old, interviewable with confusion, and required total assistance with all ADL's. The residents diagnosis included, heart disease, psychotic disorder, anxiety, anemia, stroke, Crohn's Disease, back pain, right shoulder pain and stage 3 kidney disease. Review of the residents Anxiety care plan dated 12/5/25, stated monitor for safety.1as During an interview done on 1/6/26 at 10:54 a.m., when the resident was asked do staff answer her call light timely the resident stated, It takes them awhile to get in here (stated over 30 minutes). Resident #29: Review of the Face Sheet, physician orders dated 12/25, and care plans dated 12/31/25, revealed Resident #29 was [AGE] years old, confused and required staff assistance with all ADL's. The residents diagnosis included, fracture with displacement of the neck (with a cervical color on), muscle weakness, unsteady gait, anxiety, anemia, heart disease, essential tremors, and high blood pressure. Review of the residents Fall care plan dated 12/3/25, stated I am in the falling start program (a program for close monitoring due to falls). I had a fall from bed after shift change. I wake easily so please re-round back right after report to ensure my needs are met. Nurse to ensure alarms are functioning every shift. Observation made on 1/6/26 at 10:27 a.m., revealed the resident in bed with her call light hanging over the bed on the right side, she was unable to locate it when asked. Resident #49: Review of the Face Sheet, physician orders dated 11/25, and care plans dated 7/23, revealed Resident #49 was [AGE] years old, confused and required total assistance from staff with all ADL's. The residents diagnosis included, Acute kidney failure, anxiety, anemia, diabetes, encephalopathy, altered mental status, weakness, fatigue and was born without eyes and was a fall risk. Review of the residents care plans dated 11/19/25, revealed he had behaviors, and staff were to anticipate his needs and check on him often. Observation made on 1/6/26 at 10:52 a.m., revealed the resident sitting in his rocker and his call light was dangling over the bedside night table; not within reach. During an interview done on 1/6/26 at 10:42 a.m., CNA J stated He is blind, he has behaviors, I just don't know what to do. The CNA walked out of the room, the call light remained out of reach. Review of the facility Resident Council Minutes dated 6/19/25, stated Call light-continue to monitor. Review of the Resident Council minutes dated 8/28/25, stated Call light wait time is too long. During the confidential Resident Group meeting held on 1/7/26 at 11:00 a.m., 2 resident's verbalized staff do not answer their call lights timely, stating It takes 45 minutes on days and nights, they don't have enough staff. I had an accident (incontinent) due to no one coming to answer my light, I was mad. Review of the facility Nursing In-Service held on 10/24/25, revealed Infection Control Nurse A included call lights (within reach and timely answering) in the meeting. Review of the facility call light response times for October, 25, revealed a total of 46 times resident's call light's were not answered for over an hour. There were 294 times it took over 20 minutes to answer residents call light, and 124 times it took 30 minutes to an hour to answer the call light. Review of room [ROOM NUMBER]'s call light response time on 10/8/25, revealed it was answered in 8 hours 22 seconds. During an interview done on 1/8/26 at 10:04 a.m., the facility Administrator stated it should not take more then 20 minutes tops to answer a residents call light. During an interview done on 1/8/26 at 11:20 a.m., Account V stated They (staff) are supposed to have pagers, sometimes they are out of batteries; a lot of them put them (pagers) on vibrate. I started 9/25 monitoring call lights. During an interview done on 1/8/26 at 11:40 a.m., the Director of Nursing stated We are going to pinpoint staff and I am going to hold them accountable. Review of the facility Abuse, Neglect Exploitation & Misappropriation of Resident Property policy dated 2/27/25, stated Neglect: The failure of the facility, its employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress (including call light availability and prompt answering time). Resident #4: Record review of Resident #4's medical record revealed the residents were totally dependent on facility staff for all activities of daily living. Record review of Resident #4's Kardex care guide for staff revealed that activity: to take the resident to the activity room where he can look out the window and play music for him. Observation on 01/06/2026 at 9:35 AM of Resident #4 was Observed to be seated in the activity room across the hall from the main dining room, up in Broda chair and placed so that he is facing the wall next to the room entrance doorway. The surveyor walked into the room and noted that there were no tv, photos or anything of interest on the wall. No call device noted within reach. No staff in attendance. Will monitor. Observation on 01/06/2026 at 9:50 AM Resident #4 was still in the activity room in same position in chair facing a blank wall, still no call device within reach and no staff in attendance. The surveyor noted that staff passed the activity room doorway but did not look into the room or stop to check on the resident. Observation on 01/07/2026 9:40 AM Resident #4 was seated up in WC in his room placed in front of the TV with call light in reach. 01/07/2026 1:56 PM still seated in same spot in room up in Broda chair in the same position in front of TV. No activity observed with this resident

Based on observation, interview and record review, the facility failed to ensure sufficient and adequate staffing levels were in place to meet residents' needs in a timely manner for Resident #39 and seven out of seven residents residing in the Little House (separate building from main facility) unit of the facility. Findings include: Review of the facility call light response times for October, 25, revealed a total of 46 times resident's call light's were not answered for over an hour. Review of room [ROOM NUMBER]'s call light response time on 10/8/25, revealed it was answered in 8 hours 22 seconds. On 1/6/26 at 11:50 AM, there were no Residents observed in the central area of the Little House unit of the facility. On 1/6/26 at 12:14 PM, Dietary Staff EE was observed standing beside an open cart with food plates covered with tin foil in the kitchen area of the Little House unit. When queried, Dietary Staff EE revealed they delivered the food trays to the unit from the main building kitchen but do not distribute the trays to the residents. Dietary Staff EE stated, I think it is a nurse who is supposed to serve the food. Three Residents along with several visitors/family members were observed sitting at the large table in the central area of the unit waiting for lunch to be served at this time. At 12:19 PM on 1/6/26, Certified Nursing Assistant DD entered the kitchen area of the Little House unit and began prepping beverages to go with each resident's food plate and putting them on a tray. When queried regarding other staff on the unit, CNA DD stated, The nurse is on north (in main building) and revealed they were the only staff in the Little House unit. CNA DD was observed temping the food on the plates. The temperatures were not within normal ranges and CNA DD microwaves the individual plates. When asked if they are responsible to prepare beverages and food daily, CNA DD revealed they do a couple days a week because they do not have a dedicated kitchen staff for the Little House seven days a week. When asked if CNA staff are responsible to prepare the resident trays alone on the days when a kitchen staff is not assigned to the Little House unit, CNA DD confirmed they were. CNA DD was then asked if other facility staff are in the unit to assist them and revealed staff assigned to work in the Little House include one CNA and one nurse. CNA DD explained the nurse is also assigned a unit in the main building of the facility and comes the Little House to pass medications. CNA DD was queried regarding their ability to provide care and meet resident needs in a timely manner, including serving meals, when they are the only staff member working on the unit and revealed they do the best they can do but cannot be everywhere at once. The first resident tray was served at 12:34 PM, after CNA DD prepared the beverages and microwaved the food to get it up to a safe temperature. On 1/6/26 at 1:40 PM an interview was completed with the facility Administrator. When queried regarding dining services and staff assist in the Little House, the Administrator revealed the facility has a dedicated, full-time dietary staff member for the Little House who is scheduled five days a week. The Administrator disclosed the dietary staff who had filled in and worked in the Little House when the full-time staff was off had vacated their position. The Administrator then stated they were not aware that the position had not been filled and the CNA was the only staff member providing dining assistance two days a week. On 1/7/26 at 3:30 PM to 3:54 PM, there were no residents and/or no nursing staff observed in the central area of the Little House unit of the facility. At 3:54 PM, CNA HH was observed exiting a resident room. When queried regarding staffing, CNA HH revealed the nurse assigned to the Little House also had a hall in the main building and they were the only nursing staff present in the Little House. When queried how frequently the nurse is present in the Little House, CNA HH indicated the nurse comes to pass medications and leaves as they have more residents in the main building of the facility. An interview was completed with CNA GG on 1/7/26 at 7:54 PM. When queried the lack of residents observed in the central area of the Little House unit of the facility, CNA GG replied, Yeah, everyone pretty much stays in their room all the time. When asked about activities to encourage the residents to come out of their rooms, CNA GG replied, The CNAs have to do activities over here, so it is hard. When to clarify, CNA GG revealed they were the only nursing staff currently working on the unit and were responsible for assisting and providing all ADL care including bathing/showering, responding to call lights, and planning/completing activities for all seven residents as no other staff were present on the unit all the time. CNA GG revealed the nurse assigned to the Little House is also assigned to a hall in the main building and indicated they come to the Little House pass medications and leave. CNA GG was asked staff emergency call lights in the resident rooms in case there is an emergency with a resident, such as a medical emergency or a fall, and replied, No. CNA GG revealed they have a walkie which they are supposed to use if they need assistance. CNA GG then stated, It only works if someone answers or remembers to get one. When asked if they have had instances where no one responded to the walkie, CNA GG responded they had. CNA GG verbalized safety concerns related to being the only staff member in the Little House of the facility. When queried regarding ADL care, CNA GG responded that they are often unable to answer call lights in timely manner when they are assisting another resident. CNA GG revealed they ask the other residents if they need anything prior to giving a resident a shower but it is concerning when they are unavailable and off the unit with no other staff present for 30 minutes to an hour providing a shower. CNA GG verbalized they do not consistently receive breaks and stated, No one to cover. With further inquiry, CNA GG revealed they maybe get a 10-minute break when the nurse comes to pass medications and indicated not receiving a break is very stressful. Review of Call Light Logs from 12/31/25 to 1/6/26 revealed the following call light times greater than 15 minutes in the Little House unit: - 12/31/25 at 8:03 AM; room [ROOM NUMBER]- Call light length: 20:06 minutes - 12/31/25 at 8:32 AM; room [ROOM NUMBER]- Call light length: 18:24 minutes - 12/31/25 at 8:15 PM; room [ROOM NUMBER]- Call light length: 19:14 minutes - 1/1/26 at 6:47 AM; room [ROOM NUMBER]- Call light length: 17:54 minutes - 1/1/26 at 3:36 PM; room [ROOM NUMBER]- Call light length: 16:23 minutes - 1/2/26 at 8:20 AM; room [ROOM NUMBER]- Call light length: 16:36 minutes - 1/4/26 at 12:38 AM; room [ROOM NUMBER]- Call light length: 18:15 minutes - 1/4/26 at 10:33 AM; room [ROOM NUMBER]- Call light length: 22:58 minutes - 1/4/26 at 6:51 PM; room [ROOM NUMBER]- Call light length: 18:23 minutes - 1/4/26 at 7:57 PM; room [ROOM NUMBER]- Call light length: 20:09 minutes - 1/5/26 at 8:17 AM; room [ROOM NUMBER]- Call light length: 18:17 minutes - 1/5/26 at 4:10 PM; room [ROOM NUMBER]- Call light length: 19:54 minutes - 1/5/26 at 4:22 PM; room [ROOM NUMBER]- Call light length: 29:26 minutes - 1/5/26 at 6:53 PM; room [ROOM NUMBER]- Call light length: 31:33 minutes - 1/5/26 at 6:59 PM; room [ROOM NUMBER]- Call light length: 29:33 minutes - 1/5/26 at 8:12 PM; room [ROOM NUMBER]- Call light length: 26:06 minutes - 1/5/26 at 8:42 PM; room [ROOM NUMBER]- Call light length: 15:14 minutes - 1/6/26 at 9:20 AM; room [ROOM NUMBER] – Call light length: 1:02:24 (1 hour, 2 minutes, 24 seconds) An interview was conducted with the facility Administrator on 1/8/26 at 12:07 PM. When queried what staff member is responsible for staffing, the Administrator replied, No specific person does staffing. When asked who completes the schedule, the Administrator stated, The DON (Director of Nursing) does CNAs, (Registered Nurse [RN] F) does nurses, and Unit Managers schedule their own units. An interview was completed with the DON on 1/8/26 at 12:13 PM with the DON. When queried regarding facility staffing levels, the DON revealed there are typically three nurses and nine CNAs scheduled for the building. Review of the provided nurse schedule revealed there was not an RN scheduled to work each day during the week. When queried if a RN is always scheduled to work on a unit, the DON stated, No and revealed that either a Unit Manager or themselves are available when an RN is not scheduled. When queried regarding staffing in the separate building, Little House unit, the DON stated, Little House and Loop (main building unit) share nurse and one CNA out there (in Little House). When queried regarding the CNA responsibilities in the Little House, the DON revealed the CNA assigned is responsible for all resident care needs including ADL care, activities, etc. When queried regarding staffing for the Little House including observations of the only staff in the building being a CNA, the DON relayed there are only seven residents in the unit. The DON verbalized all residents who reside in the Little House require one assistance from staff. When queried regarding assistive devices including mechanical lifts, the DON revealed one resident in the Little House uses a one assist with a sit to stand lift (mechanical lift) for transfers. When queried if it was reasonable to assume one CNA would be able to provide adequate supervision to all residents while being alone and responsible for all ADL care, the DON reiterated there were only seven residents on the unit. When asked about activities, the DON stated, CNAs provide activities or they bring them to the main building. When asked if who provided supervision to the remaining residents in the Little House if the only assigned CNA took a resident to an activity in the main building, a response was not provided. When queried regarding CNA staff statements regarding lack of coverage for breaks, the DON indicated they were unaware of staff not getting breaks. No further explanation was provided. Resident R39: Record review of Resident R39's Minimum Data Set (MDS) dated [DATE] revealed an elderly male resident with Brief Interview of Mental status (BIMs) score of 15 out of 15, cognitively intact. Medical diagnosis included: coronary artery disease (CAD), hypertension, peripheral vascular disease (PVD), renal insufficiency, obstructive uropathy, diabetes, depression and chronic obstructive pulmonary disease. Section GG physical function revealed impairment of one side of the body, use of wheelchair and/or walker. Toileting and showers/bath with substantial/maximal assistance of staff. In an interview on 01/06/2026 at10:10AM during the survey screening process on call light response. Resident #39 stated that the call lights take too long. The resident #39 stated that there have been changes in staffing with the shower aides being moved to floor aides and now the floor aides have to give the showers. On the afternoon and night shifts there is only one aide on the hallway. He stated that he had to wait over 15 minutes to use the bathroom. Observation on 01/07/2026 at 10:25AM of the 200-hallway revealed that the call lights above resident room doors do not work and the pagers are all on silent mode. Certified nurse assistants (CNAs) are observed in the hallways. How do aides know what room needs assistance? 01/08/2026 12:50 PM Record review of the call light audit forms from October 2025 revealed that the Resident of concern did not use the call light excessively, but when they did there were noted times that the call light was on for over 15 minutes. 10/3/25 at 8:10PM call light on for 17:16 minutes 10/5/25 at 10:33AM call light on for 20:09 minutes 10/8/25 at 8:06AM call light on for 9:59 minutes 10/8/25 at 11:09 AM call light on for 11:29 minutes 10/9/25 at 5:22PM call light on for 13:09 minutes 10/9/25 at 7:49 PM call light on for 11:46 minutes 10/11/25 at 7:47 AM call light on for 22:43 minutes 10/12/25 at 10:56 PM call light on for 18:46 minutes 10/14/25 at 9:15 AM call light on for 15:46 minutes 10/14/25 at 3:27 PM call light on for 11:25 minutes 10/15/25 at 7:35PM call light on for 21:48 minutes 10/17/25 at 9:31 AM call light on for 12:31 minutes 10/20/25 at 7:39 PM call light on for 35:48 minutes 10/23/25 at 8:15 PM call light on for 46:53 minutes 10/27/25 at 7:46 AM call light on for 14:02 minutes 10/27/25 at 9:33 AM call light on for 15:07 minutes 10/27/25 at 5:11PM call light on for 35:27 minutes Only one month was reviewed due to the residents' complaint. In an interview on 01/08/2026 at 10:37 AM with the facility Controller W was auditing the call lights. The state surveyor inquired about the silence of the pagers not heard while on the nursing floor. Controller W stated that the aides are not bringing the pagers back to work, yesterday 1/7/26 I was told by Certified Nurse Assistants (CNA's) H and M that there were no working pagers. Controller W stated that she went to the main nursing station and there were 4 pagers on the desk in plain sight. The batteries were dead, so I took the pagers back to my office, changed the batteries, and checked the programing to make sure they were set for CNAs. I walked the pagers back to CNA H and M who were working on the floor with no pagers. The lights above the residents' doors do not light up, that is our old call system and do not work. I am watching CNAs call light times in audits, but I am not aware that they are shutting off the call lights and not coming back. That is not acceptable.

Based on interview and record review, the facility failed to ensure that documentation of discharge and communication of information with receiving health care facility was complete in the Electronic Medical Record (EMR) for one (#52) of one resident reviewed for hospitalization. Findings include: Record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses which included surgical site infection, right sided hemiplegia and hemiparalysis (one sided paralysis) following cerebral infarction (stroke) and history of kidney transplant. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required supervision to moderate assistance for hygiene and transferring. Review of census documentation revealed Resident #52 was discharged from the facility on 11/28/25. Review of Resident #52's EMR revealed no assessment documentation pertaining to transfer and/or discharge from the facility on 11/28/25.Review of progress note documentation in Resident #28's EMR revealed the last note in the EMR was dated 11/28/25 at 9:30 AM and detailed, Health Status Note. Resident admitted to facility for strengthening rehab r/t (related to) right hip fracture requiring surgical repair. Surgical incision to right hip noted to have copious amount of bright red blood-tinged serosanguinous drainage at this time, tissue surrounding incision site is bright red and hot to the touch down to knee. Resident is receiving Cefepime (antibiotic). for infection in incision and Zithromax (antibiotic) for pneumonia. An interview was completed with Registered Nurse (RN) A on 1/7/26 at 2:26 PM. When queried regarding Resident #52 and their discharge, RN A revealed they thought the Resident had a doctor appointment and were admitted to the hospital from the doctor's office. RN A verbalized that the Resident's spouse took them to a hospital in the city because they were tired of the (local hospital). When asked what documentation is supposed to be completed by nursing staff when a Resident is transferred or discharged , RN A responded that an assessment should be completed. RN A was asked to review Resident #52's EMR. After review, RN A confirmed an assessment had not been completed. RN A was then asked if an assessment should have been completed and responded yes. Further review of progress note documentation in Resident #28's EMR revealed the following:- 11/27/25 at 11:53 PM: Health Status Note. Called to resident room. moderate amount of bloody drainage on bed pad. Dressing to right hip saturated. Dressing removed, observed drainage coming from mid incision. Noted redness surrounding the incision halfway down the outer thigh with warmth.- 11/28/25 at 9:12 AM: Health Status Note. Resident's (spouse) came in to see resident this morning and looked at resident's hip while writer was changing dressing. (Resident spouse) stated . was taking (Resident #52) down to (hospital system) on this day because felt the (local hospital) did not do the surgery correctly. Writer notified no-call provider of family request to take resident by private vehicle down to [NAME] Ford Hospital. Received okay by provider. Notified on-call supervisor of discharge. An interview was conducted with the facility Administrator on 1/8/26 at 9:19 AM. When queried what is sent with a resident when they go to an appointment at an external provider, the Administrator replied, Med list, x-rays, labs, face sheet, whatever they need. When queried if the information sent with the resident is documented, the Administrator indicated it should be. The Administrator was then queried regarding Resident #52 including where the Resident was discharged and what was sent with them. The Administrator reviewed the Resident's EMR and called the Director of Nursing (DON) to join the interview. The DON entered the interview at 9:22 AM. When queried regarding Resident #52's discharge, the DON verbalized that the Resident's husband took them to see a doctor at a different hospital. When asked how the facility knew the Resident was admitted to the hospital, the DON revealed they thought the Resident's spouse called and informed the facility. When queried regarding documentation in the EMR, the DON referred to the Health Status note dated 11/28/25 at 9:12 AM in the EMR. When asked if Resident #52's spouse took them to see a doctor or to the Emergency Department at the other hospital, the DON did not provide a response. When queried what information was sent with the Resident, the DON was unable to provide documentation of any information being sent with the Resident and/or any follow up communication. When asked if they understood the concern related to lack of documentation of discharge and communication for continuation of care with upon discharge/transfer, the Administrator verbalized understanding. No further explanation was provided. A policy/procedure related to transfer/discharge including documentation was requested at this time but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure Pre-admission Screening and Resident Review (PASARR) completion for one resident (Resident #8) of one resident reviewed for PASSAR completion resulting in lack of annual evaluation completion and the potential for lack of comprehensive assessment and care coordination. Findings includeRecord review revealed Resident #8 was originally admitted to the facility on [DATE] with diagnoses which included dementia, anxiety, depression, psychosis, and adult personality and behavior disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial to moderate assistance to complete Activities of Daily Living (ADLs) with the exception of eating. Review of Resident #8's Electronic Medical Record (EMR) revealed the Resident was receiving antianxiety, antidepression, and atypical antipsychotic medications. Review of Resident #8's Electronic Medical Record (EMR) revealed PASSAR Level I and Level II screenings were completed prior to admission by the hospital on 6/17/24. An interview was completed with Social Services Director C on 1/7/26 at 10:41 AM. When queried regarding Resident #8's PASSAR assessments, Director C reviewed the EMR and provided the PASSAR Level I and Level II assessments dated 6/17/24. When asked if the PASSAR assessment had to be completed annually at the facility, Director C stated, (Director of Nursing- DON) does those now. Director C continued, I think they are annually and we are behind on those. An interview was completed with the facility 1/8/26 with the facility Administrator. When asked how frequently PASSAR assessments should be completed, the Administrator responded annually. The Administrator revealed the facility had a change in staff and stated they knew the assessments were behind and the DON was receiving education related to PASSAR form completion. A facility policy/procedure related to PASSAR completion was requested from the facility Administrator on 1/7/26 at 12:53 PM but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to ensure that 1 resident (Resident #1) of 1 resident sampled for implementing indwelling urinary catheter care plan, resulting in cross contamination due to catheter bag being on the resident's floor. Findings Include: Resident #1:Review of the Face Sheet, physician orders dated 12/25, and care plans dated 9/22 to 1/26, revealed Resident #1 was [AGE] years old, admitted to the facility on [DATE] and re-admitted on [DATE], was his own person, and required extensive assistance from staff for all Activities of Daily Living/ADL's. The residents diagnosis included, myocardial infarction, anemia, pneumonia, back pain, malignant neoplasm of kidney, chronic lung and heart failure, acute kidney failure with a urinary catheter in place, shortness of breath, history of falling, and stroke.Review of the residents Urinary Catheter care plan dated 12/10/25, stated Ensure indwelling urinary catheter drainage bag is not touching floor.Observation made on 1/6/26 at 10:54 a.m., revealed the resident sleeping in bed with his catheter bag sitting on the floor next to his bed; no barrier was under the bag.During an interview done on 1/6/26 at approximately 10:00 a.m., Infection Control nurse, RN A stated it (the urinary catheter bag) should not be on the floor, they needed a barrier under it).Review of the facility Care Planning policy dated 1/8/26, stated The comprehensive care plan is designed to : Incorporate identified problem areas, identify risk factors associated to the identified problems, focus and build on the residents strengths, reflect goals and objectives in measurable outcomes, identify responsibility for each element of care, prevent or minimize decline in functional status.

Based on observation, interview and record review, the facility failed to update care plan interventions for 1 resident (R22) of two residents reviewed, resulting in the likelihood for missed interventions in treatment and unmet needs. Resident #22:In an interview on 01/06/2026 at 10:34 AM with the Resident #22's family member revealed that the Resident #22 got a pressure ulcer here at the facility, they have a bandage on the bottom, and they are changing it every other day. She came from Saginaw hospital after surgery on her left leg fracture then she got cellulitis. Observation on 01/06/2026 at 10:38 AM the state surveyor observed a heel up device/pad to end of bed, the family member removed the socks and the state surveyor observed the left heel had a large brown/purple deep tissue injury noted. The family member stated that the Registered Nurse Z, who stopped working at the facility back in December, before Christmas she stopped working, found the dark spot on the heel and put the foot/leg cushion (Hells-up device) on the bed and said to keep her heels off the bed. Observation of Resident #22's closet door Kardex/care guide noted no mention of the heels up device in place to the bed, or of the deep tissue injury to left heel. Record review on 1/6/2026 of resident #22's medical record/admission assessment and there was no mention of left heel deep tissue injury. No mention of pressure ulcer or deep tissue skin injury in care plans. Record review of facility 'Care Planning' policy dated 10/2/2024 noted each resident will have a care plan developed and maintained by the interdisciplinary team, in coordination with the resident and the family/representative . The individualized care plan includes measurable objectives and timetables established to meet resident's medical, nursing, mental, social, and psychological needs. (9.) Revised care plans as dictated by changes in condition. (10.) Care plan changes are made in point-click-care and a new Kardex is printed and placed in resident closets. Observation and interview on 01/07/2026 at 2:01 PM with Registered Nurses A Infection Control and F Wound care entered into the room with wound care supplies of wound wash and dry gauze. The Resident #22 was rolled to the right side and observation of the right gluteus revealed an open area pinpoint with slight serosanguinous drainage noted, wound care of wound wash and pat dry, a 2x2 Allevyn foam border dressing applied. The RN's A and F were requested by the state surveyor to remove Resident #22's socks to observed bilateral heels. Observation of Resident #22's left heel was noted with a large dark area, non-blanchable. RN A and F both were surprised and stated that they just found the deep tissue injury with the state surveyor today. The family member was in the room during observation and stated that the left heel sore had been there over 3-weeks, when Registered Nurse W the nurse does not work here anymore she found it and placed the heels-up device/pad to her bed. In an interview and record review on 01/07/2026 at 2:15 PM with Registered Nurse A RN/ICP/In-service director- Her left heel has a deep tissue injury, purple/brown in color, it new today. there was nothing there on admission assessment, I have been in there at least 1 or 2 times to assess her or transfer her. That deep tissue injury is newfound today. In an interview and Record review on 01/07/2026 at 3:02 PM with Human Resource director X of Registered Nurse Z's resignation letter noted her last date of duty was 12/19/2025. Record review on 1/8/2026 at 8:45 AM with Registered Nurse A Infection control/In-service education of Resident #22's physician order on 1/2/2026 at 1:17PM revealed 'Ensure that heels up device is in place while in bed. In an interview and record review on 01/08/2026 at 8:03 AM with the Director of Nursing related to care plan development. The DON stated that when a resident admits or comes in, we initiate care plans based on diagnosis and needs. record review of Resident #22's care plans pages 1 through 11 revealed no Deep Tissue Injury to left heel. The DON stated that there was no what, where, or when or how to treat. The DON stated that we put in/created a pressure ulcer care plan on the 1/6/2026 and then (stage II) then resolved it on 1/7/2025. I looked in the care plans and there was no pressure ulcer care plan, so I created one on 1/6/2025 and then they said that it resolved so I went back into the care plans on 1/7/2025, that's what I did. We do have an MDS contracted service that does our care plans, and we follow their recommendations. Record review with the DON of Resident #22's care plan changes presented by the Director of Nursing during the interview revealed that Resident #22 had potential for pressure ulcer development on 12/19/2025, and pressure ulcer development dated 1/6/2026 and revised on 1/7/2026.

Based on observation, interview and record review, the facility failed to ensure the provision of services, treatment and assistive devices to maintain vision and hearing abilities for one resident (Resident #15) of one resident reviewed for vision/hearing resulting in lack of equipment, audiology services, and Resident verbalization of difficulty and discontentment.Findings include:On 1/6/26 at 12:06 PM, Resident #15 was observed in their room sitting in a recliner. An interview was completed at this time. When spoke to, Resident #15 was noted to be very hard of hearing, and they did not make eye contact nor track movement with their eyes. When asked about their vision, Resident #15 stated, I can't see. Resident #15 was asked if they had seen an eye doctor while at the facility and indicated they had but stated the glasses they got did not help them to see. Resident #15 was then asked if they had hearing aids and responded they don't work. When queried if they had seen an audiologist while at the facility, Resident #15 replied they had not. The Resident then stated, I crocheted and did stuff all my life. Now I can't do anything. Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, depression, anxiety, and heart disease. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required partial/moderate staff assistance with transfers and hygiene. Review of Resident #15's Electronic Medical Record (EMR) revealed a care plan entitled, I have impaired visual function r/t (related to) macular degeneration. I have stated I am legally blind (Initiated and Revised: 10/2/24). The care plan included the intervention, Ensure my glasses are available to support my participation in activities (Initiated and Revised: 10/2/24). A second care plan entitled, I have a communication problem r/t (related to) Hearing deficit (Initiated: 10/2/24) was also present in Resident #15's EMR. The care plan included the intervention, Ensure availability of my hearing aids and that they are working properly (Initiated and Revised: 10/2/24). Review of Resident #15's EMR revealed the following progress note documentation: - 9/30/24 at 4:01 PM: MDS Note. This nurse entered resident room to find resident sitting up in wheelchair. answered all questions appropriately with this nurse. stated. utilizes glasses and is legally blind. moderate difficulty hearing without hearing aids.- 10/17/24 at 10:10 AM: Medicare Note. Resident reports is legally blind and has moderate difficulty hearing without hearing aids.- 7/30/25 at 11:50 AM: Social Service. This writer delivered resident's new glasses to staff at resident's building No further documentation was noted Resident #15's care plan/ progress note documentation pertaining to vision and/or hearing services/equipment. No documentation pertaining to audiology consultation was noted in the EMR. On 1/7/26 at 3:41 PM, a second interview was completed with Resident #15. The Resident was observed sitting in the recliner in their room. The Resident was not wearing glasses and there were no glasses observed in the Resident's room. With further inquiry regarding their vision, the Resident explained they had got new glasses, but the glasses did not help them to see, and they were unsure of where the glasses are now. When asked if they saw the followed up with the eye doctor after receiving the new glasses which did not help their vision, Resident #15 verbalized they did not. When asked about their hearing aids, Resident #15 indicated they had not been working for quite some time but did not provide further information. An interview was conducted with Certified Nursing Assistant (CNA) Y on 1/7/26 at 3:50 PM. When queried regarding Resident #15's hearing, CNA Y confirmed the Resident was very hard of hearing. CNA Y was asked if the Resident has hearing aids and stated, Not that I'm aware of. When queried if the Resident had glasses, CNA Y replied, I think they have them but doesn't use them. She just uses the magnifying glass. When asked why the Resident doesn't use their glasses, CNA Y indicated they were not sure. CNA Y was then asked if Resident #15 leaves their room and stated, No. (Resident #15) says they can't hear and can't see so it's too hard. CNA Y continued, The last time I seen (Resident #15) out was on Halloween. An interview was completed with the facility Administrator on 1/8/26 at 8:48 AM. When queried regarding Resident #15's hearing impairment, the Administrator confirmed the Resident had impaired hearing. When asked about the Resident's hearing aids, the Administrator revealed they did not know and asked the Director of Nursing (DON) to join the interview. When queried regarding the location of Resident #15's glasses, their new glasses not assisting their vision, and lack of documentation of follow up, the DON responded that the Resident is blind and not improving the Resident's vision, the DON responded that Resident #15 says they are legally blind and glasses will probably not help. When queried regarding the Resident's hearing and audiology services, the DON stated, (Resident #15) refuse ancillary services. Documentation of refusal related to audiology services was requested at this time.At 9:20 AM on 1/8/25, the DON provided a printed copy of the EMR MDS Note dated 9/30/24 at 4:01 PM. The note specified the Resident wore glasses, was legally blind, and was moderately hard of hearing without hearing aids. An interview was conducted with the Administrator and DON at this time. When asked, the DON revealed they were unable to locate any other information pertaining to ancillary vision and/or audiology services. When queried if Resident #15 had refused audiology services, the DON responded they had not. The DON then stated, (Resident #15) has a consult for audiology. The DON was asked when the audiology consult was placed and stated that a consult was sent on 9/30/24 and again in January 2025. When asked if the Resident had been seen by audiology, the DON replied, No. With further inquiry, the DON revealed they contacted the company the facility has a contract with for ancillary services, including audiology, and were informed that there is not an audiologist available. Both the DON and Administrator verbalized they were unaware that audiology was unavailable through the contracted company. When asked if alternative audiology providers had been contacted, the Administrator and DON revealed they had not. The Administrator verbalized they would address the concern. No further explanation was provided. Review of facility policy/procedure entitled, Hearing and Vision Services (Reviewed/Revised: 10/1/25) revealed, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. 4. assist the resident by making appointments and arranging for transportation. 5. Employees will assist the resident with the use of any devices or assistive equipment needed to maintain vision or hearing.

Based on interview and record review, the facility failed to ensure monitoring for anticoagulation (blood thinner) medication side effects for one resident (#37) of five residents reviewed for unnecessary medications. Findings include:Record review revealed Resident #37 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included atrial fibrillation (irregular heart rhythm), respiratory failure, and anxiety. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required partial/moderate assistance with toileting and bathing. An interview was completed with Resident #37 on 1/6/26 at 11:35 AM in their room. The Resident was sitting in a recliner in their room. When queried if they take an anticoagulant medication, Resident #37 responded they do. Resident #37 was asked the name of the medication and revealed they did not know. Review of Resident #37's Health Care Provider (HCP) orders and Medication Administration Record (MAR) in the Electronic Medical Record (EMR) revealed the Resident was currently receiving Apixaban (Eliquis- oral anticoagulant) 2.5 milligram (mg) one tablet twice a day. Review of MAR and progress note documentation in Resident #37's EMR revealed no documentation of monitoring for bleeding and/or side effects of anticoagulation medications. Resident #37 did not have a care plan in place related to anticoagulant medication therapy. An interview and record review was completed with the facility Administrator and Director of Nursing (DON) on 1/8/26 at 9:32 AM. When queried regarding facility policy/procedure related to monitoring for side effects of anticoagulation medications, the DON revealed a task for side effect monitoring is initiated on the MAR when a Resident takes an anticoagulant medication. When asked if Resident #37 is receiving an anticoagulant medication, the DON reviewed the Resident's EMR and confirmed they were. When asked if they should have anticoagulant medication monitoring in place, the DON stated, Should be. When queried where anticoagulation monitoring is documented in Resident #37's EMR, the DON reviewed the Resident's EMR and confirmed the Resident did not have monitoring in place. When asked why Resident #37 did not have anticoagulant monitoring in place, the DON indicated the monitoring task was not reordered when the Resident was readmitted to the facility and it should have been. No further explanation was provided. A facility policy related to anticoagulation medication monitoring was requested at this time but not received by the conclusion of the survey.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings include: On 01/06/2026 at 9:16am-9:45am during the initial kitchen tour with Certified Dietary Manager R, observed a carton of Lactaid with a discard date of 12/30/25, located in the walk-in refrigerator in the kitchen. According to the 2022 Food Code, 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. On 01/06/2026 at 9:16am-9:45am observed the slicer visibly soiled with a substance caked to the blade and accumulating rust, located in the kitchen. When interviewed CDM R on how often the slicer is cleaned, she stated that the slicer hasn't been used in 2 years. On 01/06/2026 at 9:16am-9:45am observed the mixer visibly soiled with a white substance, located in the kitchen. When interviewed CDM R on how often the mixer is cleaned, she stated that the mixer is supposed to be clean every time they use it. On 01/06/2026 at 9:16am-9:54am observed crumbs accumulating on top of pans stored under the counter near the 2-compartment sink, located in the kitchen. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the facility's policy on sanitation of food preparation areas, All kitchenware and food contact surfaces used in the preparation of or serving of food and drink will be cleaned and sanitized after each use and thoroughly cleaned and sanitized after each meal. On 01/06/2026 at 9:45am observed the microwave visibly soiled in the interior walls and ceiling, located in the kitchen in the Small House. When interviewed CDM R on the cleaning schedule of the microwave, and she stated that she hasn't looked inside the microwave lately, but it's supposed to be cleaned daily. On 01/06/2026 at approximately 9:45am observed the inside of the oven visibly soiled with grease, located in the kitchen in the Small House. On 01/06/2026 at approximately 9:45am observed the toaster visibly soiled with a large number of crumbs collecting at the top and bottom of the toaster, located in the kitchen in the Small House. On 01/06/2026 at noon-12:45pm observed [NAME] Q remove one glove and proceeded to don another glove without washing hands while serving food in the kitchen. On 01/06/2026 at noon-12:45pm observed [NAME] Q remove both gloves and don gloves without washing hands while preparing trays in the kitchen. According to the 2022 Food Code, 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms .immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and . Before donning gloves to initiate a task that involves working with food. According to the facility's policy on handwashing and hand hygiene, All employees and volunteers at Iosco County Medical Facility will practice proper hand washing techniques, in conjunction with standard (universal) precautions, to provide the best means of preventing and controlling infection. Hand hygiene is practiced at the following times .Before putting gloves on .after removing gloves.

Based on observation, interview and record review, the facility failed to issue a beneficiary notice (ABN/Nomnic) for one resident (Resident #155) of three residents reviewed for beneficiary notices to eligible resident/representative in writing of the items and services which are/are not covered under Medicaid or by the facility's per diem rate, including the cost of those items and services, resulting in the potential for financial hardship when changing to hospice services. Findings include: The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. Resident #155: Beneficiary Notification An interview and record review was conducted on 11/18/24 at 02:42 PM with Social Work Designee G to review the ABN/NOMNIC forms issued to residents. Review of Resident #155's ABN/NOMNIC notification forms revealed them to be unsigned by the resident or representative. Social work designee G revealed that Resident #155 admitted on [DATE] and then switched to hospice services on 9/13/2024 but stayed in the facility. Review of the ABN/NOMNIC forms were not signed/not issued at the time of the care level switch. Social work designee G did not know why the forms were not signed. and referred the writer to the billing office manager. Social work designee G revealed that she had documented notes, but that the notes did not state why the forms were not signed. An interview and record review on 11/19/24 at 01:03 PM with [NAME] staff H revealed that she types up the ABN/NOMNIC forms but does not get them signed. [NAME] staff H revealed that the forms were not signed because of the family choice of hospice. Resident #155 went right to hospice services here within the facility and there was no window of time to get the forms signed. On 11/19/24 at 12:11 PM this writer Requested the facility ABN/NOMIC policy. No ABN/NOMIC policy was received. An interview on 11/20/24 at 12:09 PM with the Nursing Home Administrator (NHA) revealed that the facility had no ABN/NOMNIC policy. The NHA stated that she did type up a policy, but it will not be ready for 2 more weeks.

Based on observation, interview and record review, the facility failed to update care plans for 2 residents (Resident's #19 and #50) of a sample of 16 resident's reviewed for care plans, resulting in delayed nursing interventions, showers not given and proper wound care given for a pressure ulcer not done. Findings Include: Resident #19: Review of the face Sheet, diagnosis sheet, orders, nurse's notes and physician progress note's dated 9/24 through 11/24, revealed Resident #19 was [AGE] years-old, had a guardian in place, admitted to the facility on [DATE], dependent on staff for all Activities of Daily Living/ADL's, and resided on the Woodlands unit (locked Dementia unit). The resident's diagnosis included, cognitive impairment, severe depression, Dementia, Parkinsonism, pressure ulcer stage II on coccyx, heart disease, stroke with weakness of left side, Aphasia (difficulty with communication) and Dysphagia (swallowing impairment). Review of the facility Brief Interview for Mental Status (BIMS) dated 11/7/24, revealed the resident had a BIMS of 2, severe cognitive decline. Review of the facility nursing progress note dated 11/12/24, stated This nurse (Wound Nurse K) assessed what was documented as a stage II pressure ulcer on resident's coccyx. Upon assessment resident was noted to have an area of blanchable erythema (reddened) measuring 4.0cm (L) x 4.0cm (W). In the center of the erythema is an area of MASD (macerated) measuring 2.2cm (L) x 1.0. (W) x 0.1cm (D). The area presented as white, wrinkled macerated skin. ROHO cushion (pressure reduction cushion) placed in wheelchair. Review of the physician order dated 11/12/24, stated Cleanse MASD (macerated area) on coccyx with wound wash, pat dry, and cover with Optifoam 3 x 3 Q (every) 3 days and PRN (as needed) if soiled. Observation of wound care was done on 11/19/24 at 2:50 p.m. During the dressing change, Resident #19 had a stage II pressure ulcer to his lower coccyx area that was red on the outside and a light pink to white in the center. Review done on 11/18/24, of the resident's facility potential for impairment to skin integrity r/t (related) limited mobility related to CVA (stroke) care plan dated 4/3/24, revealed no actual pressure ulcer care plan was in place nor any up-dates of an actual pressure ulcer was found. During an interview done on 11/19/24 at 3:03 p.m., Rehab Manager D said a communication between nursing and rehab, is what generates a care plan or a care plan change and she had none for the resident regarding pressure ulcer or preventive skin management. During an interview done on 11/19/24 at 12:03 p.m., Shower Aide/Nursing Assistant J revealed the facility had no longer used shower sheets to document any reddened areas or unusual skin concerns (pressure ulcers) noted during a shower. When the previous Director of Nursing discontinued the shower sheets, nothing was put in their place for communication to nursing of abnormal skin areas on resident's. Shower Aide J stated, We no longer have shower sheets; no communication of any abnormal skin areas was being told to nursing for skin assessment to be done. 22927 Resident #50: An observation and interview on 11/18/24 at 12:03 PM with Resident #50 revealed that her call light takes a long time to get someone to her room to assist her to the bathroom and with her bathing. Record review of Resident #50's Progress notes from admittance date of 10/29/2024 through 11/19/2024 revealed an elderly female admitted with post-surgical hip repair for rehab services. Record review of Resident #50's care plan for: Activity of Daily Living (ADL) self-care deficit related to deconditioning from recent hospitalization for right hip fracture with closed reduction (repair). Interventions included: Toileting- assist of 2 staff members to use toilet, Transfers- assist of 2 staff members with pivot transfer and front wheeled walker (FWW). Bathing- assist of one staff member participation with bathing. Record review of Resident #50's Kardex (resident care guide) noted assist of one staff member with bathing. There was no indication of what days to bathe and if the resident preferred showers or bed baths. An interview on 11/19/24 at 12:03 PM with Certified Nurse Assistant (CNA) J shower assistant revealed that resident showers are to be twice a week. CNA J stated that she does get pulled to the floor and may miss some showers. Resident #50 in room [ROOM NUMBER] was a Tuesdays and Fridays shower. CNA J reviewed Shower task and admitted Resident #50 as 10/29/2024 and the resident has been at the facility 21 days and has 3 documented showers. CNA J explained that if a resident is washed up in the bathroom, CNA's can document in the progress note, but it disappears after 24 hours. CNA's use to have paper shower sheets, but those went away this year, So CNA's no longer have written document just the disappearing progress note. It doesn't stay there very long.

Based on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL), including bathing/showering for one resident (Resident #50) of 13 residents reviewed for ADL's, resulting in missed bathing/showers and the potential for feelings of embarrassment. Findings include: Resident #50: The clinical record of Resident #50's OBRA admission assessment dated [DATE] revealed under section GG: Functional abilities- substantial/maximal assist, helper does more than half the effort for task: toileting, shower/bathing, personal hygiene. Record review of Resident #50's Progress notes from the admittance date of 10/29/2024 through 11/19/2024 revealed an elderly female admitted with post-surgical hip repair for rehab services. Record review of Resident #50's care plan for: Activity of Daily Living (ADL) self-care deficit related to deconditioning from recent hospitalization for right hip fracture with closed reduction (repair). Interventions included: Toileting- assist of 2 staff members to use toilet, Transfers- assist of 2 staff members with pivot transfer and front wheeled walker (FWW). Bathing- assist of one staff member participation with bathing. Record review of Resident #50's Kardex (resident care guide) noted assist of one staff member with bathing. There was no indication of what days to bathe and if the resident preferred showers or bed baths. An interview on 11/19/24 at 12:03 PM with Certified Nurse Assistant (CNA) J shower assistant revealed that resident showers are to be twice a week. CNA J stated that she does get pulled to the floor and may miss some showers. Resident #50 in room [ROOM NUMBER] was a Tuesdays and Fridays shower. CNA J reviewed Shower task and admitted Resident #50 as 10/29/2024 and the resident has been at the facility 21 days and has 3 documented showers. CNA J explained that if a resident is washed up in the bathroom, CNA's can document in the progress note, but it disappears after 24 hours. CNA's use to have paper shower sheets, but those went away this year, So CNA's no longer have written document just the disappearing progress note. It doesn't stay there very long. Record review of Resident #50's Shower Task documentation for a 30-day look back revealed Question #3: Bathing support provided how resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower: there were only three dates of showers given in the 30 days look back period. 10/30/2024, 11/4/2024 and 11/11/2024.

Based on observation, interview and record review, the facility 1) Failed to prevent and implement preventive measures to avoid a pressure ulcer and 2) Failed to timely identify a pressure ulcer, for 1 resident (Resident #19) of 3 residents reviewed for pressure ulcers, resulting in a Stage II pressure ulcer on the coccyx, pain, increased potential for infection, antibiotic usage and hospitalization . Findings Include: Resident #19: Observation of wound care was done on 11/19/24 at 2:50 p.m. During the dressing change, Resident #19 complained of discomfort and pain when the pressure ulcer was cleaned and dressed. The resident had a Stage II pressure ulcer to his lower coccyx area that was red on the outside and a light pink to white in the center. At this time the dressing was coming off due to loose stool. When the nurse cleaned him up, he complained of pain. Review of the face Sheet, diagnosis sheet, orders, nurse's notes and physician progress note's dated 9/24 through 11/24, revealed Resident #19 was [AGE] years-old, had a guardian in place, admitted to the facility on [DATE], dependent on staff for all Activities of Daily Living/ADL's, and resided on the Woodlands unit (locked Dementia unit). The resident's diagnoses included, cognitive impairment, severe depression, Dementia, Parkinsonism, pressure ulcer stage II on coccyx, heart disease, stroke with weakness of left side, Aphasia (difficulty with communication) and Dysphagia (swallowing impairment). Review of the facility Brief Interview for Mental Status (BIMS) dated 11/7/24, revealed the resident had a BIMS of 2, severe cognitive decline. During an interview done on 11/19/24 at 10:23 a.m., Wound Nurse, RN K stated On 11/12/24, this pressure ulcer was identified. I saw a reddened area about a week ago (no documentation was found of area). It's (a wheelchair cushion) something he should of had prior (before the development of a pressure ulcer), it (the pressure ulcer) could have been prevented. Review of the facility nursing progress note dated 11/12/24, stated This nurse (Wound Nurse K) assessed what was documented as a Stage II pressure ulcer on resident's coccyx. Upon assessment resident was noted to have an area of blanchable erythema (reddened) measuring 4.0cm (L) x 4.0cm (W). In the center of the erythema is an area of MASD (macerated) measuring 2.2cm (L) x 1.0. (W) x 0.1cm (D). The area presented as white, wrinkled macerated skin. ROHO cushion (pressure reduction cushion) placed in wheelchair. Review of the physician order dated 11/12/24, stated Cleanse MASD (maserated area) on coccyx with wound wash, pat dry, and cover with Optifoam 3 x 3 Q (every) 3 days and PRN (as needed) if soiled. Review of facility nursing progress note dated 11/14/24, stated Resident noted to have a Stage II pressure ulcer to coccyx area. Review of the physician progress note dated 11/14/24, stated Patient is seen for newly acquired Stage II pressure ulceration to the coccyx. Review of the facility Skin/Wound assessment dated [DATE], 1 of 3 pages, had no documentation of a coccyx wound; just a scabbed area on the top of the resident's head. No facility Skin/Wound assessment dated [DATE] or 11/13/24, regarding the resident's pressure ulcer, was given to this surveyor upon request. Review of the facility nursing progress note dated 11/14/24, stated Action: Treatment is to cleanse wound (coccyx pressure ulcer) with wound wash and cover with Optifoam BID (twice a day) and PRN (as needed). Response: Resident noted to have poor diet. Air mattress and Roho cushion in w/c (wheelchair) have been put into place for pressure relief. Staff to lay resident down after meals, reposition often and be prompt with brief changes. The first time an air mattress was documented as being used for the resident, after development of the pressure ulcer. During an interview done on 11/20/24 at 8:07 a.m., the MDS Coordinator, RN E stated On 11/9/24 there was an order for an open area, the Stage II pressure ulcer was identified on 11/9/24, an order given for a dressing and a skin assessment was done. It also should have been put in the wound binder for the wound nurse (on 11/9/24). The care plan was up-dated on 11/12/24, but no documentation of it being an actual care plan (no care plan for actual pressure ulcer was done, only potential). I think they should of put actual impairment (skin impairment care plan) on the 9th (11/9/24), the care plan was not up-dated until today (11/20/24), I just did it. This surveyor requested MDS Coordinator E get the wound binder; no documentation of any pressure ulcer for the resident of concern was found. Review of the resident's facility potential for impairment to skin integrity r/t (related) limited mobility related to CVA (stroke) care plan dated 4/3/24, revealed a Roho cushion intervention was added onto this care plan on 11/12/24. No actual pressure ulcer care was found. During an interview done on 11/19/24 at 3:03 p.m., Rehab Manager D revealed she had no communication from therapy to nursing or from nursing to therapy regarding a pressure reduction cushion for the resident's wheelchair. Rehab Manager D said a communication between nursing and rehab, is what generates a care plan or a care plan change. Review of the facility Therapy Communication forms dated 9/16/24 and 10/22/24 (only two available upon request), revealed no documentation of an air mattress or of a cushion for the wheelchair, preventive measures. The facility note dated 11/14/24, was the first documentation of an air mattress and Roho cushion (pressure reduction cushion) being used for the resident. Review of physician order dated 9/9/24, stated Skilled PT tx (treatment) includes: W/C (wheelchair) Management/Training (includes placing a pressure reduction cushion put on the wheelchair if resident at risk for skin breakdown). No documentation of any type of wheelchair cushion was found prior to 11/14/24 on the potential for wound/skin pressure ulcer care plan dated 4/3/24. During an interview done on 11/19/24 at 12:03 p.m., Shower Aide/Nursing Assistant J revealed the facility had no longer used shower sheets to document any reddened areas or unusual skin concerns (pressure ulcers) noted during a shower. When the previous Director of Nursing discontinued the shower sheets, nothing was put in their place for communication to nursing of abnormal skin areas on resident's. Shower Aide J stated, We no longer have shower sheets; no communication of any abnormal skin areas was being told to nursing for skin assessment to be done. The resident's pressure ulcer was not identified until it was staged as a stage II pressure ulcer. Review of the facility Nurse's education and meeting dated 10/25/24, revealed slides going over pressure ulcer preventive measures and wound care. This surveyor requested a pressure ulcer preventive policy during the survey (11/18/24 to 11/20/24), none was received.

Based on observation, interview and record review, the facility failed to maintain supervision of two residents (Resident #19 and Resident #37), of two residents reviewed for falls, resulting in Resident #19 and Resident #37 to have recurrent/repeated falls causing Resident #37 to have a head injury, pain and transfer to the emergency room and the potential for continuous falls and injuries. Findings include: Resident #37: Record review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed an elderly male with medical diagnosis included: Cancer, hypertension, Gastroesophageal reflux disease, benign prostatic hyperplasia, arthritis, dementia, anxiety, depression and glaucoma. Section I: Health conditions- noted falls of two or more since prior assessment. Observation on 11/19/24 at 08:05 AM with Licensed Practical Nurse (LPN) L during medication administration in the secured dementia unit of Resident #37 revealed left upper brow facial bruising with a small laceration. LPN L stated that Resident #37 had sustained a fall over the weekend and went out to the hospital for treatment. LPN L revealed that Resident #37 was on Ativan (Antianxiety medication) cream three times daily was out of stock per the pharmacy, so Resident #37 was ordered Ativan 1mg oral three times daily. LPN L stated that the oral Ativan snowed (sleepy/lethargic). Observation of Resident #37's medication pass revealed the resident took oral medication crushed in pudding. Record review of Resident #37 incident reports from August 2024 through November 2024 revealed: On 8/2/2024 at 2:20 PM Resident #37 misjudged sitting in recliner and sat on floor. Predisposing factors included: confusion, impaired memory, wandering, ambulating without assist, and poor safety awareness. No injuries noted. Record review of Resident #37's incident report dated 8/25/2024 at 7:10 PM revealed that the resident was in the common area and tried to sit on the small end table between the two recliner chairs. The resident misjudged the distance and sat on the floor in front of the table. Predisposing factors included: poor safety awareness. No injuries noted. In a record review of Resident #37's incident report dated 8/31/2024 at 7:50 AM Resident #37 was found by staff sitting on the floor in resident's room. Resident #37 complained of hip and knee pain with pain score of 6 expressed by facial expression, ridged, fist clenched, knees pulled up, pulling or pushing away, striking out and unable to console. Record review of Resident #37's incident report dated 9/12/2024 at 6:10 PM when staff heard loud noise and approached the dining area Resident #37 was on his buttocks next to dining chair. Predisposing factors included: confusion and ambulating without assist. No injuries noted. Record review of Resident #37's incident report dated 9/29/2024 at 9:50 AM Resident #37 was found on the floor in resident room on hands and knees with blankets between legs attempting to get up. Predisposing factors included: confusion, impaired memory, improper footwear, and poor safety awareness. No injuries noted. Record review of Resident #37's incident report dated 11/17/2024 at 2:15 AM Resident was found on floor with large golf ball size hematoma to left side of forehead with scant amount of blood. Resident tired and groggy still and mumbled incoherent responses when asked what happened. Resident had removed his socks. Resident sent to emergency room for evaluation. Predisposing factors included: confusion, impaired memory, drowsy, improper footwear, ambulating without assist, wanderer and poor safety awareness. Facility fall investigation noted that the resident #37 was incontinent/wet. Medications given in the previous 8 hours included: Anti-anxiety, cardiovascular, and anti-psychotic medications. Investigation noted that the Resident #37 was receiving Ativan 1 mg tablet due to pharmacy unable to prepare the gel/cream formula. Record review of Resident #37's 'Neurological Record' dated 11/17/2024 instructions: Complete form and describe any neurological problems on the reverse. Perform initial, then every 15 minutes, then every hour times 4 hours, then every 8 hours times 24 hours. The Neurological record stopped documenting neurological checks after six hours. In an interview and record review on 11/20/24 at 08:34 AM, Registered Nurse (RN) M reviewed the Medication Administration Record of Resident #37, who was receiving cream Ativan 1mg topical and on 11/14/2024 the order was discontinued. Resident #37 was started on Ativan 1 mg tablet oral. RN M revealed that Resident #37 had a history of falls, and he does have 4 falls in the last 2 months. There should have been a continued neurological assessment for 24 hours with the 11/17/2024 fall with head injury. Record review of Resident #37's hospital emergency room evaluation discharge instructions included diagnosis of: head injury, scalp hematoma, traumatic brain injury. Resident #37 was returned to the facility. Record review of fall program policy on 11/20/24 09:39 AM with Registered Nurse (RN) M revealed that the policy 'Catch a Falling Star Program' dated 1/23/2024 revealed that the facility was committed to the reduction of falls among residents using a systematic, multidisciplinary team approach. This program serves as an alert to all staff, including clinical and non-clinical staff. The yellow sticker star is a signal to all staff to be observant and to intervene if resident is displaying any unsafe behaviors. Record review of facility 'Fall Prevention & Follow-up' policy dated 12/21/2023 revealed each resident will be assessed for the risk of falls. Appropriate interventions are identified, care planned and follow up done to monitor effectiveness. Residents are assessed for fall risk upon admission, quarterly, with any significant change and with each fall. (4.) Post fall assessment may include: c) Neuro checks (head injury or unwitnessed fall). (5.) If head injury or unwitnessed fall: initiate neurological checks: initial, then every 15 minutes for 1 hour (5 assessments), every 1 hour for 4 hours (4 assessments) and every 8 hours for 24 hours (3 assessments). 22347 Resident #19: Review of the face Sheet, diagnosis sheet, orders, nurse's notes and physician progress note's dated 9/24 through 11/24, revealed Resident #19 was [AGE] years-old, had a guardian in place, admitted to the facility on [DATE], dependent on staff for all Activities of Daily Living/ADL's, and resided on the Woodlands unit (locked Dementia unit). The resident's diagnosis included, cognitive impairment, severe depression, Dementia, Parkinsonism, pressure ulcer stage II on coccyx, heart disease, stroke with weakness of left side, Aphasia (difficulty with communication) and Dysphagia (swallowing impairment). Review of the facility Brief Interview for Mental Status (BIMS) dated 11/7/24, revealed the resident had a BIMS of 2, severe cognitive decline. Review of the physician order dated 10/16/24, revealed Resident #19 was ordered Ativan (for anxiety) oral tablet 0.5 mg, Give 1 tablet by mouth three times a day. This medication is scheduled as a regularly scheduled med to be given 3 times per day. Review of the physician order dated 9/24/24, revealed Resident #19 was ordered Ativan oral tablet 0.5 mg, give 1 tablet by mouth every 6 hours as needed for agitation. The resident was getting a total of 1.5 mg of Ativan daily regularly scheduled, with the likelihood for getting a total of 2.0 mg Ativan as needed with no stop date (every 14 day's this medication is required to be re-ordered with explanation or stopped. This would be a total (both as needed and regularly scheduled) of 3.5 mg a day of Ativan given per order. Review of the resident's facility fall's dated 5/10/24 through 11/20/24, revealed he had fallen a total of x 7 times. Resident #19's Falls: 1. On 5/10/24 2. On 5/31/24 3. On 7/7/24 4. On 7/10/24 5. On 7/25/24 6. On 11/15/24 7. On 11/20/24 Review of the resident's Anti-Anxiety care plan dated 9/30/24, stated I am taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Review of the resident's Falls care plan dated 4/2/24, stated Anticipate and meet my needs, visualize resident while in dining room at all time. The resident fell in the dining room on . During an interview done on 11/19/24 at approximately 2:00 p.m., Medical Director C said he ordered Resident #19's Ativan, he was aware of the dose. During an interview done on 11/20/24 at 11:18 a.m., the Director of Nursing and this surveyor reviewed Resident #19's orders, and the Ativan order had not been changed and no note from Physician C was found to justify the continuing of Ativan PRN/as needed. The Director of Nursing changed the order and stated it was not changed until today (11/20/24). We will be having a manager on that unit, that will help out. Review of the facility Fall Prevention & Follow-up policy dated 12/21/23, revealed all fall investigations will include interviews with resident's and staff, vital signs, pain, injuries occurred, fall assessment, medication review (includes Ativan), psychiatric and cognitive factors, history of other fall, and causative factors. This information generates care plan interventions and safety precautions.

Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #19) remain free from unnecessary medications (Ativan) and to obtain consent for antidepressant use for one resident (Resident #26) of two residents reviewed for Ativan usage, resulting in Resident #19 receiving Ativan medication as needed with no stop date and Resident #26 receiving antidepressant medications with no consent. Findings include: Record review of the facility 'Psychotropic Medications' policy dated 12/21/2023 revealed residents receiving ant-psychotic medications with black box warnings will be provided with education regarding the significant risk of serious or even life-threatening adverse effects of the medication. A signed informed consent will be obtained for all ant-psychotic medications use in the facility. The attending physician or psychiatrist will provide an individualized risk vs benefits analysis for each resident receiving anti-psychotic medications. Specific conditions listed: Mood disorders (e.g., mania, bipolar disorder, depression ) All residents receiving newly prescribed psychotropic medications PRN (as needed) will be evaluated by provider within 14 days to evaluate need to continuation, or discontinuation of medication. Record review of the 'Nursing 2017 Drug Handbook' page 1454-1455, Identified Trazadone Hydrochloride therapeutic classification: antidepressant. Resident #26: Record review of Resident #26's physician orders on 11/20/24 at 07:55 AM revealed medications of Prozac and Trazadone were ordered on 10/29/2024. Record review of Resident #26's October 2024 Medication Administration Record (MAR) revealed that anti-depressant medications of Prozac and Trazadone were administered starting on 10/29/2024. In an interview on 11/20/24 at 08:05 AM, social service designee G revealed that Resident #26 admitted on [DATE] from hospital, referral paperwork comes prior to resident arrival. Resident #26 Started Prozac and Trazadone (antidepressants) on 10/29/2024 was administered and the written consent was obtained November 13th. Social services designee G stated that she asks the nurses to get consents signed before the first dose is administered. An interview and record review on 11/20/24 at 08:11 AM with the interim Director of Nursing (DON) M revealed that the nurses get the consent prior to administering the medications. It's in the policy to get a consent. Record review of the Psychotropic medication policy was reviewed. 22347 Resident #19: Review of the face Sheet, diagnosis sheet, orders, nurse's notes and physician progress note's dated 9/24 through 11/24, revealed Resident #19 was [AGE] years-old, had a guardian in place, admitted to the facility on [DATE], dependent on staff for all Activities of Daily Living/ADL's, and resided on the Woodlands unit (locked Dementia unit). The resident's diagnosis included, cognitive impairment, severe depression, Dementia, Parkinsonism, pressure ulcer stage II on coccyx, heart disease, stroke with weakness of left side, Aphasia (difficulty with communication) and Dysphagia (swallowing impairment). Review of the facility Brief Interview for Mental Status (BIMS) dated 11/7/24, revealed the resident had a BIMS of 2, severe cognitive decline. Review of the physician order dated 10/16/24, revealed Resident #19 was ordered Ativan (for anxiety) oral tablet 0.5 mg, Give 1 tablet by mouth three times a day. This medication is scheduled as a regularly scheduled med to be given 3 times per day. Review of the physician order dated 9/24/24, revealed Resident #19 was ordered Ativan oral tablet 0.5 mg, give 1 tablet by mouth every 6 hours as needed for agitation. The resident was getting a total of 1.5 mg of Ativan daily regularly scheduled, with the likelihood for getting a total of 2.0 mg Ativan as needed with no stop date (every 14 day's this medication is required to be re-ordered with explanation or stopped. This would be a total (both as needed and regularly scheduled) of 3.5 mg a day of Ativan given per order. Review of Resident #19's Medication Administration Sheet dated 11/24, revealed he had received the Ativan three times a day regularly scheduled and a total of x 20 Ativan doses as ordered on 9/24/24, as needed. Review of the resident's facility fall's dated 5/10/24 through 11/20/24, revealed he had a total of x 7 falls. Review of the resident's Anti-Anxiety care plan dated 9/30/24, stated I am taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. During an interview done on 11/19/24 at approximately 2:00 p.m., Medical Director C said he ordered Resident #19's Ativan, he was aware of the dose. During an interview done on 11/20/24 at 11:18 a.m., the Director of Nursing and this surveyor reviewed Resident #19's orders, and the Ativan order had not been changed and no note from Physician C was found to justify the continuing of Ativan PRN/as needed. The Director of Nursing changed the order and stated it was not changed until today (11/20/24). Record review of the facility 'Psychotropic Medications' policy dated 12/21/23, revealed the physician will provide an individualized risk vs benefits analysis for each resident receiving anti-psychotic medications (including Ativan). Residents receiving newly prescribed psychotropic medications PRN (as needed) will be evaluated by provider within 14 days to evaluate need to continuation, or discontinuation of medication.

Based on observation, interview, and record review, the facility failed to implement and operationalize a comprehensive skin management program and implement meaningful and timely interventions to prevent pressure ulcer (wounds caused by pressure) development for two residents (Resident #9 and Resident #24) of four residents reviewed, resulting in inconsistent, inaccurate, and unclear wound documentation and assessment, lack of implementation of meaningful, timely, and revised, interventions, care coordination, Resident #9 developing a Stage 3 (full thickness tissue loss with exposed subcutaneous tissue), Resident #24 developing Stage 2 (partial thickness tissue loss presenting as an open ulcer) and unstageable pressure ulcers (unknown depth), and the likelihood for lack of timely and accurate identification of pressure ulcers, additional pressure ulcer development, infection, unnecessary pain, and decline in overall health status. Findings include: Resident #9: Review of facility provided CMS-802 Resident Matrix Form dated 11/15/23 revealed Resident #9 had a stage 3 facility acquired pressure ulcer. On 11/16/23 at 9:19 AM, Resident #9 was observed sitting in a wheelchair in the activity/dining room of the facility. When queried, Resident #9 indicated they had been sitting in their wheelchair for a while but was unable to provide a specific timeframe. An interview was completed with Certified Nursing Assistant (CNA) I on 11/16/23 at 9:23 AM. When queried regarding Resident #9's skin, CNA I replied, (Resident #9 has a) pressure sore on their buttocks. Record review revealed Resident #9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral infarction (stroke), pain, epilepsy, diabetes mellitus, heart disease, and pressure ulcer. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required moderate to substantial assistance to complete Activities of Daily Living (ADL) with the exception of eating. The MDS further revealed the Resident had three stage two pressure ulcers. On 11/16/23 at 12:39 PM, an observation of Resident #9's room was completed. A foot cradle was observed sitting on the floor in the Resident's room. A passing staff member in the hallway was asked Resident #9's location and directed this surveyor to the central/dining room area of the facility. Resident #9 was observed sitting in the same position in their wheelchair as previous observation. At 1:13 PM on 11/16/23, Resident #9 remained in the same position in their wheelchair in the central/dining area of the facility. Review of Resident #9's care plans in the Electronic Medical Record (EMR) revealed a care plan entitled, I have a pressure ulcer to my coccyx. I have a bunion on my left second toe that has been inflamed and aggravated in the past (Initiated: 8/27/20; Revised: 8/1/23). The care plan included the following interventions: - Encourage ordered treatment. I refuse treatment at times, please educate me on the risks of refusing treatment (Initiated: 8/1/23) - Follow facility policies/protocols for the prevention of skin breakdown (Initiated and Revised: 8/27/20) - I have an air mattress on my bed set to my comfort level (Initiated: 8/1/23; Revised: 8/23/23) - Roho cushion in wheelchair, please ensure is properly inflated . (Initiated: 8/1/23) The care plan included the discontinued intervention, Resolved: Foot cradle on my bed (Initiated: 2/3/22; Revised: 5/24/22) Review of Resident #9's current health care provider orders revealed the following: - Cleanse L inner ankle wound with wound cleanser, pat dry, apply Medihoney & cover with optilock and wrap with kerlix. Secure with tape every day shift (Start Date: 11/16/23) - Cleanse wound on Right upper gluteal cleft with soap and water or wound cleanser, pat dry, apply Santyl cover with ABD (large dressing) and and secure every day shift for wound care (Start Date: 10/25/23) On 11/17/23 at 1:47 PM, an interview was conducted with Licensed Practical Nurse (LPN) F. When asked if the facility had a wound care and/or treatment nurse, LPN F indicated the facility had one nurse who completed wound care measurements but revealed treatments are completed by the resident's assigned nurse for the day/shift. When queried regarding observation of Resident #9's wound care treatment, LPN F replied Already done and indicated Resident #9 likes their treatment completed really early before they get out of bed for breakfast. With further inquiry regarding the Resident's wounds, LPN F revealed the Resident had wounds on their coccyx and the back of their left ankle. When asked if the wounds were pressure ulcers, LPN F confirmed they were. LPN F then stated that the left ankle pressure ulcer was fairly new, within two weeks. When queried regarding the appearance of the pressure ulcers, LPN F stated the left ankle wound had eschar (dead black or brown colored tissue) covering the wound bed. On 11/17/23 at 2:07 PM, Resident #9 was observed in their room with multiple visitors. The Resident was sitting in the same position in their wheelchair in their room. On 11/17/23 at 4:26 PM, an interview was conducted with the Director of Nursing (DON), Infection Control (IC) Registered Nurse (RN) D, and Education RN B. When queried regarding the wound care program in the facility, the DON stated, We have an LPN who does wound care measurements and treatments. When asked if floor nursing staff also complete ordered wound care treatments, the DON confirmed treatments are completed by assigned floor nurses. When queried when Resident #9's pressure ulcers were first identified, the DON, RN D, and RN B revealed they were not sure and would need to review the Resident's individual assessment documentation in the EMR. When asked if the facility had a way to monitor and tract wound progression, measurements, and treatments without having to access and review each individual assessment, the DON replied, (Wound Care LPN C) keeps a paper list. The list was requested for review and the DON exited the room. RN D and RN B were asked how many pressure ulcers Resident #9 had, what interventions were in place to prevent pressure ulcer development, and treatments/treatment changes implemented, RN D verbalized they understood the importance of the information but revealed they were unable to provide the information without opening each individual assessment. The DON returned to the room at this time with written wound care tracking forms dated 9/13/23, 9/24/23, 10/8/23, 10/27/23, and 11/9/23. Review of documentation on the form for Resident #9 detailed the following: - 9/13/23: No documentation for Resident #9 - 9/24/23: Patient: (Resident #9). Wound Type: Stage 2 Pressure Wounds. Location: Right buttocks (1) 5 cm (centimeters) X 3 cm, black scab, Right buttocks (2) 1 cm X 1 cm, shallow/gran base, Gluteal fold (3) 1.5 cm X 1 cm, shallow/gran base Acquired . Deteriorating . Treatment: Cleanse with soap and water- apply magic butt cream. Change treatment prescription . - 10/8/23: Patient: (Resident #9). Wound Type: Stage 3, Stage 2 Pressure Wounds. Location: Right buttocks 6 cm X 5 cm, Right buttocks 1.75 cm X 1 cm, Gluteal fold 2 cm X 0.5 cm . Acquired . Deteriorating . Treatment: Cleanse with soap and water- apply magic butt cream . - 10/27/23: Patient: (Resident #9). Wound Type: Stage 3 Pressure Injury. Location: Right buttocks: 5.5 cm X 4 cm, Gluteal Cleft: 2 cm X 1 cm, Gluteal Cleft/Right Buttocks: 0.5 X 0.5 cm . Acquired . Improving . Treatment: Santyl (topical debridement treatment) - cover with gauze . - 11/9/23: Patient: (Resident #9). Wound Type: Stage 3 Pressure Wounds. Location: Right Buttocks- 5 cm (centimeters) X 2 cm X 1.5 cm, Gluteal Cleft- 2 cm X 1 cm . Acquired . Improving . Treatment: Santyl . Review of documentation in Resident #9's EMR revealed the following: - 6/15/23: Skin/wound Assessment . Is Resident skin intact: Yes . Notes: Reddened bump/corn on 2nd toe right foot Is resident experiencing pain related to wound? (Blank) . Care Plan Updated? (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) . Note: There was no documentation of follow up, interventions, and/or treatment/care noted. - 6/22/23: Skin/wound Assessment . Is Resident skin intact: No . Site: Coccyx . Pressure . Length: 3.5 cm . Width: 1.5 cm . Stage 2 . Site: Other (not specified) . Pressure . Length: 1.5 cm . Width: 1.5 cm . Stage 2 . Wound Bed: Granulation Tissue . Dressing and Wound Care: Optifoam (adhesive foam dressing used for pressure ulcers) . Treatment Progress: (Blank) . Continue Treatment: Yes . Is resident experiencing pain related to wound: Yes . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) . - 6/29/23: Skin/wound Assessment . Is Resident skin intact: No . Site . Coccyx . Pressure . Length: 3.5 cm . Width: 1.5 cm . Stage 2 . Site: Other (not specified) . Pressure . Length: 1.5 cm . Width: 1.5 cm . Stage 2 . Wound Bed: Granulation Tissue . Dressing and Wound Care: Optifoam (adhesive foam dressing used for pressure ulcers) . Treatment Progress: Unchanged . Continue Treatment: Yes . Is resident experiencing pain related to wound: Yes . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) . - 7/6/23: Skin/wound Assessment . Is Resident skin intact: Yes . - 7/13/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Resident has .2 x. 3 to rt. inner upper buttocks. Optifoam applied . Note: No further description of the wound was present in the assessment. - 7/20/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Open are to rt inner buttocks 0.5 x 0.5 cm. Optifoam dressing in place . Note: Note: No further description of the wound was present in the assessment. - 7/27/23: Skin/wound Assessment . Is Resident skin intact: No . Site: Left buttocks . Pressure . Length: 0.5 cm . Width: 0.5 cm . Wound Bed (Blank) . Dressing and Wound Care: (Blank) . Treatment Progress: (Blank) . Is resident experiencing pain related to wound: (Blank) . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) . Note: Pressure ulcer identified as being on the left. - 8/3/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Resident continues with open area the size of .5 cm x 1 cm. on inner rt. Buttock, continue with z-paste (Zinc oxide paste used for skin maceration associated with moisture) . Note: Pressure ulcer size increased and no additional treatment, intervention, and/or follow-up documentation were present. - 8/10/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Resident has 2 open area to rt inner buttocks. Continue to use z-paste as ordered every shift. Area is looking better and healing . Site: Right inner buttocks . Pressure . Length: 0.7 cm . Width: 1.0 cm . Right inner buttocks . Pressure . Length: 0.5 cm . Width: 1.0 cm . Wound Bed (Blank) . Dressing and Wound Care: (Blank) . Treatment Progress: (Blank) . Is resident experiencing pain related to wound: (Blank) . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) . Note: The assessment indicated the pressure ulcer was healing while detailing an additional pressure ulcer developed as well as an increase in wound size. - 8/17/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Resident has 2 open areas on rt inner buttocks area. Cleaned, dried, and put a 4 by 4 optifoam dressing on area . Site: Right inner buttocks . Pressure . Length: 0.8 cm . Width: 1.0 cm . Stage 1 . Right inner buttocks . Pressure . Length: 0.7 cm . Width: 1.0 cm . Stage 1 . Treatment Progress: (Blank) . Is resident experiencing pain related to wound: (Blank) . Care Plan Updated: (Blank) . Provider Notified or Updated? (Blank) Dietary Notified or Updated? (Blank) . Resident or Responsible Party Notified . (Blank) . - 8/22/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Continues with 2 small circular wounds on R gluteal cleft; wound care provided, measurements collected. Please see skin/wound note for further details . Site: Right gluteal cleft . pressure . Length: 0.75 cm . Width: 0.75 cm . Stage 2 . Other (Blank) . Pressure . Length: 1 cm . Width: 0.5 cm . Stage 2 . Dressing and Wound Care . Cleanse with soap and water, pat dry and apply Z-paste to wound area . Deteriorated . Continue Treatment: Yes . Care Plan Updated: (Blank) . Provider Notified or Updated: Yes . Dietary Notified or Updated? Yes . - 8/22/23 at 1:55 PM: Skin/Wound Note . Resident's wound care/tx completed by this nurse today; resident continues with two (2) stage II pressure injuries to R gluteal cleft. Areas were cleansed with soap and water, then patted dry as ordered. Measurements collected, then z-paste (barrier) cream applied to wound area. Wounds measure: #1 - 0.75cm x 0.75cm, #2- 1cm x 0.5cm. Wound bed #1 is dry and crusty with wound bed #2 is pink/epithelial tissue, with no drainage present. Both wounds are oval/round shaped with smooth margins and are located vertically on R gluteal cleft . - 8/28/23: Skin/wound Assessment . Is Resident skin intact: No . Two wounds present on R gluteal cleft; z-paste tx (treatment) continued at this time . Site . Right gluteal cleft . pressure . Length: 0.5 cm . Width: 0.5 cm . Stage 2 . Right gluteal cleft . Pressure . Length: 1 cm . Width: 0.5 cm . Stage 2 . - 9/5/23: Skin/wound Assessment . Is Resident skin intact: No . Site: Gluteal . Pressure . Length: 0.5 cm . Width: 0.5 cm . Stage 2 . Gluteal cleft . Pressure . Length: 1 cm . Width: 0.5 cm . Stage 2 . Treatment Progress: Not Changed . Care Plan Updated: No . - 9/6/23 at 11:00 AM: Skin/Wound Note . Resident's wound care completed by this nurse today; resident continues with pressure injuries on R gluteal fold. Wound at proximal most area is a small circular scab measuring 0.5cm x 0.5cm, distal most wound measures 1cm L x 0.5cm W, wound bed is immeasurable; wound bed is pink with irregular edges. No drainage noted . On 9/11/23, Resident #9 was transferred to the hospital with a diagnosis of Urinary Tract Infection (UTI) with sepsis (life threatening condition resulting from infection). The Resident returned to the facility on [DATE]. - 9/18/23 at 8:56 AM: Skin/Wound Note . Late Entry . nurse was called to the shower room this AM to assess resident's skin; resident observed to have 3 Stage II pressure injuries on gluteal cleft and R gluteal cleft. The newest wound observed measures 1cm x 0.5cm. The distal most wound on R gluteal cleft now measures 3 cm x 2 cm with a crater-like center measuring 0.5 cm x 0.5 cm. This wound is surrounded by pink-purple- black colored skin, which is slightly raised and hardened. The proximal most wound on R gluteal cleft is unchanged and measures 1 cm x 1 cm. Barrier cream applied as ordered. This nurse spoke to resident and (family) about the importance of frequent position changes to prevent new or worsening pressure injuries . verbalized understanding. Resident currently has air mattress in place; will continue to encourage resident change positions frequently. Will update as appropriate. - 9/22/23: Skin/wound Assessment . Is Resident skin intact: No . Notes: Three small circular openings on right buttocks. Magic butt cream applied. Note: The assessment did not include wound measurements and/or any further documentation. - 9/24/23 at 4:44 PM: Skin/Wound Note . Resident now has three (3) Stage II pressure injuries present on gluteal cleft and R buttocks. Gluteal cleft measures 1.5 cm x 1 cm and is shallow with bed of granulation tissue. Wounds to R buttock measure 5 cm x 3 cm with dark black scab, pink-irregular margins, surrounded by hardened tissue. Smaller wound to R buttock measures 1 cm x 1 cm with shallow appearance and bed of pink granulation tissue. This wound has deteriorated significantly since last assessed by this nurse . - 9/26/23 at 11:34 PM: Skin/Wound Note . Late Entry . Wound on left upper gluteal appears larger than last observed. Wound bed hard w/ eschar noted. Two smaller open areas noted inside the gluteal folds. Wound bed granulated tissue noted. Noted to be dk (dark) pink around larger wound. No drainage . Cleansed w/ soap and water and applied magic butt as ordered . - 9/27/23 at 11:40 PM: 'Skin/Wound Note . Resident continue to have eschar noted on right upper buttocks. 2 smaller open areas noted inside right gluteal fold. Pink noted around periwound on right gluteal. No drainage noted. Magic butt applied to areas after cleansed w/ soap and water . - 9/28/23: Skin/wound Assessment . skin intact: No . Notes: Resident has open area to buttocks z-paste applied per orders . Note: The assessment did not include wound measurements and/or any further documentation. - 9/29/23 at 12:43 PM: Skin/Wound Note . Resident's wound care and tx completed . largest wound on R buttock now measures 5cm x 3cm with black-yellow center of eschar tissue. Margins of this wound are bright pink and irregular. Appears scab like in center of this wound. Wound on gluteal fold is shallow and resembles shearing, irregular shape margins and measures 1 cm x 1 cm. The smaller wound present on R buttock measures 1 cm x 1.5 (cm). Moderate drainage from wound noted on resident's brief; resident will not tolerate dressing on wound on buttocks. These wounds have significantly deteriorated . - 10/1/23 at 11:17 PM: Skin/Wound Note . The larger sore on right buttock-wound bed appears creamy yellow w/ small line of black noted. Peri wound is red. The second wound on right buttocks, wound bed granulated tissue noted. Third one barely open. Cleansed w/ soap and water and apply magic butt. Resident c/o (complain of) pain in area. This nurse encouraged resident to lay on right side but resident couldn't lay on right side and ended getting up in w/c (wheelchair) d/t (due to) resident stated it hurt too much to lay in bed. - 10/3/23 at 3:17 AM: Skin/Wound Note . Larger sore on right buttocks-half yellow on left side and half brownish/red on right side of sore. Wound bed hard to touch. Distal to first wound is the second open-smaller in size. Wound bed pink. No drainage noted from both open sores. Both sores redden around periwound. Cleansed w/ soap and water then applied magic butt. - 10/5/23: Skin/wound Assessment . skin intact: No . Site: Right Buttocks . Pressure . Length: 62 cm . Width: 33 cm . Depth: (Blank) . Stage: 3 . Sacrum . Pressure . Length: 7 cm . Width: 10 cm . Depth: (Blank) . Stage 2 . Sacrum . Pressure . Length: 10 cm . Width: 8 cm . Depth: (Blank) . Stage 2 . Wound Bed: Slough . Cleanse with soap and water, pat dry. Apply Z-paste . Deteriorated . Continue Treatment: Yes . Care Plan Updated: No . - 10/7/23 at 12:52 AM: Skin/Wound Note . Larger wound on right gluteal-Light yellow slough noted on wound bed. The smaller wounds distal to above wound (right gluteal) and left of this wound on gluteal cleft smaller in size. Wound bed for smaller 2-pink wound bed. Red around all wounds. No drainage noted. Cleansed w/ soap and water and applied to all wounds per doctor's order. - 10/12/23: Skin/wound Assessment . skin intact: No . Notes: Resident continues with treatment per orders. Wound care nurse will measure and tx (treat) on Friday Oct. 13th . Note: No further wound documentation was included in the assessment. - 10/13/23 at 12:28 PM: Skin/Wound Note . Resident wound care and tx (treatment) to Stage III pressure wounds to R buttock and gluteal cleft completed . The largest wound to R buttock measures 6.5 cm x 2.5 cm. A thick layer of yellow slough covering wound bed, undermining present. Wound margins are raised, irregular and bright pink. Unable to determine depth of wound d/t presence of slough. Smaller wound to R buttock measures 1.5cm x 1cm with light pink wound bed, smooth edges and no s/s of infection noted. Wound to gluteal cleft measures 2.5cm x 1cm with pink wound bed and smooth edges . Magic butt cream applied to wound beds. Wound continues to deteriorate; resident is non-compliant with frequent position changes to offload pressure from coccyx/sacrum area . Resident continues with air mattress but is reluctant to sleep in bed for reasonable amounts of time. Resident to continue with daily tx and weekly assessments . until wound has resolved. Resident has states that 'bottom is sore' . - 10/22/23 at 11:49 AM: Skin/Wound Note . Resident's wound care and tx to R buttocks x 2 and gluteal cleft completed . No drsg to discard; however, small amount of [NAME] red blood present on resident's brief . the largest wound to R buttock appears to be improving slightly. Small area of thick yellow slough present, covering a good portion of the L side of wound bed. R side of wound has undermining present with pink wound bed. The wound margins are uneven and are bright pink-red with inflammation . measures 6 cm x 3 cm x 0.5 cm . The second and smaller wound to R buttock measures 0.5 cm x 0.5 cm. This wound is shallow with a pink wound bed. The wound to gluteal cleft measures 0.5 cm x 1.5 cm, shallow with pink wound bed . buttocks were cleansed with soap and water, then gently patted dry. Magic butt cream applied as ordered. No s/s of infection present in regard to smaller wounds . Resident encouraged to make frequent position changes while in bed and in WC to offload pressure to sacrum/coccyx area to prevent further skin breakdown. Resident verbalized understanding . - 10/26/23: Skin/wound Assessment . skin intact: No . Notes: Resident continues with a stage III and a stage II open area to rt. buttocks and gluteal fold. Continues with treatment per orders . Note: No further wound documentation was included in the assessment. - 10/27/23 at 1:51 PM: Skin/Wound Note . Resident's wound care and tx completed . did not have a dressing in place, moderate yellow-opaque drainage present on resident's brief. The wound was cleansed with soap and water . Large wound to R buttock measures 5.5 cm x 4 cm with 0.25 cm depth to top R corner of the wound. Wound bed is uneven with irregular, bright red (inflamed) margins. Wound bed partially covered with thick coating of slough. Peri-wound skin is pale, but blanchable. Smaller wound on R buttock measures 0.5 cm x 0.5 cm with shallow pink wound bed. This wound shows some improvement compared to last assessment . Wound to gluteal cleft measures 2 cm x 1 cm with shallow pink wound bed and smooth margins. Peri-wound skin to smaller wounds is also pale but blanchable. Santyl ointment applied to large wound on R buttock, then covered with super absorbent dressing., secured with tape. Magic butt cream applied smaller wounds; smaller wounds left open to air . - 11/9/23: Skin/wound Assessment . skin intact: No . Notes: Resident continues with a stage II and a stage III wound to rt. buttocks/gluteal fold. Treatment in place as ordered . Note: No further wound documentation was included in the assessment. - 11/9/23 at 4:38 PM: Skin/Wound Note . Resident wound care and tx to Stage III pressure wounds to R buttock and gluteal cleft . No drsg present, moderate, yellow-tinged drainage noted on resident's brief. Wounds were cleansed with soap and water . patted dry. Wound to R buttock measures 5 cm x 2 cm x 1.5 cm. Wound has uneven margins, wound bed with less slough present than when last assessed . Wound bed is red, some granulation tissue present . Wound to gluteal cleft measures 2 cm x 1 cm with pink wound bed, smooth margins . Wound margins are no longer stiff or red with inflammation . some improvements . Santyl applied to wound bed on R buttock. Wound was then covered with small non-adherent bandage and secured with tape. Z-paste applied to wound on gluteal cleft; wound left open to air . - 11/14/23: Skin/wound Assessment . skin intact: No . Notes: Noted open area to inner LLE (Left Lower Extremity) just above ankle. Noted 2 smaller open areas just below . Site: Inner LLE above ankle . open area . Length: 2.3 . Width: 1.5 . Left inner ankle . open area . Length: 0.8 . Width: 0.7 . Left inner ankle . open area-pinpoint . Exudate Type: Serous . Amount: Small . Wound Bed: Slough . An interview was conducted with Wound Care LPN C on 11/21/23 at 11:21 AM. When queried regarding the frequency they are supposed to measure and assess wounds, per facility policy/procedure, LPN C replied, Weekly. LPN C was then asked why wound assessments were not completed weekly for Resident #9, LPN C revealed they have only been in the wound care nurse role for a couple of months and are not employed full time in the role. When asked to explain, LPN C explained they are employed full time at the facility but work as nurse on the floor. When queried if a collaborative nutritional consult was completed for Resident #9 related to their wounds, LPN C revealed they were unsure if the Resident was receiving nutritional supplementation for wound healing and/or of any dietary recommendations made. No further explanation was provided. LPN C was then queried where wound assessment and measurements are documented and revealed they use both the Skin/Wound assessment and Skin/Wound Note in the EMR. When asked where documentation is supposed to be completed per facility policy/procedure, LPN C revealed they were unsure. When queried if they received and/or completed any specialized training pertaining to wound care, LPN C stated, None. LPN C was asked the date Resident #9's pressure ulcers were first identified and indicated they would need to review the Resident's EMR. When queried, LPN C revealed they do not maintain documentation of the initial identification date for Resident wounds. LPN C was asked if all Resident #9's pressure ulcers were facility acquired and stated they were. A review of Resident #9's wound care documentation in the EMR was completed with LPN C at this time. When asked why there was no follow up documentation pertaining to the Resident's right foot second toe being intact with Reddened bump/corn on 6/15/23, LPN C reviewed the EMR and was unable to provide an explanation. When, LPN C confirmed follow up documentation and assessment should have been completed. LPN C was then queried regarding the blank areas of documentation on the assessment, if the skin was blanchable, and the cause of the redness but was unable to provide an answer. Resident #9's Skin/Wound . documentation was reviewed with LPN C at this time. When queried if the Health Care Provider had been notified of the Resident's stage two pressure ulcers in June 2023 when first documented, LPN C designated the assessments did not specify. When asked why the location of the second identified pressure ulcer was not specified, LPN C stated they had not completed the assessment and were not able to say. When asked if the wounds were of the right or the left (per 7/22/23 assessment), LPN C reviewed the documentation and indicated Resident #9's pressure ulcers had always been on the right as far as they were aware. When asked why pressure ulcers were documented as stage one on 8/17/23 after being identified as stage two, LPN C did not provide an explanation. LPN C was then asked to clarify Resident #9's wound locations and total numbers on their buttocks/gluteal cleft due to documentation being unclear. LPN C responded that Resident #9 had three facility acquired pressure ulcers in close proximately on the right buttocks/gluteal cleft. When asked if the facility utilized photographs for wounds, LPN C replied, No. When queried if Resident #9's pressure ulcers had deteriorated from a stage two facility acquired to a stage three with tunneling and undermining, LPN C confirmed the pressure ulcers had worsened. LPN C was then asked why treatments were not changed/modified timely when the pressure ulcers were not healing and/or deteriorating/worsening. LPN C was unable to provide an explanation but confirmed treatments were not modified based upon assessment of the wounds. When queried regarding turning and repositioning, LPN C verbalized Resident #9 likes to be up in their chair all day. When asked if the Resident is able to move/reposition themselves in their wheelchair, LPN C indicated the Resident was able to move a little in their chair. When asked if assistance to reposition was provided, LPN C did not respond. When queried if wheelchair positioning devices and/or a reclining/different type of chair for pressure reduction had been attempted/implemented, LPN C revealed there had not been any new interventions implemented/attempted recently. LPN C was then queried if Resident #9 had developed a new pressure ulcer on their left ankle within the prior two weeks as indicated by their assigned floor nurse. LPN C confirmed Resident #9 had developed a new wound and stated they are unable to identify and classify wound types due to being an LPN. When asked who determines wound types if they are unable to do so as the facility Wound Care nurse, LPN C indicated the Health Care Provider makes that determination. When queried if they had assessed the wound, LPN C stated they had and stated they documented in a progress note. Record review revealed the following note in Resident #9's EMR: - 11/18/23 at 3:11 PM: Skin/Wound Note . Wound care and tx to Stage III pressure wound to R (right) buttock and gluteal cleft and wound care to inner L ankle venous stasis ulcers completed . Kerlix and drsg present on L inner ankle completely saturated with serosanguineous drainage . There are two separate areas with wounds present on the L inner ankle and bridge of L foot (cluster of 3 small open areas). Area to inner L ankle is macerated with thick patches of yellow/white slough to wound bed. Wound margins are irregular, red and inflamed. This wound measures 3.5 cm x 2.5 cm. Cluster of 3 small open areas on bridge of L foot was cleansed with wound cleanser . The 3 areas are circular with more defined/smooth margins with pink wound beds. The entire cluster measures 1 cm x 2 cm . Medi-honey applied to wound beds. Wounds were then covered with Optifoam . wrapped with kerlix . then completed wound care and tx to resident's stage III pressure ulcer to R buttock and stage I pressure sore to gluteal fold. Discarded drsg from R buttock was completely saturated with yellow-red sanguineous drainage. No drsg present on gluteal cleft . Wound to R buttock measures 5 cm x 2.5 cm x 1 cm . some improvement; however, tunneling noted to top of wound . Wound margins are now smaller, wound is closing but slight coating of slough still present on wound bed. The margins remain red and irregular . Gluteal cleft wound measures 1 cm x 2 cm with smooth edges and shallow, pink wound bed. Santyl applied to R buttock wound then covered with non-adherent drsg, secured with tape. Z-paste applied to gluteal cleft. Resident tolerated well, no c/o of pain . After review of the note with LPN C, they were asked who had determined Resident #9's left ankle wounds were venous status ulcers and stated [TRUNCATED]

37668 Deficient Practice Statement (DPS) One: This Citation Pertains to Intake Number: MI00139609. Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures to ensure appropriate supervision to prevent falls for one resident (Resident #24) of two residents reviewed, resulting in Resident #24 (R24) being left unattended in the Activity Room, falling, and suffering a right hip fracture, unnecessary pain, and the likelihood for decline in overall health status. Findings include: Resident #24: Record review revealed Resident #24 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, overactive bladder, weakness, and displaced femur fracture necessitating surgical intervention following a fall in the facility. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required moderate to total assistance to complete Activities of Daily Living (ADLS) with the exception of supervision with eating. On 11/16/23 at 1:09 PM, Resident #24 was observed eating in the dining area of the locked dementia unit of the facility. Resident #24 was observed to have a purple/green colored bruise around their left eye. A heel boot (pressure reduction device) was in place on their right lower extremity. An interview was attempted to be completed at this time. When spoke to, Resident #24 made eye contact and smiled but did not provide meaningful responses to questions when asked. Certified Nursing Assistant (CNA) P was interviewed on 11/16/23 at 1:05 PM. When queried regarding Resident #24's boot, CNA P explained that Resident #24 developed a pressure ulcer (wound caused by pressure) on their right heel after returning to the facility following hospitalization . CNA P was asked why Resident #24 was hospitalized and revealed the Resident fell in the facility and fractured their hip. With further inquiry, CNA P said that before Resident #24 fell on [DATE], Resident #24 was much more mobile, using a walker with one person assist. CNA P stated, (Resident #24) was able to ambulate and transfer using a walker before the fall with fracture. When queried regarding the Resident's black eye, CNA P revealed it was from a more recent fall. An interview was completed with Nurse Q on 11/16/23 at 1:20 PM. When queried regarding Resident #24's fall on 8/20/23, Nurse Q indicated they did not recall the fall but verbalized that Resident #24's ambulation status before the fall on 8/20/23 was one assist with a walker. Activities Director U was interviewed on 11/16/23 at 1:41 PM regarding Resident #24's fall on 8/20/23. Activities Director U revealed that Resident 24's fall happened in the dementia unit activity room on 8/20/23. After the activity was done, Activities Director U described leaving Resident #24 in the activity room while they escorted a different resident back to their room. Activities Director U they were the only staff member present in the activity room and stated, No other staff was designated to watch other residents when I left the room. Activity Director U continued, Usually, (Resident #24) does not get up when sitting in their chair. Activities Director U further commented, (Resident #24) must have decided to follow me to go to their room. Activities Director U described finding Resident #24 on the floor in the activity room after returning from taking the other resident back to their room. When asked, Activities Director U confirmed the fall was unwitnessed and they found the Resident. Housekeeper R was interviewed on 11/16/23 at 2:00 PM. Housekeeper R remembered the day of Resident #24's fall in the activity room of the locked unit of the facility. Housekeeper R described they were assigned to work in the locked dementia unit on 8/20/23. When asked what had occurred, Housekeeper R revealed the activity room in the locked unit had a door between the two rooms (the activity room and the dining room). Housekeeper R recalled that when in the dining room, the door blocks anyone from seeing the residents in the activity room. Housekeeping R verbalized they were not in the activity room when the fall occurred. When queried, Housekeeper R denied being asked to watch the residents in the activity room. Housekeeper R further stated, I was unaware of what happened and left for lunch, and upon my return from lunch, I heard that Resident #24 had fallen. Review of Resident #24's Electronic Medical Record (EMR) revealed a care plan entitled, I have had an actual fall with right hip fracture. I have poor comprehension related to cognition (Initiated and Revised: 8/25/23). The care plan included the interventions: - Follow ordered transfer and ambulation orders (Initiated: 8/25/23) - I am on the falling star program indicated by a yellow star on my door and yellow rope on my walker (Initiated: 8/25/23) - Orient me as able to my surroundings, make sure my needs are met and call light in reach. Check on me frequently (Initiated and Revised: 8/25/23) - Resolved: Non-ambulatory (Initiated: 8/25/23; Revised and Resolved: 10/4/23) Note: Resident #24 did not have a care plan for fall prevention prior to their fall on 8/20/23. A second care plan entitled, I have an ADL Self Care Performance Deficit r/t (related to) Dementia (Initiated: 4/25/23). The care plan included the interventions and historical data: - Ambulation: I require two (2) assist with gait belt (Initiated: 4/25/23; Revised: 11/8/23) Review of historical care plan data revealed the following changes: On 4/25/23, Resident #24 was independent with ambulation with no device. On 8/15/23, the Resident's care plan detailed they required assist of 1 with a 4-wheel walker for ambulation. The care plan was modified again on 8/20/23 to detail, I need assist of 1 with a 4-wheel walker for ambulation. Please keep walker in front of me when left unattended. Review of hospital documentation revealed Resident #24 was transferred from the facility to the local hospital and then transferred to a tertiary hospital where they had a surgical repair completed for their right displaced intertrochanteric femur fracture. Review of Resident #24's documentation in the EMR revealed the following: - 8/17/23 at 3:59 PM: Medicare Note . Resident being treated . for decline in ADL's . - 8/20/23 at 11:52 AM: Health Status Note . CNA notified writer res was on the floor, writer entered room observed this res sitting on right hip holding upper body up with Right arm and bilateral legs were bent at the knee and on left side of trunk of body, res was able to move all extremities while sitting on the floor, pupils equal and reactive, hand grasps strong and equal, staff assisted res off the floor, as res began to walk res started to guard hip and give signs of pain, res assisted into stationary chair . Contacted . (Physician) at 1104 am, ambulance at 1105, and report given . - 8/20/23 at 12:04 PM: Health Status Note . res did have irregular shaped nickel sized blood blister to right hand btwn (between) thumb and first finger . - 8/24/23 at 4:09 PM: Health Status Note . Res arrived via ambulance and admitted to room . res is alert to self only . drsg (dressing) in place . res is noted with pain during assessment . Minimum Data Set Registered Nurse (RN) S was interviewed on 11/20/23 at 1:30 PM. When queried regarding Resident #24's level of assistant needed for ambulation at the time of their fall on 8/20/23, RN S explained the Resident ambulated with a rolling walker and one person assist. RN S was asked if Resident #24 was at risk for falls prior to falling and fracture their femur on 8/20/23 and revealed the Resident was deemed a moderate Fall Risk at that time due to their cognition, prescribed medications, and use of an assistive device when ambulating. RN S was asked if Resident #24 had a fall risk care plan in place prior to their fall on 8/20/23 and stated there was no fall care plan. When asked why, RN S did not have a response. When asked if Resident #24 had other falls in the facility, RN S indicated the recently fell again on 11/12/23. When queried the facility policy/procedure pertaining to fall risk assessment determination, RN S revealed an assessment is utilized in the EMR and Resident #24 is currently assessed as being a moderate risk for falls. Review of Resident #24's Fall Risk Assessment documentation revealed the Resident was assessed as a moderate fall risk on 4/19/23, 7/23/23, 8/20/23, and 8/24/23. The Resident was assessed as a high risk for falls on 11/11/23. The Director of Nursing (DON) was interviewed on 11/21/23 at 3:00 PM. The DON was queried regarding Resident #24 being assessed as a moderate risk for falls prior to their fall with fracture on 8/20/23 and not having a fall risk care plan in place. The DON confirmed Resident #24 should have had a fall risk care plan in place. When asked what occurred when Resident #24 fell on [DATE], the DON revealed Resident #24 was left alone and unattended in the activity with their walker not in reach. When queried if the fall was a result of lack of supervision and staff assistance, the DON validated it was. No further explanation was provided. Review of facility policy/procedure entitled, Fall Prevention & Follow-up (Reviewed/Revised: 8/11/23) detailed, Our mission is the reduction of falls through a systematic, multidisciplinary team approach. The falling star identification program identifies residents at high risk for falls . Each resident will be assessed for the risk of falls. Appropriate interventions are identified, care planned, and follow up done to monitor effectiveness. Residents are assessed for fall risk upon admission, quarterly, with any. significant change and with each fall. If a resident falls or is lowered to the floor, the resident is not moved until a licensed nurse is notified and a full assessment is done . 39059 Deficient Practice Statement (DPS) Two: Based on observation, interview and record review, the facility failed to follow and implement appropriate interventions and ensure the safety and supervision for two residents (Resident#32 and Resident #36), resulting in unsupervised wandering into other residents bathroom, a forehead bruise, and undocumented neurological status. Findings include: Resident #32: On 11/15/23, at 10:03 AM, Resident #32 was in the main dining area eating their breakfast. There was a bruise noted to their forehead approximately 2 inches by 2 inches. Resident #32 was nonverbal when asked where their forehead bruise came from. On 11/15/23, at 12:59 PM, Resident #32 was resting in a recliner in the common area with a four wheeled walker next to her. On 11/16/23, at 9:06 AM, CNA M was interviewed regarding Resident #32's forehead bruise. CNA M was asked what happened and CNA M stated, we think she hit her head on her bedside table. On 11/17/23, at 8:30 AM, a record review of Resident #32's electronic medical record revealed a readmission on 10/092023 with diagnoses that include Dementia, Anemia and delusional disorder. Resident #32 had severely impaired cognition and resided on the locked dementia unit. A review of the 11/9/2023 Practitioner Documentation Note Text: Patient is seen for new noted ecchymosis. Discussed case with nursing at length . ECCHYMOSIS TO MID FOREHEAD . Plan: Patient counseled and encouraged. No changes to plan of care. A review of the progress notes revealed 11/8/2023 . Incident Note . On 11/3/23 Resident noted to have a bruise in the center of her forehead, originally measurement of 20 x 25 cm (Nurse will be educated on measuring), area is 2 cm (centimeters) x (by) 3 cm, fading green/yellow color. Unknow how bruise occurred, Resident is not fearful at the time this Nurse was talking with her. Resident did have an outing with her Son during the day on 11/3/23. Nurses to do skin assessment upon returning from all outings. Will monitor as needed. There was no neurological assessment noted in the record for the bruising. A review of the progress notes for 11/3/2023 revealed 11/3/2023 18:27 (6:27 PM) . Resident was observed with a 20 x 25 cm light colored bruise to her forehead. Resident had no knowledge of it, and denies pain. There was no notation reporting the bruise to the abuse coordinator as an injury of unknown origin or notification to the physician and the family. A review of the incident report provided by the facility revealed: Bruising . Incident Location: Unknown . Resident was observed with a small bruise to her forehead . Resident unable to give Description . Resident did not know what happened or that she had a bruise . Mobility: Ambulatory without assistance . Witnesses . No Witnesses found . Agencies/People Notified . No notifications found . On 11/17/23, at 8:57 AM, The Director of Nursing (DON) was interviewed regarding Resident #32's forehead bruise and how did they injury their head. The DON explained that the resident may have fallen while out with their son and that an intervention was placed to assess the resident's skin upon return from family outings. The DON was asked if they had called the son to inquire if the resident fell or hit their head while out in their care and the DON stated, no, I don't think so. The DON was asked if the facility completed an investigation on the bruise/injury of unknown origin and the DON explained that the resident can be resistive to care and at times will barricade themselves in their room but denied reporting the bruise as an injury of unknown origin. The DON was again asked if the facility hypothesized, summarized, investigated or reported the injury of unknown origin and the DON stated, no. On 11/21/23, at 12:15 PM, the DON was questioned if the facility had assessed the neurological status of the resident once the forehead bruise was recognized and the DON stated, No but the nurse was educated. A review of the facility provided RESIDENT ABUSE POLICY & PROCEDURE 12-18-17 policy revealed . The Administrator / DON will ensure all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown sources . are reported immediately, but not less than 2 hours after the allegation is made, to the appropriate state agency . A review of the Abuse, Neglect Exploitation & Misappropriation of Resident Property 5-11-2022 policy revealed . It is the Facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown Source, in accordance with this policy . DEFINITIONS . Injury of Unknown Source. An injury is classified as an Injury of Unknown Source when both the following conditions are met: The source of the injury was not observed by an person, or the source of the injury could not be explained by the resident; AND The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point int time, or the incident of injuries over time. Resident #36: On 11/15/23, at 2:35 PM, Resident #36 was sitting on the side of their bed. The resident was dressed although had white socks with no grippers and no shoes on. There was an 8-inch x 11 inch sign next to their bathroom that stated, please leave bathroom light on. The bathroom light was off and the door to the bathroom was missing. The resident quickly stood up said they I need to find the bathroom and ambulated out of their room. Resident #36 ambulated out into the hallway, turned right, and headed towards another resident's room. Resident #36 entered room [ROOM NUMBER], walked into their bathroom and closed the door. The facility staff was unaware. This surveyor walked to the nurses' station where the door and window faced the center of the main hallway out of view of the 200 hall and asked if Resident #36 is allowed to use other resident's restroom. Nurse N stated, oh no as they hustled to room [ROOM NUMBER]. Nurse N entered room [ROOM NUMBER], opened up the bathroom door and Resident #36 stated, shut the door I'm trying to pee. Nurse N waited for the resident to finish, walked Resident #36 back to their room. Resident #36 sat down on their bed. Nurse N was asked if Resident #36 had gripper socks on and Nurse N stated, no. Nurse N left out of the room as they were assigned at the other end of the building in the locked dementia unit. On 11/15/23, at 2:52 PM, a staff member was noted on the 200-hall putting a hoyer lift in the utility room. CNA O was inquired why Resident #36 did not have a door on their bathroom and CNA O stated, so he can find the bathroom easier. CNA O was asked what the sign was for that said leave the light on and CNA O stated, so he knows it's his bathroom. The light was off. Resident #36 was asked if he knew what the sign was and Resident #36 stated, oh, it's my sisters. She put it up there. It's not mine. On 11/16/2023, at 11:00 AM, a record review of Resident #36's electronic medical record revealed an admission on 5/16/2023 with diagnoses that included Alzheimer's Disease, Dementia and Osteoarthritis. Resident #36 had severely impaired cognition and required assistance with Activities of Daily Living (ADL'). A review of the care plan I am at risk for falls r/t (related to) new environment and I ambulate independently without assistive device Date Initiated: 05/30/2023 . Interventions Anticipate and meet my needs . Follow facility fall protocol . A review the care plan ELOPEMENT: I am an elopement risk/wanderer AEB (as evidenced by) Disoriented to place, Impaired safety awareness Date Initiated: 06/01/2023 Revision on: 06/01/2023 . My safety will be maintained through the review date . Interventions . Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 06/01/2023 . A review of the care plan I have an ADL Self Care Performance Deficit r/t Alzheimer's Date Initiated: 05/16/2023 Revision on 05/18/2023 . Interventions TOILET USE: I require set up assistance for toilet use. Please encourage me to change my pull-up when it is soiled. I may need queuing to find the bathroom at times. I have the bathroom door removed for easier access to toilet. Date Initiated: 05/18/2023 Revision on: 10/03/2023 . The care plans did not mention the resident often wanders into other resident's bathrooms. On 11/16/23, at 3:45 PM, Resident #36 was observed ambulating out of the dining room. Resident #36 passed by the Social Worker's office towards the main entrance. Social Worker (SW) L stood up and asked Resident #36 where he was going and the resident stated, I need to urinate. On 11/16/23, at 3:50 PM, SW L was asked if they knew why Resident #36 didn't have a bathroom door and SW L stated, the son suggested it as that was worked at home. SW L stated, they tried a restroom sign on the outside of his door but that didn't work.

This Citation Pertains to Intake Number MI 654. Based on interview and record review, the facility failed to operationalize policies and procedures to ensure safe transfers and ambulation for one resident (Resident #197) of three residents reviewed for accidents, resulting in a lack of implementation of the facility policy/procedures and standards of practice for transferring and ambulation. Resident #197 suffering a fall with a subdural hematoma (brain bleed) which necessitated emergency transfer to the hospital, mechanical ventilation, and death. Findings including: Resident #197: Record review revealed Resident #197 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, anxiety, dementia without behavioral disturbance, cerebral infarct (stroke), long-term anticoagulant use, and history of falls. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed the Resident was severely cognitively impaired, required one-person, limited assistance with transferring and ambulation, and one-person extensive assistance with dressing and personal hygiene. Resident #197's medical record further revealed the Resident was discharged from the facility to the hospital on [DATE] due to injuries sustained from a fall in the facility. Review of Resident #197's progress note documentation in the Electronic Medical Record (EMR) revealed the following: - [DATE] at 12:07 PM: Health Status Note . Resident noted to have large bruise on left hip . did have a fall on [DATE] and bruise may be related . has a healing incision on the back of head . Client is A&O to self . is able to ambulate short distances only . requiring assist with all ADLs . - [DATE] at 10:21 AM: Incident Note . Resident had a fall/stumble this AM while attempting to ambulate to bathroom without assistance; CNA (Certified Nursing Assistant) was present when resident stumbled back and landed on buttocks in front of bed. Resident (did) not hit head and has no injuries, no c/o (complaints of) pain. Resident is on 72 hr (hour) /15 min checks . d/t (due to) fall. Resident continues to be unstable and wobbly on their feet . - [DATE] at 3:20 AM: Health Status Note . Resident had fall from standing position at table. (Resident #197) was changing the baby doll. Resident miss stepped and stumbled. Staff was able to grab gait belt and help resident from hitting head and getting injuries . No injuries noted - [DATE] at 10:55 AM: Health Status Note . Resident observed to have a large, dark-purple bruise on L (Left) hip as a result of fall on [DATE]. Resident c/o (complain of) mild pain this AM and was administered scheduled Tylenol for pain management (see eMAR- [electronic Medication Administration Record]). - [DATE] at 12:55 PM: Health Status Note . Client noted to have an increase in difficulty walking aeb (as evidenced by) weakness in legs, unsteady gait and stumbling when walking. Will request PT (Physical Therapy) eval. Note: There was no progress note documentation in the EMR on [DATE], the date of the fall. - [DATE] at 11:07 AM: Health Status Note . Writer received a phone call from (Resident #197's family member). We discussed the circumstances which led up to resident's fall. Investigation remains ongoing . Review of Resident #197's care plans revealed a care plan entitled, I have a history of falls r/t (related to) confusion, [CONDITION(S)] (decrease in blood pressure when change position), unawareness of safety needs and wandering (Initiated: [DATE]; Revised: [DATE]). The care plan included the interventions: - Follow facility fall protocol (Initialized: [DATE]) - I am in the falling star program as there is a star outside my door and on my wheelchair (Initiated: [DATE]) - I need a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position at night (Initiated: [DATE]; Revised: [DATE]) - I require bed and chair pad alarms for my safety as I am unable to use my call light due to impaired cognition (Initiated: [DATE]) - When assisting me from lying or sitting to standing, please move slowly and allow my blood pressure to adjust as I have [CONDITION(S)] (Initiated: [DATE]) - Ensure that I am wearing appropriate grippie footwear when ambulating or mobilizing in w/c (wheelchair) (Initialized: [DATE]; Revised: [DATE]) Resident #197 had another care plan entitled, I have an ADL Self Care Performance Deficit r/t Dementia (Initiated: [DATE]). The care plan included the interventions: - Ambulation: I require (1) one staff member assist with ambulation. Only use a FWW (four-wheel walker) when I am unsteady or complaining of back pain (Initiated: [DATE]; Revised: [DATE]) - Mobility: I utilize a standard wheelchair with long handled break levers and antiroll backs (Initiated: [DATE]) - Toilet Use: I require (1) one staff members assistance with toileting (Initiated: [DATE]; Revised: [DATE]) - Transfer: I require (1) one staff members assistance with transfers (Initiated: [DATE]; Revised: [DATE]) - Bed Mobility: I require (1) one staff members assistance to position and turn in bed (Initiated: [DATE]; Revised: [DATE]) Review of facility provided Incident and Accident (I and A) reports for Resident #197 revealed the following: - [DATE] at 6:20 AM: Fall . Description: CNA responded to Resident's bed alarm sounding. Resident was standing, and as CNA entered the room and went to Resident, they stumbled back and fell , landing on buttocks. CNA was able to hold onto Resident and assist to the floor. CNA tuned on emergency call light; this nurse arrived to find resident sitting on the floor in front of bed . Resident Description . 'I get a little wobbly' . Injury . No injuries observed post incident . Fall Investigation Report . Witnessed . Resident Room . Attempted Self Transfer . Bare feet . Resident normally continent . Were glasses on: Yes . Vital Signs . Blood Pressure- Lying: ,d+[DATE] (elevated) . Sitting ,d+[DATE] . Standing: ,d+[DATE] . SPO2 (Oxygen level) 90% . Bed Alarm . - [DATE] at 8:15 PM: Fall . Description: Resident was standing at the table changing the baby doll. Resident miss stepped and stumbled. Staff was able to grab gait belt and assist to floor, preventing injury . did hit floor but not hard. No injuries and did not hit head . Resident Description: Stated they tripped . Injury . No injuries observed post incident . Fall Investigation Report . Witnessed . Resident normally continent . Does Resident wear glasses: No . Were glasses on: Yes . Was gait assist device used at time of fall: No . Vital Signs . Blood Pressure-Lying (Blank) . Sitting ,d+[DATE] . Standing (Blank) . - [DATE] at 1:36 PM: Fall . Description: Resident had been agitated throughout the morning about (spouse) cheating who has been deceased for some time. The resident had been redirected and appeared to calm down and was sitting in the TV room in the chair watching TV with (CNA H) . got up to get ice cream when (CNA H) gently put hand on resident's gait belt at which time the resident swung around to hit (CNA H). (CNA H) pulled head back to avoid the blow while the resident continued to propel backward. (CNA H) attempted to reach for the resident as the resident continued swinging punches when they fell hitting the back of their head very hard . Immediate Action Taken: (CNA H) and (CNA R) stayed with resident while (CNA AA) notified nurse . resident was assessed . c/o (complain of) right hip pain . large hematoma on back of head. Neuro's . WNL (Within Normal Limits) . Orders given to send . to hospital . Fall Investigation Report . Witnessed . Gait assist device . Gait belt . Does Resident wear glasses: No . Were glasses on: Yes . Mood/Mental Status prior to fall: Agitated much of the morning but calm just prior to fall . Medical/Physical Status prior to fall: Gait Unsteady . How does this compare to normal? Happens often . The investigation included the following witness statements: -- Licensed Practical Nurse (LPN) BB: This nurse was asked by (CNA) from 400 hall to come down, Resident had fallen. Resident was laying on floor on right side. Head on pillow Huge hematoma on back of skull- golf ball size. C/o pain in right hip and head . Resident states . 'hit by a mouse' when asked if they knew what happened. -- CNA HH: CNA and Resident were sitting in the recliners watching TV and talking. CNA was trying to redirect Resident . Resident seemed to be calmed down and CNA and Resident were going to come to the Activity area to get and ice cream . going around the chairs the CNA touched the gate belt and Resident turned around and swung fist at CNA, CNA moved and (Resident #197) started stumbling backwards . tried grabbing gait belt . fell hitting head and Resident grabbed their had and went straight into the fetal position . -- CNA AA: Where were you when incident occurred: Assisting another Resident with lunch . On [DATE] at 4:47 PM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #197's fall, the DON stated, (Resident #197) fell hit their head, had a subdural hematoma, ended up intubated, and died . An interview was attempted to be completed with CNA AA on [DATE] at 7:40 PM. A message was left with return number, but a return call was not received. Review of Resident #197's hospital medical record documentation revealed the following: - [DATE] at 5:45 PM: History and Physical (Physician) . Problem 1: Subdural hemorrhage, post injury . Post 1 . female found down at (facility). Taken to (local) ER . was intubated for GCS (Glasgow Coma Scale- clinical scale used to measure level of consciousness after a brain injury, scores range from completely unresponsive [three] to responsive [15]) score of eight after a CT (Computerized Tomography) of the brain revealed a large right subdural hematoma. (Resident #197) was intubated . approximately 1300 (1:00 PM) today and transported to (Level Two Trauma Hospital) . flight crew (medical helicopter transfer due to severity of injury) . Also, of note . started on a Cardene drip (medication to treat high blood pressure) for reported systolic blood pressure of 200 . Disability GCS 1 . pupils nonreactive . Repeat CT brain done on arrival to (Level Two Trauma Hospital) . Medi Image . CT Head or Brain wo (without) contrast, ordered: [DATE] 16:23 (4:23 PM) . Impression: Large right frontal/temporal/parietal acute subdural hemorrhage measuring approximately 2.2 cm (centimeters) greatest thickness. Shift of the midline structures to the left by approximately 1.9 cm. On [DATE] at 10:30 AM, an interview was conducted with CNA H. When queried regarding Resident #197's fall on [DATE], CNA H revealed Resident #197 was okay in the morning and then became agitated after seeing a truck outside and thinking it was their deceased spouse. CNA H stated, It (agitation) kept getting worse and worse, (Resident #197) was pacing, swearing, and hitting at things. CNA H revealed they were caring for another Resident when (CNA AA) came and got them to switch and care for Resident #197. CNA H was asked what happened after they took over for CNA AA stated, Got (the Resident) into the Living Room (TV room). (Resident #197) was sitting in a chair. There was an empty chair beside them, so I sat down. CNA H stated, I got (Resident #197) calmed down. (Resident #197) seemed good. CNA H continued, We were on our way to go get ice cream. Either (Resident #197's) hip or foot hit the chair and I moved back because (the Resident) was swinging. When asked for clarification, CNA H stated, I was to their side and (the Resident) started swinging at me and fell to the floor. They hit their head hard. When queried why the Resident tried to hit them, CNA H replied, I think (Resident #197) thought I hit them or something when they ran into the chair. CNA H continued, (Resident #197) stumbled backwards and fell . CNA H was asked how Resident #197 transfers normally including the level of assistance they require and replied, With a gait belt. When queried if they utilized the gait belt to assist the Resident out of the chair, CNA H stated, No. CNA H then stated, To be honest, I didn't hold the gait belt at all. An explanation was not provided regarding the rationale for not using the gait belt. When queried what occurred after the fall, CNA H stated, (Resident #197) went fetal and then rolling back over and was holding their head. CNA H stated, There was no blood. When queried, CNA H stated, someone brought a pillow and the Resident remained on the floor until Emergency Medical Services (EMS) staff and took the Resident. An interview was completed with Activity Staff Y on [DATE] at 11:19 AM. When queried regarding Resident #197's fall on [DATE], Staff Y stated, (Resident #197) was sitting in the recliner and (CNA H) was just sitting beside (the Resident) not talking. Then I heard (CNA H) ask (Resident #197) if they wanted ice cream. When queried, Staff Y revealed the Resident had been agitated earlier in the shift but was calm when sitting in the recliner. Staff Y was asked what happened next and stated, I looked up and saw (Resident #197) with their hand in a fist. I got up and went around. I didn't feel the fall, but I heard it. Staff Y indicated they were behind a wall when the fall occurred. Staff Y stated, I went and told the other Aide (CNA AA). When asked, Staff Y revealed CNA AA was not in the area where the fall occurred. Staff Y was asked if they recalled anything else and stated, (Resident #197) was saying their head hurt. Staff Y revealed EMS came to get the Resident. On [DATE] at 11:37 AM, an interview was conducted with Registered Nurse (RN) Z. When queried if they were Resident #197's assigned nurse on [DATE], RN Z revealed they were. RN Z was then asked what had occurred when the Resident fell and stated, (Resident #197) had been agitated earlier in the day. The Resident would get fixated on their spouse cheating. RN Z continued, (CNA H) had (Resident #197) calmed down and then I went on break (lunch). RN Z revealed they went for a ride off the facility property and were notified that the Resident had fell while they were on break. RN Z indicated they immediately returned and stated, I wasn't even gone ten minutes. RN Z stated, I went in and started doing my assessment. (Resident #197) had a huge hematoma (abnormal collection of blood) on the back of their head. When asked if the Resident had any external bleeding, RN Z revealed there was none. RN Z stated, I only went on break because (Resident #197) was all calmed down and indicated they would not have left if the Resident would have still been agitated. When queried regarding anti-anxiety medications, RN Z stated, We looked for a PRN (as needed) anxiety med earlier but revealed none were administered because the Resident did not have an order. RN Z reiterated the Resident was completely calm when they stepped off the unit. RN Z stated, It was absolutely horrible. It was a big hematoma. With further inquiry regarding the size and location of the hematoma, RN Z replied, (Resident #197) was on anticoagulants (blood thinner medications). It was big enough to be concerning. RN Z then stated, (Resident #197) was fine and then gone (deceased ). RN Z was then asked if Resident #197 was unsteady when walking and replied, Yes. When queried if staff were supposed to hold the gait belt when the Resident was transferring and/or ambulating, RN Z stated, Yes. When queried if there was a reason staff would not hold Resident #197's gait belt when the Resident was standing up from the chair and/or ambulating, RN Z indicated the Resident was no longer agitated and there was not a reason. An interview was completed with the Director of Nursing (DON) on [DATE] at 12:01 PM. When queried if Resident #197 was supposed to have a gait belt in place, the DON replied, Yes. The DON was then asked where the gait belt use intervention was documented in the Resident's medical record and revealed Resident #197 was assessed to be a high fall risk and was under the falling star program. The DON also stated, All facility residents are supplied a gait belt for safety per the facility policy/procedure. When queried why Resident #197 was wearing a gait belt if it was not being utilized to assist in safe transfers and ambulation, the DON revealed the gait belt should have been used. When asked why CNA H stated they did not use the gait belt to assist the Resident to a standing position prior to the fall when the Resident was calm, the DON did not provide a response. An interview was conducted with the Administrator and DON on [DATE] at 12:30 PM. When queried regarding Staff H stating they did not use the gait belt to assist Resident #197 to a standing position and never touched the gait belt, the DON indicated the Resident had been agitated earlier in the shift. The Administrator and DON both indicated the CNA attempted to grab the gait belt when the Resident started to fall. When queried why the gait belt was not utilized to assist the Resident to stand when they were calm per the staff, the Administrator and DON were unable to provide an explanation. A return phone call was received from Family Member X on [DATE] at 6:41 PM. When queried regarding Resident #197, Family Member X replied, I'm really not sure, I was not there. When asked, Family Member X stated, (Resident #196) passed due to a brain bleed sustained when they fell in the facility. When queried what happened when the Resident fell , Family Member X revealed they were told (Resident #197) was having a bad day and stated, I was told that (Resident #197) stood up, went to walk, fell , and hit their head. When asked, Family Member X indicated the Resident would have a bad day on occasion but that was not their normal. With further inquiry, Family Member X disclosed they were told facility staff were not able to help the Resident when they fell but they were not sure why because the facility knew the Resident. Review of facility provided policy/procedure entitled, Catch a Falling Star Program (Reviewed: [DATE]) revealed, . a falling star is a reminder of individuals who may be at greater risk . This program serves as an alert to all staff . The star is a signal . to be observant . Review of facility provided policy/procedure entitled, Gait Belt (Reviewed: [DATE]) revealed, Gait (transfer) belts are used by staff to provide a secure hold of the resident during transfers and ambulation . each resident is given a gait belt on admission .

Based on observation, interview and record review, the facility failed to provide an environment free from both verbal and physical abuse for one (#28) of three residents reviewed for abuse, resulting in a bruise to Resident #28's right jaw line and the potential for feeling afraid and intimidated. Finding include: On 11/29/18 at 9:43 AM, Resident #28 was observed in their room. Resident #28 had a yellow bruise to their right jaw line approximately 1 centimeter (cm) by 1 cm. Resident #28 was unable to share what had happened. On 12/3/18, at 9:00 AM, a record review of Resident #28's medical record revealed an admission on 10/14/2016 with [DIAGNOSES REDACTED]. Resident #28 required assistance with all Activities of Daily Living and had severely impaired cognition. On 12/3/18, at 9:15 AM, a record review of the facility reported incident revealed the following: A hand written statement signed by Certified Nursing Assistant (CNA) C stated, On 11-25-18 (CNA D) and I were transferring a resident (Resident #28) from the 400 side to the 500 side . (Nurse E) the nurse grabbed (the resident) by the mouth with one hand began shaking (the resident's) face as she yelled, to (the resident) we're not doing this today damn it. Yelled to (the resident) not to try and bite her. I didn't see (the resident) try to bite her at all. Threw out the rest of the day, she would raise her voice to (the resident) any time she spoke . I never witnessed something like that and I kind just froze. A hand written statement signed by Nurse E stated, On the 25th of (MONTH) on the 400 side . (the resident) was 2 assisted walking with gait belt to 500 side . (the resident) was yelling and fighting as they assisted (the resident) over - I approached resident and I said (the resident's) name and not sure what else - and (the resident) tried to bite me - I then placed my hand on the side of (the residents) face and said don't bite me or don't bite at me. A typed statement signed by the Administrator A on 12-1-2018 stated, 10:30 AM DON (the Director of Nursing B) performs head to toe assessment: yellow green bruise to the right side of resident's jaw 0.6 x(by)0.6 cm, yellow-green bruise noted to top of left hand 3.0 x 2.0 cm, yellow-green bruise noted to left forearm 3.5 x 2.0 cm, yellow-green bruise noted to right outer foot 5.0 x 3.0 cm. Per the DON (DON B), in her opinion the bruise to (the resident's) face was consistent with a finger/thumb print . 1:35 PM, Trooper (Michigan state police trooper) and DON view (the resident) and trooper obtains photo of facial bruise . This investigation concludes the (Nurse E) exercised poor nursing judgement, at the very least, likely leading to a bruise on resident's face. (Nurse E) has since been terminated from employment . On 12/3/18, at 10:10 AM, attempted phone call to the Michigan State Police Trooper involved who was unavailable. On 12/3/18, at 10:15 AM, the DON B was interviewed regarding the bruise on Resident #28's face and the DON B stated, (the resident) had a small yellowish green bruise. The DON B nodded her head yes when asked if she felt it was consistent with a thumb or a finger print. On 12/3/18, at 10:32 AM, a phone call interview with CNA C was conducted that revealed the following; The nurse (nurse E) walked over and grabbed (the resident) in (the resident's) jaw area, it covered both sides, her thumb was on one side and her fingers on the other side. (The nurse) put her entire hand over (the resident's) jaw area. She squeezed (the resident's) face and it bunched up (the resident's) lip. She shook (the resident's) head and the resident said you're hurting me. (the resident) said it twice . We had to stop because (Nurse E) was blocking our way through the door . Later (the resident) tried to get up and (Nurse E) told (the resident) sit down as she yelled . She is a bully. I was afraid they wouldn't believe me . She is intimidating and I am afraid of what she could do to me in my job for standing up to her. On 12/3/18, at 10:53 AM, a phone call interview with CNA D was conducted that revealed the following; . As we came to the door me and CNA C were walking to the other side. We came through the door way . (Nurse E) had approached (the resident) I remember seeing (Nurse E) bring her hand to the resident's face. I was on the right side of (the resident) and (the resident) was facing away from me. It was one hand. I did not see two hands. CNA D was asked again if she witnessed Nurse E touch the Resident #28's face and CNA D stated, I seen (Nurse E) bring her chin up. Well kind of I seen one hand go up to the resident's face. CNA D was furthered questioned if she looked away at this time or looked down the hall and CNA D stated, I don't remember. On 12/3/18, at 11:45 AM, the Administrator A stated that the trooper involved plans to give the information to the prosecutor per their phone call over the weekend. The Administrator A denied any previous abuse concerns with Nurse E. On 12/3/18, at 12:15 PM, the facility policy Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property signed by Administrator A dated, 12-19-17 revealed the following; Residents have the right to be free from abuse . Abuse. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse . Mistreatment. Inappropriate treatment . Willful. Means the individual must have acted deliberately . Freedom of movement. Any change in place or position for the body or any part of the body that the resident is physically able to control

Based on observation, interviews, and record review, the facility failed to provide adequate supervision to prevent falls with injury for 1 Resident (#2) of 3 residents reviewed for falls from a total of 3 sampled residents . This deficient practice resulted in an unwitnessed fall with resultant harm; a right lower extremity tibia/fibula fracture requiring surgical intervention (ORIF; open reduction, internal fixation). Findings include: The medical record facesheet revealed Resident #2 is an [AGE] year old woman who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was documented to utilize a pacemaker. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 was moderately cognitively impaired Brief Interview of Mental Status(BIMs score 8/15) and required extensive assist from facility staff with activities of daily living (ADL's). Review of the Fall Risk assessment dated [DATE], showed Resident #2 scored an 18, and was at high risk for falls. Review of the 'Safety' care plan in place on 5/2/2017, revealed Resident #2 was identified at risk for falls, participated in the Falling Star program (detailed plan of monitoring residents at risk for falling), and had a bed pad alarm in place, as I (Resident #3) don't always use my call light. This will alert staff if I am up and moving. Review of the Resident Initial Kardex, dated May 2017, specified that certified nurse aides (CNA's) were to utilize a bed pad alarm when Resident #2 was in her bed or in a chair. The facility 5-day report dated 5/10/2017, revealed Resident #2 experienced 2 falls, with injury, on 5/2/2017: 1) The first fall (witnessed) occurred on 5/2/2017 at 5:40 a.m. when the Resident became dizzy while ambulating to the bathroom, and was slid to the floor by CNA A with use of a gait belt. The Resident was documented to have injured the back of her head, which required transfer to a local hospital for evaluation (CT (computed tomography)scan performed was negative) and closure of the wound with staples. Resident #2 was documented to have returned to the facility on [DATE] at 8:30 a.m. The facility 5-day report included that Resident #2, who was at high risk for falls historically due to self-transfers (Falls Risk assessment 2/2/2017), was also displaying unusual behavior following her return to the facility that morning. The CNA F assigned to Resident #2, in her written statement dated 5/02/17 wrote: I went in just prior to check on her for lunch .she was very confused .I was informing my nurse about her confusion. According to the facility 5-day report, the confusion included: talking to her husband or parents whom have passed. Orders provided on return to the facility included labwork (CBC, CMP, and HgbA1C), as needed dosing of Norco 10/325, as well as initiation of Neuro checks. There were no additional approaches to supervision for Resident #2, who was known to self-transfer, and who had just returned to the facility due to a fall with injury. 2) The second fall (unwitnessed) occurred on 5/2/2017 at approximately 1:00 p.m. when the Resident was found on the floor of her room, laying on her back with her legs bent; it was documented that the Resident's pad sensor alarm had failed to sound. The Resident was documented to have been assessed with [REDACTED]. She returned to the local hospital for evaluation (x-rays performed revealed presence of a right tibia/fibula fracture), and was transferred to another hospital for advanced care due to underlying cardio-respiratory issues. Based on the facility self-report, Resident #2 required surgical intervention (ORIF; open reduction, internal fixation) of her right lower extremity. The facility's investigation revealed the root cause of the Resident's second fall (unwitnessed) at 1:00 p.m. on 5/2/2017, was the failure of the sensor pad alarm on the Resident's bed to sound; an unsecured connector cord disrupted the vital link between the sensor pad and the battery pack. During an interview on 5/17/2017 at 9:40 a.m., Housekeeper G acknowledged that she had heard a call for help from the room of Resident #2 on 5/2/2017 at 1:00 p.m. The Housekeeper responded to the call for help, finding Resident #2 on the floor of her room, between the bed and the window. The Housekeeper said she did not hear an alarm sounding, though she saw a sensor pad on the bed. During an interview on 5/17/2017 at 9:10 a.m., CNA F said she had been assigned to Resident #2 on the dayshift 5/2/2017. CNA F acknowledged that she was aware that the Resident was a fall risk, and participated in the Falling Star program. CNA F said that she had checked for the blinking light on the sensor pad function box, but had failed to apply pressure to the sensor pad in an effort to verify the system was working. The light on doesn't mean it's working; I found that out the hard way. During an interview on 5/17/2017 at 10:10 a.m., LPN H said she had responded to Housekeeper G call for help from the doorway of Resident #2's room. LPN H said, I didn't hear any alarm, even from the hallway before I got to her. During an interview on 5/17/2017 at 11:35 a.m., Maintenance Director J said, It was brought to my attention that the connection between the pieces of the alarm system, the pad and box, have been an issue since the connection is broken due to tension on the connector. During an interview on 5/17/2017 at 1:45 p.m., Resident #2 said she was aware that she had fallen, and that she had broken her leg, but she could not recall if her alarm had sounded. She was observed seated in her wheelchair with a pad sensor in use; her right lower extremity was cradled in a leg riser with a pillow and covered by a blanket.

This citation pertains to MI# 092 Based on observation, interview, and record review, the facility failed to ensure resident safety during transport in wheelchairs for four residents (#701, 702, 703, and 704) of four residents reviewed for foot pedal use, from a total sample of four residents. This deficient practice resulted in a leg fracture (Resident #701) and the potential for injury (Residents #702, 703, 704) during wheelchair transport. Findings include: On 6/22/16 an unannounced onsite investigation began in response to a facility reported incident filed 6/12/16 which alleged .a resident was not transferred safely, resulting in injury. Resident #701 According the the Minimum Data Set ((MDS) dated [DATE], Resident #701 was admitted to the facility with history of multiple [DIAGNOSES REDACTED]. Review of facility Incident and Accident reports dated 6/10/16 revealed Resident #701 was receiving Occupational Therapy (OT) and while being transported to the bathroom Resident #701 put her feet on the floor, stopping the wheelchair and causing a lower leg fracture. During an interview on 6/23/16 at 8:00 a.m., OT A stated, We were doing reaching exercises and her bra came up. There were men present, so we stopped exercises and I was taking her to fix her bra, she was able to hold her legs up when asked, but she then put her feet down and her rubber soled shoes caught the floor. She said, Ow, ow, ow. I then put her foot rests on her chair and fixed her bra. After that I took her back to her room and told (Licensed Practical Nurse (LPN) D). My boss was already aware of what had happened. I completed an Incident Report later that same day. Review of Nurses Notes dated 6/11/16 at 10:30 a.m. revealed Resident #701 was sent to the emergency room (ER) with worsening pain and bruising to her right knee. An x-ray was performed in the ER and revealed resident had sustained a fracture to her right lower leg. Review of the Medication Administration Record revealed Resident #703 had used Percocet (a pain medication) 7.5-325 mg (milligrams) four times during May 2016. On 5/31/16 another pain medication, Norco 10-325 mg, was ordered. Resident #703 had used this medication one time on 6/1/16. Resident #701 had not used any pain medication until 6/11/16, the day after the reported incident. On that date, Resident #701 began using Norco four times a day for four days. On 6/14/16, Resident #701 was started on Fentanyl Patch (a time release morphine pain medication) 50 mcg (micrograms) per hour. Two days later, on 6/16/16, the Fentanyl Patch dose was increased to 75 mcg per hour for continued reports of pain. During an interview on 6/23/16 at 11:25 a.m. Director of Nursing stated, She (Resident #701) ended up going to the ER again because she became too sedated (from the pain medication). Per Nurses Notes dated 6/15/16, Resident #701 had a follow up appointment with Orthopedic Surgeon and resident will continue to wear knee immobilizer at all times and the reported expected healing time will be two months. Resident #702 According to the Minimum Data Set, Resident #702 was admitted to the facility with a history of multiple [DIAGNOSES REDACTED]. An observation on 6/22/16 at 1:05 p.m. was made of Resident #702 being pushed in his wheelchair from the dining to the bathroom in his room and again from his bathroom into his room by Certified Nursing Assistant (CNA) B. There were no foot pedals in place on Resident #702's wheelchair. Resident #703 According to the Minimum Data Set, Resident #703 was admitted to the facility with a history of multiple [DIAGNOSES REDACTED]. An observation on 6/22/16 at 1:00 p.m. was made of Resident #703 being pushed in wheelchair from dining room to activity table without foot pedals by Employee C. Resident #704 According to the Minimum Data Set, Resident #704 was admitted to the facility with a history of multiple [DIAGNOSES REDACTED]. An observation on 6/22/16 at 12:55 p.m. was made of Resident #704 being pushed in wheelchair, without foot pedals, from dining room to resident's bathroom by CNA B. A second observation was made at 1:10 p.m. that same day of resident being transferred, in her wheelchair without foot pedals in place, from the bathroom to her bed by CNA B. During an interview on 6/22/16 at 1:20 p.m., CNA B stated, We had training on use of foot pedals. The educator came around and talked to everyone individually and had us sign a paper. During an interview on 6/23/16 at 9:10 a.m., Registered Nurse (RN) E stated, It is our policy, if anyone pushes a resident in a wheelchair you are supposed to put foot pedals on (the wheelchair). Review of facility policy Wheelchair Footrest Use dated 4/30/08 and revised 6/12/16 reads, .Residents who need or request to be transported by staff should have footrests in place at all times. ( )

Based on observation, interview and record review, the facility failed to consistently assess and implement interventions to prevent the development of two Stage II pressure ulcers for 1 Resident (#1) of 2 residents reviewed for facility acquired pressure ulcers, from a total sample of 15 residents. This deficient practice resulted in development of avoidable skin breakdown, two Stage II pressure ulcers, with the potential for pain, discomfort and worsening of the sores for this resident. Findings include: A review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed she is an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS also revealed Resident #1 was her own person - oriented to person, place and time, ambulated with the use of a walker and wheelchair and needed assistance with transferring. A review was conducted of Resident #1's Braden Scale Assessments (a scoring tool which evaluates resident's risk of developing a pressure ulcer). The lower the score, the more apt to develop a pressure ulcer. There were only three Braden Scale Assessments documented for Resident #1: 7/13/15 - Braden Scale of 16 (at risk for development of pressure ulcer) 7/20/15 - Braden Scale of 19 7/27/15 - Braden Scale of 17 A review conducted of Resident #1's Health Status Notes and Skin/Wound Notes dated 7/14/15 through 8/27/14 revealed: 7/16/15 - (Resident #1) is here post fall at home after being home from post gall bladder removal - resident .2 assist with gait belt with .transfer. 7/26/15 - .redness to buttock treated with sealant, continue to monitor. 8/04/15 - (Resident #1) has an opened area on coccyx .the open area is a Stage II ulcer .open area is 0.5 cm (centimeter) x 0.5 cm x 0.1 cm .treatment will be started for [MEDICATION NAME] to be applied TID (3 times a day). 8/07/15 - .no new skin issues noted . No skin assessment documentation was found for Resident #1 from 8/07/15 - 8/20/15. 8/19/15 - .(Resident #1) .appetite down .likes to remain in bed with shades pulled and lights off. 8/20/15 - (Resident #1's) skin assessed open area to coccyx measures 1.5 cm L (length) x 1 cm W (width) put in physician communication book .applied [MEDICATION NAME] cream for protection .continue to monitor. 8/25/15 - .continued weight loss since admission .even with multiple interventions . (signed by Certified Dietary Manager (CDM) D) 8/26/15 - .Stage 2: left buttock measure 1 cm diameter x .1 cm depth, Stage 2 right inner buttock measures .7 cm L x .3 cm W x .2 cm D (depth). (The Stage II right inner buttock pressure was a newly acquired pressure ulcer discovered during a wound dressing change on 8/26/15 at 2:30 p.m. by RN H and observed at that time by this Surveyor ) 8/27/15 - Wound care cleanse wound with NS (normal saline), pat dry apply meplilex border sacrum, change Q (every) 3 days and PRN (as needed). A review of Resident #1's Nutritional Risk Assessment - Alternate dated 8/11/15, placed her at 'high risk' for nutritional needs. The Assessment revealed Resident #1's lab values as [MEDICATION NAME] (protein level) =2.7 (Low), HGB (hemoglobin) =11.1 (Low), BUN (blood urea nitrogen) =23.7 (High), Calcium =8.2 (Low). A review was conducted of CDM D and Registered Dietitian (RD) S's notes 7/14/15 through 8/27/15. Among them: Per 7/29/15 RD Note Nutritional consult regarding low [MEDICATION NAME], Labs (7/13) Alb ([MEDICATION NAME]) =3.4, TP (total protein) =7.7 .(7/15) TP =7.1, Alb =2.7 L (low). Per CDM note 8/04/15, 12# weight loss since 7/15, eating 57-65% of meals. (added) CIB (Carnation Instant Breakfast = 11.3 grams (protein)) daily with breakfast, supervision with all meals. Per RD note 8/17/15, .An additional 9# weight loss is noted since 7/29 review. Boost Plus initiated with meals and also ordered with med pass . Will add [MEDICATION NAME]/fortified foods at meals as able and continue to monitor for weight maintenance . Per 8/27/15 CDM Note, estimated nutritional needs .1884 kcal (kilocalories), 102 grams protein .Boost supplies 1080 kcal, 42 grams protein, will recommend [MEDICATION NAME] (twice a day) with med pass and 1 scoop pro source 3 times daily with meals . Multiple interventions had been suggested to be put in place for Resident #1, but no evidence was found to show her dietary intake, including supplements was being monitored. A review of Resident #1's Pressure Ulcer Care Plan dated 8/17/15 revealed: educate me as to causes of skin breakdown, including: transfer/positioning requirements . good nutrition and frequent repositioning . monitor/document/report to MD (physician) PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs & symptoms) of infection, wound size (length x width x depth), stage. No evidence was provided to show education had been given to Resident #1, or all aspects of skin status interventions listed above had been met. Resident #1's revised Pressure Ulcer Care Plan (dated 8/17/15, no new date) now showed Resident #1 had 2 pressure ulcers on her coccyx. A review of Resident #1's Medication Review Report revealed on 8/06/15, a physician order [REDACTED].#1 to receive BOOST PLUS 120 cc (cubic centimeter) TID (three times a day) WITH MED (medication) PASS DUE TO WT (weight) LOSS every shift. The manufacturer's label for Boost Plus shows 8 fluid ounces contains 14 grams (g) of protein. Additional protein is required for adequate weight maintenance and wound healing. During an interview with Resident #1 on 8/25/15 at 9:50 a.m., Resident #1 said she didn't drink Boost because she hated it and it made her gag. The resident stated the only thing she ate for breakfast and lunch was a donut and tea. Resident #1 continued to say, The sore on my bottom hurts .don't want to get up and sit on it . Observations made of Resident #1 on 8/25/15 at 8:50 a.m. for breakfast showed she didn't drink the CIB supplement and had no supervision. During lunch on that day at 12:30 p.m., observation by this surveyor showed she ate only a donut and tea with no supervision. On 8/27/15 at 10:00 a.m., an interview with Certified Nurse Aide (CNA) R revealed she took care of Resident #1 on a regular basis and Resident #1 only drank tea and ate a donut for every breakfast. On 8/27/15 at 12:05 p.m., an interview conducted with Registered Nurse (RN) H revealed RN H had never given the dietary supplement/Boost Plus to Resident #1 as ordered. A review of Resident #1's Medication Administration Record [REDACTED]. On 8/27/15 at 2:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed Resident #1 had not received Boost Plus during Med Pass, and the DON had no knowledge of this supplement order. The DON shook her head and said, Yes, I have been informed (Resident #1) has acquired a new pressure ulcer on her coccyx, they (staff) needed to re-evaluate (Resident #1). ( ) --

This citation pertains to intakes MI ; and . Based on Interview and record review the facility failed to do the following: (1) appropriately administer a treatment of [REDACTED].#01) of five sampled residents, when there were signs and symptoms of trauma which ranged from bruising to the peri area, including the labia and rectum, swelling, and necrotic (dead tissue) area, and pain with a significant decline to Resident # 01's eating, getting out of bed and attending activities resulting in an Immediate Jeopardy for Resident #01. The Immediate Jeopardy began on 04/04/2014 when Resident 01 was noted by facility staff with bruising and swelling of the peri anal area. Resident #01 was admitted to the hospital in the Intensive Care following surgery with complications and a [MEDICAL CONDITION] (opening into the abdominal wall from which stool is excreted into a small bag). The Immediate Jeopardy was identified on 04/17/2014 at 3:00 pm. The facility administrator was informed of the Immediate Jeopardy at 3:30 pm on 04/17/2014 and was directed to submit a corrective action plan to remove the Immediate Jeopardy. The Immediate jeopardy was removed on 4/18/2014 but not corrected for 4 out of 5 sampled residents (#02, 03, 04 and 05) whose bowel regimen protocol were not monitored and or implemented resulting in the potential for more than minimal harm at a pattern due to constipation and preventable fecal impaction. Findings Include: According to the facility incident reported on 4/09/2014, Resident # 01, an [AGE] year old female admitted to the facility on [DATE] with the diagnoses of [MEDICAL CONDITION], depression, [MEDICAL CONDITION], anxiety and [MEDICAL CONDITION]; resided in the facility locked dementia unit; and was administered a Fleet Enema by two Certified Nurse Aides (CNA) (Staff D and E) on April 3, 2014. A review of the facility investigation (April 9, 2014 and updated April 14, 2014 ) revealed that after the Fleet Enema was initially administered there was bruising of the left labia extending to the rectum. An appointment with the surgeon on 4/10/14 and "proctoscope findings included gangrenous changes extending up the left side of the anal canal which was debrided by the general surgeon and Resident is admitted to the hospital on IV (intravenous antibiotics) ". An interview with the Licensed Practical Nurse (Staff C) on 4/16/2014 at 3:25 pm, revealed that she was the charge nurse who was working on 4/03/2014 and gave the order to the two CNAS (Staff D and E) to give Resident # 01 A Fleets Enema around 9 pm. When asked why Resident # 01 needed the Fleet Enema, Staff (C) stated, "If the resident did not have a bowl movement in 2 days prune juice was given; if none in three days a Fleet Enema; on the fourth day a soapsuds enema or a suppository". Staff (C) stated that she gave [MEDICATION NAME] (a laxative) on 4/03/14 and ordered the enema to be given. Staff (C) was asked if the CNAS always gave the enemas and she stated, "Yes". Staff (C) was then asked if the proper way to give an enema was for the resident to stand and bend forward over the toilet. Staff (C) stated, " I have have seen them do it that way before". Staff (C) was then asked if it was the proper way to give an enema and she stated, "They just did it that way". Staff (C) was asked to give an account of what happened the night of 4/03/2014 and she stated, "The two CNAS (Staff D and E) gave the enema to Resident # 01 and she heard Resident # 01 scream. She came into the room and saw the two aides with the resident in the bathroom and Resident # 01 was standing. I then left the room because I had medications in my hand and needed to give them. Then Staff (D) came and got me because she said that Resident # 01 was bleeding. I looked into the toilet and saw blood at the bottom of the bowl and stool hanging from the rectum of Resident # 01. I pulled the stool out but was not able to see her bottom because she was sitting on the toilet so I had the CNAs put her into bed... I then saw what I thought was a hemorrhoid on the right side of the rectum and some bleeding...I then applied cold compresses to the area and the bleeding stopped...The next day the hemorrhoid was gone and I noted a bruise on the left side of the labia and buttocks. The bruise went from the buttocks to the labia". Staff (C) was asked if either CNAS (Staff D and E) had ever been rough with residents and she stated, "No". Staff (C) was told that there was no documentation of the enema being given and she stated," The Fleet Enemas are in the stock room and the CNAs have access to them at any time, even without the knowledge of the nurse". Staff (C) was asked if she called the physician and she stated, " No because the bleeding stopped but I wish I would have sent her (Resident # 01) to the emergency room ". On 4/17/14 at 10:45 a.m. an interview was conducted with CNA (staff D) in the conference room. Staff (D) was asked to give an account of what happened on 4/3/14 and she stated, "A little after 9 PM she and CNA E took Resident #01 to her room to get her ready for bed. They placed Resident #01 on the toilet and when CNA (staff E) gave the Fleet Enema, we stood her up and she bent over the toilet and I was in front of her . Staff (E) placed the tip of the Fleet Enema in the rectum of Resident #01 and she screamed like I never heard her scream before. Staff (E) pulled out the enema and I went and got the nurse (Staff C) because I saw the blood in the toilet. When we put Resident #01 to bed I saw what Staff (C) called this big hemorrhoid. We placed cold compresses on the rectum of Resident #01 and the next day I saw black around the rectum and the right side of the vagina was bruised". Staff (D) was asked if she charted the enema or the bruised area and Staff (D) stated, "No" because there was no place for CNAs to chart so they give the information to the nurse who would document it in the chart. Staff (D) was asked if she had been trained to give enemas and she replied, "When I took my CNA training, not in this building". Staff (D) was asked if she gave enemas with the resident standing up and she replied, "That's how we give them here. I never heard Resident #01 scream the way she did". On 4/17/2014 at 12:50 pm, the Director of Nursing (DON) (Staff B) stated that she was unable to contact CNA (Staff E). Staff (B) stated that they (the DON and the Administrator) had talked with Staff (E) several times earlier in the week and that she did not change her story. Staff (E) had the week off and as of 4/17/2014 she was not responding to the surveyor's phone calls. On 4/17/2014 at 8:05 am CNA (Staff H) a CNA working on the closed dementia unit, was interviewed and asked if she had given any enemas. Staff (H) stated," A couple". Staff (H) was then asked to explain how she gave an enema and she stated,"I have the resident lay on the bed on the left side and insert the tip very gently. Now with the new bowel policy you start with prune juice, then on the second day they give milk of magnesia and the third day either an enema or a suppository". On 4/17/2014 a review of the Nursing Progress Notes documented the following: " On 4/4/14 at 12:11, Left inner buttock, perineum, and left labia purple, blue, burgundy and swollen. Very painful to touch. Skin around left side of anus very dark purple black.... At 15:04, Ate poorly at lunch while being fed... At 16:04, Decrease in swelling of left labia, perineum and left inner buttock". On 4/5/2014 Nursing Progress Notes documented the following: "At 00:02: Facial grimacing when washing labia, none noted during care to rectum area. Resident offered fluids but would only drink 240 cc of boost. Rectum is no longer swollen... At 12:20 : Two small faint bruises on left side of lower abdomen. Hematoma from L labia to anus burgundy color, darker deep red area near anal opening measuring 5 cm by 2.5 cm". On 4/6/2014 Nursing Progress Notes document the following: "At 07:13: "Red swollen, warm area on buttocks near rectum, on call doctor notified and ordered [MEDICATION NAME] 500 mg. for 5 days and florstar for 5 days for [MEDICAL CONDITION]". [MEDICATION NAME] 500 milligrams (mg) was an antibiotic and Florstar was a laxative. Both medications were ordered but Resident # 01 was not seen by the on call doctor. At 10:51 documentation was follows: "L (left) labia to anus medium burgundy color with 6 cm by 2 cm darker reddish black area near anus. Resident combative with cares and refusing to drink". At 11:32 documentation continues , " Lips dry and tongue dry/furrowed with review of records indicating declined fluid intake with none today. Continues with bruising to labia majora (left) extending back to rectum. Called Physician Answering Service awaiting on call practitioner (Name of Practitioner) to return phone call". At 12:55 p.m. notes continue: "Practitioner (Name) with orders to draw CBC and CMP with additional orders of IV D5 45 NS at 50cc per hour". The on call practitioner ordered fluids intravenously. At 13:00 notes documented, "IV(Intravenous) saline started. [MEDICATION NAME] (pain medication) to be discontinued and return to Tylenol for pain." On 4/7/14 the Nursing Progress Notes documented the following: " At 16:23, Refusing to eat but drinking fair,Left inner buttocks red, burgundy in color with 2 brown black areas One brown black area the size of a quarter and to the left of the anus. The other brown black area is irregular shaped and below the anus. Skin in the area is very firm. Left perineum is red and swollen. Left labia is dusky gray burgundy and yellow. Eating poorly... At 22:24 , Heat to perineum/rectum TID (three times a day) - LT (left) labia bruising cont to fade-dusky gray in color no swelling observed-perineum cont to be swollen and LT buttocks has two dk (dark) black spots-the smallest of the two and lowest on the buttock has top layer of skin peeling off-resident buttocks cleaned with diluted dial soap via peri bottle and patted gently dry". On 4/08/14 Nursing Progress notes at 0915 documented ,"Assessed By (name of) P.A. (Physician Assistant)". Progress Notes made by the DON (Staff B) documented at 12:09 Spoke with (name of both daughters) via telephone with decision for surgical consult ASAP". On 4/9/14 at 00:39 documentation in Nurses Progress notes are as follows: "Resident continues to be treated for [REDACTED]. Left labia swelling has decreased but appears red". At 14:57 Nursing Notes documented the following,"Left perineum remains red and swollen. Left inner buttock remains bright red with 2 black brown areas measuring 3 cm circular to the left of the anus, and 2 cm circular below. No swelling remains noted on left labia and discoloration is yellow pink". On 4/10/14 at 16:12 Nurses Progress Notes documented, "that at 1535 To (hospital name) via gurney with staff for consult with (Dr. Name) Daughter remains with resident". According to an interview with LPN (Licensed Practical Nurse) " C " on 4/16/14 at about 3:25 p.m., it was the practice at this facility for Certified Nurse Aides (CNAs) to administer enemas. LPN " C " also stated that no doctor 's order was obtained before giving an enema to a resident and no documentation regarding enemas or the outcome were routinely entered into the resident' s record. On 4/17/14 about 8:15 a.m. two CNAs, staff " H " and " J " working on the locked dementia unit were interviewed. Both stated that it was (before the incident with resident #01) the practice at this facility for aides to administer enemas. CNA " J " stated that there were trainings on giving enemas on the computer and inservices given but she could not remember when. She stated that she had not been assigned to do any enemas in the past month and a half. On 4/17/14 at 8:45 a.m. the InService Director, staff " I " was interviewed and asked about training for nurse aides regarding the administration of enemas. Staff " I " stated that he had been at the facility for 2 years and had never given or attended any training. Staff " I " gave this surveyor the only information he could find from the computer training modules which was a training titled, " Recognizing and Treating Constipation ". This module included a brief paragraph about using enemas to treat constipation. However, there was no direction or training on how enemas should be given. The facility administrator was informed of the Immediate Jeopardy at 3:30 pm on 04/17/2014 and was directed to submit a corrective action plan. A correction plan was accepted on April 18, 2014 at 10:20 am which removed the Immediate Jeopardy. The plan, dated April 18 listed the following: 1. The facility bowel protocol, dated 11/18/2012 was revised on April 10, 2014. Only nurses to provide enemas. 2. Nursing enema competency for all facility nurses initiated with 85% completed on April 10, 2014. 3. Facility Nursing protocols (standing orders) to include bowel management protocols were updated, April 10, 2014 and 85% of nursing staff were educated on April 10, 2014 with remainder inservices at start of shift first day worked. 3. All residents will be reviewed under the facility's new bowel protocol for risk of constipation and impaction. All residents will have their care plans modified on April 18, 2014 to address the risk of constipation and impaction. 4. All administrative nursing staff and direct care nurses will be educated on importance of recognizing signs/symptoms of distress, bruising , ect. on April 17, 2014 with timely Notification to physician or on call practitioner for referral, consult and request for attention including an ER (emergency room ) referral. 5. The changes and the implemented process will returned over to the Facility Quality Assurance Committee for further guidance. The Immediate jeopardy was removed on 4/18/2014 but not corrected for 4 out of 5 sampled residents (#02, 03, 04 and 05) whose bowel regimen protocol were not monitored and implemented resulting in the potential for more than minimal harm at a pattern. A list of all residents who resided in the locked dementia unit and who had enemas administered in the past 30 days were requested by the surveyors on 4/16/14. Residents #02, 03, 04 and 05 were selected for review for substandard quality of care. According to the EMR ( Electronic Medical Record, undated) ) reviewed on 4/17/14, Resident # 02 was an [AGE] year old female admitted to the facility on [DATE] with the diagnoses of dysphagia, [MEDICAL CONDITION], dementia, gastric reflux, and depression. There was no [DIAGNOSES REDACTED].#02 was receiving [MEDICATION NAME] ( a laxative) once daily for bowel management which was ordered on [DATE]. There was no Care Plan for Constipation or Bowel Management in the record of Resident # 02. The EMR (undated) bowel records for Resident # 02 showed a period of 4 days without a bowel movement ( 3/5/14 to 3/9/14 ) even though the Resident 2 was receiving [MEDICATION NAME] ( for bowel movement) daily. There was no evidence that the Standing Orders listed in the undated document "Nursing Protocols" was followed. The protocol stated, "Evaluate bowel habits for two days before initiating bowel prep (preparations). Perform rectal exam to evaluate for fecal impaction, If after two days there is no bowel movement start [MEDICATION NAME] 17 grams daily. If no results in 24 hours notify attending physician for further orders". Resident # 02 was receiving [MEDICATION NAME] daily. There was no documentation to show the doctor was aware or notified of the four days of constipation and there was no order for an enema in the medical record of Resident # 02. According to the EMR (undated) reviewed on 4/17/14 Resident # 03 was an [AGE] year old female resident admitted to the facility on [DATE] with the diagnoses of Dementia with behaviors, dysphagia, cardiomegaly, gastric reflux and [MEDICAL CONDITION]. There was no [DIAGNOSES REDACTED]. There was no Care Plan for Constipation or Bowel Management. There was one order written on 4/15/14 for Milk of Magnesia 30 cc one time. It was unclear whether the Milk of Magnesia was effective for a bowel movement. A review of the bowel records showed a period of 7 days wherein Resident # 03 had no documented bowel movement from 3/4/14 to 3/11/14 and a four day period from 3/20/14-3/24/14 had no bowel movement documented. There were no documented interventions or information that the physician was informed of the prolonged period of time between bowel movements. There was no evidence that the Standing Orders listed in the undated document "Nursing Protocols" which stated "Evaluate bowel habits for 2 days before initiating bowel prep (preparations). Perform rectal exam to evaluate for fecal impaction. If after two days there is no bowel movement start [MEDICATION NAME] 17 grams daily. If no results in 24 hours notify attending physician for further orders" were followed. There was no documented orders for an enema nor of the use of the standing order for the [MEDICATION NAME]. According to the EMR (Electronic Medical Record, undated ) reviewed on 4/17/14, Resident #04 was a [AGE] year old female with diagnoses which included dementia, hypertension and major [MEDICAL CONDITION]. There was no [DIAGNOSES REDACTED].#04 was receiving two medications ([MEDICATION NAME] and [MEDICATION NAME]-S) for " Bowel Management " . There was no Care Plan for either Constipation or Bowel Management in the record for Resident #04. The EMR bowel records for Resident #04 showed 4 instances of more than 2 days without bowel movements: 3/8/ - 3/12/14; 3/16 - 20/14; 3/20 - 3/24/14 and 4/3 - 4/8/14. The only documentation regarding any interventions was [MEDICATION NAME] given on 3/4/14 at 5:13 p.m. and again at 11: 00 pm.; and [MEDICATION NAME] given on 3/12/14 at 5:26 p.m.. There was no evidence that the Standing Orders listed in the undated document " Nursing Protocols " which stated " Evaluate bowel habits for 2 days before initiating bowel prep (preparations). Perform rectal exam to evaluate for fecal impaction. If after 2 days there is no bowel movement start [MEDICATION NAME] 17 grams daily. If no results in 24 hours notify attending physician for further orders " were followed. There was no documentation to show that the doctor was aware of any of the instances of constipation for resident #04. According to the EMR (Electronic Medical Record, undated ) reviewed on 4/17/14, Resident #05 was an [AGE] year old female with diagnoses which included dementia, debility and [MEDICAL CONDITION]. There was no [DIAGNOSES REDACTED].#05 was receiving medication ([MEDICATION NAME]) for constipation according to an "Active physician 's orders for April 2014". There was no Care Plan for either Constipation or Bowel Management in the record for Resident #05. The EMR bowel records for Resident #05 showed 1 instance of more than 2 days without bowel movements from 3/20 to 3/25/14. There were no documented interventions or information that the physician was aware of the prolonged period of time between bowel movements. There was no evidence that the Standing Orders listed in the undated document " Nursing Protocols " which stated " Evaluate bowel habits for 2 days before initiating bowel prep (preparations). Perform rectal exam to evaluate for fecal impaction. If after 2 days there is no bowel movement start [MEDICATION NAME] 17 grams daily. If no results in 24 hours notify attending physician for further orders " were followed. The facility staff failed to implement their own Nursing Protocols for their bowel regimen. ( ) ( ) ( )

This citation pertains to MI# 700 Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being (adequate wound care) in 1 (#101) of 4 sampled residents, resulting in re-hospitalization for surgery and IV (intravenous) antibiotics for Resident #101. Findings include: Record review of facility 'Resident Assessment' policy dated 5/22/12 revealed purpose was to assure each resident has complete documentation with sufficient evidence of the care provided. Responsible person noted as licensed nurses. 1). the nurse must perform a head to toe assessment on every newly admitted resident, readmitted resident or those with significant decline of condition......3). The nurse will re-inspect surgical incisions and will clean, dress and document every 24 hours until healed. The nurse must notify the attending physician or surgeon for signs of infection.......5). Dressing changes are documented in electronic charting. Dressings should be initialed and dated by the nurse providing the care. Review of the hospital transfer summary form (undated) for hospital admitted d 5/4/12 for Resident #101 revealed Resident #101 had an elective LL (lower lumber) with spinal infusion (back surgery). Review of the facility physician orders [REDACTED]. Review of the nurse notes dated 5/9/12 at 2:56 PM revealed Resident #101's wound care per nursing (back incision) was completed. Review of the nurse notes dated 5/10/12 at 10:46 PM, revealed Resident #101 had a midline lumbar back incision that was steri stripped, was 17 cm in length, had minimal redness distal aspect of incision, and the remaining incision looks clear. Nursing staffs applied dry sterile gauze and no drainage noted on old dressing. Review of Resident #101's nurse notes dated 5/11/12 at 10:14 AM revealed in an IDT (interdepartmental team) meeting note that indicated Resident #101 was on post-surgical antibiotic course and that a surgical incision with bruising was noted. There was no measurement of the surgical wound noted. Review of Resident #101's nurse notes dated 5/15/12 at 3:48 PM, written by Licensed Practical Nurse (LPN) #3, noted: "surgical wound present in past 7 days. Proximal aspect of incision draining clear fluid and excoriating surrounding tissues and making all steri strips wet. Steri strips removed, incision cleansed with soap and water. New strips applied to all but proximal aspect where gauze was placed then secured with ABD and tape." In an interview on 2/21/13 at 10:48 AM , LPN #3 revealed that she first saw Resident #101's wound on 5/15/12 and wrote a note. LPN #3 stated that the wound was draining clear fluid from the proximal aspect of the incision. The incision was described as scabbed with bloody steri strips with incision approximately 10-12 inches in length. LPN #3 stated that she removed and reapplied steri strips to all but the lower aspect because it was open, and applied a gauze bandage. LPN #3 stated that she did not notify the physician for further guidance regarding the drainage or documented excoriation to the surrounding tissue. LPN #3 reviewed skin care plan, treatment records, physician orders [REDACTED]. Review of the facility "Notification of Change of Condition" policy revised dated 1/2/13 noted the physician is notified when a resident experiences a significant change in condition. Review of facility infection report for May 2012 revealed that the facility tracked residents who were on antibiotics, start date, type of infection, cultures, organisms and if long term care associated or community associated. Further review of the May 2012 infection report revealed that Resident #101, who was post-surgical with a wound and admitted on an antibiotic, was not being tracked on the infection control log. Review of the nurse notes dated 5/16/12 at 11:33 AM, written by LPN #3, revealed Resident #101 "has surgical wound present in past 7 days. Lumbar back upper portion of wound now has serous drainage vs. clear in moderate amounts; drainage has softened the upper portion of previously scabbed incision. Grey slough now noted. Slight increase in redness noted proximal aspect 2 cm on each side..." Review of Resident #101's physician orders [REDACTED]. Review of Resident #101's progress notes dated 5/15/12 revealed that the physician assistant (PA) noted that Resident #101's skin was warm and dry and color was pink. There was no mention of a surgical incision or of excoriated surrounding tissue noted to the incision area. Review of the physician order [REDACTED].#101 and facility staffs were to fax results to Resident #101's surgeon. The order included that facility staffs were to cleanse the upper portion of surgical incision then apply dry gauze and ADB (type of dressing) BID (twice daily). Review of the treatment administration record (TAR) dated 5/8/12 through 5/18/12 for Resident #101 revealed that on 5/16/12 treatment of [REDACTED].#3. Review of Resident #101's physician orders [REDACTED]. Apply [MEDICATION NAME] cream after drying BID (twice daily)." During the interview on 2/21/13 at 10:48 AM, LPN #3 revealed that Nurse Practioner (NP) #6 looked at Resident #101's wound on rounds at the end of the day and order to scrub the Resident #101's wound with a toothbrush and soapy water. LPN #3 stated that she and LPN #4 went down the hall to Resident #101's room, and with soapy water and gentle toothbrush, brushed the gray slough at the top of the incision, patted it dry and applied a dry gauze dressing with medigrip retention tape due to being under a corset/back support brace. LPN #3 stated that she did not write a nurse note about the wound or cleansing of the wound, not did she describe what the area looked like post cleansing or any measurements of the open areas. LPN #3 reviewed the written order and reported that the physician order [REDACTED]. LPN #3 reviewed the treatment record and reported there was no documentation of the toothbrush cleansing treatment that LPN #3 and LPN #4 had performed on Resident #101. Review or Resident #101's nursing note dated 5/18/12 at 3:42 PM, written by the LPN #3 wound care nurse, revealed Resident #101 had left for leave of absence (LOA) with family at 8:00 AM to appointment with neurosurgeon due to changes in surgical incision. At 2:00 PM informed by social services that resident was admitted to hospital for surgery and IV antibiotics. #

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE INTERVENTIONS TO ENSURE EFFECTIVE SUPERVISION, FAILED TO ENSURE A SYSTEM TO EFFECTIVELY REVISE THE PLAN OF CARE, RESIDENT WORKSHEETS, RESIDENT CARE GUIDES AND FACILITY PRACTICES TO REDUCE THE LIKELIHOOD OF ANOTHER FALL FOR ONE (#101) RESIDENT, WHO WAS KNOWN TO HAVE DIMINISHED SAFETY AWARENESS, WAS "NOT FEELING WELL", WAS ON ANTICOAGULANT THERAPY AND WHO had a history of [REDACTED]. THESE SYSTEMIC FAILURES RESULTED IN RESIDENT #101 BEING PLACED IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY DUE TO HIM FALLING AND REQUIRING URGENT AIR TRANSPORTATION TO A HOSPITAL INTENSIVE CARE UNIT (ICU) WHERE HE WAS admitted IN CRITICAL CONDITION WITH A PRELIMINARY [DIAGNOSES REDACTED]. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 11/15/12 AT 4:00 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 11/7/12 AT 5:17 A.M. WHEN RESIDENT #101 WAS FOUND ON THE FLOOR OF HIS ROOM AFTER HE ATTEMPTED TO SELF TRANSFER INTO HIS WHEELCHAIR TO TAKE HIMSELF TO THE TOILET AND THE FACILITY FAILED TO TAKE IMMEDIATE ACTION TO REVIEW THE INCIDENT THAT RESULTED IN RESIDENT #101 SHOWING "CONFUSION" AND PAIN IN HIS RIGHT HIP. THE FACILITY THEN FAILED TO REVIEW, REVISE AND ENSURE IMPLEMENTATION OF RESIDENT #101'S PLAN OF CARE FOR SAFETY AND APPROXIMATELY 5 HOURS LATER AT 11:22 A.M., RESIDENT #101 WAS LEFT UNSUPERVISED ON THE TOILET (EVEN THOUGH HE WAS COMPLAINING OF "FEELING SICK", NAUSEATED AND HAD EMESIS). APPROXIMATELY 5 TO 10 MINUTES LATER, RESIDENT #101 WAS FOUND ON THE BATHROOM FLOOR WITH A HEMATOMA AND A BLEEDING ABRASION TO HIS RIGHT FOREHEAD. RESIDENT #101 WAS SENT VIA THE AMBULANCE TO A LOCAL HOSPITAL WHERE HE WAS AIRLIFTED TO ANOTHER HOSPITAL AND admitted TO THE ICU IN CRITICAL CONDITION AND WITH A CRANIAL BLEED. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 11/15/12 AT 4:40 P.M. AND A WRITTEN PLAN FOR REMOVAL OF THE IMMEDIATE JEOPARDY WAS REQUESTED. ON 11/16/12 AT 8:11 A.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - THE FACILITY'S QUALITY ASSURANCE (QA) PROBLEM RESOLUTION PROCESS DOCUMENTED ON 11/15/12: THE CARE PLANS OF ALL RESIDENTS IDENTIFIED AS HAVING A FALL WITHIN THE LAST 30 DAYS WERE REVIEWED FOR INTERVENTIONS TO PREVENT FALLS AND UPDATED IF NECESSARY. THE INDIVIDUAL RESIDENT CARE GUIDES AND RESIDENT WORKSHEETS WERE REVIEWED TO ENSURE EACH RESIDENT'S CARE PLANNED FALL INTERVENTIONS WERE ALSO INCLUDED ON THE TWO DOCUMENTS. - ON 11/16/12, THE FACILITY BEGAN THE REVIEW OF ALL RESIDENT CARE PLANS TO ENSURE APPROPRIATE INTERVENTIONS WERE DOCUMENTED ON THE CARE PLAN, RESIDENT WORKSHEETS, AND INDIVIDUAL RESIDENT CARE GUIDES. - ON 11/16 /12, IT WAS CONFIRMED VIA STAFF INTERVIEWS, THE EDUCATION AND COMPLIANCE WITH ENSURING CONSISTENT CARE INFORMATION WAS TO BE INCLUDED ON THE CARE PLAN, RESIDENT WORKSHEETS AND CERTIFIED NURSE AIDE (CNA) CARE GUIDES. - ON 11/16/12, THE A.M. SHIFT NURSES WERE OBSERVED CONDUCTING ROUNDS TO ENSURE CNAS HAD ACCESS TO THE CURRENT RESIDENT WORKSHEETS AND THAT CNAS HAD READ THEM. - ON 11/16/12, RESIDENTS #102, #103 AND #104'S FALL CARE PLANS, RESIDENT WORKSHEETS AND INDIVIDUAL RESIDENT CARE GUIDES WERE REVIEWED TO ENSURE THE CURRENT FALL INTERVENTIONS WERE DOCUMENTED ON ALL THREE FORMS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL OF ACTUAL HARM, DUE TO: - RESIDENT #101 HAD AN AVOIDABLE FALL WHICH RESULTED IN SERIOUS INJURY AS EVIDENCED BY RESIDENT #101 BEING PLACED IN THE HOSPITAL'S ICU ON 11/7/12 IN CRITICAL CONDITION, diagnosed with [REDACTED]. - CONTINUATION OF THE FACILITY'S QA PROCESS TO COMPLETE THE REVIEW OF ALL CURRENT RESIDENT CARE PLANS ENSURING CURRENT AND APPROPRIATE CARE PLAN INTERVENTIONS ARE DOCUMENTED AND ARE ALSO INCLUDED ON THE RESIDENT WORKSHEETS AND INDIVIDUAL RESIDENT CARE GUIDES ALLOWING ALL CARE STAFF ACCESS TO THE CURRENT/APPROPRIATE INTERVENTIONS. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH PROVIDING ADEQUATE SUPERVISION TO PREVENT AN ACCIDENT. FINDINGS INCLUDE: THE MINIMUM DATA SET (MDS) assessment dated [DATE], SHOWED RESIDENT #101 HAD REadmitted to the facility on [DATE] AND WAS [AGE] years OLD. THE MDS DOCUMENTED HIS [DIAGNOSES REDACTED]. THE MDS ASSESSMENT AND THE CARE PLAN DATED 10/12, SHOWED RESIDENT #101 USED CONTINUOUS OXYGEN DUE TO SHORTNESS OF BREATH DURING EXERTION. RESIDENT #101'S MDS ASSESSMENT SHOWED HE WAS ALERT, ORIENTED AND MADE HIS OWN MEDICAL DECISIONS. THE CARE PLAN ALSO DOCUMENTED HE USED A WHEELCHAIR TO SELF PROPEL AND HE NEEDED ONE PERSON TO PHYSICALLY ASSIST HIM INTO AND OUT OF HIS WHEELCHAIR, AND ON AND OFF THE TOILET. RESIDENT #101'S MDS ASSESSMENT SHOWED HIS BALANCE DURING "TRANSITIONS AND WALKING" WAS NOT STEADY AND HE WAS ONLY ABLE TO STABILIZE HIMSELF WITH STAFF ASSISTANCE. A REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. PLAVIX IS A MEDICATION THAT REDUCES THE BLOOD'S ABILITY TO CLOT. BECAUSE OF THIS DRUG ACTION, PAVIX CAN MAKE IT EASIER TO BLEED, EVEN FROM A MINOR INJURY. A FURTHER REVIEW OF THE FOCUS AREAS IN RESIDENT #101'S CARE PLAN REVEALED HE WAS "...AT RISK FOR FALLS DUE TO WEAKNESS..." THE FALL PREVENTION INTERVENTIONS INCLUDED, "...I WILL NEED ASSIST OF ONE WITH A GAIT BELT FOR TRANSFERS, I AM FRAIL AND WEAK...PLEASE MONITOR ME WHEN I AM IN MY ROOM, I SOMETIMES FORGET TO ASK FOR ASSIST..." RESIDENT #101'S CARE PLAN IDENTIFIED THE CNAS AS RESPONSIBLE TO IMPLEMENT THE INTERVENTIONS. THE RESIDENT (#101) WORKSHEET (NO TITLE AND NO FORM PRINT DATE) DATED 11/7-11/8/12 AND SIGNED BY LICENSED PRACTICAL NURSE (LPN) "N", SHOWED UNDER "INTERVENTIONS ... REAPPROACH/REDIRECT: ASSESS FOR PAIN, OFFER ACTIVITY, OFFER TIME WITH WIFE..." THE FACILITY FAILED TO INCLUDE THE FALL INTERVENTIONS LISTED ON THE CARE PLAN ONTO THE RESIDENT WORKSHEET FOR FACILITY STAFF TO IMPLEMENT AND ENSURE HIS SAFETY. LPN "N" AND LPN "O" WERE INTERVIEWED ON 11/16/12 AT 7:35 A.M. AND 7:40 A.M. RESPECTIVELY. LPN "N" AND LPN "O" STATED THEY WERE NOT SURPRISED THAT THE FALL CARE PLAN INFORMATION WAS NOT IDENTIFIED ON RESIDENT #101'S WORKSHEET. THEY BOTH EXPLAINED THE RESIDENT WORKSHEETS AND RESIDENT CARE GUIDES WERE "HARDLY EVER" KEPT UP TO DATE. BOTH STAFF STATED IF A CURRENT FALL INTERVENTION SHOULD BE ANYWHERE, IT SHOULD BE ON THE RESIDENT WORKSHEETS, BECAUSE THAT IS THE DOCUMENT THE NURSES AND CNAS USE TO DIRECT THE SPECIFIC ASSISTANCE/INTERVENTIONS THEY GIVE TO A RESIDENT. DURING THE INTERVIEWS ON 11/16/12 WITH LPN "N" AND LPN "O", THEY SAID THEY WERE NURSES WHO HAD WORKED WITH RESIDENT #101. THEY BOTH SAID RESIDENT #101 WAS KNOWN TO ATTEMPT TO TRANSFER HIMSELF AND NOT USE THE CALL LIGHT. LPN "O" STATED SHE WAS NOT AWARE STAFF WERE LEAVING RESIDENT #101 ALONE ON THE TOILET. THEY SAID RESIDENT #101 WAS "WEAK AND FRAIL". THE FACILITY'S INCIDENT REPORTS INVOLVING RESIDENT #101 ON 11/7/12 WERE REVIEWED. LICENSED PRACTICAL NURSE (LPN) "O" WAS IDENTIFIED AS PREPARING THE 11/7/12 AT 5:17 A.M. FALL INCIDENT REPORT. ON THE THIS REPORT, IT SHOWED RESIDENT #101 WAS EXHIBITING "SOME CONFUSION" AND RIGHT HIP PAIN AFTER THE FALL. UNDER "MENTAL STATUS", THE REPORT SHOWED "... ORIENTED TO PERSON ... ORIENTED TO SITUATION ... ORIENTED TO PLACE..." UNDER "PREDISPOSING PHYSIOLOGICAL FACTORS" IT SHOWED, "CONFUSED ... INCONTINENT .... RECENT ILLNESS ... WEAKNESS ... IMPAIRED MEMORY". UNDER "PREDISPOSING SITUATION FACTORS", THE REPORT DOCUMENTATION INCLUDED "...AMBULATING WITHOUT ASSIST...POOR SAFETY AWARENESS..." THE FORM TITLED "CNA FALL RE-ASSESSMENT" (2008) UNDER "...HOW COULD IT HAVE BEEN PREVENTED?" SHOWED CNA "Q" WROTE "...BE PREVENTED BY PUTTING ON PERSONAL ALARM..." THE REVIEW OF THE 11/7/12 AT 11:22 A.M. FALL INCIDENT REPORT INVOLVING RESIDENT #101'S SECOND FALL THAT DAY REVEALED REGISTERED NURSE (RN) "J" HAD PREPARED THE REPORT. UNDER "MENTAL STATUS", ONLY "... ORIENTED TO PERSON..." WAS IDENTIFIED. THIS IS A DETERIORATION FROM THE PREVIOUS FALL THAT OCCURRED AT 5:17 A.M. UNDER "PREDISPOSING PHYSIOLOGICAL FACTORS, "...CONFUSED ... RECENT ILLNESS ... WEAKNESS/FAINTED ...." WERE INCLUDED. THE SECTION TITLED, "PREDISPOSING SITUATION FACTORS" INCLUDED, "...AMBULATING WITHOUT ASSIST ... POOR SAFETY AWARENESS ..." THERE WERE NO "CNA FALL RE-ASSESSMENT" FORMS ATTACHED GIVING INFORMATION OF POSSIBLE NEW INTERVENTIONS THAT COULD BE USED TO ASSIST RESIDENT #101 IN NOT FALLING. AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) ON 11/16/12 AT 1:00 P.M. SHE WAS ASKED IF RESIDENT #101'S FALL ON 11/7/12 AT 5:17 A.M. HAD BEEN ASSESSED/EVALUATED WITH THE CARE PLAN INTERVENTIONS, RESIDENT WORKSHEETS AND RESIDENT CARE GUIDES BEING REVIEWED TO DETERMINE IF THE FALL INTERVENTIONS IN PLACE WERE APPROPRIATE OR IF THEY SHOULD BE REVISED. THE DON SAID "NO", AND EXPLAINED THE FACILITY'S CARE PLAN REVIEW SYSTEM AND INCIDENT REVIEW SYSTEM WERE "BROKEN". THE DON CONFIRMED THE FALL CARE PLAN INTERVENTION DATED10/1/12 FOR RESIDENT #101, "PLEASE MONITOR ME WHEN I AM IN MY ROOM, I SOMETIMES FORGET TO ASK FOR ASSIST" WAS NOT DOCUMENTED ON THE RESIDENT WORKSHEET AND INDIVIDUAL RESIDENT CNA CARE GUIDE. THE DON SAID THE CNAS DO NOT ACCESS THE RESIDENT CARE PLANS. SHE EXPLAINED THE CNAS PRIMARILY USE THE RESIDENT WORKSHEETS AND HAVE ACCESS TO THE INDIVIDUAL RESIDENT CARE GUIDES ONLY. CNA "C" WAS INTERVIEWED ON 11/15/12 AT 1:15 P.M. CNA "C" CONFIRMED SHE HAD BEEN THE CNA WHO HAD ASSISTED RESIDENT #101 ONTO THE TOILET AND LEFT HIM UNATTENDED ON 11/7/12 AT APPROXIMATELY 11:00 A.M. WHILE SHE ASSISTED ANOTHER RESIDENT IN ANOTHER ROOM. CNA "C" STATED RESIDENT #101 SAID HE WAS FEELING NAUSEATED, "FEELING SICK" AND "JUST WANTED TO STAY IN BED..." CNA "C" SAID RESIDENT #101 ALWAYS WANTED HIS PRIVACY WHEN USING THE TOILET. WHEN ASKED HOW RESIDENT #101 WAS FEELING WHEN SHE ASSISTED HIM TO THE TOILET AROUND 11 A.M., SHE SAID, "HE SEEMED A LITTLE LETHARGIC OR SLEEPY, BUT I THOUGHT IT WAS BECAUSE HE HAD JUST WOKE UP...HE SEEMED FINE WHEN I LEFT HIM (ON THE TOILET)...ON A REGULAR DAY IF HE WOULD'VE TOLD ME HE WAS FEELING SICK, I PROBABLY WOULD'VE WAITED OUTSIDE THE BATHROOM DOOR...NOT LEFT THE ROOM...BUT I WAS IN HURRY TO ASSIST ANOTHER RESIDENT WHO WAS WAITING..." DURING THE 11/15/12 INTERVIEWS WITH CNA "C" AT 1:15 P.M AND AN ADDITIONAL INTERVIEW WITH CNA "D" AT 1:50 P.M., THEY BOTH STATED THEY WERE NOT AWARE RESIDENT #101 WOULD NOT ALWAYS USE HIS CALL LIGHT AND WOULD ATTEMPT TO SELF TRANSFER. THEY ALSO SAID THEY WERE NOT AWARE OF THE CARE PLAN INTERVENTION REGARDING MONITORING RESIDENT #101 WHEN HE WAS IN HIS ROOM BECAUSE HE SOMETIMES WOULD NOT ASK FOR ASSISTANCE. A PHONE INTERVIEW WAS CONDUCTED WITH RN "J" ON 11/15/12 AT 2:20 P.M. SHE CONFIRMED SHE WAS THE NURSE ON DUTY DURING THE RESIDENT'S FALL ON 11/7/12 AT 11:22 A.M. AND HAD COMPLETED THE INCIDENT REPORT. SHE STATED SHE DID NOT RECALL SEEING THE PREVIOUS (11/7/12 AT 5:17 A.M.) FALL INCIDENT REPORT, BUT WAS VERBALLY INFORMED OF RESIDENT #101'S 5:17 A.M. FALL AND WAS TOLD HE fell DUE TO HIM NOT USING HIS CALL LIGHT FOR ASSISTANCE. RN "J" STATED SHE DID NOT REMEMBER BEING GIVEN ANY CHANGES TO RESIDENT #101'S FALL PREVENTION INTERVENTIONS AFTER THE FALL ON 11/7/12 AT 5:17 A.M. SHE CONFIRMED RESIDENT #101 HAD EMESIS WHICH SHOWED HE HAD THROWN UP HIS MORNING (9 A.M.) MEDICATIONS PRIOR TO THE 11:22 A.M. FALL. SHE STATED RESIDENT #101 WAS ON CONTINUOUS OXYGEN AND HAD DAYS WHEN HE WAS "WEAKER THAN OTHER DAYS" DUE TO HIS "SERIOUS" CO-MORBIDITIES. FAMILY MEMBER "Z" WAS INTERVIEWED BY PHONE ON 11/16/12 AT 8:00 A.M. SHE STATED WHEN SHE GOT TO THE HOSPITAL'S INTENSIVE CARE UNIT ON 11/7/12, SHE WAS TOLD RESIDENT #101 WAS IN CRITICAL CONDITION AND HAD A CRANIAL BLEED. FAMILY MEMBER "Z' STATED RESIDENT #101 WAS STILL IN INTENSIVE CARE "...'VERY CONFUSED' AND THE PHYSICIANS WERE WATCHING HIM CLOSELY." DURING THE 11/16/12 INTERVIEW WITH THE DON, IT WAS LEARNED THAT HER INITIAL ANALYSIS OF RESIDENT #101'S FALL ON 11/7/12 AT 11:22 A.M. WAS NOT COMPLETE AND THE FAILITY HAD FAILED TO IDENTIFY THE ISSUE OF CARE PLAN INTERVENTIONS NOT BEING IMPLEMENTED. SHE SAID IT WAS "CLEAR NOW" THAT RESIDENT #101'S FALLS "PROBABLY" COULD HAVE BEEN AVOIDED IF THE FALL INTERVENTIONS WOULD HAVE BEEN UPDATED AND INCLUDED ON THE RESIDENT WORKSHEET AND RESIDENT CARE GUIDE FOR IMPLEMENTATION. THE DON ADDED, THE FALL COULD HAVE BEEN AVOIDED "IF A SICK RESIDENT (RESIDENT #101)" WOULD NOT HAVE BEEN LEFT ALONE ON THE TOILET..." ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT AN ELOPEMENT FOR ONE (#1) OF 17 RESIDENTS KNOWN AS ELOPEMENT RISKS REVIEWED FOR ADEQUATE SUPERVISION FROM A FACILITY POPULATION OF 69 RESIDENTS. THIS FAILURE RESULTED IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY FOR RESIDENT #1. THE IMMEDIATE JEOPARDY BEGAN ON 7/29/11 AT APPROXIMATELY 8:00 P.M. WHEN RESIDENT #1, WHO WAS KNOWN BY THE FACILITY TO BE AT RISK FOR ELOPEMENT AND SHOWING SIGNS OF CONFUSION, EFFECTIVELY EXITED THE FACILITY THROUGH A WINDOW WHILE RESIDING IN THE FACILITY'S LOCKED DEMENTIA CARE UNIT AND HITCH HIKED A RIDE TO ALPENA, MICHIGAN (APPROXIMATELY 65 MILES FROM THE FACILITY). THE FACILITY WAS UNAWARE OF RESIDENT #1'S WHEREABOUTS/SAFETY UNTIL 7/29/11 AT 11:25 P.M., WHEN THEY WERE TELEPHONED BY RESIDENT #1'S LEGAL GUARDIAN WHO STATED A RELATIVE WHO LIVES IN ALPENA CALLED HER TO SAY RESIDENT #1 HAD JUST LEFT HIS HOUSE. THE LEGAL GUARDIAN NOTIFIED THE ALPENA POLICE ABOUT THE ELOPEMENT. RESIDENT #1 WAS FOUND BY POLICE IN A RESTAURANT, AND TAKEN TO THE POLICE STATION WHERE POLICE TURNED HIM OVER INTO THE CUSTODY OF HIS GUARDIAN AT 2:00 A.M. ON 7/30/11. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 8/3/11 AT 4:00 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 8/4/11 AT 6:00 P.M. BY FACILITY ACTIONS, AS FOLLOWS: 1. PROVIDE ONE:ONE SUPERVISION FOR RESIDENT #1 UNTIL A WINDOW SECURITY ALARM SYSTEM IS INSTALLED/ADEQUATE ON THE DEMENTIA UNIT WHERE RESIDENT #1 LIVES. 2. COMPLETED A NEW ELOPEMENT ASSESSMENT FOR RESIDENT #1. 3. REVISED RESIDENT #1'S PLAN OF CARE TO INCLUDE MORE FREQUENT VISUAL CHECKS OF RESIDENT'S SAFETY/WHEREABOUTS THAN EVERY 2 HOURS. 3. PLACED A WANDERGUARD BRACELET ON RESIDENT #1. 4. INSTALLED A TEMPORARY SECURITY MECHANISM TO PREVENT THE WINDOW IN RESIDENT #1'S ROOM FROM OPENING. 5. MAINTENANCE SUPERVISOR CHECKED ALL THE WINDOWS ON THE LOCKED UNIT WHERE RESIDENT #1 LIVES AND VERIFIED THAT ALL WINDOWS HAD STOPS IN PLACE PREVENTING THE WINDOWS FROM OPENING MORE THAN 6 INCHES. 6. MAINTENANCE SUPERVISOR VERIFIED THE LOCKING MECHANISM FOR THE DOORS TO THE UNIT WHERE RESIDENT #1 RESIDES ARE OPERATING PROPERLY. 7. CONDUCTED ELOPEMENT ASSESSMENTS FOR ALL RESIDENTS - IDENTIFIED SEVENTEEN RESIDENTS WHO ARE AT RISK FOR ELOPEMENT, REVIEWED/REVISED THEIR CARE PLANS AND INSERVICED FACILITY STAFF ON CHANGES MADE. 8. PLACED A LIST OF THE SEVENTEEN IDENTIFIED RESIDENTS AT RISK FOR WANDERING OR ELOPEMENT FOR STAFF'S ATTENTION IN THE CARE GUIDES/NURSE ASSISTANT WORK SHEETS AND VERIFIED WANDERGUARDS WERE IN PLACE FOR THESE RESIDENTS AND PROPERLY FUNCTIONING. 9. DEVELOPED AND BEGAN INSERVICING STAFF ON NEW "POTENTIAL ELOPEMENT: PREVENTATIVE MEASURES POLICY", "ELOPEMENT/MISSING RESIDENT POLICY", THE EXPECTATIONS OF VISUALIZING RESIDENTS EVERY TWO HOURS AND DOCUMENTATION OF MORE FREQUENT CHECKS PER NEW POLICY. THE SURVEYOR CONFIRMED BY OBSERVATION OF 1:1 SUPERVISION BEING PROVIDED TO RESIDENT #1 AND THE TEMPORARY CLOSURE OF THE WINDOW IN RESIDENT #1'S ROOM. VERIFICATION THAT ALL EXIT DOORS WITH ALARMS SOUNDED WHEN TRIGGERED BY A WANDERGUARD BRACELET AND OBSERVATION OF FACILITY STAFFS' RESPONSE OF ALARM SYSTEM WHEN DOORS WERE OPENED. VERIFICATION THAT ON-DUTY FACILITY STAFF KNEW THE NEW "POTENTIAL ELOPEMENT: PREVENTATIVE MEASURES POLICY", "ELOPEMENT/MISSING RESIDENT POLICY", THE EXPECTATIONS OF VISUALIZING RESIDENTS EVERY TWO HOURS, AND DOCUMENTATION OF MORE FREQUENT CHECKS THROUGH INTERVIEW OF THE FACILITY STAFF. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED, AND CONTINUES AT A PATTERN LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM PENDING THE FACILITY'S ABILITY TO: 1. DEMONSTRATE THEIR ABILITY TO PREVENT RESIDENTS WHO ARE AT RISK FOR ELOPEMENT FROM EXITING THE FACILITY WITHOUT ADEQUATE SUPERVISION. 2. DEMONSTRATE THEIR ABILITY TO PROVIDE ADEQUATE SUPERVISION TO MEET THE SPECIAL NEEDS OF THE RESIDENTS WHO ARE AT RISK FOR WANDERING AND ELOPEMENT. 3. VERIFICATION BY THE STATE AGENCY. FINDINGS INCLUDE: ACCORDING TO HIS MEDICAL RECORD, RESIDENT #1 IS A [AGE] year OLD MALE WHO WAS admitted TO THE FACILITY'S LOCKED SPECIAL NEEDS UNIT (SNU) ON 12/28/10. RESIDENT #1'S PRIMARY [DIAGNOSES REDACTED]. ACCORDING TO THE DOCUMENT TITLED "RECERTIFICATION OF CONTINUED SNF/ICF (SKILLED NURSING FACILITY/INTERMEDIATE CARE FACILITY) INPATIENT CARE", SIGNED ON 1/27/11, AND MONTHLY THEREAFTER BY RESIDENT #1'S ATTENDING PHYSICIAN, RESIDENT #1 NEEDED PLACEMENT ON THE "...SPECIALIZED DEMENTIA UNIT DUE TO UNSAFE WANDERING OUTSIDE..." A 2/17/11 REPORT FROM A PSYCHIATRIC CONSULT, ORDERED BY THE FACILITY AND FOUND IN RESIDENT #1'S MEDICAL RECORD, DOCUMENTS RESIDENT #1 "HAS QUITE ADVANCED DEMENTIA WITH POOR SHORT TERM MEMORY... ON HIS COGNITIVE EXAM HE WAS ORIENTED TO PERSON ONLY. HE DIDN'T KNOW THE DAY OR DATE. HE DIDN'T KNOW THE NAME OF THE FACILITY OR THE TOWN HE WAS IN. HE WAS ABLE TO GIVE ME A FEW PIECES OF INFORMATION ABOUT HIS DISTANT PAST THOUGH COULDN'T GIVE ANY INFORMATION ABOUT HIS CURRENT CIRCUMSTANCES... HE DOESN'T UNDERSTAND HIS NEED FOR TREATMENT OR THE NATURE OF HIS TREATMENT. HE'S NOT ABLE TO PARTICIPATE IN MEDICAL DECISION MAKING." INTERVIEWS WERE HELD WITH THE ADMINISTRATOR AND THE DIRECTOR OF NURSING (DON) ON 8/3/11 AT 10:30 A.M. AND AT 3:00 P.M. THE DIRECTOR OF NURSING STATED RESIDENT #1 WAS TRANSFERRED TO THE FACILITY FROM ANOTHER NURSING HOME IN DECEMBER 2010 BECAUSE RESIDENT #1'S GUARDIAN STATED THE COURT HAD ORDERED RESIDENT #1 BE IN A LOCKED DEMENTIA UNIT. EVEN THOUGH THE FACILITY HAS NEVER SEEN THE COURT ORDER OR THE REASONS FOR THE ORDER, THE DON STATED THE FACILITY KNEW RESIDENT #1 HAD A PAST HISTORY OF ELOPEMENT AND WAS AT RISK FOR ELOPEMENT. THEREFORE, AT ADMISSION, RESIDENT #1 WAS PLACED ON ELOPEMENT PRECAUTIONS, INCLUDING HAVING A WANDERGUARD ON HIS ANKLE. THE DON DESCRIBED RESIDENT #1 AS BEING COOPERATIVE AND FRIENDLY. SHE STATED HE HAS HAD NO BEHAVIOR PROBLEMS SINCE ADMISSION. STAFF DO NOT VIEW RESIDENT #1 AS SOMEONE WHO WOULD BECOME VIOLENT. THE DON STATED RESIDENT #1 INTERACTS MOSTLY WITH STAFF, SINCE HIS COMMUNICATION SKILLS ARE BETTER THAN MOST OF THE RESIDENTS ON THE SNU. THE DON STATED STAFF REPORTED RESIDENT #1 FREQUENTLY TALKED ABOUT LEAVING THE FACILITY AND WANTING TO GO HOME. HOWEVER, RESIDENT #1 NEVER ATTEMPTED TO LEAVE THE FACILITY AND NEVER SHOWED ANY SIGNS HE WAS THINKING ABOUT ELOPING, SUCH AS HANGING OUT NEAR THE DOORS. THEREFORE, ACCORDING TO THE DON, FACILITY STAFF DID NOT CONSIDER RESIDENT #1 TO BE AT A HIGHER RISK FOR ELOPEMENT THAN OTHER SUCH IDENTIFIED RESIDENTS. THUS THEY DID NOT PUT IN PLACE ANY EXTRA PRECAUTIONS. THE ADMINISTRATOR, IN THE INTERVIEW ON 8/3/11 AT 10:30 A.M., REPORTED THE SNU WHERE RESIDENT #1 RESIDES, IS A LOCKED UNIT, WITH A KEYPAD ALARM AT THE DOORS. THE WINDOWS ON THE UNIT ARE SECURED WITH A SPECIAL SECURITY STOP, DESIGNED WITH TAMPER-PROOF SCREWS, TO PREVENT THE WINDOWS FROM OPENING MORE THAN 6 INCHES. THE WINDOWS, ACCORDING TO THE ADMINISTRATOR, WERE CONSIDERED "FOOL PROOF". THE ADMINISTRATOR STATED IT WAS THOUGHT TO BE IMPOSSIBLE FOR ANYONE TO GET OUT THE WINDOWS. HE STATED IT WAS ONLY THROUGH "BRUTE STRENGTH" THAT RESIDENT #1 WAS ABLE TO SUCCESSFULLY LIFT THE WINDOW UP AND OVER THE METAL SECURITY STOP TO GET OUT THE WINDOW. THE ADMINISTRATOR REPORTED SINCE THE ELOPEMENT, THE WINDOW IN RESIDENT #1'S PRIVATE ROOM WAS TEMPORARILY FURTHER SECURED SO IT CANNOT BE OPENED. THE ADMINISTRATOR STATED SINCE THEN, RESIDENT #1 HAS TRIED TO OPEN THE WINDOW, AND FOUND HE COULDN'T. THE ADMINISTRATOR SPECULATED RESIDENT #1 HAD PROBABLY BEEN TRYING TO OPEN THE WINDOW SINCE ADMISSION AND JUST GOT LUCKY ON 7/29/11. THE DIRECTOR OF NURSING REPORTED DURING THE FACILITY'S INVESTIGATION OF THE INCIDENT DATED 7/29/11, SHE DISCOVERED THE CERTIFIED NURSE AIDES (CNAS) WERE EITHER NOT DOING THE 2-HOUR BED CHECKS AS FREQUENTLY AS EVERY 2 HOURS, OR WERE ONLY STICKING THEIR HEADS IN THE ROOM AND NOT ACTUALLY SEEING THE RESIDENT. THE DON STATED THIS FAILURE TO FOLLOW STANDARDS OF PRACTICE AND PROPERLY ACCOUNT FOR RESIDENTS' WHEREABOUTS GREATLY DISTRESSED HER. SHE STATED WHAT BOTHERED HER THE MOST WAS THAT BECAUSE OF THIS FAILURE, THE FACILITY DID NOT DISCOVER THE RESIDENT WAS GONE. INSTEAD, THE FACILITY WAS ALERTED TO RESIDENT #1'S DISAPPEARANCE BY A FAMILY MEMBER AT 11:50 P.M. THIS WAS AN HOUR AND A HALF AFTER STAFF HAD DONE A BED-CHECK ON RESIDENT #1, AND APPROXIMATELY THREE AND A HALF HOURS AFTER THE RESIDENT LEFT THE FACILITY. THE DON REPORTED SHE CONDUCTED MANDATORY INSERVICES AFTER RESIDENT #1'S ELOPEMENT. SHE STATED THE ITEM SHE STRESSED THE MOST WAS THAT BED CHECKS HAD TO BE DONE TIMELY AND PROPERLY, EVEN IF IT MEANT TURNING ON THE LIGHTS AND ACTUALLY TOUCHING THE RESIDENT TO CONFIRM THE RESIDENT WAS IN BED. RESIDENT #1 WAS INTERVIEWED AND OBSERVED ON 8/4/11 AT 3:45 P.M. UPON INITIALLY MEETING RESIDENT #1, HIS PHYSICAL APPEARANCE AND COMMUNICATION ABILITIES APPEARED TO BE WITHIN NORMAL RANGE. RESIDENT #1 IS A HUSKY MAN, WHO WAS CASUALLY DRESSED IN JEANS, A PLAID SHIRT AND SNEAKERS. RESIDENT #1 WALKED UNASSISTED FROM THE DINING ROOM ON THE SNU TO HIS ROOM. HIS GAIT WAS NORMAL. RESIDENT #1 WAS FRIENDLY AND TALKED FREELY, IN A BOLD, SOMEWHAT LOUD VOICE. RESIDENT #1 LIKED TO JOKE. HIS LANGUAGE WAS COLORFUL, WITH SWEARING, SEXUAL INNUENDOS AND MUCH MALE BRAVADO. HE BRAGGED ABOUT HIS MANY ADVENTURES, HOW HE COULD WALK A HUNDRED MILES, AND HOW HIS "HONEY" WOULD BE KNOCKING ON THE DOOR ANY MINUTE ASKING HIM TO FORGIVE HER AND WANTING HIM TO COME HOME. AS THE INTERVIEW PROGRESSED, RESIDENT #1'S MEMORY DEFICITS BECAME MORE OBVIOUS. HE OFTEN DID NOT ANSWER THE QUESTION ASKED, OR ONLY GAVE GENERAL ANSWERS WITH DETAILS AND FACTS MISSING. HIS SPEECH WAS TANGENTIAL AND HE COULD NOT STAY ON ONE SUBJECT VERY LONG. RESIDENT #1 FREQUENTLY SKIPPED BACK TO TALKING ABOUT HIS LIFE AS A CHILD, AND HIS PARENTS AND GRANDPARENTS. RESIDENT #1'S TIME ORIENTATION WAS POOR AND HIS MODERATE AND LONG-TERM MEMORY SHOWED IMPAIRMENT. HE STATED HE HAD ONLY BEEN IN THE FACILITY FOR 2 DAYS AND CLAIMED HE HAD HITCHHIKED TO CALIFORNIA ABOUT 2-3 MONTHS AGO. HE ENJOYED TALKING IN GENERAL ABOUT THE OLD DAYS. HOWEVER, HE COULD NOT GIVE ANY DETAILS ABOUT HIS MEDICAL CONDITION, HIS PREVIOUS hospitalization S, OR HIS PREVIOUS NURSING HOME STAYS. RESIDENT #1 ALSO EXHIBITED SHORT TERM MEMORY DEFICITS. HE THOUGHT HE WAS IN A REHABILITATION CENTER IN ALPENA. HE ONLY HAD SPOTTY MEMORY OF HIS TRIP TO ALPENA (HIS ELOPEMENT) ON 7/29/11, WITH VERY POOR SEQUENCING OF EVENTS. RESIDENT #1 COULD GIVE NO ACCURATE ACCOUNTING OF THE ELOPEMENT, INCLUDING WHERE HE WENT, HOW HE GOT THERE, AND HOW HE GOT BACK TO THE FACILITY. HE TALKED MOSTLY ABOUT SEEING HIS "HONEY" AND SAID HE SAW HIS BROTHER-IN-LAW WHO WAS JEALOUS OF HIM. HE REMEMBERED GOING TO A RESTAURANT AND TALKED ABOUT PLACES IN GENERAL IN ALPENA. THE MOST LUCID STATEMENT RESIDENT #1 MADE DURING THE HOUR INTERVIEW WAS WHEN THIS SURVEYOR STATED, "I UNDERSTAND YOU TOOK OUT THE WINDOW" AND RESIDENT #1, GETTING UP TO STAND BY THE WINDOW, STATED "NO, I SLID THE WINDOW OVER AND PUNCHED OUT THE SCREEN." RESIDENT #1 THEN STARTED BRAGGING ABOUT HOW STRONG HE WAS AND HOW HE COULD WALK 100 MILES. HE WALKED OVER TO THIS SURVEYOR GRABBING ON TO HIS THIGHS TO SHOW HOW MUSCULAR HE WAS. RESIDENT #1'S UNDERSTANDING OF HIS CURRENT CONDITION WAS POOR. HIS ABSTRACT REASONING ABILITY, INCLUDING JUDGEMENT AND UNDERSTANDING THE CONSEQUENCES OF HIS ACTIONS, WAS ALSO POOR. HE STATED, CONCERNING THE TRIP TO ALPENA, "THERE'S NO LAW AGAINST GOING TO SEE YOUR 'HONEY'." RESIDENT #1 COULD NOT STATE WHY HE WAS IN THE "REHAB CENTER". HE SAID HE WAS AT THE FACILITY BECAUSE HIS SISTER WAS JEALOUS OF HIM. HE KNEW HIS SISTER HAD SOME POWER OVER HIM, BUT HE DID NOT SEEM TO COMPREHEND WHAT A GUARDIAN WAS OR WHY HE WAS IN THE FACILITY. RESIDENT #1 STATED HE DID NOT NEED TO BE IN THE FACILITY. HIS PLANS FOR THE FUTURE INCLUDED MOVING BACK WITH HIS EX-GIRLFRIEND, AND GOING TO SEE THE STATUE OF LIBERTY. RESIDENT #1 THEN STARTED TALKING ABOUT HIS PAST TRAVELS. RESIDENT #1 WAS ASKED WHAT HE THOUGHT ABOUT THE CARE AND SERVICES PROVIDED AT THE FACILITY. HE STATED HE HAD "SEEN BETTER". WHEN ASKED WHAT HE WOULD DO TO IMPROVE THINGS AROUND THE NURSING HOME, RESIDENT #1 STATED: "I'D GET THE HELL OUT OF HERE." BASED ON THE INTERVIEW WITH RESIDENT #1 ON 8/4/11, HE DOES NOT HAVE THE COGNITIVE ABILITY TO HAVE PLANNED HIS 7/29/11 ELOPEMENT. AN INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSE AIDE (CNA) "A" AT 4:40 P.M. ON 8/3/11. CNA "A" REPORTED SHE THOUGHT RESIDENT #1 HAD A "GOOD MEMORY" ESPECIALLY WHEN TALKING ABOUT THE PAST. SHE STATED IF SHE TELLS RESIDENT #1 SOMETHING NEW, HE TENDS TO GET SOMEWHAT CONFUSED, BUT COMPARED TO OTHER RESIDENTS (ON THE SNU), HE IS HIGH FUNCTIONING. CONCERNING THE ELOPEMENT, CNA "A" BELIEVES RESIDENT #1 UNDERSTANDS WHAT HE DID. CNA "A" REPORTED THAT ON THE NIGHT OF 7/29/11 AT 10:40 P.M. SHE DID A BED-CHECK ON RESIDENT #1. HOWEVER, SHE admitted SHE SAW RESIDENT #1'S SHIRT HANGING ON THE END OF HIS BED AND THE COVERS WRINKLED AND THOUGHT RESIDENT #1 WAS IN BED, WHEN HE ACTUALLY WAS NOT. CNA "A" STATED SHE DID NOT TURN ON THE LIGHT OR WALK INTO THE ROOM, EVEN THOUGH MOST OF THE BED WAS NOT VISIBLE FROM THE DOOR. CNA "A" DID NOT NOTICE RESIDENT #1'S WINDOW WAS OPEN AND THE SCREEN PUNCHED OUT. CNA "A" REPORTED IN THE RECENT FACILITY INSERVICES (7/31/11 AND 8/1/11), GIVEN AFTER RESIDENT #1 ELOPED, IT WAS STRESSED TO STAFF THAT "ANYONE CAN ESCAPE OR GET OUT AND YOU HAVE TO KEEP A CLOSE EYE ON EVERYBODY EVEN WHEN YOU ARE DOING SOMETHING ELSE." CNA "A" REPORTED STAFF HAVE BEEN INSTRUCTED TO DO BED-CHECKS ON EVERYBODY EVERY 2 HOURS AND THAT STAFF MUST ACTUALLY WALK IN THE ROOM, AND IF NECESSARY, TURN THE LIGHT ON, SO THEY CAN VISUALLY SEE THE RESIDENT OR PLACE THEIR HAND ON THE RESIDENT. CNA "B" WAS INTERVIEWED ON 8/3/11 AT 4:15 PM. CNA "B" STATED SHE FELT RESIDENT #1 WAS "JUST SLIGHTLY CONFUSED" WITH A SLIGHT MEMORY LOSS. SHE STATED SINCE THE ELOPEMENT, RESIDENT #1 HAS BEEN "ODDER" AND DOESN'T REMEMBER NAMES, "HE JUST WANTS TO GO HOME." NURSE "C" WAS INTERVIEWED ON 8/3/11 AT 4:45 P.M. NURSE "C" WAS THE NURSE ON DUTY ON THE SNU ON THE EVENING OF 7/29/11 WHEN RESIDENT #1 ELOPED. NURSE "C" STATED RESIDENT #1 HAD "PRETTY GOOD MEMORY, WITH A LITTLE CONFUSION." SHE STATED, "HE MAYBE UNDERSTANDS WHAT HE DID, BUT NOT THE CONSEQUENCES." NURSE "C" STATED RESIDENT #1'S ELOPEMENT HAS SHOWN THAT IF A RESIDENT TALKS ABOUT LEAVING, IT IS IMPORTANT TO PAY ATTENTION TO THE RESIDENT. THE NURSES HAVE NOW BEEN INSTRUCTED TO BE SURE TO RECORD/DOCUMENT WHAT THE RESIDENT IS SAYING. NURSE "C" STATED THE NURSES HAVE ALSO BEEN INSTRUCTED THAT RESIDENTS WHO ARE WANDERERS OR IDENTIFIED AT RISK FOR ELOPEMENT NEED TO BE CHECKED MORE FREQUENTLY. NURSE "C" REPORTED STAFF MUST VISUALLY CHECK ALL RESIDENTS, AND admitted THAT BEFORE THIS INCIDENT, STAFF WERE NOT ALWAYS TURNING ON LIGHTS OR SPEAKING TO RESIDENTS WHEN THEY DID BED-CHECKS. THE OBSERVATION AND INTERVIEW OF RESIDENT #1, AND THE RECORD REVIEW OF RESIDENT #1'S HISTORY, ASSESSMENTS, AND DOCTORS' EVALUATIONS, REVEALED AN INDIVIDUAL WITH MODERATE DEMENTIA, WHO IS A STREET-SMART SURVIVOR, WITH LITTLE FEAR, AND A LOT OF BRAVADO. HE HAS A HISTORY OF ELOPEMENT, AND UNPREDICTABLE BEHAVIOR, INCLUDING VIOLENCE. RESIDENT #1 WAS, AND IS, CONSIDERED AT VERY HIGH RISK FOR ELOPEMENT. IN CONTRAST, INTERVIEWS WITH STAFF REVEALED THEY CONSIDERED RESIDENT #1 BE A FRIENDLY MAN, WITH ONLY MILD MEMORY IMPAIRMENT AND SLIGHT CONFUSION, WHO JUST WANTS TO GO HOME. THE FACILITY STAFF BELIEVED, BECAUSE RESIDENT #1 WAS GENERALLY COOPERATIVE AND HAD NOT ATTEMPTED TO LEAVE THE FACILITY, MEANT HE WAS AT NO HIGHER RISK THAN OTHER RESIDENTS ASSESSED FOR ELOPEMENT. HOWEVER, THAT ASSESSMENT OF RESIDENT #1 IGNORED SEVERAL FACTORS. UNLIKE MOST NURSING HOME RESIDENTS WITH DEMENTIA, RESIDENT #1 IS PHYSICALLY STRONG AND ABLE TO AMBULATE WITHOUT ASSISTANCE. HE HAS NO OBVIOUS MEDICAL PROBLEMS OR PHYSICAL DISABILITIES. ON CASUAL OBSERVATION, RESIDENT #1 DRESSES AND ACTS LIKE A COMMUNITY-DWELLING ELDER. RESIDENT #1 IS FRIENDLY AND TALKATIVE. IN SUPERFICIAL CONVERSATIONS, RESIDENT #1 CAN MAKE "SMALL TALK" AND JOKE WITH OTHERS, AND FOR A BRIEF TIME COVER UP HIS COGNITIVE DEFICITS. FOR INSTANCE, ON 7/29/11 AT 8:30 P.M., JUST AFTER ELOPING FROM THE FACILITY, RESIDENT #1 WAS FOUND ON STATE ROAD M-55 BY A POLICE OFFICER. EVEN THOUGH AT THE TIME HE WAS HEADED TOWARDS WEST BRANCH, IN THE OPPOSITE DIRECTION FROM ALPENA, RESIDENT #1 PRODUCED A DRIVER'S LICENSE, CONVINCED THE POLICE OFFICER HE WAS JUST HITCHHIKING HOME TO ALPENA, AND GOT THE OFFICER TO GIVE HIM DIRECTIONS TO U.S. HIGHWAY 23. THE PHYSICAL ABILITIES AND APPEARANCE OF RESIDENT #1 COMBINED WITH HIS SOCIAL SKILLS, AND NATURAL BRAVADO, MAKE IT POSSIBLE FOR RESIDENT #1 TO CONVINCE OTHERS, EVEN STAFF, THAT HE IS NOT AS COGNITIVELY IMPAIRED AS HE ACTUALLY IS. THIS COMBINATION ALSO MAKES RESIDENT #1 AN EXTREMELY HIGH RISK FOR FUTURE ELOPEMENT. ( )