Every finding on record at Lake Orion Nursing Center

This citation pertains to intake: 3053736.Based on interviews and record reviews the facility failed to promptly implement treatments and interventions as directed by the clinician and failed to ensure ongoing monitoring and evaluation of a resident with an identified change in condition for one (R103) of three residents reviewed for a closed record investigation, resulting in the continued unrecognized decline that required CPR (cardiopulmonary resuscitation) and EMS (emergency medical service) transport to the hospital where the resident subsequently expired, and also failed to ensure medication was available for administration for one resident (R105) of one resident reviewed for medication availability/administration. Findings include: R103 A review of the medical record revealed R103 was admitted to the facility on [DATE] with a readmission date of [DATE] and diagnoses that included: Steele Richadson [NAME] syndrome (a rare and aggressive neurodegenerative disease), gastrostomy and the need for assistance with personal care. A Minimum Data Set (MDS) assessment dated [DATE] noted severely impaired cognitive skills for daily decision making and was dependent on staff assistance for all Activities of Daily Living (ADLs). A review of the [DATE] Medication Administration Record (MAR) / Treatment Administration Record (TAR) documented a PRN (as needed) Ipratropium-Albuterol solution 0.5-2.5 MG (milligram)/3ML (milliliter). Three ml inhaled as needed for sob (shortness of breath). The record documented on [DATE] at 5:02 PM, this treatment was administered to R103. A review of the progress notes and medical record revealed no incident to have occurred and no documentation on the resident status on why the PRN Ipratropium-Albuterol solution was administered. Further review of the record revealed there were no vital signs obtained or documented with the administration of the Ipratropium Albuterol treatment. A review of a Nurse Practitioner (NP) note dated the next day on [DATE] at 1:13 PM, documented in part . Chief Complaint / Nature of Presenting Problem: Tachypnea (rapid and shallow breathing). Called to see patient home staff and husband's request. Patient is lying in bed, positive tachypnea on exam. Patient appears in mild distress. Oxygen saturation and vitals signs are normal however patient exhibiting tachypnea and possible pain. Patient is holding a lot of secretions in her mouth in which she is unable to cough up. Patient is pale and frail. Physical Exam. Alert, +tachypnea on exam, pale and frail appearance in bed. Respiratory: Coarse throughout. Labs reviewed from [DATE]- WBC (white blood cell) 10.3, Hemoglobin (hgb) 7.1, Hematocrit 25.9. BUN (blood urea nitrogen) 38.3, Creatinine 0.5, GFR (glomerular filtration rate) 94, TSH (thyroid stimulating hormone) 10.2. Awaiting new CBC (complete blood count) for today, discussed with husband at bedside regarding low hgb of 7.1, may need to go out for blood transfusion, Start bedside suctioning prn (as needed), Give duoneb nebulizer treatment x 1 now. Discussed with patients husband at bedside, that if further decline and respiratory distress, patient may have to go to hospital, he understands and wants hospitalization. Discussed with nursing staff. A review of the medical record revealed the duoneb nebulizer treatment was not administered and a suctioning order was not implemented as directed by the NP. A review of a Nursing note dated [DATE] at 7:32 PM, by Licensed Practical Nurse (LPN) Q (the nurse assigned to R103 on [DATE]) documented, . This nurse was notified by resident spouse that he believed resident had passed at approx. (approximately) 1557 (3:57 PM), this nurse notified all nurses on floor resident was full code and grabbed crash cart and backboard. CPR (cardiopulmonary resuscitation) started at 1558, 911 called at 1559. EMS (emergency medical services) arrived at 1603, and left with resident as approx. 1615. Resident received 23 cycles of CPR prior to EMS arriving. Resident sent to (hospital name). Further review of the medical record revealed no documentation of the vitals that included respirations and oxygen saturation obtained or monitored for continued decline from the time of the NP examination to the time that CPR was initiated. On [DATE] at 12:22 PM, LPN Q was interviewed and asked to explain what they remembered regarding R103 to have required CPR on [DATE]. LPN Q provided the sequence of their documented note. LPN Q was asked if they had identified a change in condition with R103 and replied No, it was kind of her normal day. LPN Q explained the resident was not verbal with the staff and stated R103's husband sat with the resident all day and attempted to help the staff administer medications to R103. LPN Q was asked if they were aware of the NP examination that identified tachypnea, mild distress, secretions with a directive for a now nebulizer and prn suctioning and LPN Q stated they remembered having a conversation with the NP but could not recall exactly what was verbalized. LPN Q was asked if they had administered the nebulizer treatment or provided suctioning and where they would document that, and LPN Q replied it would be on the MAR. LPN Q stated there would have to be an order to suction. LPN Q was asked where they would document the vitals obtained from R103 or the monitoring of R103 condition and LPN Q replied it would be documented under the vitals tab or progress notes in the medical record. The record review revealed no documentation of vitals obtained, no documentation of monitoring of the resident status during the shift of LPN Q and no documentation of a nebulizer to have been completed or an order for suctioning implemented. A review of an Emergency Department (ED) provider note dated [DATE] (disposition time of 4:47 PM) documented in part, . Primary impression: Cardiopulmonary arrest. Chief complaint: Cardiac Arrest. Patient is [AGE] year-old female history of hypertension and progressive supranuclear palsy. She was at nursing home with her husband when she stopped breathing. CPR was initiated 911 called and brought to the ER (emergency room). Paramedics had performed ACLS (advanced cardiovascular life support) and they said it is approaching about 1 hour. Patient brought to the resuscitation bay and CPR continued. Patient has bradycardia asystolic type rhythm. kept on epinephrine drip and family discussed that patient did not want any of these advanced aggressive interventions. We agreed to stop resuscitation efforts and patient expired. On [DATE] at 12:44 PM, Assistant Director Of Nursing (ADON) A and Registered Nurse (RN) J who both covered the Director of Nursing (DON) role interim were interviewed together. The change in condition and NP examination of R103 was reviewed and discussed. ADON A and RN J were both asked the expectation of how often R103 should have been monitored with vitals obtained per the NP examination findings and both ADON A and RN J agreed that R103 should have been monitored pretty closely. ADON A and RN J was asked to review their records to see if the repeat CBC was completed and asked to provide all documentation of R103's vitals and monitoring documented for the dayshift until CPR initiation of R103 as well as the documentation of the completed nebulizer treatment and implementation of the suctioning as ordered by the NP. ADON A and RN J stated they would look into it and follow back up. At 2:39 PM, a follow up interview was conducted with both ADON A and RN J both reported they were unable to provide additional documentation or an explanation of the above findings. The facility staff provided no additional record reviews or additional information for review before the end of the survey. R105 On [DATE] a concern submitted to the State Agency was reviewed which alleged R105 was a smoker and was not provided Physician ordered smoking cessation patches. On [DATE] the medical record for R105 was reviewed and revealed the following: R105 was initially admitted to the facility on [DATE] and had diagnoses including Acute Kidney Failure and Weakness. A review of R105's MDS (minimum data set) with an ARD (assessment reference date) of [DATE] revealed R105 needed assistance from facility staff with most of their activities of daily living. R105's BIMS score (brief interview of mental status) was nine indicating severely impaired cognition. A Physician's order dated [DATE] revealed the following: Nicotine Patch 24 Hour 14 MG/24HR Apply 1 patch transdermally one time a day for Smoking Cessationand remove per schedule -Start Date- [DATE] 0900 -D/C (discontinue) Date- [DATE] 1558 A review of R105's [DATE] MAR (medication administration record) revealed R105 was not administered their Nicotine Patch on 6/11, 6/12, 6/13, 6/16, 6/17, 6/18, 6/19. A review of R105's EMAR (electronic medication administration record) progress notes revealed the following: [DATE] 09:34 Orders - Administration Note-Note Text: Nicotine Patch 24 Hour 14 MG/24HR-Apply 1 patch transdermally one time a day for Smoking Cessation and remove per schedule-Medication not available. [DATE] 09:16 Orders - Administration Note-Note Text: Nicotine Patch 24 Hour 14 MG/24HR Apply 1 patch transdermally one time a day for Smoking Cessation and remove per schedule-Medication not on, medication not available. [DATE] 09:58 Orders - Administration Note-Note Text: Nicotine Patch 24 Hour 14 MG/24HR Apply 1 patch transdermally one time a day for Smoking Cessation and remove per schedule-Medication not available. [DATE] 10:54 Orders - Administration Note-Note Text: Nicotine Patch 24 Hour 14 MG/24HR Apply 1 patch transdermally one time a day for Smoking Cessation and remove per schedule Not available. On [DATE] at approximately 11:22 a.m., Assistant Director of Nursing A (ADON A), was interviewed regarding R105's Nicotine Patches not being administered per the Physician's order and not being available for administration. The ADON indicated the facility has a standing order for Nicotine patches and was not aware of any reason why R105 should not have had their Nicotine Patch. On [DATE] at approximately 12:30 p.m., during a conversation with Nurse Manger J (NM J), NM J was queried regarding R105's patches not being administered for multiple days in a row and they reported that they did not know why R105 did not receive their Nicotine patches on the days in June. They indicated that the pharmacy never delivered them, and they did now know why. NM J reported that they believed the Nicotine patches were in the backup supply of medications and the Nurses should have pulled them from the backup and administered them. NM J reported the Nursing staff should have followed up with pharmacy when it was not available and also notified the Physician for any additional orders. NM J was queried if the Nursing staff had followed the facility's procedures for medication administration and availability and they reported they did not and that R105 should have had their patches. On [DATE] a request for the facility policy on ensure medication was available was requested and none was received.

This citation relates to Intake 3040613. Based on observation, interview, and record review, the facility failed to complete a full investigation related to an injury of unknown origin for one Resident (R100) of one resident reviewed for abuse. Findings include: Review of a Facility-Reported Incident (FRI) received on 5/29/26 at 4:16 p.m. revealed, Incident Summary: Upon resident (R100) assessment, the resident (R100) exhibited facial grimacing, guarding of the right lower extremity, and vocalization of pain with palpation. No bruising, discoloration, skin tears, swelling, or other visible signs of trauma were observed. Pedal pulses (pulse on foot) were present and capillary refill was less than 3 seconds (possibly indicative of decreased blood flow). On call physician and responsible party (son) notified, order for x-ray was obtained. X-ray results showed an acute oblique fracture (diagonal break of bone, often caused by trauma) of the right distal tibia (ankle area) with displacement and an acute oblique fracture of the right distal fibula (ankle area) without significant displacement. Resident (R100) was sent to the hospital, returned with cast in place. Resident (R100) could not give an account of the cause of injury due to her dementia.We were unable to identify any point of contact or trauma to the right lower leg. Resident remains in the facility, being monitored for comfort/signs and symptoms of pain .Review of the FRI Investigation Summary revealed, A review of the resident's medical record indicates the resident was last observed on May 26, 2026, without evidence of injury, deformity, swelling, bruising, or complaints of right lower extremity pain. Documentation reviewed from that date did not identify any concerns related to the resident's right leg or ankle. The injury was subsequently identified on May 27, 2026, at 1837 (6:37 p.m.) hours.Based on the information available at this time, the injury is believed to have occurred between the resident's last documented assessment without signs or symptoms of injury on May 26, 2026, and the discovery of the fracture on May 27, 2026. The facility has conducted a review of nursing documentation, CNA (certified nurse aide) documentation, therapy records, incident reports, transfer records, and witness interviews. No fall, accident, traumatic event, or other circumstance has been identified that would explain the fracture. No witnesses have been identified. At this time, the injury remains classified as an Injury of Unknown Origin, and the facility investigation of the CENAs and nursing Staff states resident had no signs of pain 5/26 on the day of 5/27 resident could not say what happened to them that they had pain from that leg. Patient was transfer (sic) using a lift resident was stood up and pivoted into bed/chair. Resident (sic) unable to communicate if injury was sustained. BOTH aides said resident did not voice pain that transfer was successful. reviewing the camera and documentation (Assistant Director of Nursing/ADON A) could not substantiate whether the facility was at fault there were no witnesses or injury. Medical Director did not (sic) that resident has a history of osteopenia and brittle bones history (reduced bone density or weakened bones which may predispose a person to a fracture) .Review of R100's Accident and Incident report, dated 5/27/26, revealed no clear cause was found for R100's injury of unknown origin and subsequent ankle fracture. Review of R100's face sheet revealed they were admitted to the facility on [DATE], and their family member was their responsible party (guardian). On 7/14/26 at 10:13 a.m., R100 was observed dressed in their bed, which was lowered, with an adjacent fall mat, and manual wheelchair at the foot of their bed. On 7/14/26 at 10:15 a.m., R100 was asked how they were doing, smiled, and nodded they were fine, however beyond this their speech was non-sensical. R100 was oriented to their name only when asked. On 7/14/26 at 11:19 a.m., Nurse Practitioner (NP) B was asked about R100's injuries and how they occurred. NP B indicated they were not aware and confirmed R100 had a right leg tibia fibular fracture (ankle area). NP B reported they primarily addressed pain and follow up after the fractures were identified. Review of R100's Care Plan (with revisions), accessed 7/15/26 at 3:18 p.m., revealed the following, in bold print (current), Transfer: (R100) requires x 2 (two-person assistance) staff and (Brand name) lift to transfer. Level of care may vary day to day depending on her overall condition. Date initiated: 2/12/26. Revision on 6/08/26. The Care Plan revealed R100's primary diagnoses were stroke, heart failure, adjustment disorder, and dementia. Further review of R100's Care Plan (with revisions) showed an entry in grey, Transfer: The resident (R100) requires 1 person staff assist with gait belt to move between surfaces and as necessary. Level of care may vary day to day depending on her overall condition. Date initiated 2/12/2026. Revision on 5/26/2026. It was noted R100's Care Plan was revised on the date of the transfer. (This care plan entry was included in the facility's investigation report at the time of the occurrence.) On 7/15/26 at 11:49 a.m., the ADON reported they believed R100 may have been injured during a transfer with an aide, CNA EE, when R100 had pain during a transfer. The ADON said they did not believe a fall had occurred and denied abuse concerns. The ADON said they educated their staff afterwards regarding safe transfers. The ADON earlier identified CNA D and CNA E were with the resident on 5/26/26 on the afternoon shift when the unsafe transfer may have occurred and said they had educated their staff. The ADON did not clarify the incident further when asked. Witness statements were requested again in their entirety, as there were no witness statements for LPN DD, CNA EE, or for nurses working on 5/26/26 to 5/27/26, other than LPN FF. The ADON reported CNA EE was terminated for care concerns but not specifically related to this incident. Review of CNA D's witness statement, received in the electronic data share system, received on 7/15/26 (Day 3 of survey) at 1417 (2:17 p.m.), revealed they and CNA EE transferred the resident from their chair to bed, on shift 5/26/26 to 5/27/26, and denied concerns with pain, standing, pivoting, walking, or bearing weight. There was no mention of a type of transfer, a lift, use of a gait belt, or related question. Review of CNA EE's witness statement, received in the electronic data share system on 7/15/26 at 1417 (2:17 p.m.), revealed they transferred R100 from CNA D, on shift 5/26/26 to 5/27/26, and denied concerns with pain, standing, pivoting, walking, or bearing weight. There was no mention or question about the type of transfer, lift, use a gait belt or lift, or related question. The description showed, There was nothing to report. Neither witness statement described their technique used to transfer R100 from their bed to their wheelchair. Review of LPN DD's witness statement, dated 5/28/26, showed they worked the early morning on 5/27/26. LPN DD noted pain during a two-person transfer with CNA EE however did not describe what occurred and were unable to be reached during the survey. LPN DD reported this to the oncoming nurse, LPN FF. Review of LPN FF's witness statement, dated 5/27/26, showed R100 had x-rays in the facility given pain and swelling, and was sent to the hospital shortly afterwards. No fall or injury was noted in this report. Review of the investigation folder provided in the electronic data share system revealed there were no witness statement provided for the nurses who worked on the 5/26/26 afternoon shift, from 3:00 to 11:00 p.m., with CNA D and CNA EE, per the schedule. On 7/15/26 at 2:20 p.m., CNA D was asked during a phone interview about R100's transfer. CNA D confirmed they transferred R100 with two-person assistance on 5/26/26, and R100 did not complain of pain. CNA D said nothing went wrong to their knowledge. CNA D was asked for additional description and did not elaborate. The phone connection was then lost. Two additional calls were made and not returned during the survey. On 7/15/26 at approximately 3:00 p.m., the ADON was asked by the survey team to clarify how the inappropriate transfer occurred. The ADON acknowledged they had not asked if staff had used a gait belt when the involved aides had transferred R100 on 5/26/26 and 5/27/26 during a chair / bed transfers and could not describe the incident further. The ADON acknowledged the concern, given R100's Care Plan designated use a gait belt during transfers. It was noted there were discrepancies in the investigation and conclusions with use of a lift described in the investigation summary and the investigation /interviews showing two-person transfers. The ADON understood the concerns, as they completed the investigation themselves. The DON was unavailable during the survey. On 7/15/26 at approximately 3:15 p.m., the Director of Therapy, Physical Therapist (PT) S, was asked about the facility's expectation for one to two-person pivot transfers. PT S reported their expectation per facility policy / standards of practice would have been for staff to always use a gait belt when completing pivot transfers with residents. On 7/15/26 at 3:48 p.m., CNA EE was asked to clarify specifically how they transferred R100 on 5/26/26 during the afternoon shift. CNA EE said they obtained assistance since they were new in their position, and R100 did not stand up when they attempted to transfer them alone. R100 said they completed a chair / bed transfer with another aide. CNA EE was asked to demonstrate how they transferred R100 on 5/26/26. CNA EE showed the survey team how themselves and another aide were each on the side of R100 and hooked their arms underneath R100's arms, held their pants, and completed a stand pivot transfer. There was no mention or demonstration of a gait belt or of a lift being used. When asked, CNA EE reported only then that they used a gait belt with second aide to transfer R100, however this was not demonstrated or described earlier. Review of the policy, Abuse Program and Procedure, revealed, It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.The facility will investigate all suspicions or allegations of abuse (such as suspicious bruising), will review the occurrence, patterns, and trends that may constitute abuse, and will use the information to determine the direction of the investigation. The policy did not reference an injury of unknown origin and did not describe how to complete a full investigation.

This citation pertains to intake: 2984138.Based on observations, interviews, and record reviews, the facility failed to ensure care plans and/or fall interventions were timely implemented, reviewed, and/or revised. The facility also failed to follow its fall management policy by ensuring all falls were reviewed by the interdisciplinary team and that fall risk assessments were completed in accordance with the facility policy. Findings include:A review of a complaint submitted to the SA (State Agency) reported the facility neglected to address issues regarding resident falls.On 5/13/26 an onsite investigation was conducted.R202A review of the R202's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease and chronic obstructive pulmonary disease (COPD) and history of falls. A Minimum Data Set (MDS) assessment dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 10 (which indicated moderately impaired cognition).On 5/13/26 at approximately 12:00 noon an attempt to observe and interview the resident was unsuccessful. The resident was out of the building at an appointment.A review of an Incident Note dated 2/21/26 at 6:41 PM, documented Resident noted to get up and walk in room and lost balance and fell and hit head on wheelchair. Resident has stated that she doesn't have much pain except in back and on head, head has small scrape and is bruised. Resident stated that she wanted to go to the ER (emergency room) to get checked out due to past falls where she has had a fracture or a sprain. On call called and notified, DPOA (durable power of attorney) called and notified, and on call manager called and notified. Resident awaiting non-emergent EMS (emergency medical services) transport to (hospital name)A review of a Physician consult dated 2/23/26, documented in part . Follow-up fall, ER visit. rib cage pain and multiple bruises following a fall. Patient sustained a fall resulting in rib cage pain and multiple bruises on the face, left arm, right arm, and humerus. Physical examination revealed significant bruising on extremities and face, with a large bruise noted on the humerus. Given the mechanism of injury location of pain, there is concern for possible rib fracture that may have not been adequately evaluated with initial imaging. Plan: Order ribs x-ray to rule out rib fractures, - Apply lidocaine patch to affected area for pain management.A review of the care plan revealed no modifications completed to the Risk for falls (dated 1/8/26) care plan after the resident's fall.A review of the medical record revealed no documentation of the interdisciplinary team to reviewed R202's fall and fall interventions. On 5/13/26 at 12:35 PM, the Administrator was asked to provide the fall incident reports for R202 from January 2026 to current.On 5/13/26 at 1:42 PM, the Administrator replied they had no fall incident reports for the resident.A review of a facility policy titled Falls Risk Management (no date noted) documented in part, . Purpose: Prevent falls and promote safety. If a fall occurs, an investigation is immediately initiated. A fall huddle is conducted, and witness statements obtained. A preliminary. is completed at the time of the fall and nursing interventions will be initiated. An usual occurrence form is completed at the time of the fall. is completed and reviewed by the interdisciplinary team within 24-72 hours of the fall. R203On 5/13/26 at 11:39 AM, R203 was observed sitting up in bed sipping on water. A brief interview was conducted with the resident at that time.A review of the medical record revealed R203 was admitted to the facility with diagnoses that included: acute respiratory failure with hypoxia and orthostatic hypotension.A review of a Nursing note dated 4/16/26 at 7:08 PM, .During dinner resident was sitting in wheelchair and writer was informed that resident had fall in dining room , observed resident on floor, resident stated she was not in any pain and was able to move her extremities, patient did hit her head she stated redness was observed on front of forehead.A review of an occurrence report for the 4/16/26 fall provided by the Administrator documented in part, . Follow up. Education, Care Plan updated, Care Plan generated, Referred to therapy for screen. CNA's (certified nursing aides) to offer to resident to assist her into bed to rest when tired, frequent rest periods.A review of the care plans revealed a care plan titled The resident has had an actual fall with. Poor Balance, Unsteady gait initiated on 3/4/26. This care plan noted no interventions implemented until 4/21/26, five days after the residents 4/16/26 fall.A review of the progress notes and incident reports provided revealed the resident had additional falls on - 1/1/26, 2/15/26, 3/4/26, and 3/25/26.Further review of the care plans revealed a care plan titled . is at risk for falls r/t weakness. initiated on 2/6/26. All interventions on the care plan were also initiated on 2/6/26, more than a month after the residents 1/1/26 fall.A review of a fall risk assessment completed on 12/31/25, noted the resident to be Moderate Risk with a score of 10 and noted to have a history of falls in the last three months.A review of the medical record revealed no fall care plans implemented prior to 2/6/26, despite the resident's fall risk score and history of falls.Further review of the facility policy titled Falls Risk Management documented in part, . all residents are assessed for fall risk by completing a Fall Risk Assessment. Depending on risk level, appropriate interventions will be initiated. A Fall Risk Assessment is to be completed by the restorative nurse or designee for the following. Post Fall.A review of the resident's fall risk assessments revealed no post fall risk assessments completed for the 1/1/26, 2/15/26, 3/4/26 and 4/16/26 falls.R204On 5/13/26 at 11:42 AM, R204 was observed lying on their back in bed. Two grey mats were observed on each side of the bed. A brief interview was conducted with the resident at that time.Review of a Nursing note dated 2/19/26 at 8:16 AM, documented in part . a loud noise was heard coming from resident's direction. Nurse writer went to room and observed resident on floor in front of wheelchair, laying on his Left side, head on bedside mat. Nurse writer asked what happened. Resident state <sic> I was trying to plug my phone in. Non skid footwear on. Call light laying across bed. Small skin tear to L elbow. Area cleansed and treatment applied. Resident denies pain at this time .A review of the resident's fall risk assessments revealed no post fall risk assessment completed for the 2/19/26 fall.On 5/13/26 at 2:48 PM, Nurse A (who was acting as the Director of Nursing (DON) and Assistant Director of Nursing (ADON) in their absences during the survey) was interviewed and asked if an occurrence (incident) form is completed for every fall. Nurse A reported that the unusual occurrence paperwork is completed for every fall and reviewed by the interdisciplinary team (IDT). Nurse A reported the IDT team reviews the occurrence and fall interventions. Nurse A reported the facility's Quality Assurance committee also reviews the occurrence fall report. When asked if an occurrence report was not made for a fall, if it was safe to say that the IDT team and Quality Assurance committee did not review the fall and interventions for that particular fall and Nurse A replied that to be true. Nurse A was asked when staff are expected to complete the residents' fall risk assessments and Nurse A replied they would look into it and follow back up. Nurse A was then asked about R202 fall on 2/21/26 that required a transfer to the hospital. Nurse A was asked why an occurrence form was not completed for the fall and why there were no documentation in the medical record of the residents fall care plan to have been reviewed and modified after the 2/21/26 fall. Nurse A was also asked why fall interventions and/or care plans were not timely implemented to prevent falls for R203, despite multiple falls documented. Nurse A was also asked about the fall risk assessments for R's 203 & 204 to not have been completed post fall per the facility's policy. Nurse A stated they would look into it and follow back up. At 3:54 PM, Nurse A returned with the facility's Fall Coordinator (FC) B. Nurse A confirmed they looked into all of the concerns and were unable to find additional information to provide for review.

This citation relates to Intake 2645567. Based on observation, interview, and record review, the facility failed to provide adequate staffing for two residents, R403 and R404, which had the potential to affect all facility residents. Findings include: Review of an anonymous complaint received by the State Agency on 10/01/25 revealed an allegation when R403 was not assisted with timely toileting on 9/29/25 from 11:00 p.m. to 7:00 a.m. due to short staffing. The complainant alleged, I was speaking with a coherent resident (R403) who stated she sat on the toilet for one hour and 45 minutes and she turned the call light on and no one came to assist for an hour. She (R403) had to use her cell phone to call the facility downstairs and have them send help. After using her own cell phone to call for help it was another 45 minutes before someone came to help her off the toilet, in which she told me she had to scream, 'help, help'. The building is always short staffed . The complainant alleged nursing management did not come in to assist so that the residents get the proper care. The complaint described, .Working (the) midnight shift aides with one person for 40 people is unacceptable. On 12/23/25 at 10:35 a.m., R403 had left the facility with their family. On 12/23/25 at approximately 10:37 a.m., R403's room was observed to have a wide bedside commode adjacent to their bed. On 12/23/25 at approximately 10:38 a.m., Licensed Practical Nurse (LPN) J, was asked about staffing. LPN J reported they had 24 residents including new rehabilitation residents assigned to them on 3 North on this date, which included higher acuity residents who needed wound care, peg tube care, medications passed, extra pain medications, and rehab residents including admissions who may have had more acute treatment needs. LPN J reported when they worked on the [NAME] Hall they had up to 26 residents. LPN J acknowledged at times this could make the medications and treatments late, and the residents became upset sometimes. LPN J reported they did not understand why the other 3 floor nurse had only about 13 residents. LPN J reported they had brought this to management's attention but the situation had not changed. LPN J stated they believed staffing was more number than acuity based, and they wished resident acuity was taken into account more. LPN J reported the aides had anywhere from 15 to 16 residents each on their unit, so they needed to help with transfers and patient care at times as well, and they were concerned they could make a mistake in providing care with such high acuity and residents. LPN J confirmed this had not occurred but they felt there needed to be a solution. LPN J stated they did not understand why the second floor always had three nurses and the 3rd floor had only two nurses assigned. LPN J said the facility had recently hired new nursing management and unit managers assisted at times with the medication pass, but concerns remained as they needed more assistance for resident care needs to be met timely and without being rushed with the current resident census. On 12/23/25 at 11:22 a.m., CNA J was asked about resident care on the 3rd floor, as they were assigned there. CNA J reported they had too many residents and not enough assistance, with up to 15 residents on the day shift. CNA J clarified they could meet the residents' care needs but they were late, which frustrated the residents. CNA J explained it was difficult to check and change residents every two hours so sometimes residents had to wait longer, which concerned them and some of the residents. CNA J said the nurses were understaffed as residents were sometimes getting their medications late as the residents yelled at them about getting late medications. CNA J stated when there were only two nurses up here they had up to 30 residents each and said they watched the nurses' scramble. CNA J explained there was a new rule about two weeks ago that no other staff could help them (the aides) answer call lights. CNA J said the housekeeping staff used to answer call lights to assist with tray or water pass, and other lighter non-certified needs. CNA J was unsure why this rule had been changed but said now they had more duties on them and the nurses, including non-care needs. CNA J said the nurses could not help the aides much as they had pain medications, IV's (intravenous liquids/medications), tube feedings, colostomy bags and other high acuity needs on the 3rd floor.On 12/23/25 at 11:34 a.m., CNA K was asked about caring for residents on the 3rd floor. CNA K confirmed R403 told them of an incident when they were left on their bedside commode too long, which upset them, but said they did not have the details. CNA K reported the 3rd floor residents had higher acuity needs, so with 3 aides or less they struggled. CNA K explained some of the residents were frequently incontinent, needing to be turned, required mechanical lifts, and had frequent toileting needs, so it was difficult getting their care needs met timely, and stated their second schedules check and changes may be late or were not able to be completed. CNA K said some of the residents complained about waiting for care. CNA K said yesterday they had about seven residents who required lifts and two additional who were total care with frequent incontinence who required considerable time and attention. CNA K reported the housekeeping staff used to help them pass trays and this was taken away and they did not understand why as now this was placed back on the aides. CNA K reported some the meal trays were delivered late without the extra assistance, which made the resident's food cold, and they had not seen management coming to assist them. On 12/23/25 at 12:31 p.m., Housekeeping Staff, Staff L, was asked about any assistance they provided the nursing aides. Staff L confirmed they had assisted the nursing aides with passing and picking up meal trays and assisted with making the beds. Staff L reported about a few weeks prior they were told by their supervisor they could no longer assist the aides. Staff L said they felt bad, because the aides were struggling to get the meal trays out timely and there were no concerns with assisting with non-care tasks. Review of the 9/29/25 schedule showed LPN M was assigned to R403 on the afternoon / night shift (12 hours). On 12/23/25 at 1:14 p.m., LPN M confirmed during a phone interview they were R403's nurse on 9/29/25. LPN M stated, We had no aides (on their side of the 3rd floor hall). We probably had one aide for that whole floor and two nurses. We needed one more aide. Families were complaining and I told them the best thing they could do was complain to the Administrator.It was very unacceptable and for some reason all the lights (call) went off and she (the one aide) could not answer each light in a timely manner and she had showers to do and I ended up telling her not to do showers. It was 9/29/25. I was jumping in (to assist) where I could and we had some meds that had to be given at the exact time. I was all over the place because we didn't have the staff . LPN M explained with the unit being primarily there were many residents who needed mechanical lifts who needed two-person assistance for safety but this was difficult without enough aides. LPN M said this occurred from 7:00 p.m. to 11:00 p.m. and clarified they were short (aides) the whole shift. LPN M reported R403 was very upset and said, Did you know I was on the commode so much time? She said it was about an hour. (R403) is A & O x 4 (alert and oriented to person, place, time, and situation) .LPN M said management was always called and we talked to the DON (on 9/29/25) and we called a couple managers. LPN M said residents were waiting up to 2-3 hours for their call lights to be answered on this evening (9/29/25) which was not acceptable. LPN M reported they did not understand why the second floor had two aides and they only had one aide. LPN M said it was an unsafe ratio of patients to staff. LPN M explained by October (2025) they were losing many nurses (who left employment) and aides and by the end of October they only had one aide frequently on the night shift. LPN M reported this could be up to a 1:43 ratio and they felt the residents did not get the care they deserved. LPN M stated nursing was short as well and it could take an hour to an hour and a half for meds to passed beyond their due times, and no management came in to assist them often. On 12/23/25 at 2:05 p.m., R403's Family Member, FM O, reported during a phone interview with R403's permission (who was also on the call due to their hard of hearing) the incident occurred as described in the complaint. FM O stated R403 sometimes used a bedside commode by their bed often. FM O explained they frequently waited on the commode 30 minutes or beyond, which upset R403. FM O described R403 had range of motion impairment in their shoulders and thus needed assistance with peri care and clothing management and needed assistance with transfers on and off the commode. FM O understood R403 waited the hour and a half on several occasions and stated this remained a current concern for R403, as the long call wait times continued to occur. FM O confirmed R403 could tell time accurately and had good cognition and was only hard of hearing. FM O reported this concerned them, as they worked in healthcare and expected timely quality care for R403 and the other facility residents. On 12/23/25 at 2:10 p.m., R403 reported during the phone interview they have talked to the nursing supervisor about their concerns and LPN M. R403 stated yesterday (12/22/25) they went to bed at 7:00 p.m. and did not get changed until 7:00 a.m. in the morning and said they had put their call light on. R403 explained that day (9/29/25) they waited an hour and a half on the commode. R403 said, They don't have enough aides. and described sometimes there was only one aide on the floor (unit) and said she was changing residents as fast as she could. R403 reported, It is still happening and when I sit there so long, I start screaming. R403 reported waiting extended periods for assistance with brief changing for urine and getting onto or off their commode to have a bowel movement. R403 said this made them feel, I don't matter. They wouldn't like it (staff). They don't have enough people. They got (have) enough managers. R403 said they did not see the managers helping, or at least very few. R403 stated, There are some people there just for the paycheck. Review of timecards from 9/29/25 showed there were only 3 aides in the facility from approximately 7:00 p.m. to 11:00 p.m. when R403's toileting incident occurred, which the NHA acknowledged. This would likely have been two aide's downstairs and only one aide for the third-floor residents. Review of the 12/23/25 daily census sheet showed there were 38 residents on the third floor. On 12/23/25 at 2:10 p.m., LPN C reported during a phone interview the facility did not have the proper management coming in when they were short staffed for patient safety as they had concerns about their license. LPN C reported there was a December date when they were short on nurses on the midnight shift, and they came in to assist, and the DON declined. Their main concern was sometimes the afternoon or midnight shift had 2 CNAs for 56 residents, or one CNA for 46 residents earlier this month. LPN C reported R404 fell on [DATE] because their pink incontinence pad underneath them was wet, so they fell because they were sitting in urine and could not get help. Per LPN C, R404 sustained a wrist fracture from the fall. LPN C reported another concern was housekeeping staff were assisting with tray pass and non-care tasks but this had been removed from their duties because of staff conflict. LPN C said housekeeping staff had been essential in assisting with the food tray and non-care dining assistance to relieve the aides of some non-certified tasks. On 12/26/25 at 3:55 p.m., R404 was asked about their fall with fracture. R404 pointed to an orange cast on their nightstand, which had since been removed and said they did not exactly recall how their fall occurred, and said they broke their left wrist. R404 showed surveyor they fell in the space between their bed and bookcase, and they said they slipped and found themselves sitting on their floor. R404 denied any abuse occurred. Review of R404's progress note, dated 10/13/25, revealed, 9:35 (a.m) CNA reported that res (resident) is on the floor. Upon nurse entry into the res's (resident's) room, res was observed sitting upright on the left side of the bed with their legs stretched out straight and their feet under the bed. Res reported that she tried to brace herself during the fall and the impact hurt their left wrist. Per the resident, There was a wet pad on my bed. I stood up to remove it. Then I slipped. I don't know how but as you can see I am on the floor ., The note further revealed, Res (resident) c/o (complained) of pain to L (left wrist).Some swelling noted to L wrist.Res complained of back pain and insisted being sent out 911 emergently, although the facility attempted to get in house x-rays . Review of R404's unusual occurrence report revealed, Res was standing up on the left side of her bed attempting to remove a wet pinky (incontinence) pad from the bed and she slipped.Pain to left wrist.Sent to ED (emergency department hospital). Review of R404's post fall huddle form showed, .0 (no) midnight aide to do check and changes; res (resident) does not recognize physical limitations.Alert and oriented x 3 (spheres). Review of R404's recent BIMS (brief interview for mental status) assessment revealed a score of 15/15, showing they were cognitively intact. Review of the staff schedule, provided by the NHA, for 10/12/25, the midnight shift before R404's fall, showed two aides working on the third floor from 11:00 p.m (10/12/25) to 7:00 a.m. (10/13/25), which showed lower staffing before R404's fall. Review of R404's hospital x-ray, dated 10/13/25 at 2:02 p.m., showed they had an avulsion fracture of the styloid process (wrist fracture). On 12/23/25 at approximately 5:45 p.m., the staffing concerns were reviewed with the NHA and DON. Both understood the concerns related to occasional staffing challenges with afternoon and nighttime aides and reported they were working on hiring and recruitment. Both denied staffing concerns with nursing staff numbers. The DON reported acuity was considered with staffing, as well as staffing numbers/ratios. Review of requested staff schedules and assignment sheets did not show acuity being considered in the staffing numbers. Review of the facility assessment, reviewed 8/28/25, revealed, .Our resident profile. Licensed to provide care for: 120 (residents).Average daily census for 9/30/25 - 10/01/26: 95 (residents).Staffing plan for average daily census which for last year FY25 95 Staffing Grid available for different census numbers: Licensed nurses providing direct care: 4-5 days, 4-5 midnights. Nurse aides: 9-13 (aides) days, 9-11 afternoons, 5-6 midnights.Contingency staffing plan: In the event of a staffing emergency, resident care will be made a priority. All staff will be utilized to provide care. Nurse managers will be moved to the floor to provide care and administer medications. CNAs that work in other departments will be moved to the floor to provide care. All non-licensed staff will complete other tasks such as meal tray distribution, passing water, and other non-direct care tasks. In the event that there is a staffing emergency due to inability to hire internal staff, agency staff will continue to be utilized.Recruitment and retention of direct care staff.Retention incentives: Employee of the Month, Shout outs or employee recognition, events such as a .summer party, or holiday party.communication initiatives such as All-staff huddles and CNA/nurses meetings. It was noted the plan provided did not take into account staffing acuity and referenced the staffing grid only. The resident census was 91 residents on 12/23/25, per the resident census list, close to the average census of 95 residents noted on the Facility Assessment. Review of the facility policy, Staffing Policy, undated, revealed, Purpose: To ensure safe, effective, and compliant staffing levels that meet resident care needs, regulatory requirements, and operational demands while supporting quality outcomes and fiscal responsibility. Policy Statement: The facility will maintain sufficient numbers of qualified, licensed, and competent staff on all shifts to meet resident census, acuity, and service needs. Staffing decisions will be guided by resident care requirements, regulatory standards, quality indicators, and operational efficiency. Scope: This policy applies to all departments, including Nursing (RN, LPN/LVN, CNA), Therapy, Social Services, Dietary, Environmental Services, and Administration. Staffing Determination Staffing levels are determined and adjusted based on daily census, admissions and discharges, resident acuity, case-mix index (CMI), payer mix, state and federal regulatory requirements, infection control needs, quality outcomes, and operational demands related to census growth and throughput. Staffing plans are reviewed daily and modified as conditions change. Minimum Nursing Coverage Licensed nursing coverage will be maintained at all times in accordance with state and federal regulations. CNA staffing will support timely completion of activities of daily living (ADLs) and resident safety. Additional licensed staff may be scheduled to support admissions, treatments, wound care, IV therapy, care coordination, and clinical oversight as needed. Acuity and Throughput Adjustments Staffing levels may be increased to support high-acuity or short-term rehabilitation populations, new admissions and census growth, behavioral or complex medical needs, infection outbreaks, enhanced monitoring requirements, and safe throughput with reduced delays in care transitions. Overtime and Agency Use Overtime and agency staff may be utilized to ensure safe staffing when internal resources are insufficient. Agency use is intended as a temporary solution and will be monitored for cost, quality, and consistency. Recruitment, retention, and scheduling efficiencies will be pursued to reduce reliance on agency staffing. Scheduling and Accountability Department leaders are responsible for maintaining schedules that ensure adequate coverage, minimize burnout, and promote staff retention. Staffing variances and call-ins will be addressed promptly to protect resident safety. Monitoring and Review Staffing effectiveness will be monitored through quality indicators, incident reports, survey outcomes, overtime and agency utilization, and budget variance analysis. This policy will be reviewed and updated as operational needs evolve.Overtime and Agency Use Overtime and agency staff may be utilized to ensure safe staffing when internal resources are insufficient. Agency use is intended as a temporary solution and will be monitored for cost, quality, and consistency. Recruitment, retention, and scheduling efficiencies will be pursued to reduce reliance on agency staffing. Scheduling and Accountability Department leaders are responsible for maintaining schedules that ensure adequate coverage, minimize burnout, and promote staff retention. Staffing variances and call-ins will be addressed promptly to protect resident safety. Monitoring and Review Staffing effectiveness will be monitored through quality indicators, incident reports, survey outcomes, overtime and agency utilization, and budget variance analysis. This policy will be reviewed and updated as operational needs evolve.

This citation pertains to Intake 2546912Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced residents' dignity for three (R402, R404 and R405) of three residents reviewed for dignity. Findings include: R404 On 12/23/25 at 11:58 a.m., R404 was observed in their room dressed and seated on the edge of their bed. R404 stated two to three days prior an aide (Certified Nurse Aide S) rushed them off the toilet when they were trying to have a bowel movement. R404 reported they typically needed one-person assistance to get off their commode. R404 explained CNA S was mean to them when they kept telling them to get off the toilet over and over in a raised voice and then made them get off the commode. R404 further described CNA S and said they were going to report them to their supervisor to come down and see what they caused (which was unclear to them). R404 said this made them feel terrible, belittled.I am scared of (CNA S) now. R404 clarified CNA S had not cared for them since the incident, and they would not allow them to care for them every again and told their nurse (unnamed) about their concerns. R404 said, Give (CNA S) more training. I said something to (CNA S) about her manner and I said, You don't talk to people like that as you don't know why they are here (in the facility). R404 added, She (CNA S) needs extra help with her personality, and I hope (management) can work on her. I hope I don't see her back here. I am fine as long as I don't see her. R404 reported no one had followed up with them about the incident afterwards. R404 denied abuse and described this as undignified conduct with a (negative) attitude and called them aggressive. R404 said they were fine now and had no lasting effect, other than they will not let them work with them. R404 was alert and oriented to herself, time, situation and place. Review of R404's Care Plan, accessed 12/23/25, showed R404 was a [AGE] year-old patient who required one-person assistance with toileting and transfers. They were admitted to the facility on [DATE] with diagnoses including frequent falls, anxiety, heart failure, and late onset Alzheimer's disease. Review of R404's Brief Interview for Mental Status, dated 11/14/25, showed a score of 15/15, which revealed they were cognitively intact. Review of R404's progress notes confirmed there was no nursing, social services, or staff documentation or follow-up about this employee to resident incident, as described by R404. On 12/23/25 at 4:42 p.m., the scheduler, Staff P confirmed they had not been made aware of any incident between R404 and CNA S, and had not removed them from the schedule, and would follow up with management. Staff P confirmed CNA S worked with R404 on 12/21/25, and recently. On 12/23/25 at approximately 5:00 p.m., the Human Resources Consultant, Staff Q, reviewed CNA S's employee file with this Surveyor. The file review confirmed CNA S had received abuse training and had no current or recent disciplinary action since two unprofessional conduct concerns in 2023. Staff Q reported they had not been made aware of the incident and said they would typically be a part of any disciplinary action. No recent competencies were found for CNA S since 2023. On 12/23/25 at approximately 5:15 p.m., R404's concerns regarding this incident and CNA S were reviewed with the Nursing Home Administrator (NHA) and Director of Nursing (DON). Both reported they had not been made aware of the incident and acknowledged the dignity concerns. The DON reported they were considering disciplinary action and would refer CNA S to the [NAME] (Employee Assistance Program). Since both denied being made aware of the incident, they confirmed CNA S had not been removed from working with R404 and ensure this would occur going forward. The DON acknowledged CNA S had abuse and behavioral training however it appeared there were no recent competencies in their employee file. The NHA reported their staff had completed a competency fair with all staff this year, however no documentation of such was received by survey exit upon request, so it was unclear if CNA S had updated competencies. The NHA and DON both reported they would follow up, do retraining, up to disciplinary action, and ensure there were no other resident outcomes for facility residents. R405 On 12/23/25 at 4:18 p.m., R405 was observed laying in their bed with a long brace on their left leg. Their bed was observed by the room door. R405 agreed to be interviewed and reported they were going home tomorrow. A curtain was observed on the right side of their bed. On 12/23/25 at 4:20 p.m., R405 was asked their care at the facility. R405 stated they had a concern the other night (about two days ago) when they were talking with their sister on the phone and their sister asked them a question about a nurse. R405 reported CNA S all of a sudden came around from behind that curtain (on their right side), and I said, Excuse me, and (CNA S) said, I will not be taking care of you anymore tonight, rudely, and said, I am going to get the nurse.(CNA S) told them (their nurse) I was talking about them (R405 confirmed she was not). R405 reported two nurses came in and said, Did something just happen?. R405 said they responded, I don't understand what I did wrong, and began to cry as they felt upset. R405 said the nurses apologized and said CNA S reported their HIPPA (privacy rights) was violated. R405 said CNA S was mixing things up and then told they told their sister to pick them up as they wanted to immediately leave the facility and go home. R405 said the nurses apologized to them, planned to follow-up with CNA S, and talked them into staying. R405 decided to stay after talking with nursing management, as they were told they would have been leaving AMA (Against Medical Advice), and CNA S was immediately relieved from their care. R405 reported their sister came to the facility and stayed with them until 1:00 a.m R405 said, I am ok now, and said they never wanted CNA S to ever care for them again. R405 reported CNA S had not worked with them again since the incident. It was noted R405 was alert and oriented to person, place, time, and situation. On 12/23/25 at approximately 5:30 p.m., the NHA and DON reported they had been made aware of this incident between CNA S and R405, and nursing management had been involved as described. Both confirmed CNA S had not worked with R405 since the incidents. Both reported they understood the undignified care concerns and planned to follow up .including up to disciplinary action and ensuring CNA S would not be working with either R404 or R405 and ensured their safety. Review of the Policy, Policy on Dignified Care, undated, received from the NHA, revealed, Purpose: To ensure all residents receive care that preserves dignity, respect, individuality, and autonomy, and promotes quality of life in accordance with ethical standards and regulatory requirements. Policy Statement: The facility is committed to providing dignified, person-centered care to every resident. All residents shall be treated with respect, compassion, and consideration for their physical, emotional, cultural, psychosocial , and spiritual needs.Principles of Dignified care: Be treated with courtesy, respect, and kindness.Care Practices: Staff shall: Knock, introduce themselves, and explain care before initiating any interaction.Use appropriate draping and close doors or curtains during care.Communicate in a clear, respectful, and age-appropriate manner.Staff responsibility and accountability: Staff are responsible for upholding this policy and reporting concerns related to undignified care, abuse, neglect, or disrespect through appropriate channels. Failure to comply with this policy may result in corrective action. R402 A complaint was filed with the State Agency (SA) that alleged in part, .on 10/16 [2025]. an administrator was also yelling at [R402] to stop crying. were screaming at her and asking if she wanted to go to the hospital and get placed in a psychiatric unit. On 12/23/25 at 8:45 AM, R402 was observed lying in her bed. R402 was asked about what happened on 10/16/25. R402 explained Supervisor 'C' rushed into her room and told her she had C. diff [Clostridioides difficile – a contagious infection of the colon]. she did not know what that was. the staff told her they had to move her to a different room. she did not want to move. she started crying. the Administrator got in her face and told her if she did not stop crying she was going to send her to the psych ward. they moved her in the bed to the elevator to go to another floor, all the staff was standing at the nurse station and they were staring at her, she felt like an animal on display. she could not stop crying. put her in a room with another resident who they said had the same infection. her new roommate was allowed to leave the room, go downstairs to activities, but she was told she could not leave the room. R402 was asked what would have made it easier for her to be moved to another room. R402 explained the staff needed to treat people with respect and dignity. Review of the clinical record revealed R402 was admitted into the facility on 8/4/21 and readmitted on [DATE] with diagnoses including: anxiety disorder, diabetes and spinal stenosis. According to the Minimum Data Set [MDS] assessment dated [DATE], R402 was cognitively intact. Review of R402's Psychosocial Well-Being care plan revealed an approach edited 9/28/25 that read in part, 1. Continue to promote a relationship of mutual trust and respect. 2. Offer choices daily and encourage simple decision making. 4. Provide active listening, validation, and reassurance as needed. On 12/23/25 at 12:28 PM, Licensed Practical Nurse [LPN] 'B' was interviewed and asked about what she observed with R402 on 10/16/25. LPN 'B' explained she was R402's assigned nurse that day, she told R402 that she had C. diff, she said she did not want to move to another room. she told Supervisor 'C' and the Administrator that R402 did not want to move to another room. they said she had to move and then they took over. they told her she had to move, she was yelling and crying, she did not want to move, they moved her anyway. LPN 'B' was asked if she had heard any staff member tell R402 they were going to send her to the psych ward. LPN 'B' explained she had not heard anyone say that, but R402 had told her after that the Administrator had told her that. LPN 'B' was asked if Social Work had been asked to talk to R402 before the move. LPN 'B' explained she did not remember either Social Worker talking to R402 before they moved her. On 12/23/25 at 1:12 PM, former Supervisor 'C' was interviewed by phone and asked what had occurred with R402 on 10/16/25. Supervisor 'C' explained R402 was upset and crying that she had to move. the Administrator told R402 she did not have a choice about moving. R402 said she did not want him in her room so he left and let the Administrator handle the situation because sometimes a change of face will help. they moved her to the other room, she was crying the whole way. On 12/23/25 at 1:25 PM, Social Worker [SW] 'D' was interviewed and asked if she had been involved with moving R402 to another room on 10/16/25. SW 'D' explained she did not know anything about what had happened until after R402 was moved to another room. SW 'D' was asked if she was ever requested to help out if a resident was upset. SW 'D' explained she would have expected staff to get her if a resident was that upset. On 12/23/25 at 1:55 PM, the Administrator was interviewed and asked to describe what happened on 10/16/25 with R402. The Administrator explained R402's nurse came and told her R402 did not want to change rooms and was positive for C. diff. she went and talked to R402 who said she did not want to go by wheelchair. told R402 they could move her in the bed. got two maintenance men and they pushed the bed and she went with them to the new room. The Administrator was asked if R402 was yelling and crying when they were moving the bed. The Administrator explained R402 was not crying or making any noise, she just kept her arms folded across her chest and had her eyes tightly shut the whole way. When asked if anyone had told R402 she was going to be sent to the psych ward if she did not stop crying, the Administrator said no. The Administrator was asked why Social Work had not been asked to talk to R402 before being moved. The Administrator explained Social Work had already talked to the resident before she had. On 12/23/25 at 2:01 PM, SW 'F' was interviewed and asked if she had talked to R402 before being moved to a different room on 10/16/25. SW 'F' explained she had only found out about what happened after R402 was in the new room. On 12/23/25 at 2:05 PM, Maintenance Worker [MW] 'G' was interviewed and asked if he had helped move R402 on 10/15/25. MW 'G' explained they usually do not move beds, and hardly never with a resident in the bed. we were told she had to be moved per physician orders. she did not want to be moved, she was upset and crying. everyone could hear her and were looking at her. it was an uncomfortable position for us to be in. the Administrator told us we had to move her. On 12/23/25 at 2:18 PM, former Infection Control Nurse [ICN] 'E' was interviewed by phone and asked about R402 having to move rooms on 10/16/25. ICN 'E' explained she had not been working that day, and if she had been, the entire situation would have been handled differently. R402 should not have been moved to a different room, R402's roommate should have been moved. the room was already contaminated, so R402 should have stayed in the room and her roommate moved out. she made it abundantly clear that in the future the uncontaminated person is the one who should be moved, not the one with the infection. ICN 'E' was asked if R402's new roommate had been allowed to leave the room. ICN 'E' explained the new roommate was just finishing her isolation for C. diff when they moved R402 into her room. should not have moved R402 into that room, R402 could have reinfected her. ICN 'E' was asked if she had seen R402 when she was in the new room. ICN 'E' explained R402 remained very upset the whole time she was in that room until she was allowed to go back to her original room. Review of R402's census record revealed R402 was moved from her room on 10/16/24 to a room on a different floor, and moved back to her previous room on 10/28/25. On 12/23/25 at 3:15 PM, MW 'H' was interviewed and asked if he had helped move R402 on 10/16/25. MW 'H' explained the Administrator came and got them and told them they had to move a resident per doctor's orders. thought it was an infection control issue. R402 was not happy, she was yelling and crying the whole way. everyone could hear her. he felt bad for her, she did not want to move.

This citation pertains to Complaint #1337621.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (R801) of three residents reviewed for accidents and supervision, resulting in the resident being hospitalized for alcoholic ketosis due to alcohol ingestion and lactic acidosis due to walking in 94 degree Fahrenheit (F) temperatures after staff allowed him to go on a leave of absence (LOA) with an unknown individual without consent from the legal guardian and did not identify he had not returned for approximately 30 hours. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that noted the following, .two days ago a male resident left the facility and no one knew where he was at for 1.5 days .Someone signed him out but they can't read who it was. The police were contacted. The resident was found at (hospital name) and is still there at this time .On 9/9/25 to 9/10/25, an unannounced onsite investigation was conducted.A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis following a stroke, alcohol dependence with withdrawal (as of 6/30/25), type 2 diabetes mellitus, and schizoaffective disorder bipolar type. It was indicated on R801's face sheet that he had a legal guardian. A review of R801's Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had intact cognition. A review of a Letters of Guardianship form revealed R801 was appointed a legal guardian with an expiration date of 11/10/25. The letter noted, Having filed an acceptance of appointment, you have the care, custody, and control of that individual .as to the following powers and responsibilities only: MEDICAL, PHYSICAL & PLACEMENT .A review of a Physician's Statement Attesting to Decision making Capacity revealed two physicians signed the form on 10/25/24 and 11/4/24 and indicated Resident does not have the capacity to make informed medical decisions and had a legal guardian.A review of R801's hospital records revealed the following:A review of an Emergency Documentation note revealed R801 was admitted to the emergency room (ER) on 6/23/25 at 1:57 PM (21.5 hours after R801 was signed out of the facility by an unknown person saying he was going to a restaurant). The following was documented in the note, .presents to (hospital) Emergency Department (ED) via EMS (Emergency Medical Services) due to chest pain, pain all over his body, heat exposure (It was a high of 94 degrees F on 6/23/25). EMS reports they were called for chest pain and when they got to the scene the patient seemed to have been drinking and was complaining of pain all over his body. Patient does have a significant cardiac history with CABG (coronary artery bypass surgery) and MI (myocardial infarction - heart attack) .Patient reassessed numerous time throughout his ED stay. he continued to complain of chest pain and pain all over his body .troponin only mildly elevated, likely type II MI due to acidosis and dehydration. Patient was given Versed push for alcohol withdrawal and copious IV (intravenous) fluids .Lab derangements likely due to dehydration and alcohol use disorder .Due to significant lactic acidosis and need for CIWA (Clinical Institute Withdrawal Assessment of Alcohol Scale) protocol patient will be admitted to the stepdown unit for further evaluation and treatment .A History and Physical Report dated 6/23/25 that read, .presents with chest pain, generalized pain, heat exposure .He endorses prolonged heat exposure while being outside and walking as well as feeling dehydrated from multiple episodes of vomiting. Patient is concerned for alcohol withdrawal symptoms as well .admitted to stepdown unit for alcoholic ketosis (A condition that can occur when a person consumes alcohol and does not consume enough food or water to compensate for the alcohol intake and lactic acidosis/a buildup of lactic acid in your bloodstream when your body produces too much lactic acid and/or cannot metabolize the lactic acid it produces) .2/2 (secondary to) starvation and heat exposure .A review of a Consultation Note from the hospital dated 6/24/25 at 2:16 AM revealed, .complaining of chest pain, pain all over his body, heat exposure. He is having difficulty answering questions. Endorses having multiple episodes of emesis (vomiting) today after being outside and walking. He indicates he had 3 beers today. He is requesting medication for alcohol withdrawal .On 9/9/25 at 12:01 PM, an interview was conducted with Unit Clerk 'A'. When queried about the procedures when a resident went on a LOA, Unit Clerk 'A' reported there was a log book that the resident signed out in. If the residents sign themselves out, a contact number was requested. If someone else signed the resident out and they were not recognized, they ask who they are and request a contact number. When queried about the process when a resident had a legal guardian, Unit Clerk 'A' reported residents with legal guardians were permitted to leave with the guardian or others approved by the guardian. Unit Clerk 'A' reported any restrictions on who a resident was permitted to leave with would be indicated on the face sheet.On 9/9/25 at 12:50 PM, R801 was observed seated on the side of the bed. R801 was pleasant and able to participate in an interview. When queried about his hospitalization in June 2025, R801 said a buddy named (R801's friend's name) came to the facility to pick him up, he went to the person's house in (a local city approximately 10 to 12 miles away from the facility). R801 explained he was left with no ride back to the facility, walked to a store, realized it was very hot outside, tried walking back to his friend's house to see if he could get a ride, but got overheated and passed out on the street. According to R801, a bystander saw him and called an ambulance, and he was taken to the hospital. When queried about whether the staff knew that he left the facility, R801 reported his friend arrived at the facility and said he got me a ride so I went with him. We had to go back upstairs, and the nurse told him to sign me out. R801 reported he had a legal guardian and a brother that he was in contact with. R801 did not reveal any additional information. A review of a Release of Responsibility for Leave of Absence form that noted, Authorization must be signed by the patient or by the nearest relative when a patient is physically or mentally incompetent. An entry dated 6/22/25 at 4:30 PM revealed R801 was signed out by an unknown person (signature was illegible). The address and phone number of the destination was only the name of a restaurant with no address or phone number.A review of a progress note dated 6/23/25 at 9:19 PM, written by Registered Nurse (RN) 'B', noted, 2 North nurse assigned to work the 2nd shift informed the other supervisor part that resident (R801) hasn't returned from going on LOA yesterday .preceded to start trying to get in contact with residents family and guardian .the DON (Director of Nursing) and another arrived and preceded to contact the police and gave report regarding the resident being missing since yesterday .Further review of R801's progress notes revealed the following Nursing notes entered as late entries:On 6/22/25 at 7:30 PM (Recorded as a late entry on 6/23/25 at 9:11 PM), Licensed Practical Nurse (LPN) 'C' wrote a note that read, Oncoming nurse was notified about resident going out to (restaurant name).On 6/22/25 at 9:05 PM (Recorded as a late entry on 6/23/25 at 9:09 PM), LPN 'C' wrote a note that read, Resident left to go out to (restaurant name). Resident was signed out in sign out book at the nurses station.On 6/23/25 at 6:35 AM (Recorded as a late entry on 6/23/25 at 8:37 PM), LPN 'D' wrote a note that read, Received report from dayshift Nurse that resident was on LOA with family. Resident did not return to facility during shift. It should be noted that nurses worked 12 hour shifts at the facility. A review of nursing staff assignment sheets for 6/22/25 and 6/23/25 revealed LPN 'E' was R801's assigned nurse on the first shift (7:00 AM to 7:00 PM) on 6/23/25. There were no progress notes regarding R801 not yet returning to the facility during that shift. A review of a progress note dated 6/24/25 at 2:14 AM revealed a police officer returned to the facility and reported R801 was admitted into the hospital.A review of a progress note dated 6/24/25 at 11:18 AM revealed a note written by LPN 'E' that read, Resident's brother called and informed writer that no one besides himself .his brother (name redacted), or his guardian should be able to pick resident up saying 'Anyone else who comes to take him is up to no good'.On 9/9/25 at 1:05 PM, a telephone interview was conducted with LPN 'C', who was assigned to R801 on first shift on 6/22/25. When queried about R801's LOA, LPN 'C' reported R801 was alert and oriented and had been leaving the facility with unknown people in the past. On 6/22/25, LPN 'C' explained R801 asked to leave so she told him to go see the receptionist and sign out before leaving. R801 came back to the unit and LPN 'C' stated, I was really busy so I just told the person to sign him out. LPN 'C' reported it was around 4:30 PM when R801 left the building and the person who picked him up said they were going to a restaurant. LPN 'C' reported she had not recognized the person, but because she knew he had gone out before and she was very busy, she just asked him to sign R801 out before leaving. LPN 'C' further reported she was unaware of any facility policy at that time and did not know she should have also obtained a contact number of the person who picked R801 up and did not ask when he would be expected back. When queried about whether R801's legal guardian permitted R801 to go out with unknown individuals, LPN 'C' said at the time she was not aware of a LOA policy so she did not contact the guardian. LPN 'C' reported R801 did not return before she left from her shift around 7:00 PM so she notified the incoming nurse that R801 was on LOA and had not returned yet. On 9/9/25 at 2:00 PM, a telephone interview was conducted with LPN 'B' who was the second shift (7:00 PM to 7:00 AM) nurse supervisor on 6/23/25. When queried about what happened with R801, LPN 'B' reported a nurse came to them and another nurse supervisor and said she could not find R801. LPN 'B' reported they looked around the whole facility and could not find him. They looked in the LOA logbook and saw that there was something in the log from the previous day at 4:30 PM, but could not read the signature of who signed him out. LPN 'B' explained it was not reported to second shift that R801 was on LOA or that he was not in the building. LPN 'B' further reported it was discovered R801 was admitted to the hospital. When queried about R801 and whether he was safe to be out on LOA with an unknown individual, LPN 'B' stated, All I will say is that he is very lucky! LPN 'B' reported it was known that at least one other time R801 went on LOA with a friend. LPN 'B' reported they felt R801 required more supervision related to going on LOA and did not feel it was in his best interest for unknown friends to pick him up. LPN 'B' said he contacted R801's legal guardian but she did not answer. A review of an investigation conducted by the facility revealed the following:A Quality Improvement Communication and Education Documentation .Staff Education/In-Service Documentation form for LPN 'C' indicated they were in-serviced on LOA Documentation and Assessment. The form noted, It is imperative that nurses document the activity of our residents. In the case of a LOA the documentation must include who the resident is leaving with, where, and when do we expect the residents return. The nurse must also assess if the person can leave with the party. Does the resident have a legal guardian? Does the guardian give their permission for the LOA? The form was signed by LPN 'C' and LPN 'B' (nurse supervisor) on 6/23/25.A copy of an e-mail sent to the DON by LPN 'D' on 6/23/25 documented, Received report from dayshift Nurse that resident (R801) was on LOA with family. Resident did not return to facility during shift.A handwritten statement by LPN 'E' on 6/24/25 documented, I was told that he was not here, family took him out and he hasn't come back yet. The report sheet said LOA. I didn't write a note because I was told he was gone with family. I assumed the nurse whose shift he left on would have reported/made a note about it. I've never wrote a progress note about someone who was already gone with family before I arrived.An In Service document regarding LOA documented, It is imperative that nurses document the activity of our residents. In the case of LOA, the documentation must include: Resident name and room number .Who the resident is leaving with (The name on the log must be legible and with a WORKING phone number) .Where is the resident going and when do we expect them to return .Dose <sic< the resident have a legal guardian? If so, did the guardian give permission? .There must be a doctor's order if the LOA is overnight to leave the facility .Documentation should be in the logbook at the nurses station and a progress note should be written. LOA need to be reported to the oncoming shift and nurses need to notify supervisors if the resident has not returned at the expected time.On 9/9/25 at 3:37 PM, an interview was conducted with the DON, who was the person the Administrator said conducted the investigation into R801's extended LOA. When queried about the facility's protocol for residents going on LOA, the DON reported there should be a doctor's order that says they are allowed to go out. The resident should alert the nurse if they wanted to go on LOA and the nurse should have the resident or the person signing them out sign the log with their name, a contact number for the person taking them out, where they were going, and the time they were expected back. When queried about how the nurses would know who the residents were permitted to leave with if they had a legal guardian who made decisions for them, the DON reported they would not know unless they contacted the guardian or if something was flagged in the medical record. The DON said if a resident had a legal guardian, the nurse needed to obtain consent prior to allowing the resident to leave. When queried about what staff should do if the resident did not return to the facility, the DON reported they should call the resident, the family, the guardian if they were not back by midnight.At that time, the DON was queried about the investigation into R801's LOA. The DON reported she received a call from one of the nurses around 11:00 PM on Monday night (6/23/25) and they said R801 had not returned from LOA since Sunday afternoon, 6/22/25. The DON asked if R801 was signed out on the LOA log and they said he was signed out in the afternoon on 6/22/25, but it was unknown who signed him out. They started calling family and the guardian and neither picked up the phone. They tried to call the resident and he did not answer. The DON explained the police were called to report R801 as a missing person. The DON contacted the nurse who worked on 6/22/25 when R801 left the building on LOA (LPN 'C') and asked her who he left with and when was he expected to return and she did not know and notified the nurse on the second shift that he had not yet returned from LOA. The DON said she called the second shift nurse (LPN 'D') from 6/22/25 and she said LPN 'C' told her he was on LOA, but she did not do anything further on her shift (from 7:00 PM to 7:00 AM) to check to see where the resident was. The DON said she called the first shift nurse from 6/23/25 (LPN 'E') and she told her she did not see R801 during her shift and did not notify anyone. The DON reported both LPN 'D' and LPN 'E' who were contracted through a staffing agency were no longer scheduled to work at the facility because they did not continue to check for R801's return or notify anyone when he had not returned. When queried about whether she interviewed the resident to determine where he had gone and what happened, the DON stated, No. I just left him alone. When queried about what the legal guardian's response was and what additional interventions were put in place for R801 were, the DON said the legal guardian did not call back. When queried about whether any attempts were made other than the night when LPN 'B' realized he had not returned, the DON did not know and said that guardian was difficult to get a hold of. When queried about whether the guardian was unable to be contacted for almost three months, the DON did not offer a response. The DON said no additional interventions were put in place for R801 and there was nothing in place to prevent him from leaving with an unknown person again, other than staff were educated in general on the LOA policy and the form in the logbook were updated to get a contact number. When queried about whether R801 could leave with the unknown person he left with before, the DON stated, Technically he can.A review of R801's Physician's Orders revealed an order since 4/16/25 that noted, MAY LEAVE ON FACILITY SPONSORED TRIPS IF DEEMED MEDICALLY STABLE. There were no other orders regarding LOA. On 9/9/25 at 4:14 PM, an interview was conducted with Social Worker (SW) 'G'. When queried about R801's legal guardian and whether she was able to get in contact with her, SW 'G' said sometimes, but is not too bad to work with. SW 'G' reported she last talked to her a few weeks ago but never discussed anything regarding LOA with her. On 9/10/25 at 9:36 AM, a telephone interview was attempted with LPN 'D'. LPN 'D' was not available for interview prior to the end of the survey.On 9/10/25 at 9:37 AM, a telephone interview was conducted with R801's legal guardian. When queried about R801's LOA and hospitalization in June 2025, the legal guardian said nobody called her and she was unaware that he went on LOA or was in the hospital. The legal guardian explained that anyone other than his brothers would require getting consent from her before allowing R801 to leave the facility. On 9/10/25 at 9:48 AM, an interview was conducted with R801's brother. R801's brother was aware of R801's hospitalization and when asked if he knew what happened said R801 had a bunch of friends in (city name) and if he was with them they will not be doing anything good. R801's brother said the friends find out R801 has some money and they will pick him up and take him out. He said, Nothing good will ever come of it, if he goes with those friends. R801's brother said he let a nurse at the facility know R801 should only go out with him, his other brother, or the guardian.On 9/10/25 at 1:45 PM, an interview was conducted with the Administrator. The Administrator reported it was her first week working in the facility when the incident with R801's LOA occurred. The Administrator reported the DON was responsible to do the investigation. When queried about why no additional interventions were put in place for R801 after he went on LOA with an unknown person and did not come back to the facility and ended up in the stepdown unit at the hospital, the Administrator reported R801 did not have limitations on who he could go out with. When queried about any discussions with the legal guardian about LOAs since R801 returned to the facility on 6/30/25, the Administrator reported the guardian did not call back. When queried about any monitoring that was put in place to ensure the staff followed the policy they were educated on and what was done to ensure other residents did not experience the same type of incident, the Administrator said the staff were educated and that was it. The Administrator said R801 still goes out all the time. A review of a facility policy titled Signing Out Residents, revised 3/15/14, revealed, in part, the following, Each resident leaving the premises must be signed out .If necessary, medications that must be administered while the resident is out will be given to the resident or the person signing the resident out .Restrictions noted on the resident's chart concerning who may not sign the resident out must be honored. Such restrictions may only be placed on the medical record of each resident declared 'medically incapable' by his or her attending physician, and will be designated by the resident's legal representative .Residents must be signed in by a nurse upon return to the facility .

This citation pertains to Complaint #1337621.Based on interview and record review, the facility failed to ensure a resident with a substance abuse disorder was assessed and interventions put in place for one (R801) of one resident reviewed for behavioral health services, after it was discovered he went on a leave of absence (LOA), consumed alcohol, and was treated for alcoholic ketosis and withdrawal in the hospital. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that noted the following, .two days ago a male resident left the facility and no one knew where he was at for 1.5 days .The resident was found at (hospital name) .On 9/9/25 to 9/10/25, an unannounced onsite investigation was conducted.A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: alcohol dependence with withdrawal (as of 6/30/25). It was indicated on R801's face sheet that he had a legal guardian. A review of R801's Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had intact cognition. A review of a Letters of Guardianship form revealed R801 was appointed a legal guardian with an expiration date of 11/10/25. The letter noted, Having filed an acceptance of appointment, you have the care, custody, and control of that individual .as to the following powers and responsibilities only: MEDICAL, PHYSICAL & PLACEMENT .A review of a Physician's Statement Attesting to Decision making Capacity revealed two physicians signed the form on 10/25/24 and 11/4/24 and indicated Resident does not have the capacity to make informed medical decisions and had a legal guardian.A review of R801's hospital records revealed the following:A review of an Emergency Documentation note revealed R801 was admitted to the emergency room (ER) on 6/23/25 at 1:57 PM (21.5 hours after R801 was signed out of the facility by an unknown person saying he was going to a restaurant). The following was documented in the note, .presents to (hospital) Emergency Department (ED) via EMS (Emergency Medical Services) due to chest pain, pain all over his body, heat exposure (It was a high of 94 degrees F on 6/23/25). EMS reports they were called for chest pain and when they got to the scene the patient seemed to have been drinking and was complaining of pain all over his body .Patient reassessed numerous times throughout his ED stay .Patient was given Versed push for alcohol withdrawal and copious IV (intravenous) fluids .Lab derangements likely due to dehydration and alcohol use disorder .Due to significant lactic acidosis and need for CIWA (Clinical Institute Withdrawal Assessment of Alcohol Scale) protocol patient will be admitted to the stepdown unit for further evaluation and treatment .A History and Physical Report dated 6/23/25 that read, .presents with chest pain, generalized pain, heat exposure .He endorses prolonged heat exposure while being outside and walking as well as feeling dehydrated from multiple episodes of vomiting. Patient is concerned for alcohol withdrawal symptoms as well .admitted to stepdown unit for alcoholic ketosis (A condition that can occur when a person consumes alcohol and does not consume enough food or water to compensate for the alcohol intake and lactic acidosis (a buildup of lactic acid in your bloodstream when your body produces too much lactic acid and/or cannot metabolize the lactic acid it produces) .2/2 (secondary to) starvation and heat exposure .A review of a Consultation Note from the hospital dated 6/24/25 at 2:16 AM revealed, .complaining of chest pain, pain all over his body, heat exposure. He is having difficulty answering questions. Endorses having multiple episodes of emesis (vomiting) today after being outside and walking. He indicates he had 3 beers today. He is requesting medication for alcohol withdrawal .A review of R801's Psychiatry Follow Up note dated 6/19/25, completed by the contracted behavioral health provider revealed, 5/8/25 History of ETOH (alcohol) abuse. Patient currently does not drink alcohol.A review of a Psychiatry Follow Up note dated 8/7/25 (after R801's hospitalization mentioned above) revealed, .Patient was readmitted from (hospital name) on 6/30/25 with diagnosis of alcoholic ketosis .History of alcohol abuse. Patient currently does not drink alcohol. (It should be noted that it was documented in the hospital record that R801 had consumed alcohol which contributed to his admission into the hospital. A review of a History and Physical dated 7/2/25, written by Physician 'G' revealed, .Patient was concern for alcohol withdrawal symptoms as well .When I asked the patient if he was drinking alcohol while is was on his trip outside he denied it in spite of the hospital record showed elevated alcohol level .Diagnosis and Assessment .Alcohol withdrawal syndrome with complication .Treated in the hospital .Lactic acidosis .Due to alcohol intoxication .Alcohol use disorder .Counseled the patient about alcohol use especially while taking narcotics and being diabetic .A review of R801's social services progress notes revealed no documented discussion regarding R801's alcohol abuse disorder.A review of R801's care plans revealed no care plan to address R801 having a substance use disorder (alcohol). On 9/9/25 at 4:14 PM, an interview was conducted with Social Worker (SW) 'F'. When queried about R801 having an alcohol abuse disorder and what interventions were in place to address it, SW 'F' confirmed there was no care plan in place. On 9/10/25 at 1:45 PM, an interview was conducted with the Administrator. When queried about whether R801 should have interventions in place to address R801 having an alcohol abuse disorder, the Administrator reported there should be a care plan in place. A facility policy was requested regarding residents with substance abuse disorders. A policy was not provided prior to the end of the survey.

This citation pertains to Intake Number(s): MI00153580. Based on interview and record review, the facility failed to provide supervision according to the individualized plan of care for one (R801) of three residents reviewed for falls, resulting in an acute intertrochanteric fracture of the left femur (hip) and an acute subdural hematoma (bleeding between the brain and the skull that ultimately resulted in the resident's death after R801 was left unsupervised on the toilet and sustained a fall. Findings include: A review of R801's hospital records revealed the following: A Discharge summary dated [DATE] documented, Discharge Final Diagnosis: Subdural hematoma .(R801) .presented to hospital on [DATE] s/p (status post) unwitnessed fall at her assisted living facility (nursing home). Pt (patient) unresponsive on arrival and not protecting her airway. Pt intubated in the ED (Emergency Department) and taken for CT (Computed Tomography) imaging. Imaging showed acute subdural hematoma measuring 3.6 cm (centimeters) with mass effect, 2.8 cm midline shift, and subfalcine and uncal herniation (a critical condition where accumulating blood compresses and displaces the brain structure causing herniation). Extensive discussion had with family regarding goals of care and comfort measures elected. Pt compassionately extubated on [DATE]. Patient condition continued to decline after extubation. (R801) died on [DATE] at 9:39 . (It should be noted that R801 died on [DATE] at 9:39 per the discharge summary date). A H&P (history and physical) Trauma note documented R801 had a CT of the chest/abdomen/pelvis on [DATE] which revealed an acute intertrochanteric fracture of the left femur and that R801 was unresponsive on evaluation, absent brainstem reflexes. On [DATE], an unannounced, onsite investigation was conducted. A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses that included: hypovolemic shock (a condition caused by severe loss of blood of fluids), dementia with behavioral disturbances, and psychotic disorder. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had intact cognition, no behaviors, required supervision or touching assistance for toilet transfers, and did not have any falls during the assessment period. A review of R801's progress notes from 3/2025 through 5/2025 revealed the following: On [DATE] R801 was observed on the floor on the right side of her bed. R801 reported she slipped while sitting up on the side of her bed and then reaching for her shoes to put on to prepare for a shower. On [DATE], R801 was observed sitting on the floor mat next to the bed. R801 reported she was trying to reach the wash basin and the wheelchair and slid off the bed. R801 was encouraged to use the call light for assistance. On [DATE], R801 was observed on the floor. R801 reported she leaned forward to reach for the wheelchair that was placed by the window. It was documented R801 attempted to self transfer to wheelchair, was a 1 person assist for transfers, but had poor safety awareness and often attempted to transfer independently. It was documented R801's call light was activated at the time of the fall, but R801 did not wait for assistance. On [DATE] at 5:00 AM, R801 was observed on the floor in her room. R801 said she wanted to get to the bathroom and said she did not fall, but sat on the floor mat to prevent herself from falling. The call light was within reach and activated, but R801 did not wait for help. R801 was encouraged to use the call light for assistance. On [DATE] at 2:50 PM, R801 was observed on the floor a second time and said she was trying to go to the bathroom and fell and hit her head on the floor. R801 had a hematoma on the left side of her forehead and was transferred to the hospital in accordance with the physician's orders. R801 returned to the facility at 10:26 PM the same day. On [DATE] at 11:35 PM, R801 was observed on the floor a third time, approximately one hour after returning to the facility from the hospital. R801 reported she did not know what happened and safety checks every hour were implemented for the next 24 hours. On [DATE] at 1:50 AM, R801 was observed on the floor for the fourth time within less than 24 hours. R801 reported she was trying to get cream to put on herself. However the Certified Nursing Assistant (CNA) had already put the cream on a few minutes ago. On [DATE] at 9:30 AM, R801 was observed on the floor by the nurse's station with her wheelchair in front of her. R801 was referred for physical therapy. On [DATE] at 11:15 AM. R801 was observed attempting to self transfer from bed and was placed on one to one supervision. At 11:22 PM, while at the nurse's station, R801 told the nurse she saw a gorilla in her room who almost hit her in the head. At 4:25 PM, R801 was observed on the toilet in her room. R801 reported she transferred herself from the bed to the wheelchair and to the toilet and said she forgot to activate the call light. It was documented that the CNA waited with R801 until she was finished using the toilet and then provided assistance. On [DATE] at 10:13 AM, R801 was observed in her wheelchair. R801 reported she transferred herself and took herself to the bathroom and reported she forgot to use the call light. It was noted R801 refused to wear non-slip socks. On [DATE], R801 took herself to the bathroom and the nurse reminded her to use the call light. R801 said she did not have time to wait. A review of a progress note dated [DATE] at 2:41 PM documented as a late entry (on [DATE] at 8:33 AM) by Licensed Practical Nurse (LPN) 'A' revealed, Writer called in room by 2N (2 North Unit) nurse stating that resident (R801) was on the floor in the bathroom. Writer went in to assess resident and observed resident positioned on laying on her back positioned between wall and toilet. Resident assessed and noted to have left temple with large hematoma and c/o (complained of) pain to her L (left) hip. Resident was assisted back to bed via 2 person manual lift .NP (Nurse Practitioner) present at facility and called to assess. Orders were placed for STAT (right away) X-ray to left hip .Neuro checks initiated . A review of a progress note dated [DATE] at 3:03 PM documented by LPN 'D' revealed, Writer called room for reports of resident on floor in bathroom. Res (resident) positioned on buttocks leaning backwards against toilet seat, positioned between wall and toilet. left temple with large hematoma. Reports pain to left him. Pain with attempts to perform ROM (range of motion). Resident was assisted back to bed via 2 person manual lift .NP present at facility and called to assess .Resident reports that she had been seated on toilet and had 'tried to get my wheelchair' and 'slipped off' toilet. CNA assigned to resident was in 2 [NAME] hallway where a majority of residents are assigned, providing care. Was unaware that resident was on the toilet . A review of a progress note dated [DATE] at 4:35 PM documented by LPN 'D' revealed, Writer called room for reports of res (resident) lethargic. Observed in bed, not responding to verbal or tactile stimuli. Diaphoretic (excessive sweating). BP (blood pressure) 200/88. 911 called and notified need to transfer to (hospital) . A review of an investigation conducted by the facility revealed the following: An Investigation Summary that was also submitted to the State Agency (SA) noted, On the afternoon of [DATE], (R801) was placed on toilet by assigned nurse, (LPN 'A'). Resident was within reach of call light, and able to utilize. (LPN 'A') reported that she had exited room to request that CNA assist with toileting. A short time later it was reported that light was observed to be turned on. Nursing, upon entering room observed (R801) on the floor in the bathroom; nurse proceeded to request assistance of additional nursing staff to assist with assessment and transfer. Three nurses entered room; (LPN 'A'), (LPN 'B') and (LPN 'D'). At that time (R801) was yelling out, in discomfort, holding left hip/sacrum area, reporting pain to area. (NP 'E') was at desk and was notified of concerns with left hip pain and likelihood of fracture, prior to attempting anticipated transfer to bed. Verbal orders obtained to perform STAT X-ray to area .Upon assessment a large hematoma was noted to be developing to left forehead/temple. (R801) reported to have been insisting she 'didn't hit my head'. Nurse Practitioner was then called in to assess the injury .ordered Neuro checks per facility policy for head injuries. Nurses continued neuro checks as ordered, although later in afternoon, during an assessment it was noted that (R801) became unresponsive; pupils dilated. 911 was called and sent to hospital. Later determined that resident had sustained a hip fracture and a subdural hematoma; it was reported by hospital that resident had been vented and then placed on comfort care, and passed away .Written statements of involved parties were taken, cameras were surveyed at time of incident. Residents fall interventions were reviewed. Fall care plan in place and approaches were appropriate. It was noted that (R801) was a Falling Star (a facility program for residents at high risk for falls) due to having sustained a recent increase in impulsive behavior and fall trend in weeks leading up to incident; Part of Falling Star policy involved not leaving a resident unattended on toilet. (LPN 'A') insisted that she had observed (CNA 'C') in hallway and asked her to assist with care of resident. (LPN 'A') reported that she would have remained with resident if she had felt that (CNA 'C') was not going to perform delegated task. Management, during watching the cameras noted that interaction with (CNA 'C'), was not observed to have transpired. Bathroom light was seen for 8 minutes before staff entered room, at which time (R801) has sustained the reported fall .Upon investigation, it was determined involved staff were aware of the facility's star protocol and that (R801) was determined to be a falling star. As a result of this investigation (LPN 'A')'s contract with (facility name) was terminated. (CNA 'C') .was also terminated . A review of R801's care plans revealed the following: A Cognitive Loss/Dementia care plan initiated on [DATE] that read, Resident has a memory/recall problem r/t (related to) dementia. A Falls care plan initiated on [DATE] and edited on [DATE] that read, Resident at risk for falling r/t decreased mobility, keeps door closed for privacy causing staff difficulty visualizing attempts to self transfer; takes medications that can cause falls; falls hx (history); debility from recent hospital stay. The care plan noted multiple interventions initiated on [DATE] (after R801 had five falls within 24 hours between [DATE] and [DATE]) that included: Falling star protocol. A review of the facility's policy and procedure for Falling Star Protocol revealed, in part, the following, Purpose .To identify residents who are at high risk for falls and provide visual awareness to all employees at (facility), so that they can participate as a team in an effort to prevent falls from occurring and reduce the risk for injury. All staff are educated on the falling star program .Procedure .Staff must remain in attendance of resident while toileting, either in the bathroom with the resident or just outside the door . Further review of R801's clinical record revealed Physician's Statement Attesting to Decision Making Capacity forms from [DATE] and [DATE] that indicated R801 does not have the capacity for make informed medical decisions. A review of the camera footage from outside of R801's room on [DATE] between 1:26 PM and 2:32 PM revealed R801's call light was activated at 1:26 PM. At 1:37 PM, LPN 'A' entered R801's room and exited at 1:40 PM. At 1:43 PM, R801's bathroom call light was activated. At 1:48 PM, CNA 'C' walked by R801's room, looked at call light, and did not enter. At 1:50 PM, CNA 'C' walked by R801's room and did not answer the call light or enter the room. R801's call light is no longer lit up at 1:51 PM, but nobody was observed to enter the room. At that time, it was explained by the Director of Nursing (DON) that R801 might have turned the call light off herself. At 1:55 PM, LPN 'B' entered R801's room and exited again. LPN 'B' reentered R801's room at 1:56 PM, followed by LPN 'D' and LPN 'A'. Several other staff members were observed to enter the room, including CNA 'C'. NP 'E' entered R801's room at 2:11 PM. On [DATE] at 11:33 AM, an interview was attempted with LPN 'A' via the telephone. A message was left, but LPN 'A' was not available for interview prior to the end of the survey. On [DATE] at 12:18 PM, an interview was attempted with LPN 'B' via the telephone. LPN 'B' was not available for interview prior to the end of the survey. On [DATE] at 12:22 PM, an interview was conducted with CNA 'C' via the telephone. When queried about what occurred with R801 on [DATE], CNA 'C' reported she was not assigned to R801 that day but was assigned to that hallway. R801's assigned CNA had to work on another hallway as well. CNA 'C' reported she did not witness R801's fall or provide any care to the resident. CNA 'C' recalled seeing R801's call light, but was the only person on the hall at the time and there were other call lights going off so she tried to find someone else to help answer it. CNA 'C' reported at some point the call light was no longer activated and she went into another resident's room. When she came out of the other resident's room, someone told her R801 had fallen. When queried about whether anyone asked her to assist R801 in the bathroom, CNA 'C' reported nobody asked her to assist and it was her understanding someone left R801 in the bathroom. CNA 'C' reported she had been assigned to R801 in the past and she was usually mentally aware and often self transferred, but after a recent hospitalization R801's mental status seemed altered and explained the resident became more anxious and fixated on medical issues and other things. On [DATE] at 2:17 PM, an interview with the DON was conducted. When queried about R801's fall and what the conclusion of the facility's investigation was, the DON reported R801 was a frequent faller and that her cognition teeters. The DON reported LPN 'A' explained to her that she entered R801's room to answer the call light and assisted her onto the toilet. LPN 'A' left the room and explained to the DON that CNA 'C' was outside of the room and she told CNA 'C' to look for R801's call light and when it was activated to help her off the toilet. The DON reported when the facility reviewed the camera footage, LPN 'A' was observed leaving the room and CNA 'C' was not outside of the room and LPN 'A' was not observed talking to CNA 'C'. The DON reported LPN 'A' should have stayed in R801's room until she was done using the toilet. The DON further explained that all staff should answer resident's call lights regardless if they were assigned to that resident, especially when it was blinking which indicated they activated the call light in the bathroom.

Based on observation, interview and record review, the facility failed to ensure continuous oxygen therapy was accurately documented and administered per physician orders for two (R31 and R4) of two residents reviewed for respiratory care. Findings include: R31 On 4/29/25 at 10:36 AM, R31 was observed sitting in a wheelchair in his room with no oxygen on. An oxygen tank was attached to the back of R31's wheelchair and the oxygen tubing was coiled up and in a canvas bag hanging from the handle of the wheelchair. The pressure gauge on the oxygen tank showed the needle between the 1000 and 2000 PSI (pounds per square inch) markings. An oxygen concentrator was observed in R31's room with the oxygen tubing coiled around it. R31 was asked if he usually wore oxygen. R31 explained he had been told he only needed oxygen at night and did not wear it during the day. Review of the clinical record revealed R31 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute respiratory failure with hypoxia (low level of oxygen in body tissues), pulmonary fibrosis and anemia. According to the Minimum Data Set (MDS) assessment dated [DATE], R31 had moderately impaired cognition, and was on continuous oxygen therapy. Review of R31's physician orders revealed an active order for, OXYGEN 2_L (liters)/NASAL CANNULA CONTINUOUS. Every Shift Day, Night. On 4/30/25 at 8:31 AM, R31 was observed sitting in a wheelchair in his room with no oxygen on. The pressure gauge on the oxygen tank, attached to the back of the wheelchair, was at exactly the same level as on the previous day. On 4/30/25 at 3:53 PM, R31 was observed propelling himself in a wheelchair out of the first floor activity room after playing Bingo to the patio to sit outside. R31 was not wearing the oxygen tubing, it was still coiled in the canvas bag on the handle of the wheelchair. Review of R31's April 2025 Medication Administration Record (MAR) revealed the physician order for 2L continuous oxygen was being marked as completed twice a day for the entire month with no blank spaces including 4/29/25 and 4/30/25. On 5/1/25 at 8:20 AM, R31 was observed sitting in a wheelchair in his room with no oxygen on. The pressure gauge on the oxygen tank was still on the same marking as observed on 4/29/25 and 4/30/25. On 5/1/25 at 10:47 AM, Registered Nurse (RN) D was interviewed and asked if R31 wore oxygen. RN D explained R31 had an order for 2L, but would usually not wear it. RN D walked to R31's room and asked him if he wanted his oxygen on. R31 explained they told him to only wear it at night. When asked who they were, R31 did not know. On 5/1/25 at 11:20 AM, the Director of Nursing (DON) was interviewed and informed of the observations on 4/29/25, 4/30/25 and 5/1/25 of R31 not wearing oxygen and the pressure gauge at the same level. The DON explained R31 would usually refuse to wear the oxygen. The DON was asked about the MAR being marked as completed twice a day for the entire month. The DON explained if R31 had refused the oxygen, the MAR should have been marked as refused and not as completed. R4 On 4/29/25 at 10:40 AM, R4 was observed sitting in a wheelchair in his room wearing nasal cannula tubing that was connected to an oxygen concentrator. The concentrator was observed set at 5L. R4 was asked how much oxygen they were supposed to be getting. R4 explained he was supposed to get 2L, but found it at 6L one time and said I guess I don't have to breath as often when it's like that and laughed. Review of the clinical record revealed R4 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: pulmonary fibrosis, chronic respiratory failure with hypoxia and dependence on supplemental oxygen. According to the MDS assessment dated [DATE], R4 was cognitively intact and was on continuous oxygen. Review of R4's physician orders revealed an active order for, OXYGEN_2_L/NASAL CANNULA CONTINUOUS. Every Shift Day, Night. Review of R4's oxygen care plan revealed with an intervention created on 2/2/25 that read in part, Administer oxygen as directed . On 4/30/25 at 8:33 AM and 5/1/25 at 8:20 AM, R4's oxygen concentrator was set on 5L. Review of R4's O2 (oxygen) Saturation documentation revealed: .Oxygen Use: Yes - Liter flow - 2 . 04/29/2025 09:42 AM . .Oxygen Use: Yes - Liter flow - 2 . 04/29/2025 09:15 PM . .Oxygen Use: Yes - Liter flow - 2 . 04/30/2025 08:00 AM . .Oxygen Use: Yes - Liter flow - 2 . 04/30/2025 07:38 PM . .Oxygen Use: Yes - Liter flow - 2 . 05/01/2025 09:51 AM . On 5/1/25 at 10:51 AM, RN D was asked how much oxygen was ordered for R4. RN D explained the order was for 2L. When RN D observed R4's concentrator set at 5L, RN D changed the concentrator to 2L. RN D was asked who was supposed to check to ensure the oxygen was set correctly and RN D explained sometimes the nurses were so busy when passing medications, the concentrators were not checked. On 5/1/25 at 11:20 AM, the DON was informed of the observations on 4/29/25, 4/30/25 and 5/1/25 of R4's oxygen concentrator being set for 5L. The DON explained the nurses should be checking the concentrators when they were in the rooms. When asked about the documentation on R4's O2 Saturations being marked as 2L when observations of the concentrator was set at 5L, the DON offered no further explanation. Review of a facility policy titled, Oxygen Administration revised 1/9/24 read in part, .10. Turn on the oxygen. Start the flow of oxygen at the rate ordered by the physician. Oxygen rate is located on care card and in resident's chart .The following information should be reported to the staff/charge nurse and should be documented in the resident's medical record: .3. The rate of flow, route, and rationale . 8. If the resident refused the procedure, the reason(s) why .

Based on observations, interviews and record reviews, the facility failed to monitor bowel movement and initiated facilities bowel protocol for one (R19) resident reviewed for bowel and bladder. Findings include: On 4/29/25 at 1:34 PM, R19 was observed in room sitting in a wheelchair. R19 was asked how their stay was at the facility, R19 replied that they enjoyed the facility, but they needed to have a bowel movement, and the facility was refusing to give them prune juice. R19 was asked when their last bowel movement was. R19 reported, two or three days ago, and that their stomach had started to experience abdominal discomfort. A record review revealed that R19 was admitted to the facility on [DATE] with medical diagnoses of hemiplegia, cognitive communication deficit and constipation. Review of the minimum data set(MDS) for brief interview for mental status score (BIMs) revealed a 13, which indicated intact cognition. On 4/30/25 at 11:22 AM, a review of the medical record revealed that on 4/26/25 at 11:08 AM, R19 had a medium sized bowel movement, there were no additional bowel movements documented in the clinical record. On 4/30/25 at 12:12 PM, an interview was conducted with the Director of Nursing (DON). When asked, does the facility have a bowel protocol, the DON reported that the nurse managers are to look at the medical record to find the residents who have not had a bowel movement and follow up to see if it's accurate or not. Then, the nurse would start the bowel protocol according to the standing orders. If after everything had been administered and still no bowel movements, the provider will be contacted for further instructions. Everything is to start on day three of no recorded bowel movement. On 5/01/25 at 11:00 AM, an interview was conducted with the DON. When asked when staff should have started the bowel protocol for R19, the DON reported the bowel protocol should have started on 4/29/25 and milk of magnesium should have been administered to the resident. The DON further reported, the managers and nurses should have assessed the resident for a bowel movement. A review of the facility's undated policy titled Bowel Protocol documented .Analyze report to include any residents who have not had a bowel movement in 72 hours. 2. If a resident has not had a bowel movement in 3 days, start protocol. a. Order Milk of Magnesia b. If no results after 8 hours, order Bisacodyl Suppository. There was no additional information provided by the exit of the survey.

Based on observation, interview and record review, the facility failed to ensure a resident's physician ordered treatment was dated and timely provided for one (R23) of two residents reviewed for skin care management. Findings include: On 4/28/25 at approximately 11:25 AM, R23 was observed lying in bed, their right ankle/foot was wrapped with what appeared to be white gauze. There was no date on the wrapped gauze on their ankle. The resident, who was alert and able to answer all questions was asked as to why their left ankle was wrapped and when was the last time nursing staff wrapped it. The resident reported that they had a very deep pressure ulcer on their heel/ankle that was mostly resolved however, they still suffered from what they believed was caused by nerve issues from their wound, and having their heel wrapped helped to lessen the pain. R23 was asked when the last time it was wrapped and their ankle was observed, the resident responded it was several days ago and was believed it should have been removed, and another wrap should have been placed on the ankle a few days ago. Following the interview with R23, Nurse I who was assigned to R23 was asked about the resident and their right ankle treatment. Nurse I reported that they had not done any treatment for the resident. They noted that they did not work directly for the facility but employed through an Agency and had only worked at the facility for two days. Nurse I reported that they had not changed the resident's wrap. Nurse I then went and viewed R23's clinical record and reported that the last treatment was completed on 4/25/25. A review of R23's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: Type II diabetes, cellulitis of left and right lower limb, and generalized anxiety disorder. The resident's Minimum Data Set (MDS) revealed the resident has a Brief Interview for Mental Status (BIMS) score of 14/15 (which indicates intact cognition). Further review of R23's clinical record revealed the following: An order on 4/6/25, Apply Kerlix (Gauze bandage wrap) and abdominal pads(ABD) (gauze used for draining wounds) to right heel, prophylactic PRN (as needed). A progress note on 5/1/25, Res (resident) continues to report tenderness to Right heel. Area of resolved pressure ulcer prior to admission; remains closed .prefers ABD, kerlix wrap for comfort, will continue to monitor . *It should be noted that there were no additional notes pertaining to the resident's Kerlix wrap noted in their clinical record and/or care plan. The Medication Administration Record (MAR) was reviewed for the month of April 2025 and noted the resident received Kerlix and ABD pad to their right heel on 4/22/25 (2:55 AM) and 4/25/25 (7:15 AM) with notes that indicated the PRN reason as completed and noted as effective. On 5/1/25 at approximately 10:58 AM, an interview was conducted with the Director of Nursing (DON) regarding R23. The DON was asked as to the facility's policy/protocol regarding dating and labeling treatment orders. The DON reported that all treatments including R23's Kerlix wrap should be dated. The DON was further asked about the PRN order for R23 and reported that the resident did not like wearing heel protectors but was not clear as to when they wanted their Kerlix changed.

Based on observation, interview and record review, the facility failed to develop comprehensive care plans per residents' assessed needs for two (R72 and R31) of 18 residents reviewed for care planning. Findings include: R72: On 4/29/25 at 10:18 AM, a housekeeper was observed talking to R72 about the bathroom towel bar being ripped off the bathroom wall from a fall the resident had the night before. On 4/29/25 at 10:31 AM, R72 was observed lying in bed with their feet propped up on a wheelchair placed next to the bed. There was a large, white, undated bandage to their left elbow. When asked how they were doing, R72 reported they were doing good and was almost ready to go home but had a bad fall in the bathroom and hit their left elbow and cut it and hit their head. They reported their head was not too bad, but their elbow was the worst. The resident further reported they should've been wearing their grippy socks, they were barefoot and knew better. When asked about the bar if that was broken from the fall, they thought it did but they couldn't remember exactly where/how they fell - they just recall saying 'oh sh** ' and falling down quickly. Resident currently wearing yellow grippy socks. R72 also reported they had ongoing pain with their right shoulder which was the main focus with therapy. On 4/30/25 at 8:46 AM, R72 had the same undated bandage to their left elbow. When asked if they were having any pain or changes in their pain since the fall, R72 reported their pain level was about a seven or eight out of ten (using a 0-10 pain scale, with 10 being the most severe pain level) . They also reported visual hallucinations and thought they saw a [NAME] in the hallway on the floor and it turned out it was a potato chip. They reported they had visual hallucinations prior to coming to the facility that started with the first fall prior to admission. Review of the clinical record revealed R72 was admitted into the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus without complications, depression, syncope and collapse, unspecified fall, and pain in right shoulder. According to the Minimum Data Set (MDS) assessment dated [DATE], R72 scored 11/15 on the Brief Interview for Mental Status Exam (BIMS) which indicated moderately impaired cognition, received scheduled and prn (as needed) pain medication, the pain assessment interview confirmed pain presence and for how much of the time have you experienced pain or hurting over the last 5 days? was marked 3. Frequently, the pain intensity numeric rating scale (00-10) asked the resident: Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine. this was marked as 08. The section for falls noted fall in the last month prior to admission yes, fall any time in the last 2-6 months prior to admission yes, any falls since admission - no. Review of the care plans revealed there were none initiated for fall risk, diabetes, pain, or skin condition. The baseline care plan mentioned the resident will be free from falls. On 4/30/25 at 8:55 AM, an interview was conducted with Nurse Supervisor (Nurse 'A'). When asked who was responsible for initiating care plans Nurse 'A' reported they thought restorative started them, but also thought the MDS Nurse did as well and further reported they didn't do the care plans. On 4/30/25 at 1:05 PM, an interview was conducted with the Director of Nursing (DON). When asked who was responsible for completing care plans, especially for residents at risk for falls, skin concerns, and pain, the DON reported the MDS Nurse was responsible for that. They acknowledged R72 did not have these care plans and further reported they would have to revisit their facility's practices so that care plans were implemented timely and addressed specific care needs. On 4/30/25 at 2:14 PM, the facility was requested to speak with the MDS Coordinator and the Administrator reported the previous MDS Coordinator's last day was 4/18/25 and they were using a consultant as they looked for a new one. 39592 R31 On 4/29/25 at 10:36 AM, R31 was observed sitting in a wheelchair in his room with no oxygen on. An oxygen tank was attached to the back of R31's wheelchair and the oxygen tubing was coiled up and in a canvas bag hanging from the handle of the wheelchair. An oxygen concentrator was observed in R31's room with the oxygen tubing coiled around it. Review of the clinical record revealed R31 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: acute respiratory failure with hypoxia (low level of oxygen in body tissues), pulmonary fibrosis and anemia. According to the Minimum Data Set (MDS) assessment dated [DATE], R31 had moderately impaired cognition, and was on continuous oxygen therapy. Review of R31's physician orders revealed an active order for, OXYGEN 2_L (liters)/NASAL CANNULA CONTINUOUS. Every Shift Day, Night. Review of R31's care plans revealed there were none initiated for oxygen therapy. On 5/1/25 at 10:47 AM, Registered Nurse (RN) D was interviewed and asked about R31's oxygen that was not on. RN D explained R31 usually refused his oxygen. On 5/1/25 at 11:20 AM, the DON was interviewed and asked if R31 should have a care plan for oxygen therapy. The DON explained that yes, R31 should have a care plan for oxygen therapy. When asked if R31's refusals to wear oxygen should also be care planned, the DON said, Yes. According to the facility's POLICY AND PROCEDURE FOR CARE PLANS dated 4/28/25: .The following steps will be implemented in developing comprehensive care plans for the residents to ensure that their ADL, cognitive, communication, psychosocial, mood, activity and health condition needs are adequately being met .Identify problems or needs or etiologies - specific statements that list anything that causes concern to the resident .Problem/need statements refer to anything of concern to the resident .Evaluation and reassessment will determine whether the goal has been met .All care plans will be re-evaluated as outlined in the MDS Process Policy . '

This citation pertains to Intake Number(s): MI00150810, MI00150926, MI00151349 Based on interview and record review, the facility failed to ensure one (R801) of three residents reviewed for accidents, was transferred in a safe manner with fully functioning equipment and with the proper level of assistance, resulting in the resident falling out of the mechanical lift sling and sustaining an acute impacted fracture (fracture typically caused by force or trauma) of the right hip, a distal intertrochanteric fracture (fracture between the bony protrusion of the thighbone) of the right hip, an acute intertrochanteric fracture of the left hip, and Focal round hyperdensity (spot brighter than the surrounding brain indicating an abnormality) within the right sylvian fissure (part of the brain) measuring approximately 5 mm (millimeters) .potentially representing aneurysm (bulging blood vessel) or hemorrhage (bleeding). Findings include: A review of a complaint submitted to the State Agency revealed an allegation that on [DATE], R801 was dropped out the (brand name for mechanical lift). There was only one care giver moving the resident. It was noted R801 was transferred to the hospital where it was determined she had broken both femurs (hips), left wrist, had a brain bleed, and heart stress. R801 had surgery on the femurs, was in the intensive care unit (ICU), and signed onto hospice services on [DATE]. On [DATE] at 10:58 AM, the complainant provided additional information. It was reported R801 died on [DATE] and the death was deemed accidental according to the medical examiner. At that time, a copy of the death certificate was requested. A review of a second complaint submitted to the State Agency revealed an allegation that Certified Nursing Assistant (CNA) 'A' transferred R801 with a mechanical lift without the assistance of another CNA, did not have the sling under the resident appropriately, and R801 was dropped from the mechanical lift. It was alleged R801 had broken femur bones, a hematoma, a brain bleed, and remained hospitalized . It was further alleged CNA 'A' reported the mechanical lift was missing clamps. A review of a Facility Reported Incident (FRI) submitted to the State Agency revealed R801 slipped out of the mechanical lift while being transferred and sustained injuries. An unannounced, onsite investigation was conducted on [DATE]. A review of R801's clinical record revealed the following: R801 was admitted into the facility on [DATE], readmitted on [DATE], and discharged to the hospital on [DATE] with diagnoses that included: Multiple Sclerosis (MS). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had moderately impaired cognition and was dependent on staff for transfers and all activities of daily living. A progress note dated [DATE] at 12:45 PM, written by Licensed Practical Nurse (LPN) 'C', noted, Writer called into room and upon arrival writer observed resident on floor. (CNA) stated that she was getting resident up in chair for lunch and bingo with the lift and a second person. She stated when she went to lift her up and move her she began to slide out of the sling and hit the floor. (CNA) was unable to tell if resident hit her head stating everything happen so fast. Writer assessed resident and noted large hematoma on top of resident L (left) hand, no lumps or bruises were noted to resident head at the time and resident had no c/o (complaints of) pain to her head .Resident communicating at baseline with staff. Due to the extent of resident fall a pillow was placed under resident head for comfort and resident was not moved , writer remained at resident side and sent for supervisor. Supervisor came to room and began the process of sending resident out 911. EMS (Emergency Medical Services) arrived to facility around 11:30 (AM) and resident was sent to (hospital) . A review of R801's care plans revealed care plan initiated on [DATE] that noted the following intervention: TF (transfer) with (brand name mechanical lift - a lift used to transfer residents who are unable to stand or assist with transfers). A review of R801's Imaging results from the hospital revealed the following: A CT (Computed Tomography) CHEST/ABDOMEN/PELVIS . completed [DATE] at 4:15 PM revealed, .REASON FOR EXAM: trauma, dropped from (mechanical lift) .Impression: 1. Acute impacted fracture in the subcapital region of the right hip. Additional distal intertrochanteric right hip fracture. 2. Acute intertrochanteric fracture of the left hip extending into the proximal left femoral shaft, incompletely visualized .4. Suspect mildly impacted acute fracture of the distal left radius (wrist) . A CT HEAD WO (without) CONTRAST completed [DATE] at 4:15 PM revealed, .REASON FOR EXAM: trauma .Impression: Focal round hyperdensity within the right sylvian fissure measuring 5 mm. This appears new from prior study and is nonspecific, potentially representing aneurysm or hemorrhage . A review of an investigation conducted by the facility revealed the following: (R801) was being transferred in a (mechanical lift) by (CNA 'A'). One of the sling's loops in the arm of the lift slipped off and (R801) slid to the floor during a transfer from her bed to her wheelchair. 911 was called after complaints of leg pain. Administrator notified on ,d+[DATE] that (R801) has an acute displaced spiral fracture of bilateral femoral metadiaphysis and mild foreshortening of the right femur. She has also a suspected nondisplaced radial styloid fracture. She is currently in the hospital. The lift was immediately pulled from the floor and inspected. It appeared to be in good working order however a safety clip on the arm was not present . .Investigation Summary/Actions Taken .(R801) .has been bed bound for a number of years .The Administrator and Director of Nursing (DON) met with (CNA 'A') and reenacted the incident with the same lift to determine the root cause. (CNA 'A') was using the (mechanical lift) to transfer (R801) from her bed to her wheelchair. She had another staff member present (Housekeeper 'B') .(CNA 'A') lifted her off the bed and then moved the lift away from the bed. She began to turn it towards her wheelchair, which was placed at the foot of her bed. As she was turning the lift, (R801's) body weight shifted, and the sling swung out. The legs of the lift were extended but the motion moved one of the slings loops off the arm of the lift and (R801) slid out of the sling and onto the floor. She began to complain of pain in her left hip and had a large hematoma on top of her left hand .She was immediately sent to (hospital) for evaluation . .It was determined the next day, while reviewed hospital paperwork, that she was diagnosed with Bilateral femur fractures and suspected left radial styloid fracture .Her initial CT of her head was negative. Repeat imaging was completed and neurosurgery stated that she likely sustained a mild traumatic brain injury with the development of a very small acute subarachnoid hemorrhage (brain bleed). (R801) is set to have surgery on ,d+[DATE] to repair her fractures .The family has decided to pursue palliative care and will not be returning to (facility) . .Investigation showed that preventative maintenance was completed quarterly on the lift and was just serviced on [DATE] .A post incident evaluation of the lift was completed and found that the only concern was a safety clip missing from one arm .It appears that the sling loop slipped out of the arm due to the safety clip not being present .At this time, it appears the missing safety clip played a pivotal role in (R801's) fall. A full nursing staff education is being completed .This education will be focused on the proper assessment of lift equipment prior to use, how to determine what type of transfer status a resident has been approved for . On [DATE] at 11:19 AM, an interview was conducted with Housekeeper 'B' via the telephone. When queried about what happened to R801 on [DATE], Housekeeper 'B' explained she went into R801's room and CNA 'A' was getting R801 ready for lunch. The sling for the mechanical lift was underneath R801 and R801 was lying in bed. When CNA 'A' lifted R801 up using the lift, R801 fell out of the sling and onto the floor. Housekeeper 'B' reported there were no other staff members in the room during the transfer. When queried about whether they were cleaning R801's room at the time, Housekeeper 'B' stated, I guess I was just in there. Housekeeper 'B' reported CNA 'A' asked her to come into the room to spot her with (R801). Housekeeper 'B' explained she was just in the room and did not provide any assistance to CNA 'A' during the mechanical lift transfer of R801. Housekeeper 'B' went to get the nurse after R801 fell . On [DATE] at 11:25 AM, an interview was conducted with CNA 'A'. CNA 'A' reported she began working in the facility in [DATE] and had been a CNA for [AGE] years. When queried about how R801 fell on [DATE], CNA 'A' explained she was getting R801 up for lunch and bingo afterwards. She got R801 dressed and did her hair and placed the sling (for the mechanical lift) underneath the resident who was on the bed. CNA 'A' reported she checked the battery for the lift and that the feet of the lift were fully expanded. CNA 'A' said she had a spotter in the room with her. CNA 'A' explained she got the sling hooked up to the lift, raised the resident up in the sling, turned the resident to position her over the wheelchair, and when she did that, R801's weight shifted and she fell out of the sling from the lift and onto the floor. When queried about who was assisting her with the transfer, CNA 'A' reported Housekeeper 'B' came in to spot. When queried about why she asked a housekeeper to spot and did not get a nurse or a CNA to assist with the transfer, CNA 'A' reported the other CNA assigned to the hall was in with another resident, the CNA orientee was showering a resident, she did not know where the other CNA was, and the nurse was busy passing medications. According to CNA 'A', the paper she received during orientation regarding mechanical lift transfers only mentioned having a second person in the room as a spotter and she understood that to mean another set of eyes and not actually assisting with the transfer. CNA 'A' further reported one of the clips on the hanger bar to the lift (the part where the sling is clipped too) was missing. CNA 'A' explained that the sling is hooked onto the bar and a clip locks the sling in place. CNA 'A' reported she noticed it was missing on the hook located by R801's right leg and stated, It is what we had available and explained she continued to transfer the resident with the missing clip. CNA 'A' explained she did not think the sling would come off the hook with or without the clip because everyone had been using the mechanical lifts with missing clips, but she could see how that may have contributed to her fall because it was the side R801 fell from. On [DATE] at 12:58 PM, an interview was conducted with the Administrator. When queried about what was discovered through the facility's investigation into R801's fall, the Administrator reported CNA 'A' walked her through what happened and explained after examining the sling and the lift, the side R801 slipped out of was the side with the missing safety clip so they determined that to be the likely cause of R801's fall from the lift. The Administrator further reported after reviewing the facility policy regarding mechanical lift transfers at the time of R801's fall, it was discovered it said two people were required, but did not specify what that meant. It was further reported that the manufacturer's manual for the mechanical lift did not mention the safety clips so it was unclear if it was important. When queried about the purpose of the clips, the Administrator reported the clip locked the sling into place on the hook but that the importance of them was likely not clearly communicated to nursing staff. When queried about CNA 'A' asking a Housekeeper to spot during a mechanical lift transfer requiring two people to assist, the Administrator reported CNA 'A' made a bad decision and should have waited for a member of the nursing staff team to assist. On [DATE] at approximately 3:30 PM, an observation of the type of mechanical lift used on [DATE] with R801 was conducted. On each end of the hanger bars were hooks that secured with a metal clip. At that time, CNA 'D' was interviewed regarding the safety clips on the mechanical lifts. CNA 'D' explained before a month ago, there were times where they would be missing from the lift. CNA 'D' further said they were easy to remove and demonstrated how to remove them and stated, I have never done it, but could see someone taking the clip off because it would be easier to get the sling off the hook after the transfer. On [DATE] at 4:45 PM, an interview was conducted with LPN 'C'. When queried about what happened to R801, LPN 'C' reported she was notified by Housekeeper 'B' that R801 fell from the mechanical lift. LPN 'C' was not in the room when in happened, but assessed R801 after the fall. When queried about whether CNA 'A' requested assistance with transferring R801, LPN 'C' reported she did ask for assistance, but she was in the middle of administering medication. LPN 'C' reported CNA 'A' said she needed assistance, but after LPN 'C' passed the medication, CNA 'A' was in the resident's room and did not return to ask for help. A review of a .Discipline Employee Counseling Report dated [DATE] revealed CNA 'A' received counseling regarding not following the policy regarding lift safety and have a second person during a mechanical lift that was a trained caregiver. A review of a form titled, Orientation - CNA Expectations signed by CNA 'A' upon hire on [DATE] revealed, .Lifts demonstrated first time as 'spotter'/second person . A review of an undated facility policy titled, Resident Transfers revealed, in part, the following, .Prior to transferring the resident, refer to the Care Card for the appropriate transfer status .Safety is our primary concern with transfers . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included inspection of all mechanical lifts to ensure they were in working order and updated the policy to include ensuring safety clips were part of the safety check process, education was provided to all licensed nursing staff to include proper safety checks of the mechanical lifts and to ensure appropriate assistance is provided according to the resident's plan of care. The facility conducted audits of staff who provide transfers using a mechanical lift to ensure they were used in a safe manner and audits of the mechanical lifts to ensure they were inspected and in proper working order. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake MI00148758. Based on observation, interview and record review, the facility failed to safely serve a hot beverage for one Resident (R908) of one reviewed for hot beverages, resulting in first-degree burns (superficial burn or wound that affects the first layer of the skin) on their abdomen and chest. Findings include: A review of a Facility Reported Incident (FRI) Intake MI00148758 revealed on 11/27/24 at 6:43 AM, The facility provided R908 a cup of hot coffee without proper containment to prevent spilling and R908 sustained a liquid burn to their chest and abdomen. Clinical record review revealed R908 was admitted to the facility on [DATE] with a history of heart disease, and TIA (Transient Ischemic Attack also known as a mini stroke caused by brief blockage of blood flow to the brain) with intracranial injury which resulted in R908 having functional decline with fine motor skills and weakness. R908's most recent BIMS (Brief Interview for Mental Status) scored 15/15 indicating R908 was cognitively intact. On 1/29/25 at 9:30 AM, during initial introduction and interview, R908 recalled the incident and acknowledged when handed a cup of coffee, it spilled on them (they were not able to grip the cup). R908 exposed and pointed to their upper abdomen commenting the area got red after the spill. Record review of the post incident medical assessment performed on 12/2/24 revealed R908 was diagnosed with first degree burns on the abdomen and chest requiring treatment with Silvadene cream (a prescription medication used in the treatment of burn wounds). On 1/29/25 at 2:30 PM, an interview with the Nursing Home Administrator acknowledged during their investigation, R908 was passed a cup of hot coffee by Dietary Aide A without it being covered as per their protocol and the hot liquid spilled onto R908. On 1/29/25 at 2:40 PM, an interview was conducted with Dietary Aide A and confirmed they poured a hot cup of coffee for R908, passed it to them without it being covered and when R908 went to grab the cup handle, R908 did not have a firm grip resulting in the coffee spilling onto them. Dietary A confirmed they did not cover the coffee and did not follow the hot beverage procedure policy. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included .(education to staff, immediate staff one to one of dietary staff, updated individual resident care plan, etc.). The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview and record review the facility failed to ensure a comprehensive infection control program that consistently identified infections based on symptoms and justified the use of antibiotics, (Using McGeer's Criteria for the definition of infections), as well as calculated infection rates, demonstrated on-going tracking, trending, in-services, education, and environmental rounding. Findings include: On 3/25/24 at 3:18 PM a review of the facility's infection control program data was reviewed and revealed the following: August 2023: A document titled Antibiotic Usage Log revealed resident infections both facility acquired and community acquired, however; the data did not include any identification of symptoms or consistent usage of labs or imaging to justify the use of antibiotic therapies. September 2023: There was no monthly summary included with the data, nor did the monthly data contain a calculated infection rate. A review of the Antibiotic Usage Log revealed resident infections both facility acquired and community acquired, however; the data did not include any identification of symptoms or consistent usage of labs or imaging to justify the use of antibiotic therapies. A review of the facility mapping of infections only contained a map of the second floor (the building has two floors with residents) with 11 rooms identified with a pink high-lighted mark, however; the key on the mapping did not identify what type of infection was denoted by a pink mark. October 2023: A summary within the monthly data did not show a break-down of the different types of infections and the Antibiotic Usage Log only documented COVID-19 infections despite an Antibiotic Usage report that documented and identified antibiotics had been prescribed for other types of infection including: respiratory, skin, and urinary tract infections. The only map contained in the monthly data was for the second floor with 10 rooms identified with a pink high-lighted mark, however; the key on the mapping did not identify what type of infection was denoted by a pink mark. November 2023: The Antibiotic Usage Log revealed resident infections both facility acquired and community acquired, however; the data did not include any identification of symptoms or consistent usage of labs or imaging to justify the use of antibiotic therapies. It was further noted no evidence of environmental or department rounding for infection control had been completed. December 2023: The Antibiotic Usage Log revealed resident infections both facility acquired and community acquired, however; the data did not include any identification of symptoms or consistent usage of labs or imaging to justify the use of antibiotic therapies. It was further noted no evidence of environmental or department rounding, or in-services or education for infection control. January 2024: The Antibiotic Usage Log revealed resident infections both facility acquired and community acquired, however; the data did not include any identification of symptoms or consistent usage of labs or imaging to justify the use of antibiotic therapies. It was further noted no evidence of environmental or department rounding, or in-services or education for infection control. February 2024: The Antibiotic Usage Log revealed resident infections both facility acquired and community acquired, however; the data did not include any identification of symptoms or consistent usage of labs or imaging to justify the use of antibiotic therapies. It was further noted no evidence of environmental or department rounding, or in-services or education for infection control. On 3/26/24 at 9:47 AM, an interview was conducted with Nurse 'E', the facility's Infection Control Preventionist. They said they had been in the role since January 2024 and the facility had several different people over the last year overseeing the program. Nurse 'E' acknowledged concerns identified within the program with regards to antibiotic stewardship, mapping trends, education, and environmental rounding. On 3/26/24 at 10:09 AM, an interview with the facility's Administrator was conducted and they acknowledged concerns identified with the facility's infection control program. A review of a facility provided document titled, Surveillance for Infections was conducted and read, The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) an other epidemiologically significant infections .The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms for Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. 1. The criteria for infections are based on McGeer's Criteria definitions of infections .

Based on interview and record review, the facility failed to ensure the offering of pneumococcal (pneumonia) vaccines to one resident (R29), of five residents reviewed for pneumococcal vaccines. Findings include: On 3/25/24 at 2:38 PM, a review of R29's clinical record was conducted and evidence they had been offered pneumococcal vaccines was not contained in the record. On 3/25/24 at 3:20 PM, the facility's Infection Control Preventionist, Nurse 'E' was asked to provide evidence R29 had been offered the pneumococcal vaccine. On 3/26/24 at 9:47 AM, Nurse 'E' reported they were unable to locate any evidence R29 had been offered the vaccine. A review of a facility provided policy titled, Pneumococcal Protocol was reviewed and read, At the time of admission, the Resident or responsible party is given a consent to sign either granting permission to administer pneumococcal vaccine per physician's order, stating prior vaccination, or declining the vaccine. The consent form states possible side effects of the vaccine. Signed consent is maintained in the EHR (electronic health record).

Based on observation, interview, and record review, the facility failed to follow the recommendations and physician orders for assistive devices to maintain range of motion and positioning for one (R19) of three residents reviewed for positioning resulting in the potential for a decline in range of motion and worsening of contractures. Findings include: R19 A record review revealed that R19 was a long-term resident of the facility, originally admitted on [DATE]. Based on the Minimum Data Set (MDS) assessment dated [DATE], R19 had severe cognitive deficits and they were non-verbal. R19's admitting diagnoses included contracture of left hand, stiffness of right and left hip, poly-osteoarthritis, stroke, and dementia. R19 was totally dependent for staff assistance with mobility and positioning in bed. R19 received their nutrition and hydration through a Percutaneous Endoscopic Gastrostomy (PEG) tube (A tube inserted through the wall of the abdomen directly into the stomach surgically to administer nutrition and hydration). An initial observation was completed on 3/24/23, at approximately 10:40 AM. R19 was observed sitting up in their wheelchair. R19 did not respond to any of the questions. R19 was sitting with both arms close to their chest, both elbows bent and both hands in almost full fist position, the left hand more than the right. R19 was not able follow any directions. The fingertips on both hands were in contact with the palm of the hands and they were in a closed fist position. A palm protector (a small cushion that can be used for in hand contractures to help prevent skin breakdown in the palm) and blue wrist/hand splint (brace) was sitting on top of chest across the bed. Later that day a second observation was completed at approximately 1:50 PM. R19 was observed in their bed. Both hands were in a closed fist position with elbows bent across their chest. R19 did not have the palm protector on. The palm protector and the hand splint were observed on top of the cabinet across the bed. R19 also had two assist bars on either side of their bed. The bar on the left side was padded (had a green cover) and the bar on the right side was left open. On 3/25/24, at approximately 9:10 AM, R19 was observed sitting in their wheelchair. R19's both elbows were bent, and hands were in a closed fist position. R19's palm protector was observed on top of the chest and the hand brace was observed on a stand on the corner of the room. Later during the rounds at approximately 10:15 AM the surveyor observed R19 from the hallway, sitting in their wheelchair and did not have the brace or the palm protector on. A follow up observation was completed later that day, at approximately 11:30 AM. R19 was observed in their bed. Both elbows were bent, and both hands were in a closed fist position. The padding on the right side of the assist bar was not in place. The palm protector and the hand brace were observed on top of the chest/stand. At approximately 1:50 PM, R19 was observed on their bed, in the same position with no palm protector on their hand. A bedside care plan was located on R19's room in a binder that had a right hand brace, left palm protector and right PRAFO (Plantar Resist Ankle Foot Orthosis) boot (a boot to take the pressure off the heel and to maintain the foot/ankle in a neutral position) while in bed were checked off with details. R19 did not have any boot on their right foot. The restorative nurse LPN B was in R19's room with the surveyor. R19 was in their bed with no braces on and they witnessed the brace/palm protector on the chest/stand and R19 did not have any PRAFO boot on. There was no PRAFO boot that was visible, and LPN was checking the room for their PRAFO boot. Review of R19's Electronic Medical Record (EMR) revealed physician orders that included, Padded assist bars - check placement every shift; patient to wear palm protector to left upper extremity per splint plan of care day and night to patient tolerance; PRAFO to right foot/ankle as tolerated; provide right upper extremity splint per splint plan of care during night to patient tolerance. Review of R19's care plan for assistive devices/braces revealed a (most) recent update dated 9/30/2020 (reviewed and updated over three years ago) read, Bilateral (both sides) padded bars; right- and left-hand splint per splint plan of care. There were no care plan updates for the palm protector or PRAFO boot. A review of the CNA (Certified Nursing Assistant) plan of care/task response report included the communication for padded assist bars - check placement every shift; patient to wear palm protector to left upper extremity per splint plan of care day and night to patient tolerance; PRAFO to right foot/ankle as tolerated; provide right upper extremity splint per splint plan of care during night to patient tolerance. An interview with restorative nurse LPN B was completed on 3/25/24, at approximately 1:45 PM. LPN B was queried about the splint/brace application process and oversight for residents with and or at risk of limitation for range of motion. LPN B reported that they received the orders for braces based on the recommendations from the therapists. They did not have any restorative aides currently and they were in the process of hiring. CNAs who were assigned to care for the resident were responsible to follow the plan of care and apply the braces. LPN B was queried on the facility process to ensure that the CNAs were following the plan of care, they had reported that currently they did not have way to document and ensure that the braces were applied or not and they were looking into a process. LPN B reported they had checked during rounds in addition to the other nurse supervisors. LPN B was notified of the observations for R19 on 3/24/24 and 3/25/24. LPN B reported they understood the concern and they would follow-up with the facility leadership. An interview with the Director of Nursing (DON) was completed on 3/26/24, at approximately 9:45 AM. During the interview, the DON was queried about the facility process to ensure how CNAs were following the plan of care for braces and assistive devices for residents. The DON reported that they currently did not have a process in place and they were discussing with their team to come up with a plan. Observations for R19 and the interview with LPN B were shared with the DON. The DON reported that they understood the concern and they were working on a plan. A policy for splints/braces/positioning devices etc. that covers application, monitoring of application to ensure that the ordered plan of care was followed by the floor staff/CNAs was requested via e-mail on 3/26/24. The facility provided document titled Splinting/Orthosis did not address the component to monitor and ensure compliance with the recommend plan of care for brace/assistive devices.

Based on interview and record review the facility failed to ensure consent for vaccines were obtained by the appropriate authority for one resident (R29), of two residents reviewed for choices. Findings include: On 3/24/24 at 2:51 PM, a review of R29's clinical record revealed documents titled PHYSICIAN'S STATEMENT ATTESTING TO DECISION MAKING AUTHORITY dated 10/21/22 and 1/8/24 were reviewed and indicated R29 had the capacity to make their own informed medical decisions and their Durable Power of Attorney (DPOA) for Healthcare had not been activated. R29's Durable Power of Attorney for Healthcare was reviewed and revealed R29's sister had been named as their Durable Power of Attorney. Continued review of R29's consents for vaccines was conducted and revealed the following: a consent to receive the influenza vaccine dated 11/13/23 signed by R29's sister, a declination for a COVID-19 vaccine dated 1/3/24 signed by R29, and a consent to receive a COVID-19 vaccine dated 2/3/24 signed by R29's sister. DPOA. On 3/25/23 at 12:30 PM, an interview was conducted with Social Worker 'A', they indicated R29 was their own responsible party and their DPOA for healthcare had not been activated. On 3/26/24 at 10:16 AM, an interview was conducted with the facility's Administrator. They were asked about R29's sister signing their consents and said R29 should be signing their own as they were their own responsible party. A review of a facility provided policy titled, Resident Rights was conducted and read, .You have the right to designate a representative .If you designate a representative, that representative has the right to exercise your rights to the extent you have delegated them, in accordance with applicable law. You retain the right to exercise those rights not delegated to a resident representative .

This citation pertains to Intake #MI00139234 Based on observation, interview and record review the facility failed to ensure a resident received their soup in dignified manor for one (R24) of 10 resident's reviewed for accidents. Findings include: A Facility Reported Incident (FRI) was reported to the State Agency (SA) that alleged R24 spilled their soup causing burns/blisters to the upper chest area. Following their investigation, the facility's intervention was to ensure the resident received all their soup in a two handled cup, not a bowl. On 3/24/24 at approximately 10:40 AM, R24 was observed lying in bed. The resident was alert and able to answer all questions asked. R24 was asked about the incident that led to burns/blisters on their upper chest in July 2023. R24 reported that they had been a resident at the facility for over three years following a fall at home that led to severe back issues with pain. The resident noted that in July they were served soup in their room while in bed, they spilled the soup and received burns/blisters to their chest. The resident stated that following the incident, the facility only serves them soup in a sippy cup ( a cup that has a detachable lid with a protecting hole designed to help a young child sip liquid from the cup without spilling). The resident noted that it makes them feel disrespected, like they were insinuating that they caused the burns themselves when actually the soup was just served too hot. The resident reported that prior to the incident they never wore a clothing protector and was able to eat soup out of bowl without incident. A review of R24 clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: encephalopathy (brain injury), type II diabetes, dysthymic disorder (major depression) and anxiety disorder. A review of the resident's Minimum Data Status (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition). A review of the facility's Investigation/Accident (IA) report documented, in part, the following: .(R24) .BIMS Score: 15 .Date/Time Discovered: 7/11/23 -3:52 PM .Incident Summary: (R24) did not eat lunch .requested soup was brought up to the floor at 1:40 PM .when soup was presented to her she refused to use the clothing protector .(R24) was found to have three different burn blisters on her right chest .(R24) did not notify her nurse until 3:52 PM .Upon interview (R24) stated she has a routine for eating soup .she never wants to use the clothing protector because she feels her napkin is sufficient .Investigation Summary: (R24) reported she spilled soup on herself while eating it .while reviewing the incident with (R24) this writer re-educated the resident about the risk of further injury however she became upset and said this writer was 'blaming her' .An intervention to minimize risk is that all her soups will be provided in a two handled cup . A Resident Concern form dated 12/27/23 documented, in part, the following: Resident insists that she does not want the double handed cup anymore in which soup and oatmeal are served because she feels it is a dignity issue Follow up: OT (occupational therapy) to try to see if there is any other adaptive equipment that would work for her .Resident aware of resolution however not agreeable to interventions . R24's Care Plan documented, Category: ADL's (activities of daily living) Functional Status .Noncompliance R/T (related to) nonuse of clothing protector to protect from liquid spills (12/30/23) .Category: Nutritional Status (Edited 7/26/23) .Approach: All soups will be served in double handled cup with lid for safety . On 3/24/24 at approximately 12:15 PM, an interview was conducted with Dietary Manager (DM) F. When asked about R24's soup that was going to be served to the resident, DM F reported that the resident does receive all their soup in a two handled sippy cup. DM F reported that the resident had tried to eat their soup while lying in bed and had spilled it down her front. They then stated, It's not her preference, but it's a safety issue . On 3/26/24 at approximately 9:54 AM, an interview was conducted with the Administrator. When asked about R24's concern that eating soup from a sippy cup is a dignity issue, the Administrator reported that we initiated the cup to ensure her safety as she refused to wear clothing protectors and does not seem interested in any other forms of adaptive equipment. The Administrator reported that since the incident on 7/11/23, the resident has not received soup in a facility soup bowl. A review of the facility policy titled: Resident Rights (11/28/16 ) read, in part: It is the policy of the facility that all residents are afforded their Rights as guaranteed under Federal and State Law .As a basic premise, all residents have the right to a dignified existence .You have the right to participate in the development and implementation of your person centered plan of care .the right to request, refuse and/or discontinue treatment .You have the right to be treated with respect and dignity Self Determination .You have the right to right to make choices about aspects of your life in the facility that are significant to you .

Based on interview and record review the facility failed to ensure staff members timely reported allegation of Abuse/Restraints for one (R701) out of three residents reviewed for Abuse/Restraints. Findings include: A Facility Reported Incident (FRI) was submitted to the State Agency (SA) on 5/25/23 that reported they were informed that R701 was observed restrained by a gait belt around their chest and tied behind their wheelchair. The facility policy titled, Abuse Program Policy and Procedure was reviewed and documented, in part: Policy Statement: It is the policy of this facility to maintain an environment free of abuse and neglect .This includes but is not limited to freedom from .physical or chemical restraint .All allegations of abuse are to be reported immediately to the administrator of her designee. All any <sic> allegations involving abuse .are to be reported immediately, but not later than 2 hours after the allegation is made . A review of the Incident/Accident (IA) documentation revealed, in part, the following: Administrator was notified by Nurse C, that day Certified Nursing Assistant (CNA) D, reported that the midnight CNA A, found R701 with a gait belt around her chest, under her arms, and buckled in the back of her wheelchair when she started her shift .Investigation Summary: .R701 was allegedly found by midnight CNA A with a gait belt around her chest and under her arms with it buckled behind the wheelchair. According to CNA A she was told by afternoon CNA B that she did it to keep her from falling out of the chair. CNA A stated she put her into bed when she found her. Upon interview with CNA B she denied using a gait belt to secure R701 from falling out of her wheelchair .This writer attempted to complete a new BIMS (Brief Interview for Mental Status) multiple times however she refused. When questioned if anyone used a gait belt to keep her in her wheelchair she stated no. Will continue to try to obtain her current cognitive status . Continued review of the investigation documents, noted the following: A handwritten signed Statement by CNA A (dated 5-27-23): During the week of 5-15, I came in a got verbal report. I saw R701 in her chair with a gait belt wrapped around her chest and chair. It was buckled in the back. Afternoon staff stated she kept falling out of her chair that's why the gait belt was around R701. I started to take the belt off R701, and I put her to bed. On 6/15/23 at approximately 11:11 AM, a phone interview was conducted with CNA A. CNA A was queried as to the incident involving R701 being restrained by a gait belt. CNA A reported that they worked the week of 5/15/23 and on one of those dates they started work at the facility at or about 11 PM and observed R701 had a gait belt wrapped around their chest and hooked to the back of the wheelchair. They stated that that CNA B admitted to tying the gait belt around R701 to prevent them from falling. When asked if the facility policy allowed residents to be restrained, CNA A stated they were aware that staff were not to restrain residents. CNA A stated that they forgot about it for about a week or so and during a shift change with CNA D on the morning of 5/25/23 they discussed that R701 was attempting to get up more and was a fall risk and then they recalled what had happened the week prior (using a gait belt to keep from falling) and wanted CNA D to know about it. CNA A noted that they received a warning based on their failure to report the incident to the Administrator. On 6/15/23 at approximately 2:00 PM, an interview was conducted with the Administrator/Abuse Coordinator. The Administrator reported that they became aware of the incident via an e-mail on 5/25/23 from Nurse C. They then reported the allegation to the SA. When asked as to CNA A not reporting timely, the Administrator reported that CNA A should have immediately reported their observation to them and/or a Staff member. The Administrator stated that CNA A was given a warning and received additional education.

This citation pertains to intake: MI00133899. Based on interview and record review the facility failed to timely assess, identify and notify the physician of the worsening of the sacrum wound and consistently implement and apply adequate treatment and interventions for one (R69) of three residents reviewed for pressure ulcers, resulting in the development of an infected stage IV pressure ulcer (Stage 4 Pressure Ulcer- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). Findings include: Review of the medical record revealed R69 was admitted to the facility on [DATE] with a readmitted [DATE] and diagnoses that included: dementia, chronic kidney disease, difficulty walking and muscle weakness. A Minimum Data Set (MDS) assessment dated [DATE] documented Moderately impaired cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). Review of the progress notes documented on [DATE] revealed the resident fell , complained of pain, and an x-ray revealed an intermediate central left inferior pubic ramus and lateral left superior pubic ramus/acetabular fractures. The resident was transferred to the hospital for a higher level of care. Review of a Social Worker note dated [DATE] at 1:31 PM, documented the resident was readmitted with a diagnosis of a left inferior pubic ramus fracture after a fall. Review of the medical record revealed a Braden Scale for Predicting Pressure Sore Risk was not completed upon readmission back to the facility on [DATE]. Further review of the medical record documented the last Braden assessment completed was on [DATE] at 1:47 PM, which indicated the resident was At Risk with a score of 16.00. This was not an accurate score to reflect R69's status and change of condition upon readmission into the facility on [DATE] after their fall. Review of the [DATE] Medication and Treatment Administration Record (MAR/TAR) documented the following order in part, . Remedy Phytoplex Z-Guard . zinc oxide-white petrolatum . OTC (Over The Counter) paste; ,d+[DATE] % . apply liberal amount to excoriation to anus every shift until healed . This order started on [DATE], the day R69 was readmitted back to the facility. Review of a Shower Sheet dated [DATE] at 5:57 PM, documented in part . Discolored/bruised skin area on buttocks. Excoriated area noted on buttocks . Review of a Nurse Practitioner (NP) note dated [DATE] at 6:37 PM, documented in part . complaints of left hip pain and inability to ambulate s/p (status post) fall [DATE] . Therapy reports significant decline from prior level of function. Was ambulating . with 2WW (two-wheel walker) and now a lift (hoyer). Therapy reports uncontrolled pain with any LE (lower extremity) movement as does nursing . This reflected the decline identified with R69 after readmitting back to the facility. Review of a Shower Sheet dated [DATE] at 5:41 PM, documented in part . Discolored/bruised skin area on buttocks. Excoriated area noted on buttocks . Review of a NP note dated [DATE] at 4:42 PM, documented in part . left hip pain and inability to ambulate s/p fall [DATE] . Therapy reports need for pressure relieving mattress - starting to get skin breakdown at coccyx per staff . breakdown to coccyx - not assessed . Further review of the medical record revealed no documentation of any assessment, measurements, or characteristics to the skin breakdown on the coccyx. Review of a NP note dated [DATE] at 11:07 AM, documented in part . Nursing reports patient not eating . Down 8 pounds in the last week . breakdown to coccyx - not assessed . Decline in function / gait impairment ,d+[DATE] (secondary to) fall . Review of a Shower Sheet dated [DATE] at 3:26 PM, documented in part . Buttocks area excoriated. Cream applied as ordered . Review of a NP note dated [DATE] at 6:15 PM, documented in part . Skin changes to BLE (Bilateral Lower Extremities); breakdown to coccyx - not assessed . Review of a Registered Nurse RN note dated [DATE] at 6:10 AM, documented in part . 10x3.8 cm (centimeters) wound to sacrum with 6x3cm slough (slough- non-viable yellow, tan, gray, green or brown tissue; usually moist can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) to wound center. Surrounding skin is pink and intact. Initiated treatment: Santyl, NS (Normal Saline) damp gauze, Foam dressing-change Q (every day) . Alternating airflow mattress in place. Roho cushion to wc (wheelchair) . repositioned frequently/side to side only. Will continue to monitor and adjust care plan as appropriate. Further review of the medical record revealed no documentation of identification of worsening to the sacrum wound prior to [DATE] or that appropriate treatment was implemented timely to prevent worsening of the coccyx/sacrum area. Review of R69's care plans documented the following interventions implemented prior to [DATE], . BLE (bilateral lower extremity) tubigrips; on in am, off at hs (hour of sleep) . A&D to heels q (every) HS . Adequate fluid and food intake . Assist bar to bed for bed mobility . Assist with toileting and repositioning . Body/skin audit at least weekly . Braden scale quarterly and PRN (as needed) . give incontinence care after each episode . Hydraguard protectant cream to buttocks and peri area after each incontinent episode . keep call light within easy reach . keep closet stocked with briefs . maintain good body alignment w/ weight distributed evenly . Nystatin powder under B (both) breast prn . Report any red or open areas . ROHO cushion to wc, check inflation qs (every shift) . Further review of the care plans revealed on [DATE] the facility implemented the following intervention- Santyl, NS damp gauze, Foam dressing- change Q day, No further interventions were implemented. Review of the [DATE] MAR and TAR documented an order to Reposition side to side Q 2 hours - keep pressure off of coccyx area . every shift with a start date of [DATE]. Review of the medical record revealed the initial physician assessment of the sacral ulcer was on [DATE], more than two weeks after the identification of the wound worsening. Review of a physician consult dated [DATE], documented in part . sacral ulcer . Continue Santyl daily . see (physician name) . for deep debridement . follow up with me in 2 weeks . Review of a RN note dated [DATE] at 9:37 AM, documented in part . Sacrum, unstageable (unstageable- Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) - 3.0x8.0cm - Dry wound bed with 70% thick, spongey, yellow-green slough/ 5% necrosis to center of slough/ 25% pearly pink bed. Santyl appears to be effectively debriding wound, irregularly shaped . mild pungent odor . Review of a RN note dated [DATE] at 3:59 AM, documented in part . Sacrum, unstageable- 7.5x3.0cm - Dry wound bed with 30% thick, spongey yellow-green slough to center of wound/ 70% pearly pink bed surrounding slough, Santyl appears to be effectively debriding wound . Scant exudate. Moderately pungent odor . Painful with dressing change . Review of the [DATE] MAR and TAR documented staff continued to apply the Zinc oxide-white petrolatum paste liberally to the excoriation to anus every shift with the Santyl ointment that was applied to the sacrum daily. Review of a physician consult dated [DATE], documented in part . significant stage IV pressure ulcer (Stage 4 Pressure Ulcer- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed .) sacrum with exposed bone with extensive necrotic tissue. Unable to debride at bedside. Will require O.R. (operating room) debridement. Discussed palliative vs active care with daughter . Santyl to ulcer daily . Turn Q2 (every two) side to side . Palliative/hospice consult . If active treatment, will require . ostomy, OR debridement, PEG with tube feeding . Doxycycline 100 mg (milligram) BID (twice a day) x 14 days . Cipro 500 mg BID x 14 days . Review of the medical record revealed no documentation of the staff to identify the worsening of the sacrum wound prior to the physician assessment on [DATE]. Review of a Licensed Practical Nurse (LPN) note dated [DATE] at 7:03 PM, documented in part . Treatment in place <sic> coccyx wound. Oral ABT (antibiotics) ordered for wound infection . Review of the [DATE] MAR and TAR documented the Santyl ointment was discontinued on [DATE]. Review of the medical record revealed no documentation on why the Santyl ointment was discontinued on [DATE], despite the physician ordering the Santyl treatment to continue on [DATE]. Review of the [DATE] MAR and TAR documented the following order . mild soap and water, pat dry, cover wound cover <sic> with foam dressing. Change Q day and PRN this order started on [DATE] and was discontinued on [DATE]. This is not an appropriate treatment for a stage IV pressure ulcer. Review of the medical record revealed no documentation on why the Santyl treatment was stopped on [DATE] and why the soap and water treatment started on [DATE] and was discontinued on [DATE]. Further review of the [DATE] MAR and TAR revealed no treatment to have been applied to the sacrum wound from [DATE] until the date of R69's death on [DATE]. Review of the medical record revealed no documentation on why the wound treatment to the sacrum was stopped. Review of the medical record revealed R69 was admitted to hospice care on [DATE] and was pronounced deceased on [DATE]. On [DATE] at 2:31 PM, the Director of Nursing (DON) was interviewed and asked why there was no timely physician assessment of the sacrum wound, no timely identification of the worsening of the wound, no timely and adequate interventions and treatment implemented for the sacrum wound, completion of a readmission Braden assessment, and why the treatment for the sacrum wound was stopped on [DATE] and an order for soap and water started and was stopped on [DATE] with no further treatment to the wound until the resident's death. The DON stated they would look into it and follow back up. On [DATE] at 8:32 AM, the DON returned for a follow up interview and stated the [DATE] Braden assessment was an inaccurate reflection of R69's status upon readmission on [DATE], a new Braden should have been completed. The DON was unsure on why the Santyl treatment was discontinued but believe hospice implemented the soap and water treatment. The DON stated they found orders that was supposed to be implemented for the sacrum wound, however reviewed the MAR's and TAR's, and found the orders was never implemented for staff to apply to R69's sacrum wound once it was discontinued. The DON stated staff should have notified the physician and documented in the progress notes regarding the worsening of the wound. The DON stated they would start education with their staff immediately. No further explanation or documentation was provided by the end of survey.

This citation pertains to Intake MI00133679 Based on observation, interview and record review, the facility failed to ensure one (R707) of two residents reviewed for accidents was transferred in a manner consistent with their plan of care, resulting in a fracture to R707's left humerus (long bone in the arm that runs from the shoulder to the elbow). Findings include: Review of a Facility Reported Incident (FRI) read in part, .(R707) had an increase in pain after a transfer on 12/12/22 . a follow up x-ray was completed 12/27/22 . left proximal humerus fracture . On 1/18/23 at 10:32 AM, R707 was observed lying in bed. R707 was asked how her left arm was injured. R707 explained it was her shower day and the Certified Nursing Assistant (CNA) came in to give her a shower, she told him she needed a mechanical lift, but he told her he was strong enough to pick her up, he then put the shower chair up close to the bed and lifted her up by putting his arms under her arms and lifted her up and put her in the shower chair . he lifted her left arm higher than her right arm. R707 explained she told the CNA, well, that was uncomfortable, and that she did not want to have a shower, so he picked her up again and put her in the bed and gave her a bed bath. When asked if she told anyone about her arm injury, R707 explained she told the nurse during the night because her arm was hurting so bad she needed a pain pill. In R707's room, a blue binder was observed on the wall in a vertical wall file with R707's bed number on it. Upon opening the binder, a bedside care plan documented R707's transfers as, Vander or Vander II (mechanical lift), 2 assist. R707 asked what was in the blue binder as she had never seen anyone look at it before. R707 was asked how staff transferred her. R707 explained they used a mechanical lift. When asked how many staff transferred her with the mechanical lift, R707 explained she knew there were supposed to be two staff, but a lot of the time there was only one staff member that would transfer her. Review of the clinical record revealed R707 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: stroke affecting the left side, diabetes and heart failure. According to the Minimum Data Set (MDS) assessment dated [DATE], R707 was cognitively intact and required the extensive to total assistance of staff for all activities of daily living (ADL's). Review of R707's ADL care plan revealed an approach edited 12/10/20 that read, TF (transfer) = vanderlift x 2PA (two person) with sling wrapped as cocoon. Review of R707's progress notes revealed: A nursing note by Licensed Practical Nurse (LPN) D dated 12/13/22 at 1:51 AM that read in part, 1:39 am Resident c/o (complaining of) pain on left shoulder, when asked why her shoulder hurt stated It hurts when I move it, the big black man picked me up today for a shower and told him that he can't do that because it hurt, so he put me down and end up giving a bed bath. Resident was given norco (pain medication) . A physician note dated 12/13/22 at 3:54 PM read in part, .patient complained of pain to left shoulder after attempted transfer for shower . Patient is irritable today and reports pain to shoulder with any movement or touch . A nursing note by LPN E dated 12/13/22 at 7:06 PM read in part, Resident has been complaining of L (left) shoulder pain, prn (as needed) pain medication given, appetite poor during dinner . A physician note dated 12/15/22 at 4:43 PM read in part, Patient seen in follow up of left shoulder pain . Patient reports that her left shoulder continues to hurt . patient remains tender to touch. Patient reports shoulder pain is acute. No prior history of shoulder pain. Pain is worse with movement and increased with log rolling for brief changes. Patient reports difficulty sleeping secondary to pain . A physician note dated 12/20/22 at 4:19 PM read in part, .Patient reports continued left shoulder pain. Reports of increased pain with movement of any part of left arm . A physician note dated 12/27/22 at 2:26 PM read in part, .Patient seen in follow up of left shoulder pain . Repeat left 2 view x-ray done today showing: Acute appearing fracture of the surgical neck as noted . On 1/18/22 at 3:35 PM, CNA B, R707's assigned CNA on 12/12/22, was interviewed and asked what happened with R707 on 12/12/22. CNA B explained he was going to give R707 a shower, he sat her up on the side of the bed, pulled the shower chair up to the bed and did a stand a pivot and put her in the shower chair. CNA B was asked if he knew what R707's transfer status was before he transferred her. CNA B explained she was a mechanical lift, but sometimes R707 would stiffen up when using the lift and he knew he could lift residents up and they would not fall. CNA B was asked what happened after he got R707 into the shower chair. CNA B explained R707 objected and said it was uncomfortable and wanted to be put back in bed, so he put her back into the bed and gave her a bed bath. When asked if R707 ever told him her left arm or shoulder hurt, CNA B explained R707 did not say anything hurt. On 1/18/23 at 4:00 PM and 1/19/23 at 8:00 AM, CNA E, R707's assigned midnight CNA, was called and a message was left. No return phone call was received by the end of the survey. On 1/19/22 at 9:12 AM, LPN D was interviewed by phone and asked about R707's left arm. LPN D explained sometime after 1:00 AM, CNA E came to her and said R707 was complaining of arm pain, so she went in and R707 told her the big black man picked her up and it hurt, so he put her back in bed and gave her a bed bath. LPN D was asked if she knew if R707 had gotten a shower the day before. LPN D explained it was documented that CNA B had given R707 a shower on 12/12/22. On 1/19/23 at 10:50 AM, the Director of Nursing (DON) was interviewed and asked if staff could pick up a resident and do a stand and pivot on someone that was a two person mechanical lift. The DON explained residents should always be transferred per their transfer status. Review of a facility policy titled, Resident Bedside Care Plans dated 1/15/14 read in part, It is the policy of [Facility] to use a Resident Bedside Care Plan Cart to communicate to direct caregiver's the information needed to care for the resident . Information on the Resident Bedside Care Plan will include, but not be limited to, .transfer status . The Resident Bedside Care Plan will be placed in each resident's room for easy access .

Based on observation, interview and record review, the facility failed to ensure that staff assisted resident transfers via mechanical lift (machine used to lift a resident) were performed safely for two (#501 and #506) of 15 residents reviewed for falls, out of a total sample of 23, resulting in falls with a fracture (broken bone) and bruising. Findings include: On 7/22/14 at 9:20 A.M., during the initial tour of the facility, Resident # 501 was observed in a wheelchair in the room with a removable cast on the right leg. Resident #501 was wearing a self releasing alarming seatbelt, and also had a safety alarm on the bed, and fall mats beside the bed. The resident was alert and had memory impairment, but was was able to answer simple questions appropriately. When asked about the cast, Resident #501 stated, "I broke my leg", but was unable to state how and when. Certified Nursing Assistant (CNA) "D", who was present in the room, stated, "I believe she broke it here, on an "Easy Stand" (mechanical sit to stand lift) during a transfer." On 7/24/14 at 9:30 A.M., Resident #501's current clinical record was reviewed and revealed the following: A face sheet documented that Resident #501 was originally admitted into the facility on [DATE], and readmitted on [DATE] after a hospitalization . Readmission [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #501 had severely impaired cognition (dementia), impaired ability to understand speech, needed extensive physical assistance from one staff for transfers to the wheelchair, toileting and hygiene, did not walk, and had impaired balance. A hospital emergency room (ER) Physician Consultation Report dated 6/29/14 at 10:48 A.M., documented the following information regarding Resident #501, "The patient is being seen in medical pre operative consultation prior to orthopedic surgery. Presents to the Emergency Center today from her Extended Care Facility (ECF - nursing home) with positive femur fracture on X-Ray. Per ECF notes, the patient fell around 6:00 P.M. There was positive deformity of the right lower extremity (RLE - right leg), so X-Rays were obtained and showed a femur fracture." "Past Surgical History" documented that Resident #501 had had both knees replaced. The ER report also documented that a hospital X-Ray report noted, "a displaced, predominantly oblique (diagonal) fracture of the distal right femoral diaphysis with anterior/superior dislocation of the distal fracture (complete separation of the bone at the break)." On 7/24/14 at 1:45 P.M., Resident #501's current and previous admission (closed) clinical records and facility "Unusual Occurrence Reports (I&A) were reviewed with the Director of Nursing (DON), who was also interviewed at this time, and revealed the following: A Nursing Care Plan for "Falls", dated 10/09/13, noted that Resident #501 was "at risk for falls due to (R/T) impaired cognition, strength, balance and mobility", and contained the following staff instructions (interventions), "transfer with sit to stand, purple (brand name of mechanical lift) lift with large sling with padded arms with one person assistance ( x 1 PA)." A Nursing Care Plan for Activities of Daily Living (ADLs), dated 10/09/13, for Resident #501, contained an intervention, added 6/20/14, to correct a problem with the resident's ability to maintain a safe sitting position, "Velcro seat belt to wheelchair for trunk support, positioning." Review of facility I&A revealed three I&As that documented that Resident #501 had suffered injuries as a possible result of transfers with the sit to stand lift. An I&A dated 2/28/14 at 3:15 A.M., documented that Resident #501 was found to have a "small greenish (old) bruise on jawline". The report noted, "resident is a sit to stand, possibly bumped on brown EZ stand (sit to stand lift)." When asked about this, the DON stated, "We came to the conclusion that she got the bruise during a transfer with the EZ stand lift. We changed her care plan to state that she needed to use the purple sit to stand lift." An I&A dated 6/9/14 noted that Resident #501 was found to have a yellow (old) bruise three inches in diameter on the left upper thigh. The report noted, "resident is a sit to stand." When asked about this, the DON stated, "We figured the bruise probably happened during a transfer." An I&A for Resident #501, dated 6/30/14, documented the following, "6/28/14, 8:25 P.M., CNA was transferring resident into bed with EZ stand (sit to stand mechanical lift). Bed was too high for resident to be seated fully on. CNA tried to lower bed, but bed was locked out, went to unlock and resident slid down side of bed. CNA called Nurse. Resident observed sitting on right lower leg with left leg bent in front of her and back against the bed. Scratch to right foot, bruising to right lateral knee. Resident sent to (hospital). Staff educated regarding proper transfers with lifts and ensuring resident is positioned and secured in lift properly, as well as proper bed height." On 7/24/14 at 2:15 P.M. the DON was interviewed and stated, "We've enacted that fall at least four times to try and figure out how it happened. The CNA is fairly new, but was inserviced on hire, and in May (2014) on mechanical lift transfers." On 7/24/14 at 2:25 P.M., CNA "D" was interviewed regarding using the sit to stand (EZ stand) mechanical lift to transfer a resident from the wheelchair to bed. CNA "D" stated, "The first thing you do, is to unlock the bed height controls (demonstrated a switch located beneath the footboard of the bed) so you can change the bed height if you need to. Then make sure the bed is the right height. If the bed is in the low position, the angle of the bed frame makes it difficult to get the lift legs under the bed. If the bed is too high, the resident can't sit down on the bed. It's a bit tricky. You have to get the height just right. That's why you need to unlock the bed (height) control first so you can adjust the height if you need to during while you're moving the resident." On 7/24/14 at 2:35 P.M., CNA "E" was observed transferring Resident #37 using the sit to stand lift. CNA "E" stated, "If the bed is knee high, or lower, you can't get the lift close enough to the bed to do the transfer because you start hitting the bed frame or the cord for the alarms. You have to lift the bed up, or you can't get the resident close enough to the bed. Too high, and the resident can't sit on the bed. First, you unlock the bed controls (demonstrated by switching the bed height lock mechanism off under the footboard). Try not to lift the bed too much so it'll be hard to get their butt on the bed, (demonstrated by raising the bed using the hand held controls, which did not operate until the bed height mechanism was turned off). We leave the beds locked out when they're in bed or not in here, for safety, so residents can't change it. You put the sling around the resident under their arms (demonstrated). Hook it up to the lift (demonstrated), put the safety strap around under their chest and fasten it (demonstrated), put the leg strap around their legs so they don't slide (demonstrated). Make sure their legs are placed right on the stand (lift platform), then raise up the lift." CNA "E" then placed the hand held bed height control on the resident's bed. The lift raised and held Resident #37 in a standing position. CNA "E" moved the lift next to the bed, and slowly lowered the resident into a seated position on the bed. CNA "E" said, "Now you take the sling and leg straps off. You take the safety strap off last. You need the bed controls where you can get them, in case the bed is too high when you get the resident over there." On 7/24/14 at 3:00 P.M., In the presence of the DON and the Administrator, CNA "F", the CNA who transferred Resident #501 at the time of the fall with fracture on 6/28/14, was interviewed regarding the incident. CNA "F" stated, "The bed was too high. I couldn't get (Resident #501) on the bed properly. I tried to raise the bed higher, but it didn't work, it was locked out, so I tried to raise up the lift instead. I had already taken off the chest safety strap and the leg strap, only the sling (wide cloth belt) under her arms was still attached, and when I raised the lift, she started sliding out from underneath the sling. I didn't want her arm to get caught and dislocated, so I lifted her right arm up so it didn't get caught." On 7/24/14 at 3:15 P.M., the facility Staff Development Coordinator, Nurse "G" was interviewed regarding proper technique for transfers using the facility sit to stand lifts. Nurse "G" stated, "It's not safe to raise or lower the lift without the safety strap fastened." When queried if it was safe to raise or lower the lift without the resident's legs secured with the leg strap, Nurse "G" responded, "No." Nurse "G" stated, "We lock out the bed height for safety, so prior to transferring a resident, unlock it, and then once the transfer is done, lock it back out so another resident won't tamper with it." At this time, the outline was reviewed for a staff "inservice/education" on "mechanical lifts" attended by CNA "F" on 5/7/14. There were no instructions on the outline regarding ensuring that the bed height controls were unlocked prior to the transfer. There were no instructions indicating that the lift should not be used without the leg strap and/or safety strap securely fastened. Nurse "G" could not explain this, and, when queried, was unable to state that these safety steps had been discussed during facility inservices on mechanical lift transfers. When queried, the Staff Development Coordinator "G" stated that she didn't realize that there was only a small difference in bed height between the bed being too low, and it being too high for a sit to stand transfer to occur safely. When queried, the Staff Development Coordinator stated that she was not aware that CNAs stated that the bed height controls needed to remain unlocked during the transfer to enable then to adjust the bed height during the transfer process. On 7/25/14 at 2:00 P.M., review of the facility policy entitled, "Easy Stand/ (brand name) Lift, dated 10/2012, the instructions noted that chest and shin (leg) straps were removed last, but included no warning not to adjust lift height once they were removed. The policy did not include instructions to ensure that the bed height controls remained unlocked during the transfer, noting the steps as: "1. Verify transfer status. 2. Adjust the height of the bed, if transferring to/from bed. Unlock the bed height controller if necessary." On 7-22-14 at 9:30 A.M., Resident #506 was observed sitting in wheelchair at the bedside. The resident was appropriately dressed and groomed with multiple bruising noted to both upper arms and right forehead (fading). The resident was questioned and stated, "The lift and sling caused the bruising. The sling is too tight and a couple weeks ago the lift fell on me." On 7-22-14 at 1:30 P.M. Resident #506's clinical record was reviewed. The resident's current admission was dated 8-19-12. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) resident assessment and care screening dated 5-13-14, described the resident as cognitively independent, and able to make her needs known. The resident required extensive assistance from the nursing staff, a two person physical assistance for full transfer (brand name for mechanical lift) with use of a bariatric sling. A plan of care for falls was in place, dated 2-16-14 that identified the resident was at risk for falling due to decreased mobility and weakness due to exacerbation of COPD. The care plan approaches included: use of full lift, gripper mat to seat of recliner and under recliner to prevent slipping, anti-slip glides, bilateral assist bars to bed to increase bed mobility. On 7-23-14 at 10:00 A.M., the Unusual Occurrence Report for Resident #506, dated 7-1-14 at 4:30 A.M. was reviewed. It was identified that, "Nurse responded to a call for help from CNA's (certified nurse aides). Upon entering the room the nurse observed the resident laying sideways across her recliner chair. Two CNA's were present one on each side, with resident in bariatric sling hooked to the (name brand of mechanical lift). Lift bars were across the resident's face. As the nurse entered the room, a candle fell from the shelf onto the resident's head. The staff lowered the resident to the floor slowly. A full assessment was done. Neurological checks were within normal limits with no injuries observed, no complaint of pain. The physician and family member were notified. The physician ordered x-rays of the hip and left ankle and foot (pain) to rule out fracture. A review of the radiology reports dated 7-2-14, "showed ankle swelling but no evidence of ankle or hip fracture." The physician note for Resident #506's incident on 7-1-14, dated 7-2-14 (time not indicated) noted, "The patient had a fall. She sustained a bruise to the right side of her face. She is not having any pain. She is complaining of pain in her left leg, but she says that has been there for a long time and is not new. Plan: Fall precautions." On 7-25-14 at 9:30 A.M. the Director of Nursing (DON) was interviewed regarding Resident #506. The DON was queried about the resident's fall. She said, "The resident was being transferred (name brand of mechanical lift) with two CNA's from bed to wheelchair when the lift began to tip. They moved the wheelchair out of the way and lowered the resident sideways, with sling in place, down onto the floor. The resident plan of care and transfer were reviewed." When queried about the current bruising to the resident's right and left shoulders, there was no acknowledgement. However, interview (7-25-14 at 10:00 A.M.) with the resident and family member identified that the bruising on both arms had resulted from use of the (name brand of mechanical lift/sling). On 7-25-14 at 10:15 A.M., the Director of Rehababilitation Therapy, Employee 'J', was interviewed regarding Resident #506. When queried about the fall, she stated, "I do not know what caused the mechanical lift to tip. It was weight appropriate. Her weight was around 318 pounds and the lift accommodated up to 450 pounds." On 7-25-14 at 11:00 A.M., an attempt was made to contact the employee 'H', Resident #506's assigned CNA at the time of the fall on 7-1-14, however, she was not available. A review of the written statement provided for the facility investigation, dated 7-1-14 (time not indicated), was reviewed. It stated, "She (Resident #506) was a two person transfer from chair to bed. I reached back with one hand to move her chair, and the (name brand of mechanical lift) fell over. I tried to catch her from the fall, then I yelled for help." On 7-25-14 at 1:00 P.M. Employee 'I', CNA was interviewed by phone regarding Resident #506's fall on 7-1-14. She stated, "I was helping with a two person transfer for (Resident #506). I was holding and guiding. As employee 'H' moved the lift, it started to tip. The (name brand of mechanical lift) hit the dresser, and we lowered her to the floor. I called the nurse into the room to assess. It took six of us to pick her up from the floor and place her into the chair." When queried about the cause of the fall, the CNA stated, "It was probably because the legs of the lift were too close together. But, the room was small and the legs could not spread open far enough. But, it (the lift) moved easier when the legs are close." When queried about noticing the current extensive bruises to Resident #506's arm/shoulder the CNA stated, "I noticed bruising on (Resident #506's) upper arm and shoulders, and we had begun to place towels as a barrier between the sling and the resident's arm. The resident requested the use of the towel to prevent further bruising." The CNA did not recall reporting the bruises. On 7-25-14 at 2:00 P.M., per review of the facility's "Fall Risk Screen" dated 3-25-14, "It is the policy of this facility to maintain the highest safety level with our residents." On 7-25-14 at 2:10 P.M., a review of the operating manual for the (brand name for mechanical lift, dated June 2008), identified that it is a hoist that can lift patients in a seated or prone position. Review of the facility's procedure for transfer from a wheelchair or bed entitled, "Mechanical Lift", dated 3/19/14, revealed: 3) Make sure there is enough room in the patient's room to do the transfer. Move furniture or other things that may be in the way. 10) Move the lift into position...open the base to its widest position." ( )( )

This citation pertains to intake numbers MI 173 and MI 222. Based on observations, interviews and record reviews the facility failed to implement appropriate corrective measures to prevent falls and provide adequate supervision for two (#502 and #503) of five sampled residents of a total sample of five, at high risk for falls resulting in a fracture of the left superior and inferior pubic bones for (#502) and fracture of the right femoral neck for (#503) and potential for further injury. Findings include: Resident #502 Record review on 10/14/11 at 2:45 p.m. revealed that resident #502 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #502 had moderately impaired cognitive status with short and long term memory problems, required limited assistance with bed mobility, transfer and ambulation; and extensive assistance with toileting. Resident #502 was hospitalized at the time of the unannounced survey. Further review of the resident's clinical record revealed a fall risk assessment with a total score of 35 from the time period of 08/30/11 through 09/21/11, and a score of 38 on 10/10/11. A score greater than 20 indicated a need for additional interventions. The resident's "Fall" plan of care dated 08/31/11 and Bedside Care plan revealed the following interventions: Pressure sensitive alarm (PSA) to bed and wheel chair to alert staff of self transfer attempts, Non-skid footwear when out of bed, Transfer with one assist and gait belt, Pull up brief for incontinence. Review of the "Unusual occurrence report" dated 10/09/11 at 1:15 am, revealed that Resident #502 was "observed on floor, call light clipped to bed. PSA mat in place, alarm turned off, non skid footwear at end of bed, resident not wearing a brief. No wet brief found in room, bathroom or garbage can. Call light was not activated. Observed resident lying supine, feet inside bathroom, head outside. Inquired what resident was doing, she stated, I had to go to bathroom. Asked if she was hurt, she said yes, my head hurts. patient was lying in wet puddle with liquid also on floor by bed...when range of motion performed on lower extremities, patient stated legs painful." An interview was conducted with Nurse #9 on 10/14/11 at 2:30 p.m. Nurse #9 explained that on the day of the incident, "I was in a resident's room when I heard a knocking sound. I couldn't tell where it was coming from so I went to the room next to the room that I was in, it wasn't coming from there. So I went to the room next to that and I saw the resident laying on the floor. Her feet were inside of the bathroom and her body was laying outside of the bathroom. The resident was knocking on the door, but wasn't saying anything. The resident had an alarm on her bed but it was turned off. The aide was supposed to check it. I don't know how we missed the alarm. I did not check the alarm." Nurse #9 went on to say, "she was not wearing a brief, the floor was wet, there was a puddle around her and she had nothing on her feet. She was not wearing gripper socks. The resident complained of left hip and left upper arm pain." An interview was conducted with Certified Nurse Aide (CNA) #10 on 10/14/11 at 3:00 p.m. The CNA reported that "when I saw the resident on the floor, I called for the nurse, but I realized that the nurse was already aware of the fall because she was in the room with the resident. I didn't hear an alarm so I asked if the alarm was on. I looked at the bed alarm and it was turned off. The floor was soaking wet, so I asked where the resident's pull up was because she was not wearing one, nor did she have on any gripper socks. The resident complained that her hips were in a lot of pain." The resident was transferred to the hospital at approximately 0500 a.m. on 10/09/11. Review of the diagnostic report for Resident #502 dated 10/09/11 revealed that the resident sustained [REDACTED]." The Director of Nursing and the Administrator, when interviewed on 10/17/11, at 9 a.m., verified that interventions to prevent falls were not in place for Resident #502. Resident #503 Review of the clinical record for Resident #503 revealed that she was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Resident #503 had severely impaired cognitive status with short and long term memory problems, and required limited assistance with bed mobility, transfer and ambulation. Resident #503 was hospitalized at the time of the unannounced survey. Review of the residents "Fall Risk Assessment" revealed a total score of 56 on 09/19/11. The residents "Fall" plan of care included the following interventions: EZ release Velcro alarm seatbelt plus magnet alarm to wheelchair. Anticipate residents needs and assist as needed, Falling Star protocol, Review of Unusual Occurrence Reports on 10/17/11 at 10:30 a.m. revealed the following: On 09/18/11 at 6:15 p.m., "resident removed velcro belt was getting up, pressure alarm sounding. Resident turned to push wheelchair backwards and fell into hallway, hitting the back of her head on the ground...stat skull x-ay ordered. Slight ecchymosis to back of head was noted." On 09/25/11 at 10:35, "alarm sounding, nurse went into room and observed resident on the floor of bedroom next to bed. Resident said she was trying to go to the bathroom. Denied pain. No injury evident." On 10/10/11 at 635 p.m., "resident was observed on the 2 South hallway floor, on her right side with the EZ belt and magnet alarm sounding. She stated that her right arm hurt...right hip and right upper leg hurt...x-ray of right hip ordered." Resident was transferred to hospital on [DATE] at 1:10 a.m. Review of diagnostic report dated 10/11/11 revealed, "Right femoral neck fracture." On 10/14/11, at approximately 4 p.m., an interview was conducted with Nurse #7. Nurse #7 stated that on 10/10/11, she was about to get on the elevator to go on break when a CNA reported to her that Resident #503 had fallen. Nurse #7 returned to the unit to assess the residents condition. The nurse explained that Resident #503 has had previous falls in the facility. The nurse also explained that the resident had prior history of self transfer attempts at the facility. Nurse #7 stated, "she does it daily, many times a day." The nurse further stated, the resident had a cast on her arm as she was admitted into the facility with a fracture. "She requires constant supervision." On 10/14/11 at approximately 4:15 p.m., an interview was conducted with CNA #13. CNA #13 stated she was familiar with the resident who resided on the Alzheimer's unit. The CNA explained that she was not assigned to the resident that evening, but shortly after dinner time the resident began to get a little anxious. CNA stated, "the resident opened her alarm belt, said that she was looking for her social security card. After closing it (the belt) back, I pulled her closer to where myself and my hall partner was toileting another resident who required a two person transfer. The resident was right outside of the room in the hallway. Both of her alarms sounded, my hall partner ran out to the hallway, but by the time he got there the resident had already fallen." According to CNA #13, they (CNA #13 and her hall partner) were unable to see Resident #503, because the door to the toilet room was closed. On 10/17/11 at 10:15 a.m., an interview was conducted with CNA #11, who reported that the day of the incident was the first time that he was ever assigned to work with the Resident #503, but he had witnessed her attempting to remove her seatbelt and trying to walk prior to that date. The CNA stated, "right after dinner I asked the resident if she needed to be toileted and she refused to go to the bathroom. She kept pulling on her seat belt and said that she wanted to get her keys out of the wall. The nurse was about to go on break, and my hall partner needed assistance toileting another resident who required a two person assist, so I went to help her with that. We brought Resident #503 down to the room that we were in, so she could be closer to us. She attempted to remove her seatbelt a couple of times before the fall occurred. I had to go out in the hallway to assist her each time I heard the alarm. Then, I returned to help my partner. Just as we finished toileting the two person transfer and put her in her wheelchair, I heard the alarm again, but by the time I ran out there that time, she had just fallen." Review of the Policy entitled "Falling Star Program" dated 09/06/2011 revealed "identify residents who are at high risk for falls and provide visual awareness to all employees, so that they can participate as a team in an effort to prevent falls from occurring and reduce the risk for injury." The Director of Nursing and the Administrator, when interviewed on 10/17/11, at 9 a.m., were unable to explain why Resident #503 was not kept within visual range for supervision, as required by the "Falling Star Program."

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROPERLY MONITOR, DOCUMENT, AND IMPLEMENT INTERVENTIONS FOR TWO (#'S 501 AND 514) OF 10 SAMPLED RESIDENTS REVIEWED FOR NUTRITION FROM A TOTAL OF 22, RESULTING IN WEIGHT LOSS AND THE POTENTIAL FOR FURTHER COMPROMISE IN NUTRITIONAL STATUS. FINDINGS INCLUDE: THROUGHOUT EACH DAY OF THE SURVEY, RESIDENT #514 WAS OBSERVED SITTING IN A WHEELCHAIR WITH HER HEAD, LEFT SHOULDER, AND LEFT ARM EXTENDING OVER AND BEYOND THE WHEELCHAIR ARM REST ON THE LEFT SIDE. IN ADDITION, HER CHIN WAS RESTING ON HER LEFT COLLARBONE. ON 9/9/11 AT 12:30 PM, RESIDENT #514 WAS OBSERVED AT THE DINING ROOM TABLE FOR LUNCH. THE RESIDENT WAS STILL LEANING SEVERELY TO THE LEFT SIDE ABOUT ONE FOOT AWAY FROM THE EDGE OF THE TABLE WITH THE LUNCH TRAY OUT OF REACH. HER HEAD WAS AT THE LEVEL OF THE EDGE OF THE TABLE. PER NURSING STAFF, THE RESIDENT WAS OCCASIONALLY ABLE TO FEED HERSELF. AT 12:45 PM, THE RESIDENT REFUSED TO EAT WHEN STAFF ATTEMPTED TO SPOON FOOD INTO HER MOUTH. THE RESIDENT CONTINUED TO LEAN AFTER A PILLOW WAS PLACED ON THE LEFT ARM REST TO PREVENT THE LEAN. THE REGISTERED DIETITIAN (RD) ENTERED THE ROOM AND WAS QUERIED ABOUT THE RESIDENT'S POSITION DURING THE MEAL. THE RD WAS UNABLE TO RESPOND ABOUT THE POOR POSITIONING. WHEN ASKED, SHE INDICATED THAT THERE WAS NO DISCUSSION WITH THERAPY STAFF ABOUT PROPER POSITIONING TO FACILITATE EATING AND DIGESTION OF FOOD. O.T. (OCCUPATIONAL THERAPIST 'G') AND THERAPY DIRECTOR 'F' ENTERED THE ROOM AND SAW THE RESIDENT'S POSITION. A REVIEW OF RESIDENT #514'S CLINICAL RECORD WITH THE RD, O.T. 'G,' AND DIRECTOR 'F' REVEALED: THE RESIDENT WAS ORIGINALLY admitted on [DATE] WITH [DIAGNOSES REDACTED]. SHE WAS RE-admitted on [DATE] FOLLOWING hospitalization FOR A STROKE. THE MDS dated [DATE], NOTED THAT THE RESIDENT DID NOT REQUIRE ASSISTANCE FOR EATING. THE MDS dated [DATE], NOTED THAT SHE REQUIRED EXTENSIVE ASSISTANCE. THE RESIDENT'S MONTHLY PHYSICIAN RENEWAL ORDERS FOR 9/2011 NOTED: "POSITION RESIDENT TO KEEP FROM LEANING TO SIDE." THE RESIDENT'S "NUTRITION" CARE PLAN, WRITTEN BY THE RD, DID NOT MENTION PROPER POSITIONING DURING MEALS FOR EATING AND TO AIDE IN DIGESTION, EVEN WITH THE [DIAGNOSES REDACTED]. THE FOLLOWING WEIGHTS WERE RECORDED FOR RESIDENT #514: 5/2011=123 POUNDS. 6/2011=123 POUNDS. 7/2011=120 POUNDS. 8/2011=116 POUNDS. 9/2011=107.5 POUNDS, A SEVERE 13% LOSS OF BODY WEIGHT SINCE 6/2011 (3 MONTHS). THE RESIDENT'S WEIGHTS WERE BEING OBTAINED MONTHLY RATHER THAN WEEKLY FOR CLOSER MONITORING. THE RD WAS UNABLE TO STATE WHY. WHEN ASKED ABOUT THE RESIDENT'S WEIGHT DECLINE AND INTERDISCIPLINARY TEAM APPROACHES, THE RD STATED THAT THE RESIDENT'S WEIGHT WAS DISCUSSED WITH THERAPY STAFF IN A "NUTRITION AT RISK (WEIGHT)" MEETING ON 8/26/11, BUT THERE WAS NO INDICATION THAT THERAPY STAFF ATTENDED. DIRECTOR 'F' AND O.T. 'G' STATED THAT THE RESIDENT WAS ABLE TO WALK AFTER THE STROKE IN 5/2011 BUT THEY HAD NOT SEEN THE RESIDENT SINCE 7/12/11 AND WERE UNAWARE OF THE LEFT LEAN. A REHABILITATION SCREEN FOR RESIDENT #514, WRITTEN BY O.T. 'G' ON 7/12/11, NOTED: "RECEIVED ORDER TO SCREEN RESIDENT FOR WHEELCHAIR POSITION. OBSERVED RESIDENT SITTING IN WHEELCHAIR....AT TIMES LEANS TO LEFT SIDE. SHE HAS MAINTAINED THAT POSITION FOR PAST SEVERAL MONTHS." THE RECOMMENDATIONS FROM O.T. 'G:' CONTINUE TO REPOSITION RESIDENT FREQUENTLY AND PROVIDE LATERAL TRUNK SUPPORT WITH A PILLOW. WHEN QUERIED ABOUT DEVICES TO HELP MAINTAIN A MORE UPRIGHT POSITION, DIRECTOR 'F' SAID, "I GUESS WE COULD TRY BOLSTERS OR LATERAL TRUNK SUPPORTS." THE O.T. AND THE DIRECTOR WERE UNABLE TO EXPLAIN WHY THESE DEVICES WERE NOT ATTEMPTED BEFORE. PER RESIDENT #514'S NUTRITIONAL ASSESSMENT WRITTEN BY THE RD DATED 3/25/11, THE RESIDENT WAS FIVE FEET 5 INCHES IN HEIGHT WITH A USUAL ADULT BODY WEIGHT OF 131-135. ON 8/19/11, THE RD RECOMMENDED SUPER (FORTIFIED) CEREAL FOR BREAKFAST BECAUSE THE WEIGHT "HAS SLOWLY BEEN TRENDING DOWN" PER THE RD'S DOCUMENTATION DATED 7/19/11. THERE WERE NO FURTHER DOCUMENTED INTERVENTIONS TO HELP MAINTAIN BODY WEIGHT, SUCH AS APPETITE STIMULANTS, MEDICATION PASS SUPPLEMENTS, OR OTHER NUTRITIONALLY ENHANCED FOOD ITEMS. THE RD WAS UNABLE TO STATE WHY. PER THE FACILITY'S UNDATED "NUTRITIONAL PARAMETERS" POLICY: -IF A SIGNIFICANT OR PERSISTENT WEIGHT LOSS HAS OCCURRED, THE RD MUST DOCUMENT THE POTENTIAL CAUSE OF THE WEIGHT LOSS AND THE ACTIONS TAKEN TO CORRECT THE PROBLEM. -THE RESIDENT MUST BE ADDED TO THE WEEKLY WEIGHT SCHEDULE. -THE RD MUST MONITOR THE RESIDENT'S RESPONSE TO THERAPEUTIC INTERVENTIONS UNTIL THE RESIDENT HAS AT LEAST THREE CONSECUTIVE STABLE WEEKLY WEIGHTS AND THE PROGRESS MUST BE DOCUMENTED. PER THE FACILITY'S "POSITIONING" POLICY DATED 2004: -THE PURPOSE IS TO PREVENT THE RESIDENT FROM SECONDARY medical complications [REDACTED]. IMPROVED POSITIONING MAY ENHANCE THE RESIDENT'S ABILITY TO PERFORM FUNCTIONAL ACTIVITIES OF DAILY LIVING, SUCH AS EATING. -POSITIONING EQUIPMENT CAN INCLUDE COMMERCIALLY AVAILABLE DEVICES, SUCH AS WEDGES, LATER TRUNK SUPPORTS, AND OTHER SUPPORT SUPPLIES. -ONCE A REHAB SCREEN IS PERFORMED, WHICH IS A BRIEF NON-HANDS-ON REVIEW, A COMPREHENSIVE EVALUATION MAY BE RECOMMENDED BY O.T. OR RE-SCREENINGS MAY BE PERFORMED ON A PERIODIC BASIS WHEN A PROBLEM IS IDENTIFIED. ON 9/9/11 AT 10:10 AM, RESIDENT #501'S FEET WERE OBSERVED. THE RESIDENT'S FEET WERE [MEDICAL CONDITION] WITH VENOUS ULCERS AT VARIOUS STAGES OF HEALING. HE HAD A THICK, PROTECTIVE BOOT ON THE RIGHT FOOT. ON 9/9/11 AT 10:30 AM, THE CLINICAL RECORD FOR RESIDENT #501 WAS REVIEWED WITH THE REGISTERED DIETITIAN (RD). THE RESIDENT WAS admitted on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT HAD SEVERE COGNITIVE IMPAIRMENT BUT REQUIRED LIMITED ASSISTANCE WHEN EATING PER THE MINIMUM DATA SET((MDS) dated [DATE]. THE MDS NOTED THAT THE RESIDENT WEIGHED 168 POUNDS WITH A HEIGHT OF 5 FEET 11 INCHES. THE RESIDENT WAS PRESCRIBED [MEDICATION NAME] (WATER PILL) 20 MILLIGRAMS DAILY ON ADMISSION. THERE WAS NO WEIGHT RECORDED ON RESIDENT #501'S ADMISSION ASSESSMENT WRITTEN BY NURSING STAFF ON 6/30/11. THE RESIDENT'S WEIGHTS AND VITAL SIGNS SHEET NOTED THAT HIS ADMISSION WEIGHT WAS 157 POUNDS. ON 7/1/11, THE RD DOCUMENTED ON THE RESIDENT'S NUTRITIONAL ASSESSMENT THAT THE RESIDENT WEIGHED 167.5 POUNDS ON ADMISSION AND HAD 3 PLUS (+) PITTING [MEDICAL CONDITION] TO THE RIGHT FOOT, WHICH WAS A 10.5 POUND, 6 PERCENT (%) WEIGHT DISCREPANCY. THE RD WAS UNABLE TO EXPLAIN THE WEIGHT DIFFERENCE OR VERIFY WHICH ADMISSION WEIGHT WAS CORRECT. THE RESIDENT'S USUAL ADULT BODY WEIGHT WAS NOT RECORDED IN THE ASSESSMENT BY THE RD TO ESTABLISH A BASELINE. THE RD WAS UNABLE TO EXPLAIN WHY THIS WEIGHT WAS NEVER OBTAINED. THE RESIDENT WAS PLACED ON WEEKLY WEIGHTS ON ADMISSION. THE FOLLOWING WEIGHTS WERE OBTAINED: 7/6/11=157.5 POUNDS. 7/12/11=155.5 POUNDS. ON 7/11/11, THE RD DOCUMENTED THAT THE RESIDENT'S "JULY WEIGHT (WAS) 167.5 POUNDS." THE RD WAS UNABLE TO EXPLAIN THE 10 POUND DIFFERENCE. 7/19/11=157.0 POUNDS. 7/26/11=160.5 POUNDS. RESIDENT #501 BEGAN TO BE WEIGHED MONTHLY BEGINNING ON 8/2/11. HIS WEIGHT ON 8/2/11 WAS 159.5 POUNDS. ACCORDING TO RESTORATIVE AIDE 'D,' THE RESIDENT WAS WEIGHED BY NURSE AIDES WHILE IN THE SHOWER WITHOUT CLOTHES, OR THE BOOT ON THE RIGHT FOOT. THERE WAS NO RECORDED MONTHLY WEIGHT FOR 9/2011. THE RD AND AIDE 'D' WERE UNABLE TO STATE WHY THE WEIGHT HAD NOT BEEN OBTAINED. THEY STATED THAT MONTHLY WEIGHTS WERE USUALLY OBTAINED BY THE 7 TH OF EACH MONTH. ON 9/9/11 AT 11:15 AM, RESIDENT #501 WAS OBSERVED BEING WEIGHED BY AIDE 'D' AND A SECOND RESTORATIVE AIDE, WITH CLOTHING AND THE BOOT ON. AIDE 'D' STATED THAT THE BOOT WEIGHED 1.5 POUNDS. THE RESIDENT WEIGHED 149.7 POUNDS. WITHOUT THE BOOT, THE RESIDENT WEIGHED 148.2 POUNDS, AN 11 POUND, 7% WEIGHT LOSS SINCE 8/2/11, OR A LOSS OF 11.5% SINCE 6/30/11 BASED ON THE ADMISSION WEIGHT OF 167.5 POUNDS DOCUMENTED BY THE RD. ON 7/26/11, 7/27/11, 7/28/11, 7/29/11, 8/8/11, 8/22/11, AND 9/6/11, THE WOUND CARE SPECIALIST AND THE RESIDENT'S PHYSICIAN DOCUMENTED THAT THE RESIDENT WAS "POSITIVE FOR [MEDICAL CONDITION]" AND "LOWER EXTREMITY [MEDICAL CONDITION]" DESPITE ADMINISTRATION OF [MEDICATION NAME] TO REDUCE THE [MEDICAL CONDITION]. WHEN INFORMED THAT THE RESIDENT'S WEIGHT WAS DOWN TO 148.2 POUNDS, THE RD WAS UNABLE TO RESPOND. PER THE RESIDENT'S NUTRITIONAL ASSESSMENT ON 7/1/11, THE RD NOTED THAT HIS IDEAL BODY WEIGHT SHOULD HAVE BEEN 172 POUNDS. ( )